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Home , Neurology, Neuropathology, Neuroradiology

STANFORD UNIVERSITY

The neuroradiology fellowship at Stanford University Medical Center is designed to be a well-balanced academic training program that encompasses all of the basic and advanced clinical and research areas of both adult and pediatric neuroradiology.

The overall aims of this fellowship are two-fold: to produce neuroradiologists with the highest level of clinical expertise, and to produce the future leaders in academic neuroradiology. The goal of this fellowship program is for Neuroradiology fellows to develop knowledge, skills and attitudes necessary to properly evaluate, diagnose and manage with neurological, ENT and neurosurgical . Therefore, this fellowship requires participation in clinical, research, and educational aspects of neuroradiology.

Neuroradiology fellows will be exposed to all imaging modalities used to evaluate neurologic , including CT, MR, myelography, angiography, and imaging guided , during the course of the fellowship. Interventional neuroradiologic procedures are also performed at state-of-the-art levels at Stanford, and neuroradiology fellows will actively participate in these procedures.

Goal of the Neuroradiology Fellowship Program Core Competencies Fellows should achieve the Interpersonal System following objectives: and -Based Medical Practice-Based Communicati Professional Learni Care Knowledge Learning on Skills ism ng 1. Acquire specific knowledge about the physical principles of imaging modalities (CT,MR, and digital subtraction angiography). X X 2. Identify the practical uses of CT, MR, ultrasound and digital subtraction angiography in the evaluation of neurologiocal, ENT and neurosurgical diseases. X X X 3. Develop thorough knowledge of the physical and physiological properties of contrast agents used in CT, MR, and angiography; including contraindications and management of potential complications. X X X 4. Effective implementation of CT and MR scanning protocols with the appropriate use of contrast agents. X X X 5. Assess appropriate X X X clinical indications for neuroradiologic procedures. 6. Effectively counsels patients and/or family members prior to neuroradiologic procedures and obtains written informed consent. X X X 7. Master the manual techniques and intraoperative skills required for performing neuroradiologic procedures; including identification and management of potential complications. X X 8. Identify pertinent radiologic findings on CT,

MR and digital subtraction angiography examinations. X X X 9. Properly interprets and formulates an impression of the CT, MR and digital X subtraction angiography findings. 10. Demonstrate the appropriate use of X X recommendations and follow-up imaging. 11. Identify normal anatomy and development of the , spine and head X X and neck on all imaging modalities. 12. Perform prioritization and for neuroradiologic X X X X emergencies during routine work day and on-call duties. 13. Perform expert consultation of neuroradiologic imaging studies with referring clinicians. X X X 14. Produce clear, concise and accurate dictated reports. X X X 15. Develop of cost effectiveness of diagnostic studies and their resource limitations in . X X X 16. Participate in conferences and teaching of residents and medical students. X X 17. Develop a detailed knowledge of neurological, ENT and neurosurgical . X X 18. Gain an understanding of research methodology, study design and presentation of results. X 19. Demonstrate good interpersonal skills among professional colleagues and support staff. X X X 20. Always demonstrates respect, compassion, integrity and honesty. X 21. Demonstrate initiative, proactive learning and insight. X X 22. Punctuality and attendance for all daily activities. X 23. Effective use of information resources, scientific studies and technology to pursue improvement and education. X X X 24. Provide quality patient care X X X

The fellow’s evaluation will be based on his/her individual performance in fulfilling these competencies.

Website

A lot of resources (clinical, education and research) are available from our website, which you are encouraged to visit and explore: http://med.stanford.edu/neuroimaging.html

Assigned Rotations and Responsibilities:

The fellowship is divided into multiple assigned clinical rotations, which include the following: First year Shared Second year inpatient Sherman late Hoover II (PET-MRI) myelo/ENT/procedures Hoover night float myelo/ENT/procedures Hoover Sherman early vacation VA/float fellow INR INR LPCH LPCH conference/protocols elective elective board preparation (elective early in the year)

Please note the differences between first year and second year rotations and time spent on particular rotations, reflecting different goals for the first and the second year, and different levels of knowledge and expertise.

A schedule is posted for each month, and neuroradiology fellows, along with the residents on neuroradiology, will be assigned to one or more of these rotations each day. It is anticipated, schedule permitting and clinical performance following milestones, that each fellow will receive research elective time of at least two weeks in the first year of fellowship and at least eight weeks in the second year of fellowship. Elective time will vary depending on the overall number of fellows. Note also that assignments to the various rotations can change on a daily basis, but generally clinical rotations last approximately one week.

