Diagnostic Neuroradiology Fellowship
Introduction
The recent years witnessed great development and advancement in medical
disciplines, including neurosciences and medical imaging. Neuroradiology matches
the developments in these two areas and became one of the most demanded services
in secondary and treaty healthcare settings in which subspecialty is an essential
requirement for safe and efficient practice. In these settings the complexity of clinical
cases requires more than general radiology experience.
To meet the demand of the growing healthcare services in the Kingdom of Saudi
Arabia and to overcome the increasing completion and difficulty of admission to
neuroradiology fellowship programs internationally, there should be a national
neuroradiology fellowship program that meets the international standards and bridges
the gap in the demand on this subspecialty. This is adequately achievable with the
presence of good number of national neuroradiologists who were trained in elite
centers and currently practicing in well-equipped hospitals in the Kingdom.
General Objectives
To afford high standard training and ensure subspecialty competency in all aspects of
Neuroradiology, including head & neck imaging. The graduates are expected to
function as specialist consultants and play an important role in the diagnosis and
radiological evaluation of pathological processes of the brain and spine as well as the
head & neck. The graduates should become resources for advanced subspecialty
multidisciplinary medical care and education in this field.
Although the program will provide good exposure to neurointerventional procedures,
it is not the aim of the program to graduate neurointerventionalists as this requires
additional dedicated training.
Specific objectives
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Acquire knowledge of relevant to embryological, anatomical,
pathophysiological, biochemical and clinical aspects of brain, spine, and head
& neck diseases.
Obtain in-depth understanding of the major imaging techniques relevant to
neuroimaging.
Grasp in-depth knowledge of the indications, contra-indications,
complications and limitations of surgical, medical and radiological
interventions and procedures pertaining to central nervous system and head &
neck region.
Master clinical knowledge relevant to medical and surgical central nervous
system and head & neck region disease and confidently discuss the
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appropriate imaging strategies for the clinical problem with the referring
clinician.
Acquire the skill of writing clear, accurate, and concise neuroimaging reports
and giving appropriate and informative neuroimaging consultations.
Obtain a detailed knowledge of current developments in the specialty.
Acquire direct practical exposure with appropriate graded supervision in
neurointerventional procedures.
Acquire appropriate competency and accuracy in the selection, performance,
supervision and reporting of neuroimaging investigations and minor imagingguided interventions.
Understand and practice appropriate Islamic and medical ethics and undertake
an attitude of accepted professional conduct that shall be applied throughout
the fellow's subsequent medical career.
Admission Requirements
To be admitted to the Saudi Diagnostic Neuroradiology Subspecialty Program, a
candidate must:
1) Possess a Saudi Specialty Certificate in Radiology or its equivalent (which is
approved by the Saudi Commission) or have at least successfully completed
the written component to the Saudi Specialty Certificate in Radiology.
2) Be licensed to practice medicine in Saudi Arabia.
3) Provide written permission from the sponsoring institution, allowing him/her
to participate in full-time training for the entire two-year program.
4) Successfully pass the interview.
5) Provide three letters of recommendation from consultants with whom the
candidate has recently worked.
Training Requirements
1. Training shall be full time. Trainee shall be enrolled for the entire two-year
period.
2. Training shall be conducted in institutions accredited for training by the Saudi
Board of Radiology and the subspecialty of Diagnostic Neuroradiology.
3. Training shall be comprehensive and include all aspects designated in the
structure and content of the program.
4. Trainees shall be actively involved in patient care with gradual progression of
responsibility.
5. Trainees shall abide by the other training regulations and obligations set by the
Saudi Board of Radiology and the Saudi Commission for Health Specialties.
Center Accreditation
Centers will be accredited to participate in the program based on the fulfillment of
several criteria which include but are not limited to the following:
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1. The imaging department is already accredited by SCHS for residency training
in radiology.
2. The imaging department has an established neuroradiology subspecialty
section.
