TRAINING

TRAINING RESIDENTS IN ENDOVASCULAR NEUROSURGERY

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Robert E. Harbaugh, M.D.
Department of Neurosurgery,
Pennsylvania State University
College of Medicine,
Milton S. Hershey Medical Center,
Hershey, Pennsylvania
Akash Agarwal, M.D.
Department of Neurosurgery,
Pennsylvania State University
College of Medicine,
Milton S. Hershey Medical Center,
Hershey, Pennsylvania
Reprint requests:
Robert E. Harbaugh, M.D.,
Department of Neurosurgery,
Pennsylvania State University
College of Medicine,
Milton S. Hershey Medical Center,
500 University Drive,
Hershey, PA 17033.
NEUROSURGEONS HAVE A long history of treating cerebrovascular disease. Under-
standing the vascular anatomy and physiology of the nervous system and management
of patients with abnormalities of theses vascular structures are vitally important aspects
of neurosurgery resident training. Over the past decade, the treatment of cerebrovas-
cular disease has been evolving toward endovascular strategies for many patients.
Interventional neuroradiologists were the pioneers in developing this area of therapy,
but the number of neurosurgical trainees in neuroendovascular treatment is increasing,
and other specialties, including neurology, vascular surgery, and cardiology, are now
entering the field of neuroendovascular treatment. The purpose of this article is to
review the current credentialing guidelines for neurosurgeons to use endovascular
techniques in the treatment of cerebrovascular disease and to consider options for
resident training in the rapidly evolving field of endovascular neurosurgery.
KEY WORDS: Cerebrovascular disease, Endovascular neurosurgery, Endovascular surgical neuroradiology,
Endovascular treatment, Interventional neuroradiology, Neurosurgical trainees, Neuroendovascular
treatment
Neurosurgery 59:S3-277-S3-281, 2006 DOI: 10.1227/01.NEU.0000237355.55265.03 www.neurosurgery-online.com

I
Received, January 25, 2006. nterventional neuroradiology, endovascular
Accepted, June 19, 2006. neurosurgery (ENS), and endovascular sur-
gical neuroradiology are some designations
for specialties dealing with the endovascular
treatment of cerebrovascular disease. The fact
that three different titles refer to the same sub-
specialty field indicates the fluid nature of this
rapidly progressing area of clinical activity.
Neuroendovascular treatment began as a hybrid
of traditional neurosurgical and neuroradiologi-
cal approaches. Because of their clinical training
and experience with management of critically ill
patients with cerebrovascular disease, neurosur-
geons have, in general, had a superior under-
standing of the pathophysiology, the indications
and contraindications for treatment, and the
medical management of patients with cerebro-
vascular disease. Neuroradiologists, on the
other hand, have had more expertise in diagnos-
tic imaging and catheter skills. The collaborative
efforts of endovascular neurosurgeons and in-
terventional neuroradiologists have resulted in
improving the practice of neuroendovascular
practitioners from both disciplines and in devel-
oping neuroendovascular specialists who pos-
sess expertise in both neurosurgical and neuro-
radiological areas.
One accomplishment of the collaboration
between neuroradiologists and neurosur-
geons has been the Accreditation Council for
Graduate Medical Education (ACGME) ac-
credited specialty of endovascular surgical
neuroradiology. This has become an estab-
lished medical subspecialty with program re-
quirements for fellowship training set forth by
the ACGME (1). These requirements, along
with training standard guidelines recom-
mended by the Executive Committees of the
Cerebrovascular Section and the American So-
ciety of Interventional and Therapeutic Neu-
roradiology (4), were designed to make the
endovascular neurosurgeon a hybrid of tradi-
tional neurosurgical and radiological training.
As noted above, this agreement was a great
accomplishment when it was forged. How-
ever, the field of neuroendovascular treatment
is evolving so rapidly that this agreement may
no longer be the best strategy to follow. At
present, neuroendovascular procedures are
being performed by neurosurgeons, neurora-
diologists, neurologists, interventional radiol-
ogists, vascular surgeons, and cardiologists.
We question whether the ACGME fellowship
model is now ideal or even appropriate for the
coming generation of neurosurgical trainees.
We will argue that endovascular training
should become a standard part of neurosur-
gery residency training, at least in those pro-

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HARBAUGH AND AGARWAL
grams that offer adequate experience in this technique for
dealing with cerebrovascular disease. Furthermore, we think
that residents finishing an American Board of Neurological
Surgery (ABNS)- approved residency program in which ade-
quate endovascular training has been received should be cre-
dentialed to perform endovascular neurosurgical procedures.
