Neuroradiology Fellowship

Fellows rotate through the different rotations in weekly blocks. The day shift rotations are Monday through Friday from 7:00 AM to 3:00 PM, with one academic day per week.

The call rotation is from Friday to Thursday from 3:00 PM to 10:00 PM. The nine fellows share call responsibilities equally, with a frequency of approximately one weeknight in nine and every ninth weekend. As St. Joseph’s Hospital is home to a radiology residency program, a radiology resident is in house to review imaging studies performed after 10:00 PM. On-call responsibilities for fellows primarily involve performing emergent procedures and occasionally providing assistance to the on-call residents.

Vascular

This dedicated vascular imaging rotation provides exposure to state-of-the-art imaging for acute stroke and other vascular pathologies. Barrow Neurological Institute is one of the most experienced and expert stroke programs in the country, caring for more stroke patients and participating in more clinical stroke treatment and prevention research trials than any other center in the Southwestern United States. Uniquely at Barrow, we have a dedicated MR scanner in the emergency department, allowing us to use MR as our default imaging modality for acute stroke. Our exclusive, ultra-fast stroke MR protocol allows full imaging of the brain and vasculature from the aortic arch through the circle of Willis in 9 minutes. We perform over 3,500 dedicated stroke MRI examinations per year.

Every month, we utilize MR to image over 100 candidates for endovascular intervention using perfusion imaging and RAPID software analysis. Additionally, our cerebrovascular neurosurgery program has pioneered surgical and endovascular procedures for treatment of aneurysms, vascular malformations, and cerebro-occlusive diseases. This allows the fellow the opportunity to gain experience imaging microsurgical approaches, novel minimally invasive endovascular techniques, and unique intracranial arterial bypasses.

Magnetic Resonance Imaging

Our MR experience is unparalleled in terms of both volume and breadth of pathology. We perform over 29,500 neurological MRI examinations per year at Barrow, with an additional 8,000 neurological MR examinations performed at Phoenix Children’s Hospital. At Barrow, 75% of our MR imaging is brain and includes advanced imaging techniques such as quantitative perfusion imaging in brain tumors, black-blood vessel wall imaging, MR neurography, and diffusion tensor tractography.

Our case load is complex and high level, as neurosurgeons and neuro-oncologists are our top referents. Fellows are not expected to protocol routine MR examinations. Our workflow places the responsibility for protocoling routine studies on the MR technologists so that fellows may concentrate on image interpretation. Fellows are only called to assist in protocoling when an unusual issue arises.

Computed Tomography

Our CT rotation provides exposure to both large volume and complex cases. At Barrow, we perform over 30,000 neurological CT examinations per year, and half of these are complex inpatient CT examinations performed on neurosurgical inpatients. Additionally, Barrow is a level one trauma center, providing fellows exposure to CT in high-level traumatic injuries.

We are a leading center for minimally invasive spinal surgery and thoracolumbar corrective spine surgery, allowing fellows to gain experience in correctly interpreting spinal CT in the setting of the latest techniques in spinal fusion.

Our ENT experience is also centered around this rotation and involves interpretation of the neck CT and PET or CT examinations of patients with head and neck cancer from our dedicated oncology hospital, the University of Arizona Cancer Center. We also have an active head and neck endocrine service with a high volume of 4D CT examinations for hyperparathyroidism. Finally, our neuro-otology service is at the cutting edge of hearing restoration surgeries and results in experience with temporal bone CT examinations both in patients with hearing loss and in patients with cochlear implants for optimization.

Spine and Procedures

Fellows are trained in state-of-the art, image-guided diagnostic and therapeutic procedures. We perform a large variety of spine and nonspine interventional procedures. During this rotation, our fellows are supported by a team of dedicated IR technologists and nurses, who are specifically assigned to spine and neuroradiology procedures. Two dedicated neuroradiology procedure rooms with flat panel detectors and rotational cone beam CT capabilities are at the disposal of the procedural fellow, including a 3D biplane system.