3. The section has a minimum of two full-time certified neuroradiologists.
4. The imaging equipments are of satisfactory standard and meet the following
minimum requirements:
• CT scan: Multi-detector scanner (16 detector rows or more).
• MRI: 1.5 T or above scanner with basic sequences, in addition to
Diffusion-weighted and 3D angiographic sequences.
• 3D post processing workstation: capable of all basic techniques for
reformations, angiographic and functional analysis.
5. The volume of imaging examinations is sufficient and satisfies the minimum
weekly volume. As follows:
Examination
CT brain
CT head & neck
MRI brain
MRI spine
MRI head & neck
Cases per week
100
50
100
100
20
Structure of the Training Program
This is a two-year (104 weeks) fellowship program that will conform to the following
structure (see table below):
1. Neuro CT (Total 26 weeks): Routine brain CT examinations should be
prescribed, supervised, interpreted and reported by the fellow. Emphasis will
be placed on learning multidetector CT techniques for a wide variety of
applications. Specialized examinations such as CT angiography should all be
learned. Since some examinations also include imaging of the orbits, paranasal
sinuses, neck, and spine, there will be significant exposure to diseases these
areas that will serve as introduction to the dedicated rotations in the program.
The fellow should become comfortable after this period manipulating the
imaging data at dedicated 3D workstations for both interpretation and
illustration.
2. Neuro MRI (Total 38 weeks): Emphasis must be placed on learning practical
physical principles as they relate to neuroimaging including MR angiography.
Fellows should be heavily involved in direct supervision of examinations;
working with technologists to make necessary adjustments to parameters and
protocols as the studies are being performed. Indications and precautions for
the use of a variety of MR contrast agents should also be learned. Proper postprocessing of imaging data is a central part of the rotation.
3. Head & Neck imaging (Total 12 weeks): Emphasis must be placed on detailed
knowledge of imaging anatomy of the head & neck region including,
paranasal sinuses, neck, orbits, skull base and temporal bone. The fellow must
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4.
5.
6.
7.
also be familiar with the different pathologies in these areas and the best
radiological management of such conditions.
Pediatric Neuroimaging (Total 12 weeks): Emphasis must be placed on the
particular issues in neuroimaging in which children differ from adults,
particularly the issues related to radiation protection, sedation and MR safety.
The fellow must become familiar with the imaging of congenital and acquired
conditions that are seen in this pediatric population. During this rotation, the
fellow shall be responsible for all CT & MR neuroimaging of children.
Elective rotation (Total 8 weeks): This period allows flexibility to enhance
exposure to certain areas in the field of neuroradiology or to work in areas of
particular interest to the fellow. Examples of elective rotations are: adult
neurology, pediatric neurology, neurosurgery, neurophysiology, and
neuropathology. …etc.
Neurovascular rotation (Total 8 weeks): This rotation is dedicated for
diagnostic and interventional radiology of the neurovascular system. This will
include CT and MR vascular imaging as well as the neurointerventional
procedures. The fellow shall master post-processing of CT and MR angio
studies on the dedicated workstations and shall be aware of and familiar with
the current neurointerventional procedures.
Research activities: The fellow will be granted an average of one half day per
week of protected academic time during the second year of the program to
complete one peer reviewed journal publication in which the fellow is the
primary author, supervised by a staff member(s). It is expected that the fellow
will come up with a project proposal that is approved by the program director
during the first year of training in order to be granted the half day protected
academic time.
Didactic activities
Fellows will be required to attend and participate in a weekly joint lecture/journal
club series. Their attendance at this activity should not be less than 75%. During the
entire period, fellows will be expected to demonstrate scholarly activity; such as
review of specialized texts and recent literature, teaching of residents and junior staff,
as well as involvement in relevant clinical-radiological conferences.