The efforts toward this end at Penn State Hershey Medical
Center will be reviewed.
ACGME REQUIREMENTS FOR
ENDOVASCULAR SURGICAL
NEURORADIOLOGY
The ACGME requirements for an endovascular surgical
neuroradiology training program include: 1) performing a
neurological examination; 2) recognizing the clinical signs and
symptoms and the neuroimaging manifestations of cerebro-
vascular disease; 3) understanding the pathophysiology and
natural history of cerebrovascular disease; 4) recognizing the
therapeutic options available for management of patients with
cerebrovascular disease and the indications for these options;
5) demonstrating opportunities for basic or clinical research; 6)
understanding the periprocedural management of patients; 7)
understanding radiation physics, radiation biology, and radi-
ation safety; and 8) performing endovascular procedures. It is
obvious from a review of this list that neurosurgery residency
training already addresses items one through six and that item
seven can readily be obtained through didactic courses. I think
that, if a neurosurgery residency allows residents to perform
an adequate number of endovascular procedures, the resi-
dents finishing that program should be credentialed for endo-
vascular capabilities without additional training. We need to
treat ENS the same way we treat spinal instrumentation, im-
age guided surgery, and radiosurgery, as techniques within
the armamentarium of neurosurgery. We need to see the
angiography suite as an operating room and catheters as
flexible scalpels. If we continue to set ENS aside as the enclave
of a small number of fellowship-trained neurosurgeons, neu-
rosurgery will lose the entire field of cerebrovascular disease
treatment to non-neurological catheter-based specialties.
RESIDENCY TRAINING IN
ENDOVASCULAR NEUROSURGERY
In this article, we will use the term ENS for the sake of
convenience. However, we think that a better term is endovas-
cular techniques in neurovascular surgery, and that we must view
catheter-based treatment as another option to be used by
neurosurgeons to treat neurosurgical patients with vascular
disease. Catheter techniques should be an integral part of
neurosurgery, not a small enclave set apart. Much as cranial
base surgical approaches can be used to treat patients with
vascular disease and tumors, catheter-based surgical ap-
proaches can be used to treat neurosurgical patients with, for
S3-278 | VOLUME 59 | NUMBER 5 | NOVEMBER SUPPLEMENT 2006
example, vascular disease and vertebral compression frac-
tures.
As for any other technique in neurosurgery, residency train-
ing in ENS must take place in an environment dedicated to
teaching the core competencies of neurosurgical practice. For
ENS, this will include didactic teaching of the anatomy, phys-
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iology, pathology, and pharmacology critical to endovascular
neurosurgical procedures. Conference time must also be de-
voted to teaching the basics of radiation physics, radiation
safety, and radiation biology. In addition, neurosurgery resi-
dency training must provide sufficient exposure to the spec-
trum of diseases treatable by endovascular techniques and to
a wide variety of endovascular procedures. Residents must
have the opportunity to perform preprocedural examinations
of patients, evaluate preliminary diagnostic studies, and for-
mulate treatment plans. They must also be given the oppor-
tunity to perform diagnostic and interventional procedures
and generate reports in the endovascular suite just as they do
in the operating room. Finally, residents must also participate
in the inpatient and outpatient postprocedural management of
endovascularly treated patients to assure that they are familiar
with the short- and long-term complications of ENS.
Of major importance for resident training is access to ade-
quate case material that encompasses the range of cerebrovas-
cular disease. The question arises as to how we are to deter-
mine what is adequate. The Cerebrovascular Section and
American Society of Interventional and Therapeutic Neurora-
diology have recommended 100 diagnostic angiograms before
starting training in endovascular procedures, such as emboli-
zation of aneurysms, arteriovenous malformations and tu-
mors, angioplasty and stenting for the treatment of intracra-
nial and extracranial occlusive cerebrovascular disease, and
the performance of invasive functional testing (2, 3).
We find this number of concern. First, such numbers are
almost always arbitrary. As for any other surgical procedure,
some residents or fellows are ready to perform procedures
quickly, and some need many more repetitions before gaining
competence. This is certainly the case for other neurosurgical
procedures and for any other type of learned manual activity.
Are endovascular procedures different from all other manual
procedures?
Second, as noninvasive methods of imaging the cerebral
vasculature improve, the indications for diagnostic angiogra-
phy decrease, making it increasingly difficult to obtain the
designated number of 100 diagnostic angiograms before being
involved in any neuroendovascular treatment procedure. The
use of arbitrary numbers makes it more difficult for people to
enter the field of ENS. This, we think, is the real reason such
numbers have been recommended.
