Criteria for training and accreditation in Interventional Neuroradiology-Neurointervention, approved by the Spanish Group of Interventional Neuroradiology (GENI), the Spanish Society of Neuroradiology (SENR), the Spanish Group of Cerebrovascular Diseases (GEECV), the Spanish Society of Neurology (SEN), and the vascular disease specialists in the Spanish Society of Neurosurgery (SENEC). Requirements for accreditation in Interventional Neuroradiology-Neurointervention for institutions and specialists

Abstract

Background

The development of endovascular techniques has put Interventional Neuroradiology (INR) as the first-option treatment in the majority of vascular diseases of the central nervous system. Scientific societies in developed countries have created standard procedures for training and accreditation for a safe practice in these procedures.

Discussion

In Spain, we are waiting for the development of the legislation on the accreditation for specialists which will establish the official formative model to achieve an accreditation in INR. Until this moment comes, it is necessary to establish standards that define desirable minimums for the formative period in INR. Radiology specialists as well as neurologists and neurosurgeons will have access to INR accreditation. Specific requirements for the hospitals that wish to offer this technique and training should also be defined.

Conclusion

The Spanish Group of Interventional Neuroradiology, the Spanish Society of Neuroradiology, the Spanish Group of Cerebrovascular Diseases, the Spanish Society of Neurology and the Spanish Society of Neurosurgery have approved the content of this document and will create a committee in order to put into practice the accreditation of formative centres and INR specialists.

Resumen

Introducción

El desarrollo de las técnicas endovasculares ha colocado a la Neurorradiología Intervencionista-Neurointervencionismo (NRI-NI) como una alternativa de primera elección para el tratamiento de gran parte de las enfermedades vasculares del sistema nervioso central. Al no disponer de programas formativos en NRI-NI normalizados, las sociedades científicas de los países desarrollados han creado estándares de formación y acreditación para la práctica segura de estos procedimientos.

Desarrollo

En España, estamos a la espera del desarrollo legislativo de las Áreas de Capacitación Específicas que establecerán el modelo formativo oficial para los especialistas que deseen formarse en NRI-NI. Hasta que llegue ese momento, se hace pertinente disponer de unos estándares que definan los mínimos deseables para el periodo formativo en NRI-NI al que puedan acceder especialistas no solo de la Radiología, sino también de la Neurocirugía, y la Neurología, así como los requisitos exigibles a los hospitales que realizan esta actividad y quieran impartir dicha formación.

Conclusiones

Para poner en práctica la acreditación de centros formativos y la acreditación de los centros formadores y especialistas formados en NRI-NI, el Grupo Español de Neurorradiología Intervencionista (GENI), la Sociedad Española de Neurorradiología (SENR), el Grupo de Estudio de Enfermedades Cerebrovasculares (GEECV) de la Sociedad Española de Neurología (SEN) y el grupo experto en enfermedades vasculares de la Sociedad Española de Neurocirugía (SENEC), han aprobado el contenido de este documento de consenso y crearán un comité acreditador.

Introduction

The term ‘Interventional Neuroradiology-Neurointervention’ (INR-NI) describes the array of diagnostic and therapeutic activities that have been developed in neurology and radiology for use in certain diseases affecting the nervous system, its meningeal and osteoarticular layers, and the cervicofacial region.

Well-developed INR-NI activities include endovascular techniques, which are now widely recognised for use in diagnosis and treatment of vascular diseases of the central nervous system.^1–3

The advancement of endovascular techniques in the past 30 years has elevated INR-NI to the first choice treatment alternative for a long list of vascular diseases affecting the central nervous system.

In addition to endovascular techniques, INR-NI has developed percutaneous techniques for use in diagnosing and treating certain diseases in the craniocervical area and spinal column.

Given the lack of standardised INR-NI training programmes, medical societies in developed countries have been elaborating training and accreditation frameworks to certify professionals to practise these procedures. Minimum requirements for the length of training programmes, the theoretical and practical content of the programmes, and the requirements for hospitals intending to provide training have been established both in Europe⁴ and in the United States.⁵ There are more than 50 hospitals with INR-NI training programmes in the United States that demonstrate the interest by neuroradiologists, neurosurgeons, and neurologist in acquiring these techniques.⁶ These training activities and their results were analysed recently.^7,8

In Spain, law 44/2003 for the regulation of health professions⁹ provides for the establishment of specific areas of accreditation (SAA); once these areas have been established legally, they will provide the frameworks for post-specialty medical training programmes with content pertinent to one or more specialties.

In 2007, the Spanish Group of Interventional Neuroradiology (GENI) and the Spanish Society of Neuroradiology (SENR) proposed the creation of an SAA for Interventional Neuroradiology (INR) and submitted the application to the Spanish Ministry of Health by means of the National Committee on Radiodiagnostics, and with the approval of the National Committees on Neurosurgery and Neurology (Fig. 1).

Figure 1.

Agreement formalising the launch of the training/accreditation programme in interventional neuroradiology/neurointerventionism signed on 25 May 2015.