Our procedure mix is very diverse, providing fellows with experience beyond traditional lumbar punctures, myelograms, and fluoroscopic pain procedures. We perform digital subtraction myelography and have a significant volume of CT guided procedures, including spine biopsies, transforaminal fibrin glue injections, as well as transfacial and skullbase biopsies. Catheter angiography is not a part of our diagnostic neuroradiology fellowship, but experience in endovascular procedures can be arranged by elective on an individual basis.

Pediatrics

Fellows gain their pediatric experience at our dedicated children’s hospital. The pediatric rotation involves six dedicated weeks at Phoenix Children’s Hospital, named one of the “Best Children’s Hospitals” eight years in a row by U.S. News and World Report, ranking in 10 out of 10 specialties. Phoenix Children’s Hospital is a 433-bed facility and the only level one pediatric trauma center in Arizona.

Children are transferred to Phoenix Children’s Hospital from across the southwest. This patient referral base provides our fellows with exposure to a large clinical volume with a diverse mix of common and uncommon pediatric neurological and neurosurgical diseases. Six dedicated pediatric neuroradiologists participate in daily one-on-one read outs at the PACS station and didactic lectures. Additionally, fellows participate in neuroradiology departmental and multidisciplinary conferences, case-based reviews, interesting case conference, and Journal Club.

Stroke Clinical Case Conference

Occurring every Monday, this conference focuses on interesting vascular cases of the preceding week. This is a case-based learning opportunity for fellows to not only see unique and complex cases, but to understand how imaging guides decision making in vascular patients. Each case is examined for the likely mechanism (where, what and why) and is used as a springboard to discuss one or several cerebrovascular topics.

CSF Leak Case Conference

Barrow has become a leading referral center for CSF leaks and is an official referral center for the CSF Leak Foundation. Occurring every other Monday, this conference reviews patients treated for CSF leaks from the previous week and uses a multidisciplinary approach to plan treatment for upcoming CSF leak patients. This conference is a rare opportunity for fellows to participate in both the diagnosis and treatment of patients.

Here, neuroradiologists act in both a diagnostic capacity reviewing imaging, and in a treatment capacity planning percutaneous interventions. This is a growing field in neuroradiology, and competency in the diagnosis and treatment of CSF leaks is becoming a very valuable and sought after expertise.

Skull Base Tumor Board

Complex skull base tumor cases from across the Phoenix area are discussed at this monthly meeting. Diagnostic dilemmas on rare lesions as well as treatment decisions are debated for a wide variety of pathologies. Lesions are seen arising intracranially, within the bone of the skull base itself, and extracranially.

Fellows are introduced to the full array of transcranial skull base approaches, including minimally invasive keyhole approaches such as transorbital and endoscopic-assisted retromastoid approaches, and endoscopic endonasal approaches. This conference provides a rare opportunity to see both complex skull base anatomy cutting-edge treatment of skull base disease.

Head and Neck Tumor Board

The Head and Neck Tumor Board meets monthly. This collaborative conference of ENT surgeons, oncologists, and radiation oncologists, discuss complex cases and referrals from across the Phoenix area. This tumor board provides exposure to a high volume of head and neck cases and includes patients undergoing cranial base surgery, major head and neck surgery, and those involved in chemoradiation protocols. Fellows are exposed to the role of conventional and PET/CT imaging in head and neck cancer and learn about different surgical approaches merged with modern radiation and medical oncology.

Pituitary Tumor Board

Barrow is the largest pituitary center in the Southwest. At our pituitary tumor board, dedicated skull base neurosurgeons, neuroendocrinologists, and neuroophthalmologists review difficult clinical and surgical cases.