The specific responsibilities of the fellow on each rotation are generally self-evident but are detailed below:

INR is a rotation under the direction of Drs. Michael Marks, Huy Do, Jeremy Heit and Robert Dodd. Specific duties for this rotation will to some extent vary according to the abilities of the fellows and will evolve with time. Details should be clarified with Drs. Marks, Do, Heit and Dodd. It is anticipated that the fellows will gain significant expertise in all aspects of diagnostic neuroangiography, and in addition will receive gradual exposure to neurointerventional procedures. Note that a dedicated neurointerventional fellow will also participate in these procedures.

CT and MRI are either separate or combined rotations under either Outpatient Sherman, Outpatient Hoover 2 or InPatient depending on where the fellow is located. During these rotations, the fellow has the primary responsibility of giving preliminary readings, calling emergency reports and all significant findings to the ER or referring , handling any problems encountered by technologists, protocol direction, and preparing cases for formal read-outs with the neuroradiology attendings. It is often the case that old films and more extensive history are important, and the fellow should make all efforts to obtain these when possible. The Neuroradiology Reading Rooms should be the major places of residence by the fellow when assigned to these rotations during the day.

Specific duties include 1) making sure that the appropriate protocol is implemented for each patient; 2) helping to solve any problems with sedation in MR; 3) triage of add-on requests by clinicians; 4) review of MR cases when appropriate prior to taking the patient off the table; and 5) answering all questions or problems from MR technical staff. The assigned attending on the Read-Out rotation is the back-up for questions regarding these areas and should be sought when necessary. Fellows must always be available on beeper during these assignments. Dictations are performed by the fellow or assisting resident for all cases. No dictations are to be finalized prior to review with the attending. (Note: during noon resident conferences, the fellows are responsible for all CT and MRI coverage)

Myelography and Biopsies at Stanford is a specific assignment. Usually this rotation is assigned along with another rotation to the same fellow or resident. Biopsies and myelograms will be performed by fellows with direct supervision by an attending. Fellows will initially perform all myelograms, but radiology residents will be given graded degrees of responsibility in performing myelograms after neuroradiology fellows demonstrate adequate expertise. All invasive procedures will be monitored by a staff neuroradiologist in addition to a neuroradiology fellow. The fellow will be expected to obtain patient consent, to place appropriate orders, to communicate with CAPR and to insure that the patient is stable for discharge.

Conferences:

Neuroradiology actively participates in multiple clinical and didactic conferences. Assigned fellows are required to attend most of these conferences (unless otherwise noted as optional), and they are scheduled to give teaching conferences to the radiology residents during the year.

The most important fellow conference is the Interesting Case Conference held every Tuesday morning, during which current cases of interest are shown to the group. Fellows and residents are responsible for preparing these cases (retrieving old films, obtaining history, etc.) and presenting them.

Fellows are also expected to attend as often as possible the Grand Rounds held every Friday morning.

Below is a comprehensive list of didactic and clinical conferences:

CONFERENCES ATTENDED BY NEURORADIOLOGY TRAINEES

Conference Frequency Responsible individual or service/Department Pediatric ENT Conference 3rd Wednesday Otolaryngology Oto Radiology Conference 2nd Monday, bimonthly Otolaryngology Skull Base Conference 1st Monday Otolaryngology Pediatric Neuro Tumor Weekly Neuroradiology Board Work Rounds with Steinberg, Do and Weekly Radiology, Marks Clinical Conference Weekly Radiology, , Neurosurgery Interesting Case Conference Weekly Radiology Pediatric Neurology – Neuro Weekly Neurology Work Rounds Resident Conference Weekly Radiology Pediatric Vascular Anomalies 2nd Wednesday Radiology, , Plastic Conference Surgery Neurology – Neuroradiology Bi-weekly Neurology, Neuroradiology Conference Head and Neck Tumor Board Weekly Otolaryngology Conference Weekly Neurology Interventional Spine Conference 3rd Thursday Radiology, Sports Neuroradiology Research Weekly, Thursday Neuroradiology Conference ENT Case Conference Quarterly Otolaryngology Neurosurgery Grand Rounds Weekly Neurosurgery Neurology Grand Rounds Weekly Neurology Perinatology Conference Weekly Adult Brain Tumor Board Weekly Neurology, Neurosurgery