Third, endovascular simulators now offer an alternative for
developing catheter skills before doing any procedure on a
patient. In speaking to endovascular specialists who have
used these simulators, they have been enthusiastic in their
endorsement of the realism of these simulators and their value
in teaching catheter techniques. A technically facile neurosur-
www.neurosurgery-online.com

gery resident should be able to develop considerable catheter
skills using such simulators.
Finally, ENS is the only neurosurgical subspecialty in which
we expect those who perform any procedure to be competent
to perform all procedures. In all other subspecialty areas, we
expect every neurosurgeon to be able to do some procedures
but not necessarily all procedures. However, for ENS, those
deemed competent to perform intra-arterial thrombolysis
must also be trained to stent and coil a wide-necked aneurysm
and embolize a complex arteriovenous malformation. Why
should ENS be treated differently than all other techniques in
neurosurgery?
THE AMERICAN ASSOCIATION OF
NEUROLOGICAL SURGEONS
ENDOVASCULAR TASK FORCE
I cochaired (RH) (with L.N. Hopkins, M.D.) the American
Association of Neurological Surgeons Endovascular Task
Force. This task force was charged by then- American Asso-
ciation of Neurological Surgeons President, Roberto Heros,
with generating ideas for increasing the number of endovas-
cularly trained neurosurgeons and determining “what we can
do, as organized neurosurgery, to ensure that endovascular
surgery becomes a mainstream discipline within neurosur-
gery.⬙ Other members of the task force, in addition to Drs.
Hopkins and Heros, included Drs. Robert Rosenwasser, Ralph
Dacey, and Lee Guterman. Some of the findings of this task
force are germane to the present discussion. These are out-
lined below:
1) The challenge to neurosurgery from other specialties in
regard to the care of patients with cerebrovascular dis-
ease is, in many ways, analogous to the challenge from
orthopedic surgery in regard to the treatment of patients
with spine disease. Although significant differences exist
between the two situations, they are similar enough that
the neurosurgical response to the orthopedic challenge
can be used as a starting point for the neurosurgical
response to the challenge of other specialties using en-
dovascular therapy in the treatment of cerebrovascular
disease.
2) A mandate from the ABNS and the Residency Review
Committee for Neurosurgery requiring exposure to en-
dovascular neurosurgical techniques, although burden-
some for neurosurgery residency program directors,
would be helpful for introducing neurosurgery residents
to endovascular techniques and helping neurosurgeons
obtain access to angiography suites.
3) It is in the best interests of our patients and our specialty
to continue to work closely with interventional neurora-
diology. Organized neurosurgery has no desire to ex-
clude interventional neuroradiologists from the market-
place. These findings and conclusions will be elaborated
upon below.
NEUROSURGERY
TRAINING RESIDENTS IN ENDOVASCULAR NEUROSURGERY
THE ANALOGY WITH SPINAL SURGERY
When neurosurgeons were faced with the possibility of
losing spine surgery to orthopedics, they fought back aggres-
sively by developing spine fellowships, offering training
courses, and garnering industry support for training neuro-
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surgeons to perform spinal instrumentation. A similar ap-
proach may work for ENS, but will be more difficult. In the
case of spinal instrumentation, neurosurgeons were familiar
with the operating room environment, and spinal instrumen-
tation cases were not dramatically different from other proce-
dures. Neurosurgeons used the same basic techniques as were
used for other procedures and simply added a layer of exper-
tise. To do endovascular procedures, neurosurgeons need to
have access to digital angiographic imaging and to become
familiar with a set of tools, such as catheters, stents, coils,
balloons, and thrombolytic agents, that they have never used
before.
The ACGME-approved 2-year fellowship presently avail-
able to neurosurgery residents is working in the same way
spine fellowships worked, by developing a cadre of fully
trained endovascular neurosurgeons who can do any neu-
roendovascular procedure. If there were no time constraints
and no non-neurologically trained neuroendovascular special-
ists, this slow addition of endovascular neurosurgeons would
be adequate to assure that neurosurgery remains active in the
endovascular treatment of cerebrovascular disease.
THE COMPETITION FROM OTHER
SPECIALTIES
Unfortunately, there is a time constraint, and there are other
competitors. Specialty societies in vascular surgery and cardi-
ology have developed short courses of instruction to allow
their diplomates to perform neuroendovascular procedures.
