Vascular Junior Resident Curriculum
A. CEREBROVASCULAR SURGERY
Demonstrate an understanding of the anatomy, physiology, pathophysiology and presentation of cerebrovascular diseases, including ischemic and hemorrhagic stroke, and other diseases and malformations of intracranial, extracranial, and spinal vasculature. Demonstrate the ability to formulate and implement a diagnostic and treatment plan for cerebrovascular diseases, including medical and surgical management.
COMPETENCY-BASED KNOWLEDGE OBJECTIVES:
- Describe the anatomy of the extracranial and intracranial vessels, including the carotid, vertebral, and spinal arteries.
- Describe the location of key perforating arteries involving the anterior and posterior circulation, their target distribution, and the consequence of occlusion or injury.
- Review the anatomy of the venous circulation as it pertains to the central nervous system.
- Identify the classic syndromes of vessel occlusion of the following:
- internal carotid artery
- middle cerebral artery
- anterior cerebral artery
- recurrent artery of Heubner
- anterior choroidal artery
- vertebral artery
- posterior inferior cerebellar artery (PICA)
- lower and upper basilar trunk
- Identify the classic brain stem ischemic syndromes.
- Explain the concepts of cerebral blood flow, cerebral autoregulation (hemodynamic and metabolic), ischemic thresholds, intracranial pressure, and cerebral perfusion pressure. Describe the impact of intracranial hypertension with and without mass lesion on cerebral blood flow.
- Recognize the common causes of brain ischemic states including:
- cardiac embolism
- embolism from proximal vasculature
- large vessel occlusion
- intracranial conducting vessel occlusion
- small vessel disease
- Associate computed tomography (CT) and magnetic resonance (MR) evidence of ischemic injury with likely anatomic substrate.
- Describe the epidemiology, physiology, and underlying pathophysiology of ischemic brain injury, including concepts of critical therapeutic window.
- Recognize the common causes of intracranial and intraspinal hemorrhage including:
- aneurysmal disease
- vascular malformations
- degenerative diseases
- hemorrhagic arterial infarction
- venous infarction.
- Relate typical imaging characteristics of central nervous system hemorrhagic lesions to probable causes.
- Categorize common causes of intracranial hemorrhage, subarachnoid hemorrhage, and ischemic stroke.
- Explain the principles of fluid and electrolyte resuscitation and maintenance, respiratory physiology, cardiac physiology, and nutritional physiology, as applied to the neurological patient following ischemic or hemorrhagic stroke. Integrate this knowledge with the specific issues of the perioperative period.
- Recognize the need for laboratory evaluation for systemic illness.
- List the appropriate diagnostic neuro-imaging studies utilized to evaluate ischemic and hemorrhagic stroke.
- Recognize the typical clinical course of patients with ischemic and hemorrhagic stroke, including peak risk intervals for edema, vasospasm, re-bleeding, etc.
- Identify the periods of high vulnerability to systemic complications of cerebrovascular illness, including deep venous thrombosis, pulmonary embolism, bacterial pneumonia, aspiration, congestive heart failure, etc.
- Explain the principles of augmentation of cerebral blood flow during cerebral vasospasm.
- Discuss the principles and indications for medical, endovascular, and surgical interventions for ischemic and hemorrhagic stroke.
- Relate the principles of timing of medical, endovascular, and surgical intervention in these same disease states.
- Explain the principles, indications for, and complications of barbiturate coma.
- Recognize the principles and interpretation of normal and common abnormal findings on skull, chest, and abdominal x-rays in the Critical Care Unit.
- Describe the fundamentals of CT scanning, including the typical appearance of acute, subacute, and chronic blood, calcification, ventricular anatomy, and mass effect.
- Describe the typical CT appearance of hemorrhagic and ischemic stroke. Provide a detailed explanation for the typical delay between the onset of stroke and appearance of confirmatory CT findings.
- Explain the fundamentals of MR imaging. Distinguish between normal and abnormal findings within the realm of cerebrovascular disease. Recognize the classic MR appearance of:
- arteriovenous malformations
- venous angiomas
- cavernous malformations
- List the indications for non-invasive vascular imaging, including ultrasound, magnetic resonance angiography (MRA), and CT angiography. Recite the limitations of non-invasive studies.
- Describe the practical application of commonly employed non-invasive studies, such as transcranial Doppler, in the setting of cerebral vasospasm. Â
- List the indications for catheter angiography. Interpret the findings of angiography in ischemic and hemorrhagic cerebrovascular conditions. Identify the key segments of the internal carotid artery including the upper cervical, petrous, cavernous, and supraclinoid components.
- Recite the principles of localizing focal intracranial and spinal vascular pathology by the use of traditional topographic measurements and the application of stereotactic guidance.
- Describe the surgical anatomy and the principles of exposure of the cervical carotid artery.
- Describe the principles of pterional craniotomy, including scalp and bony anatomy, as well as the anatomy of the sphenoid ridge.
- Explain the principles of cerebrovascular surgery detailed in the previous objectives to medical students and allied health personnel during conferences.
COMPETENCY-BASED SKILL OBJECTIVES:
- Perform a comprehensive neurological history and clinical examination.
- Perform a comprehensive systemic evaluation.
- Adapt comprehensive evaluation to specific pertinent positives and negatives with regard to ischemic and hemorrhagic stroke.
- Demonstrate an understanding of urgency and the ability to prioritize during emergent aspects of hemorrhagic and ischemic disease states.
- Demonstrate the ability to manage cardiac and pulmonary complications following cerebrovascular illness and therapy, and review the need for specialty and subspecialty consultations.
- Apply the principles of perioperative care following common endovascular and surgical procedures directed at cerebrovascular disease.
- Demonstrate the ability to be vigilant in the clinical detection of subtle neurological change during the acute and subacute phases of illness.
- Demonstrate the ability to place an arterial catheter, central venous catheter, and pulmonary artery catheter. Perform placement of a ventricular catheter via a burr hole or twist-drill craniostomy.
- Perform lumbar puncture and cerebrospinal fluid (CSF) reservoir tapping.
- Define the proper placement of a craniotomy flap in the planned surgical evacuation of hematoma. This should be performed using both topographical as well as stereotactic-assisted navigation techniques.
- Assist in the opening, exposure, and closure of cervical carotid procedures.
- Assist during pterional craniotomy for vascular disease.
- Assist in the performance of intracranial hematoma evacuation.
- Demonstrate the ability to keep accurate and timely records.