Below is the curriculum for the Thursday fellow conference, which spans two years:

Date Topic Speaker 02.07.15 Protocols I: Brain and Spine All 09.07.15 Protocols II: Head and Neck All 16.07.15 Protocols III: Peds All 23.07.15 Stroke: MRP, ASL Greg Zaharchuk 30.07.15 RSL Research Projects RSL Speakers 06.08.15 Stroke: CTP Max Wintermark 13.08.15 Faculty Research Projects Faculty 20.08.15 Library Resources Librarians 27.08.15 Introduction to clinical fMRI/DTI Michael Zeineh 03.09.15 Journal Club TBA 10.09.15 Hold 17.09.15

24.09.15 Prashant Raghavan (UVA) 01.10.15 TBA Lawrence Recht 08.10.15 TBA Ram Srinivasan 15.10.15 Hold 22.10.15 BRACCO Guest Speaker 29.10.15 fMRI and DTI cases Michael Zeineh 05.11.15 Resting State fMRI Michael Greicius 12.11.15 TBA Mrudula Penta 19.11.15 TBA Wilson Chwang 26.11.15 Journal Club TBA 03.12.15 RNSA 10.12.15 Fellow (2nd year) Osamu Kaneko 17.12.15 Fellowship Meeting 24.12.15 CHRISTMAS 31.12.15 NEW YEAR 07.01.16 Protocols IV All 14.01.16 QI in stroke imaging Aleks Kalnins 21.01.16 Fellow Project Update 28.01.16 Fellow Project Update 04.02.16 Fellow (2nd year) Brian Boldt 11.02.16 Hold 18.02.16 BRACCO Guest Speaker 25.02.16 Fellow (1st year) 03.03.16 10.03.16 17.03.16 Fellow (1st year) 24.03.16 Hold 31.03.16 Journal Club TBA 07.04.16 Fellow (1st year) 14.04.16

21.04.16 BRACCO Guest Speaker 28.04.16 Fellow (1st year) 05.05.16 ASNR Practice Talks 12.05.16 ISMRM - No conference 19.05.16 ASNR Practice Talks 26.05.16 ASNR - No conference 02.06.16 Fellow (1st year) 09.06.16 Fellowship Meeting 16.06.16 Fellow (1st year) Alexis Crawley 23.06.16 Hold 30.06.16 Fellow (1st year) Neil Thakur

Topic Speaker Any topic Gary Steinberg Stroke trials update? Maarten Lansberg Movement disorders Kathleen Poston "Radiosurgery in the CNS" or other Scott Soltys Brain tumor topic Lawrence Recht Resting State fMRI Michael Grecius Tinnitus Prashant Raghavan (UVA) MRI physics (2 talks) ? Bammer, Moseley, or Hargreaves

Topic Speaker MR Perfusion GZ CT Perfusion MW Facial anomalies KY TBA PB fMRI and DTI MZ Epilepsy MZ

Please note that this schedule includes a journal club by the fellows, recorded for AJNR, speed research presentations by the neuroradiology and RSL faculty, clinical and research presentations by the fellows, preparation sessions for the RSNA, ASNR and ISMRM, as well as a visiting neuroradiology professorship when outside guest speakers are invited to come and discuss topics selected by the fellows. The second-year fellows also get to teach a small number of lectures to our residents.

Late shift, Night Float and Call Week-end:

Week-Days

Late Fellow

The late fellow arrives at Sherman at 2pm and finishes when Sherman closes AND when the duties listed below are completed. a) The late fellow reads outpatients with the attending from 2pm until 4pm and dictates these studies. b) After 5pm and until 10pm, the late fellow checks the resident wet reads for ED/inpatient CTs and adds his/her agreement/disagreement in an addendum note indicating fellow status.* c) Also, the late fellow checks all MRI (ED, inpatients, outpatients) until 10pm. d) THE LATE FELLOW DICTATES POWERSCRIBE DRAFTS FOR THE ED CTs and MRIs but does not sign the reports and leaves them at status 60 (D) so they are not visible on PACS or EPIC. THESE POWERSCRIBE DRAFTS WILL BE FINALIZED THE NEXT DAY BY THE INPATIENT RR RESIDENTS/FELLOWS AND ATTENDINGS. e) The late fellow puts wet reads on the inpatient CTs and MRIs. If there is a critical result on an inpatient CT or MRI study, a Powerscribe draft should be dictated. Inpatient CT and MRIs without critical findings need wet reads only.