The allotted number of weeks for training in each area is summarized below:
First year
Second
year
Total
12
8
26
12
20
38
8
4
12
12
12
Rotation
1st three
months
Rest of the
1st year
General brain CT
6
General brain MRI
6
Head & Neck imaging
Pediatric neuroimaging
Neurovascular
4
4
8
Elective
4
4
8
52
104
Total
52
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Program Content
A. Modalities: Fellows will become proficient in the physical principles,
indications, setup, logistics and performance of imaging modalities related to
neuroimaging. They must be knowledgeable in advanced protocols,
techniques, artifacts, contraindications and precautions related to the
performance of these examinations. They should also become proficient at
post processing techniques of 3D data sets and functional studies utilizing
dedicated workstations.
B. Contrast agents: The fellow will become familiar with the variety of contrast
agents available for clinical use in neuroimaging examinations and their
preparation, indications, methods of administration, precautions,
contraindications, limitations, artifacts and reactions. Basic knowledge in new
developments in the field of contrast media is expected.
C. Anatomy & Physiology: The fellow will master the essential anatomical details
of the brain, spine, and head & neck and how these details are identified by
imaging. The fellow will also master the essential details of the physiological
functions of the brain, spine, and head & neck and correlated imaging findings
with the clinical dysfunction.
D. CT & MR physics: The fellow will understand the physical principals of CT
and MRI as well as the physics of the different CT techniques and MR
sequences. The fellow will be able to recognize artifacts and suggest solutions
to overcome them.
E. Pathology: The fellow will become familiar with the presentations, imaging
findings, differential diagnosis, complications and management of disease
processes related to the brain, spine, and head & neck. These processes
include, but are not restricted to the following:
1. Congenital abnormalities.
2. Infectious diseases (acute and chronic).
3. Inflammatory disorders.
4. Neoplastic diseases (benign or malignant).
5. Vascular disorders.
6. Metabolic and degenerative disorders.
7. Traumatic & iatrogenic conditions.
8. Emergencies related to brain, spine, and head & neck.
F. Procedures: The fellow will have the opportunity to learn how to perform
diagnostic angiography and will assist in neurointerventional procedures in the
brain, spine, and head & neck
G. Teaching & Didactic activities: The fellow must demonstrate ability to instruct
and guide residents by conducting unknown case tutorial sessions at least once
a month, providing advice on imaging techniques & patient management, as
well as conveying important teaching points during case readouts and reviews.
The fellow will also exhibit the capability to assimilate information & data and
organize it into concise formal educational presentations. Participation in
preparing and moderating relevant clinical-pathological meetings will also be
required. A regional journal club meeting should be arranged every three
months with active participation by the fellow.
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H. Research & Literature: Fellows should become familiar with the major
radiological journals and should review them critically on a regular basis.
They should learn how to conduct research by making every effort to
participate in at least one research project during their training. Participation at
a conference or scientific meeting is strongly encouraged.
I. Radiation & safety: The fellow will acquaint him/herself with all aspects
related to radiation & magnetic field safety and protection, following accepted
guidelines of practice to ensure the safety of patients and staff alike.
J. Professional attitudes will be emphasized including adherence to medical and
Islamic ethics & practices, as well as maintenance of an attitude of continuing
education & learning. Constructive interaction with senior staff, clinicians and
technical staff will be exercised. Attributes such as responsibility, dedication,
cooperation, teamwork and a solid work ethic will be reinforced through
emphasis upon role models. The fellows shall follow and adhere to the
institutional policies and procedures of hospitals where they spend their
rotations in.
K. On-call duties: The fellow will be a second on-call exclusively for
neuroimaging cases, backing up the on-call residents. The fellow will not be
on-call less than three times a month and no more than eight nights per month.
This should include at least one weekend per month.
Methods of Instruction/Training
The program objectives shall be achieved through all of the following:
• Direct supervision of fellows during performance of their duties with
appropriate feedback.
• Discussion of methods of investigation, diagnosis and management of various
clinical problems during readout sessions.
• Review of reports dictated by the fellow prior to verification with the
provision of feedback and verbal instruction when significant errors are found.