Regulations pursuant to that Royal Decree and regulating specialised healthcare training by establishing core curriculum and by creating and expanding SAAs are still being drafted. The perspective of the neurological sciences is that, since SAAs have not yet been implemented legally, it would be prudent to define guidelines spelling out the minimum requirements for an INR-NI training programme that would be open to neurosurgeons and neurologists as well as to radiologists. These guidelines would also list requirements applicable to the hospitals performing INR-NI techniques and intending to offer the training programme.

Individuals and hospitals will be able to obtain INR-NI accreditation based on these standards, which are endorsed by the GENI and the SENR and reflect the ability of these pertinent medical societies to provide specialist training. The accreditation programme proposed here is intended not as a means to an official diploma, but as a more or less temporary stopgap measure to meet the need for objective certification of training.

The reality is that modern healthcare requires guidelines indicating the minimum standards that must be implemented to guarantee better quality care with less variability in clinical practice.

In order to provide a means of accrediting INR-NI capability for teaching centres and specialists alike, the medical societies endorsing this consensus statement will formally approve its content in writing. They will also create an accrediting body whose composition and functions are specified in Appendix 1.

Requirements for a healthcare training setting

• 1.

  Training in INR-NI involves gaining proficiency in percutaneous and/or endovascular access techniques that can be used to treat certain diseases of the central nervous system, bulbospinal territory, and head and neck. This training is intended to complement pre-existing knowledge and abilities in neuroradiologists, neurosurgeons, and neurologists wishing either to acquire such competencies or certify and accredit them if they have already been acquired.

• 2.

  Training programmes must ensure trainees’ knowledge of the diseases that may be diagnosed or treated using percutaneous or endovascular access techniques, and they must follow a single syllabus that specialists will be required to complete in full.

• 3.

  Once the training activities have been completed, the accredited specialist must be able to perform, as a member of an INR team, the procedures pertaining to this area of knowledge.

• 4.

  A new INR-NI team will include, at the very least, a specialist with accredited INR-NI training and more than 5 years of experience, a licensed nurse experienced in setting up for INR-NI techniques, and an available anaesthesiology/reanimation specialist. During procedures, the team will also require a second licensed nurse to provide specific tools and to support the anaesthetist.

• 5.

  The hospitals aiming to provide INR-NI training must be accredited to provide specialist training in the fields of radiology, neurosurgery, and neurology; they must also have the resources and clinical activity specified in Appendix 2.

Means of access and training itineraries

The training programme must last a minimum of 2 years and may be extended to 3 years at the most for candidates with deficiencies in their prior training. It must also be presented in a hospital accredited for training residents (MIR).

The training programme must provide the theoretical basis and the clinical experience necessary to address the full array of clinical knowledge in INR-NI. Before the trainee may assume the responsibility of performing a neurointerventional procedure, he or she must acquire or certify a foundation of clinical and neuroradiological knowledge.

Candidates must have completed their residency cycle (MIR) in a related area: radiology, neurosurgery, or neurology.

• a.

  Itinerary for candidates trained in radiology:

  • •

    Candidates without 9 months of previous training in neuroradiology must complete that training in full, including imaging techniques (MRI, CT) and invasive diagnostic tests, until they are certified as having performed a minimum of 100 diagnostic cerebral angiographies.

  • •

    They will spend a total of 6 months on rotation in the neurology department, with a special emphasis on the stroke, neurosurgery, and intensive care units.

  • •

    In any case, they must complete a minimum of 18 months of advanced specific training in INR-NI techniques.

• b.

  Itinerary for candidates trained in neurosurgery or neurology:

  • •

    During the programme, candidates will complete training in diagnostic neuroradiology in an accredited unit (minimum of 9 months). This will include a grounding in the physical basis, use, and biological effects of ionising radiation. Candidates must also accredit having performed a minimum of 100 diagnostic cerebral angiographies. Where applicable, they may accredit any training in these areas that they may have completed during their residencies.

  • •

    Candidates must necessarily complete a minimum of 18 months of advanced specialist training in INR-NI techniques.

In all cases, the INR-NI programme will require candidates to complete specific hands-on training in which the specialist will participate actively in no fewer than 100 therapeutic procedures during the programme. Candidates must certify having performed the following (numbers are approximate):

• •

  25 endovascular procedures to treat cerebral aneurysms

• •

  15 endovascular procedures to treat cerebrovascular malformations

• •

  15 extracranial artery angioplasties with stent placement

• •

  10 cases of endovascular treatment for acute stroke

• •

  15 miscellaneous (e.g. intracranial angioplasty due to stenosis or vasospasm, correction of vascular malformations of the external carotid or venous vascular malformations, tumour embolisation, etc.)

• •

  5 bulbospinal endovascular procedures (spinal dural arteriovenous fistula, spinal arteriovenous malformation, etc.)

• •

  15 spine interventional procedures (vertebroplasty; kyphoplasty; discolysis; paravertebral, periradicular, or periganglionar infiltrations; biopsies; etc.)

If a candidate is unable to complete the full training programme at a single hospital, he or she may use external rotations to meet the entire list of requirements.

Conflict of interest

No conflict of interest.