Night Float Fellow

The night float fellow is expected to help the late shift fellow as needed before 10pm and takes over from home from 10pm until 7:30 am. a) The night float fellow checks the resident wet reads for ED/inpatient CTs and adds his/her agreement/disagreement in an addendum note indicating fellow status from 10pm until 7:30 am.* b) Also, the night float fellow checks all MRI (ED, inpatients, outpatients) from 10pm until 8am. c) UNTIL 12 AM, THE NIGHT FLOAT FELLOW DICTATES POWERSCRIBE DRAFTS FOR THE ED CTs and MRIs, but does not sign the reports and leaves them at status 60 (D) so they are not visible on PACS or EPIC. THESE POWERSCRIBE DRAFTS WILL BE FINALIZED THE NEXT DAY BY THE INPATIENT RR RESIDENTS/FELLOWS AND ATTENDINGS. d) The late fellow puts wet reads on the inpatient CTs and MRIs. If there is a critical result on an inpatient CT or MRI study, a powerscribe draft should be dictated. Inpatient CT and MRIs without critical findings need wet reads only.

Weekends

Call Fellow

The call fellow covers the inpatient reading-room from 7:30am to 5pm both Saturday and Sunday. a) The call fellow is responsible to read with the call attending and dictate all ED and inpatient CTs and MRIs done on Friday night, Saturday and Sunday until noon. A number of these studies will have preliminary reports from the night float fellow (and late fellow from Friday evening). b) The call fellow is responsible to read with the call attending and dictate all the ED studies done until 5pm on Saturday. c) The call fellow is responsible to read with the call attending and dictate all LPCH studies done until midnight on Saturday. d) The call fellow is responsible to read with the call attending and dictate all outpatient studies done until midnight on Saturday. If time permits on Sunday (considering that there is only the call fellow during the day on Sunday), the fellow and attending should read Sunday’s outpatient exams until 10am. e) The call fellow is responsible to put wet reads for all LCPH studies done on Sunday until 5pm and check outpatient cases for emergencies until Sunday 5pm. f) The call fellow checks the resident wet reads on ED/inpatients CT studies, and puts in their own wet reads on ED/inpatient MR studies done on Sunday between 12pm and 5pm.* g) THE CALL FELLOW DICTATES POWERSCRIBE DRAFTS FOR THE ED CTs and MRIs AND FOR INPATIENT CTs AND MRIs WITH CRITICAL FINDINGS UNTIL 5pm. h) On Saturday, the nightfloat fellow will come in the morning to help the weekend call fellow with the tasks listed above until no longer than 12pm.

Night Float Fellow

The night float fellow takes over from home from 5pm until 7:30 am. a) The night float fellow checks the resident wet reads for ED/inpatients CTs and adds his/her agreement/disagreement in an addendum note indicating fellow status from 5pm until 7:30am.* b) Also, the night float fellow checks all MRI (ED, inpatients, outpatients) from 5pm until 7:30am. c) FROM 5PM UNTIL 12PM, THE NIGHT FLOAT FELLOW DICTATES POWERSCRIBE DRAFTS FOR THE ED AND critical result INPATIENTS CTs and MRIs, but does not sign the report and leaves them at status 60 (D) so they are not visible on PACS or EPIC. THESE POWERSCRIBE DRAFTS WILL BE FINALIZED THE NEXT DAY BY THE INPATIENT RR RESIDENTS/FELLOWS AND ATTENDINGS. d) THE NIGHT FLOAT FELLOW STARTS THEIR 7 NIGHT SHIFT ON SATURDAY. e) THE NIGHT FLOAT FELLOW HELPS THE CALL FELLOW IN THE INPATIENT READING- ROOM ON SATURDAY ONLY FROM 8AM TO 12 PM.

* We want the residents to evaluate all the ED and inpatient CTs in order to preserve their education. The late, call or night fellows should always let the residents perform the initial review of the ED and inpatient CTs. If, however, the resident falls behind (such as could happen when several trauma cases come in all at once), then the late, call or night fellow is expected to help and issue wet reads without waiting for the resident, so that there is no significant delay that could compromise patient care. The resident should make their best effort to alert the on-call neuroradiology fellow of such a situation, so that they are aware.