• Provision of opportunity for consultation with senior staff to solve clinical
problems.
• Provision of opportunity for conducting clinico-radiological meetings relevant
to neuroradiology under the supervision of the attending neuroradiologist.
• Conducting unknown case tutorials, both by and for the fellow.
• Provision of guidance and assistance regarding learning resources and
educational opportunities.
• Provision of guidance and assistance during performance of research projects.
Training Rotations
The aim of the program is to enhance knowledge and skills acquisition of fellow by
giving them the chance to rotate between several hospitals in the training region or the
country and to have the chance to work with the maximum number of
neuroradiologists and see the maximum variety of cases. For that purpose the
rotations shall be organized by the subspecialty committee to make use of the
advantages of the participating institutions. Fellows should spend at least 24 weeks
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outside the sponsoring institution doing rotations in the other participating institution
excluding annual and Eid vacations.
Vacations
Fellows entitled for four weeks of annual leave during the program in addition to only
one of the two Eid vacations (7-10 days) each year. Annual vacation should not be
more than any particular rotation specified in Appendix 2. Leave requests must be
submitted well in advance. One week of appropriately justified emergency leave and
one week of properly confirmed study leave may be allowed each year during the
program.
Evaluation & Certification
Fellows' clinical performance, professional attitude and assimilation of knowledge
will be regularly evaluated by mentoring staff members. Periodic (every three
months) written evaluations (Appendix 3) will be obtained from concerned staff and
summarized by the fellowship director into a single form that will be reviewed and
signed by the fellow. These evaluations will be reviewed by the fellowship training
committee periodically to identify aspects that may require further emphasis or
counseling. Attendance at didactic activities will also be monitored.
Provided that evaluations and attendance are satisfactory, the fellow will be required
to undergo an OSCE examination at the end of the first year in order to be promoted
to the second year. At the end of the second year, the fellow must pass both a written
and an oral examination. The examination committees will be formed by the
subspecialty committee of the Saudi Commission.
Upon satisfactory completion of the above requirements, the Saudi Commission for
Health Specialties will confer upon the trainee the official certification of the
subspecialty training program.
Graduation Requirements
1. Satisfactory completion of all rotations with scores >60%.
2. Attendance at didactic sessions >75%.
3. Completion of one research paper accepted or published in peer reviewed
journal.
4. Pass all exam requirements.
Program Revision
The scientific committee of the Neuroradiology fellowship program shall be
responsible for periodic review and update of the program according to the current
standards of practice. The changes and modifications shall be submitted to the
scientific board of radiology for approval.
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Saudi Commission
For Health Specialties
Neuroradiology Fellow In-Training Evaluation
Name: __________________________ Registration No.: _____________________
Level of Training:
F1
F2
Rotation: __________________________________ Date From: ____________________________ To: ______________________________
PERFORMANCE EXPECTATION
No.
I
II
III
CRITERIA
Unsatisfactory
(<5)
Below
Average
(5-<6)
Meet
(6-7)
Above
Average
(>7-<9)
Outstanding
(9-10)
Not
Applicable
Knowledge and Academic activity
1. Basic Science
2. Clinical Science
3. Current Literature
4. Participation in Scientific Activities
5. Research
Clinical and Technical Skills
6. Organization of Work
7. Records and Reports
8. Interpretation and Utilization of Information
9. Clinical Judgment and Decision-Making
10. Indications for Procedures
11. Procedures and Operative Skills
12. Performance in Emergencies
13. Supervision and Consultations
Attitudes and Ethics
14. Discipline and Reliability
15. Patient Relations
16. Inter-professional Relations
17. Ethical Standards
Total Score:
Total Score
No. of Evaluated
× 10 =
Comments:
__________________________________________________________________________________________
__________________________________________________________________________________________
Director:
Fellow:
Fellowship Training Program
____________________________________________
Signature:
_____________________________
Date:
_______________________
Signature: ______________________________ Date: ________________________