This has had the effect of rapidly increasing the number of
physicians who have been trained to perform neuroendovas-
cular procedures, often with little or no understanding of the
nervous system or cerebrovascular anatomy and pathophysi-
ology. The greatest threat is from interventional cardiologists
who exist in large numbers, possess catheter skills, have access
to angiographic imaging, have demonstrated a desire to do
procedures, and who have the infrastructure for patient access
and follow-up. Cardiologists already perform the majority of
carotid stenting procedures in the United States, and they
have no plans to stop at the cranial base. Protests from other
specialties about cardiologists’ inadequate training to perform
neuroendovascular procedures will be ignored by cardiolo-
gists and by hospitals without interventional neuroradiolo-
gists or endovascular neurosurgeons.
LEVELS OF EXPERTISE
ENS, because it is relatively new, is being treated differently
than every other subspecialty area in neurosurgery. In other
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HARBAUGH AND AGARWAL
subspecialty areas, such as tumor, spine, peripheral nerve,
vascular, stereotactic, and functional and pediatric neurosur-
gery, we recognize that there are varying levels of difficulty of
procedures and corresponding levels of expertise needed to
perform them. For instance, we do not expect every neurosur-
geon who can do a carpal tunnel release to be competent to
perform a brachial plexus reconstruction or that every neuro-
surgeon who treats tumor patients should be able to remove a
clivus meningioma.
It is only in ENS that we require full fellowship training to
do any procedure. This is particularly concerning because the
procedures used for the treatment of ischemic stroke will be
the largest potential market and will require the least endo-
vascular expertise. Neurosurgery needs a strategy that signif-
icantly speeds up the production of endovascular neurosur-
geons, as was the case with spinal neurosurgeons trained to do
instrumentation. Full fellowship training was available for
neurosurgeons who wanted to be able to do any and all spinal
instrumentation cases, but in a relatively short time, spinal
instrumentation became a routine part of neurosurgical resi-
dent training. I think the same process should occur for ENS.
NEUROSURGERY RESIDENT TRAINING
OPTIONS?
We see three options for training neurosurgery residents in
endovascular techniques in cerebrovascular surgery. One
would be to require all neurosurgeons who wish to perform
any neuroendovascular procedure to complete an ACGME-
defined fellowship. This was a reasonable approach when the
joint training agreement was being developed, but I do not
think that it is the best strategy for neurosurgery at present.
Training in endovascular techniques is now readily available
in some neurosurgery residency programs, and a steadily
increasing percentage of patients with neurovascular disease
are being treated endovascularly. Other specialties with no
neurological expertise are eager to treat these patients. Adher-
ence to the ACGME fellowship training approach could have
disastrous consequences for neurosurgical training and for
patients with neurovascular disease who end up being treated
by endovascular specialists with little or no understanding of
cerebrovascular disease.
A second approach would be for the ABNS to require
competence in endovascular techniques for successful comple-
tion of training in all neurosurgery training programs. With
this approach, all ABNS-eligible or certified neurosurgeons
would automatically be certified in endovascular techniques.
This requirement would put an intolerable burden on many
neurosurgery resident training programs, and otherwise good
programs might not be able to meet this requirement. Further-
more, many residents might be inadequately trained, but cer-
tified to use endovascular techniques, resulting in poorer qual-
ity of care for their patients.
We think a third option should be considered. This option
would require exposure to endovascular techniques as part of
S3-280 | VOLUME 59 | NUMBER 5 | NOVEMBER SUPPLEMENT 2006
all neurosurgical resident training programs and recognize
some programs as supplying adequate training in the use of
endovascular techniques. Competence to perform neuroendo-
vascular procedures would be determined by performance
criteria determined by the ABNS and Residency Review Com-
mittee for Neurosurgery with a certificate of added qualifica-
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tion in endovascular techniques awarded at the completion of
resident training for those residents who meet the criteria.
This would increase the supply of well-trained endovascular
neurosurgeons and avoid the adverse effects on other pro-
grams.
THE RELATIONSHIP WITH
INTERVENTIONAL NEURORADIOLOGY
AND OTHER SPECIALTIES
The field of endovascular treatment of cerebrovascular dis-
ease has benefited from the collaboration between interven-
tional neuroradiology and vascular neurosurgery. Through
the efforts of the Cerebrovascular Section and American Soci-
ety of Interventional and Therapeutic Neuroradiology, we
should continue to work in a collegial and collaborative fash-
ion. It must be clear that our efforts to train endovascular
neurosurgeons are not done to exclude our interventional
neuroradiology colleagues from the marketplace but to aug-
ment the number of endovascular practitioners with expertise
and training in caring for patients with neurological disease.