Logistics:

2 new laptops with large 17” monitors and dictating capability will be made available for the on call fellow and the late fellow.

Powerscribe Drafts:

Late and night float fellows create Powerscribe draft report using Radiology Manager because the attending is not definitely known during the week. The weekend attending probably is known, and reports can be assigned to that individual if the fellow is sure of this.

Day shift read-out; different fellow, resident, and attending will review Powerscribe draft report created by fellow

Fellow or resident logged into PS360 will use browse function to find Powerscribe drafts created the previous night. See screen shot below. If edits need to be done to the report, the person that opens the report (if different than the creator, or assigned attending) will assume ownership of the report. The original creator then automatically becomes a contributor.

Whomever takes ownership of the report the next day MUST assign a correct attending and remove Radiology Manager from the report. NOT DOING THIS WILL CAUSE THE REPORT TO FAIL TO GO OUT TO EPIC.

Supervision:

During the late shift and night coverage, our fellows get familiar and increase their expertise with studies obtained in the emergency setting.

There is never a time when a fellow is on call (late shift, night float, week-end call) without an attending as back-up, and it is mandatory that the attending is called when a significant question arises that the fellow is not comfortable answering. The fellow is the first back-up on beeper for the in-house on-call radiology resident and must be available 24 hours a day during the call week for all emergency consultations. Likewise, an attending is available 24 hours a day on beeper for back-up. The exact details of call responsibilities for the fellow when on the INR rotation for neurointerventional procedures should be worked out with Dr. Marks.

On weekend days, all neuroradiology cases (CT and MRI) are interpreted by neuroradiology.

Occasional additional responsibility during late shift, night float and week-end call include being on- site for contrast media administration during imaging procedures. The on call fellow may be asked to perform tasks such as introduction of intravenous lines, central line injection and access.

During the late shift, the fellow’s responsibilities are to be carried out at the Sherman outpatient imaging center when fellows are also responsible for of patients who undergo intravenous contrast administration.

Each fellow will perform this shift, as well as the night float and the week-end calls at a frequency commensurate with their Neuro Fellow peers.

Procedures Log

All fellows are required to log their procedures into the Med Hub database throughout their fellowship term.

Dictating Cases:

Cases should be dictated after read-out with the attending. All cases should be dictated with a succinct impression that specifically answers the clinical question. In addition, fellows should note and save cases with educational value for the Interesting Case Conference. After dictating cases, the fellow is expected to check and correct reports in as quickly as possible and release them to the attending’s queue.

Teaching Files (TF):

A system (Primordial) has been implemented to result in the accrual of a large number of images of all interesting cases for the neuroradiology fellows (and faculty) from our PACS clinical material. It is extremely important for the fellows to actively participate in this system, and the reward is a valuable resource for teaching conferences and lectures.

Vacation/Meeting Time

3 weeks (15 days) vacation/meeting time per year

Vacation/meeting time needs to be approved in advance by the Neuroradiology Fellowship Program Director or the Neuroradiology Section Chief – this approval can be expected if the “scheduling fellows” have signed off on the request. We request that half of your vacation time be used in the first half of the year in order to preserve options for the second half of the year.

Elective

The goal of electives is to obtain additional education and training in specialized aspects of neuroradiology or to conduct and perform in approved research projects.

All clinical electives and research projects are subjected to the approval of the Neuroradiology Fellowship Program Director and the Neuroradiology Section Chief. What the fellow will be doing during the elective needs to be described in detail before any approval can be even considered.

You must always keep in mind that clinical coverage comes first without exception and that you may be called from your elective to cover the clinical service as needed.

Sick Leave and Family/Medical Leave Policy The fellows are to follow the current “House Staff Policies and Procedures” as specified by the GME Office.

Suggested Reading Materials:

Fellows are expected to read significantly during all neuroradiology rotations. The following represents an incomplete list of suggested textbooks. and neurology textbooks are extremely valuable to learning neuroradiology. These texts are available in the Lane Medical Library, and in the Stanford Neuroradiology office suite.