Epilepsy Conference

Every Wednesday, patients from the Epilepsy Monitoring Unit are reviewed by a collaborative team of experienced epileptologists, neuropsychologists, and neuroradiologists. This multidisciplinary conference provides an opportunity for fellows to correlate imaging with EEG findings, semiology, and neuropsychological testing. It also provides exposure to advanced imaging in epilepsy, including FDG-PET, SPECT, and MEG.

Brain Tumor Board

With the establishment of the Ivy Brain Tumor Center, the Barrow has become one of the world leaders in clinical trials for brain tumors. We perform more than 3,300 MR examinations each year for brain tumors. This tumor board allows fellows to see the treatment and care of a brain tumor from their initial imaging to surgery. Additionally, fellows will see rare tumors referred to the Barrow, as well as learn about imaging features associated with novel therapies for glioblastoma that are part of tertiary care.

Lawton Imaging Rounds

Michael T. Lawton, MD, President and CEO of Barrow Neurological Institute, is referred complex cerebrovascular cases from all around the globe. At this case conference, neuroradiologists and fellows are given the unique opportunity to sit beside one of the world’s experts in cerebrovascular and skullbase surgery. Neuroradiologists assist Dr. Lawton in his recommendations on the most difficult neurovascular cases referred from tertiary referral centers seeking his expert opinion.

Images from cases referred to Dr. Lawton are reviewed by him directly with neuroradiology, as he prospectively assesses patients and considers broad state-of-the-art treatment options. These rounds are held three times a week and provide fellows the opportunity to discuss complex cerebrovascular cases with Dr. Lawton, including aneurysms, arteriovenous malformations (AVMs), arteriovenous fistulas (AVFs), carotid disease, moyamoya, and cavernous malformations.

Explore the resources that are available to trainees at Barrow Neurological Institute.

Equipment and Scanners

We have 13 MR scanners, including one 7T and four 3T systems. A highlight is our dedicated MR scanner in the emergency department. We perform approximately 40-60 MR studies per day from the emergency department. After installation of the ED MRI scanner, MR examinations ordered from the emergency department increased 40%. This provides fellows with exceptional exposure to ultra-fast imaging protocols. Experience with ultra-fast protocols, as well as the ultra-fast protocols themselves, are something unique that the fellows can bring to any future practice to improve diagnosis and increase throughput.

We also have eight CT scanners at Barrow, including one 256 slice scanner, three 64 slice scanners, and two interventional CT scanners, including CT fluoroscopy. We also have two portable scanners that are 32 and 8 slice scanners, respectively. Our ultra-fast scanners allow us to perform unique CT examinations, including dynamic CT myelography for CSF leaks.

Clinical Faculty

Barrow Neurological Institute has one of largest neuroscience faculties in the nation. In addition to dedicated neuroradiologists, there are 30 neurologists, 26 neurosurgeons (not including neurosurgeons at satellite hospitals and Phoenix Children’s Hospital), 16 neuro-anesthesiologists, two neuropathologists, and 15 neuropsychologists.

These experienced, highly skilled, and comprehensive neurological specialists not only attract complex referrals but also serve as an important clinical resource to the fellows. They not only provide fellows with clinical feedback on cases, they also teach the fellows how their interpretation of neuroradiology cases fits into the context of complete patient care.

Barrow Center for Imaging Innovation

The Barrow Center for Imaging Innovation encompasses 5,000 square feet of space dedicated to imaging research. The center was built to bring together clinical, academic, and industry expertise to produce robust clinical imaging technology and bring it to market. To that end, it houses faculty and researchers of the Division of Neuroimaging Research, Arizona State University graduate students, a scientist from Philips Healthcare, and works with collaborators across the Phoenix Valley as a multi-institutional team in pursuit of this common goal.

The staff of the Center operate a whole body 3-Tesla Philips Ingenia MRI scanner dedicated entirely to research. They work with neuroradiology faculty wishing to utilize this scanner for imaging protocol optimization or research. There is also sufficient funding at Barrow to provide a year of dedicated research time to fellows who would like to pursue research beyond their clinical year.