Closer collaboration between interventional neuroradiologists
and endovascular neurosurgeons will benefit both groups.
Interventional neuroradiologists often have much more in
common with vascular neurosurgeons than they do with other
radiologists. Joining departments of neurosurgery would give
them immediate access to outpatient and inpatient clinical
infrastructure that most radiology departments do not have.
THE PENN STATE EXPERIENCE
The Departments of Neurosurgery and Radiology at the
Penn State Hershey Medical Center have developed what we
think is a unique approach for training radiology and neuro-
surgery residents in interventional neuroradiology/ENS. Two
faculty members, one interventional neuroradiologist and one
endovascular neurosurgeon, have been jointly hired by the
Departments of Neurosurgery and Radiology. Each depart-
ment is responsible for 50% of the faculty members’ salary,
fringe benefits, and other expenses. The neuroendovascular
specialists each have academic appointments in neurosurgery
and radiology and attend both departments’ faculty meetings.
Fifty percent of all revenue generated by each faculty member
go to each department. For example, if the interventional
neuroradiologist interprets a diagnostic study, 50% of that
revenue goes to neurosurgery. If the neurosurgeon operates
on an acute subdural hematoma, 50% of that revenue goes to
radiology. This equal sharing of expenses and revenue has
effectively removed financial incentives for a “turf war.”
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Both physicians see outpatients in the neurosurgery clinic
with the neurosurgery residents, and both have their endo-
vascular procedures scheduled by the Department of Neuro-
surgery. Diagnostic procedures are scheduled through the
Department of Radiology. Both faculty members have admit-
ting privileges, and all postprocedural patients who require
admission are admitted to the neurosurgery service and are
cared for by neurosurgery residents. Emergency neuroendo-
vascular calls are shared equally between the two faculty
members. Radiology and neurosurgery residents have equal
access to the neuroendovascular suite, but the neurosurgery
residents have shown much more interest in developing neu-
roendovascular skills.
Each resident receives his or her own set of lead protective
garments when starting the residency program. The neurosur-
gery residents are required to cover neuroendovascular pro-
cedures in the same way they cover neurosurgical procedures
in the operating room or radiosurgical facility. They are in-
structed to consider the neuroangiography suite as an operat-
ing room and to learn to use a catheter as they would learn to
use a scalpel or ionizing radiation. This is expected whether
the endovascular neurosurgeon or the interventional neurora-
diologist is doing the procedures. Our neurosurgery residents,
starting in their first year, gain experience in endovascular
techniques just as they gain experience in other neurosurgery
techniques. It should be noted that we have had facile first
year residents successfully coil intracranial aneurysms. Neu-
rosurgery residents with good manual dexterity, a knowledge
of neuroanatomy and neurophysiology, and the commitment
to excellence that comes with a decision to pursue a career in
neurosurgery are fertile ground for growing neuroendovascu-
lar skills quickly.
One of our residents who is finishing resident training this
year is fully capable of using the entire spectrum of neuroen-
dovascular techniques for treating patients with cerebrovas-
cular disease. This resident recognized that he wanted to be a
cerebrovascular surgeon and that endovascular techniques
were an increasingly important part of cerebrovascular sur-
gery. He availed himself of every opportunity to gain endo-
vascular experience during his residency, including a 6-month
elective in neuroendovascular surgery and an enfolded fel-
lowship year on the neuroendovascular service at Penn State.
As of March 31, 2006, he had performed 220 diagnostic and
NEUROSURGERY
TRAINING RESIDENTS IN ENDOVASCULAR NEUROSURGERY
317 interventional neuroendovascular procedures and had
cared for hundreds of patients with cerebrovascular disease in
clinic, on the wards, and in the neurointensive care unit. We
think that he is perfectly competent to use endovascular tech-
niques in treating patients with cerebrovascular disease at the
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time he finishes his residency.
CONCLUSION
Endovascular techniques for treating patients with cerebro-
vascular disease are evolving rapidly. The ACGME has rec-
ognized a 2-year fellowship training standard for accredita-
tion in endovascular surgical neuroradiology. However, as
neuroendovascular availability in neurosurgical training pro-
grams increases, and competition from other specialty societ-
ies grows; last year’s solution may be this year’s problem. We
think it is time for neurosurgeons to start training residents in
ENS in the same way we train neurosurgeons in every other
neurosurgical discipline.
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