The Amyrsis series

Neuroradiology: Key Differential Diagnoses and Clinical Questions Juan E. Small, Pamela Schaefer

Neuroradiology: The Requisites David M. Yousem

CT: Lee and Rao MRI: Atlas Williams and Haughton Naidich (for normal anatomy) Ball or Barkovich (for pediatric) Fischbein - Teaching Atlas

ENT: Som and Curtin Angio: Osborn – Diagnostic Cerebral Angiography Mancuso Morris – Practical Neuroangiography Valvassori Marks/Do – Endovascular and Percutaneous Ric Harnsberger - Handbook of the Brain and Spine of Head and Neck Imaging: Handbooks in Radiology Series, 2a

Neuro-: Miller (Hoyt’s) Neurology: Victor and Adams

Neuropathology: Davis : Kandel Greenfield Russell & Rubinstein

Web resources:

ASNR Neuro Curriculum http://www.asnr.org/asnr-neurocurriculum-live

Head Neck Brain Spine http://headneckbrainspine.com

Skull Base Anatomy – Wayne State University http://www.med.wayne.edu/diagRadiology/Anatomy_Modules/axialpages/Home_Page.html

E-Anatomy: Radiologic Atlas of the https://www.imaios.com/user/login Note: We already have access to this resource through the Stanford Lane Library Website

White Matter Atlas – DTI atlas for white matter tracts http://www.dtiatlas.org

PROCEDURES FOR NEURO ANGIOGRAPHY

The neuroradiology service evaluates inpatients and outpatients. These patients may be admitted to the Hospital on the day of or day preceding angiography. There may be slight differences in the way these patients are worked up prior to angiography; however most of the pre-angio evaluation for both in and out patients is the same.

PRE ANGIO

Scheduling Scheduling of angio procedures is to be done through the front desk in the angio area (3-7676) and patients are generally entered in the computer by the referring physicians. It is the responsibility of the fellow covering the angio service for the week to ensure that he/she knows which cases are scheduled for the following day. All cases are listed in a schedule typed up at the front desk for the next day, and by late afternoon they are on the scheduling board. Be sure to check not only the usual neuro room (Room 8) but all angio rooms as neuro cases may be scheduled in one of three radiology rooms. Also check the OR list) usually the last page of the printed schedule) for intra-op neuro angiograms. These will usually be the responsibility of the neurointerventional fellow. The fellow must check the schedule at the beginning of each week for routine cases as well as check each day in the late afternoon for add ons. If a case is scheduled on the weekend for Monday either a staff person or fellow will be contacted to do that scheduling. It is the responsibility of that person to ensure that the angio fellow that week is aware of a case that has been added, particularly for a Monday. When scheduling on the weekend, you should generally write the new case into the Monday scheduling board, but also you need to be sure to call the Monday angio fellow with this information.

Add-Ons and Emergency Cases during the Day Not infrequently patients will be added to the schedule during the day. In most cases the service attempts to accommodate these requests. There is however circumstances when the schedule is full and patients may need to be done by the person on call or the case is moved to the next day. All add-ons should be discussed with the attending assigned to angio coverage that day. If you are called in the evening and given a new case which can be done at night or as a first case the next day you must be sure that there is room in the daytime for this add-on. Do not promise the case will be done without knowing it can be done. This means you should either check with the angio fellow or neurointerventional fellow or stop by the front desk in advance of night call each day. You must know there is room for a first case before committing our service to doing it.

On-Call Emergencies Either the attending or fellow is usually contacted by the referring team usually from neurosurgery or neurology. If the fellow is contacted he or she should ok the case with the attending and then take responsibility for calling the angio tech and nurse in and seeing the patient immediately.

Patient Evaluation and History Inpatients should be seen on the day before angiography. There will be emergency inpatient studies which will necessitate evaluation on the same day. The angiography fellow on the service that day should make an attempt to see the patient prior to doing angiography if at all possible. Outpatients scheduled in advance may sometimes also be difficult to see until the day of the examination, but should be seen as soon as possible in the ATU. This means that the angio fellow is here in the hospital and on the ward by no later than 7:30 a.m. the morning of the angio.

You should be sure that you understand why the angio is being ordered. When patients are scheduled in advance you should obtain some form of written history if possible. There are three ways this can be done. A history can be obtained from LAST WORD. You can call the office of the referring and ask that letters or history be FAXED to our office or to cath-angio. Generally these referrals come from vascular neurosurgery (3-5575) or stroke neurology (3-4448). You can call the nurse coordinator or the physician that have seen the patient.

If the patient is an add-on/emergency you would usually call the referring physician or house officer responsible for the patient directly to obtain a patient history and understand what is needed angiographically. In addition it is important that you arrange to have available for angiography any prior radiographic studies that may assist us with the procedure. These include CT scans, MRIs, prior angiograms, and occasionally ultrasound reports. If the patient is scheduled in advance Stanford films will usually be brought to the cath angio area in front of Room 10. If the referring physician is Dr. Steinberg, additional films may be brought to cath-angio by the neurosurgery film person. If at all possible you should discuss the case with the staff person on angio coverage before the angiogram. This means before the patient is on the angio table.

Pre-angio Orders This set of orders may have to be tailored to the patient and depends upon whether the orders have been written prior to or after seeing the patient. If a patient is being seen in the ATU as an outpatient, it is important that orders be written the night before. These orders should be hand delivered or tubed to the ATU. This is necessary because these patients often will check in between 6 and 7 a.m the day of the procedure. If a patient is an inpatient you should see the patient prior to writing orders. These patients must be entered in the POE system.

You can use a copy of the "Neurointerventional radiology pre-procedure orders" appropriately modified for diagnostic angiograms.

Consent An order is included in the routine order sheet “Have patient sign consent for angiography by Dr. (staff person and associates)”. This does not replace discussing the risks, benefits, and alternatives directly with the patients and their families. All patients must be properly consented directly by you or the attending on angiography. Any questions regarding this should be completely reviewed with your attending. On the floors or in the ICU you personally must obtain the consent signature. In the ATU you may write an order to obtain the signature but you are still obligated to discuss the procedure and risks/benefits/alternatives with the patient. An attestation form must be filled out for all patients. This is known as the physician pre-procedure record. A copy is enclosed.

Labs 1) Hgb/Hct/platelets 2) BUN/creatinine/glucose 3) PT, PTT, INR These labs are routinely ordered for any patient undergoing angiography. Note that they represent a minimum lab screening and may be modified for different patients.

Pre-angio note. It is extremely important that the attestation form (physician pre-procedure record) be completely filled out and put on the chart in all patients. This note must be completed before any angio is started. It should be done prior to the patient going to the cath lab. This note will include all of the following: a) A brief history outlining the reasons for angiography. b) Significant past as it relates to the reason for the angiogram or the possible risks of angiography. c) Medications and . d) Pertinent findings on the physical exam and documentation of peripheral pulses. e) A statement that the procedure has been described to the patient and that the patient understands the risks and benefits of this procedure and wishes to proceed.

POST ANGIO All patients should have a "cath angio post-procedure or "neuro interventional post procedure" sheet filled out following angiography. Examples are enclosed with this handout. All inpatients and outpatients should be seen several hours after the angiogram or prior to discharge. A note should be left on the chart documenting the time and the patient’s condition to include any complaints the patient has, the presence or absence of a hematoma, and state of the patient’s pulses. This should be done for medical-legal purposes as well as for the care of the patient. In addition a post procedure note form should be filled out for each patient. A copy is included.

ALLERGIES AND CONTRAST Those patients at high risk for angiographic complications (renal compromise, diabetes, CHF, etc.) or where there is a relative contraindication to angiography such as bleeding diathesis should be discussed with the staff person more fully prior to doing angiography. Those patients with a well documented history of a major contrast reaction should also be discussed with the neuro staff person doing angiography on that patient. If a procedure is definitely necessary, generally a 12 or 24 hour prep with steroids and preangiographic use of Benadryl is recommended. I prefer to use 50 mg prednisone q8  hours starting 24 hours prior to angio and 50 mg Benadryl I.V. on call to angio.

INTERVENTIONAL PATIENTS (Usually the responsibility of the Neurointerventional Fellow) These cases should be discussed more fully with myself or Dr. Do prior to scheduling or planning angiographic procedures. Generally, these patients will require additional orders which will include: 1.) Foley. 2.) Decadron 4 mg IV or PO on call to angio (this should be given to patients undergoing AVM embolization).

WADA TEST PATIENTS There is to be NO premedication given in these cases. A copy of the patient’s workup and any pertinent films will be left in the neuro reading room before angiography. These cases require the combined effort of our section and the EEG lab. It is important that if at all possible these exams not be “bumped”, particularly for routine cases, as the EEG technologist, machine, and neurologist are all arranged to be present at a specific time.