Neurocritical Care Fellowship

Stanford Stroke Center Neurocritical Care Fellowship

Since its inception in the year 2001, the Stanford neurocritical care program has provided unparalleled care for patients with critical neurologic illness. The neurocritical care team provides 24 hour clinical coverage of the neurocritical care unit, the emergency room, and the other inpatient units at Stanford, caring for patients with primary neurologic illness, neurological complications of systemic illness, and neurological emergencies. The diseases treated by a neurocritical care physician are broad, and include stroke, intracerebral hemorrhage, traumatic brain injury, brain injury after cardiac arrest, seizures, spinal cord injury, neuromuscular disorders, and many others.

In addition to the breadth and depth of the clinical activities, the Stanford neurocritical group has a long history of experience and success in performing clinical trials and basic science research. As one of the leading neurocritical care research groups in the country, there are numerous ongoing clinical trials in neurocritical care and robust basic science and translational research programs. Recognizing that the treatments of tomorrow are rooted in the research of today, all of the neurocritical care faculty members participate extensively in this research mission

The Stanford neurocritical care group is committed to rigorously training future generations of neurointensive care and vascular neurology physicians. The faculty work closely to focus on neurocritical care training for the neurocritical care fellows, vascular neurology fellows, surgical and medical critical care fellows, and Stanford neurology and neurosurgery residents and medical students as well. Graduates from our two year UCNS certified neurocritical care fellowship have gone on to work in a variety of practice settings and make significant contributions to the field.

Goals and Objectives of the Neurocritical Care Fellowship

Goals

  • Understand how to treat acute neurological emergencies and manage all patients in the intensive care unit who are neurologically critically ill or have a neurological complication
  • Learn the principles of general critical care medicine
  • Gain proficiency in procedural skills related to critical care medicine
  • Learn to prioritize and triage competing care needs
  • Develop expertise in the diagnosis, management, and prevention of vascular neurological disorders
  • Learn from the diverse neurological disorders seen in various patient populations
  • Gain an understanding of the process of clinical research and the critical evaluation of the literature
  • Acquire skills to teach neurology to medical students, interns, neurology residents, and physicians of other disciplines
  • Develop a sense of purpose with regard to ethical and humanistic aspects of care, with an emphasis on compassion and respect for patient-centered values

 

Objectives

Fellows learning objectives follow the ACGME core competencies of patient care, medical knowledge, practice-based learning and improvement, professionalism, interpersonal and communication skills, and system-based practice.

Rotations

The Stanford Neurocritical Care Fellowship program is a UCNS certified two-year education curriculum. While fellows care for neurologically critically ill patients throughout their two years of training, the first year of education is primarily focused on general critical care medicine principles and in the second year neurocritical care principles are emphasized. The majority of clinical rotations occur at Stanford University Hospital; however, fellows also spend time at Santa Clara County Medical Center. Fellows have in-house call during their first year that is shared with the critical care medicine fellows (anesthesia, pulmonary, EM, CCM). During the second year fellows share home call with the vascular neurology fellows, but are expected to come in to the hospital to assist the residents and for potential endovascular acute ischemic stroke cases. Duty hours are tracked in MedHub and strictly follow UCNS and ACGME policies.

Year 1*

Year 2*

5 Medical-surgical- neuroICU blocks
2 NeuroICU blocks
1 Surgical trauma block
1 Anesthesia block
1 Neurosurgery block
3 Elective/research blocks
6 NeuroICU blocks
2 Medical-surgical- neuroICU blocks
1 Vascular Neurology block
1 Neurosurgery block
3 Elective/research blocks

*(Total of thirteen 4-week block rotations)

Curriculum

Throughout the two-year fellowship, fellows receive education through daily bedside teaching rounds and weekly didactic lectures. Lecture topics by faculty reflect the below core curriculum. Examples include: ventilator management, sepsis, post-cardiac arrest care, intracerebral hemorrhage, EEG in the ICU, acute ischemic stroke endovascular trials, and transcranial doppler, among many others. During the fellows first year of training, fellows receive bedside transthoracic ECHO teaching and quarterly simulation teaching on communicating difficult news to families. Fellows are expected to present at conferences including journal club, difficult case conferences, morbidity & mortality (M&M) conferences, and ECHO conferences. Fellows also receive a copy of the UCNS core curriculum for self-study.

General Core Curriculum

Obtain understanding of the following:

  • Cerebrovascular anatomy
  • Physiology of cerebral blood flow, metabolism and intracranial pressure
  • Pathophysiology and treatment of increased intracranial pressure, altered cerebral blood flow states and coma
  • Neurological examination techniques, including examination techniques for a comatose patient
  • Neurosurgical and neurology imaging techniques
  • TCD monitoring and interpretation
  • EEG application in the ICU
  • EVD management and sampling
  • CSF diagnostics
  • Various neuro-monitoring techniques and their use in guiding hemodynamic therapy
  • Ventilator management for brain injured patients
  • Hemodynamic management for patients with brain or spinal cord injuries including fluid resuscitation and vasopressor therapy
  • Airway management with special focus on patients with reduced level of consciousness, cranial nerve impairment and patients with traumatic brain, facial and cervical spine injuries
  • Sedation regimens, scores, weaning and special considerations in neurocritical care patients
  • Special considerations of pain management in neurocritical care patients
  • Management of fluid, acid-base, and electrolyte disturbances
  • Management of nutrition including routes, indications and ability to create basic nutritional plan
  • Basic infection control risks, strategies to prevent and treat ventilator associated pneumonia, urinary tract infections, central venous line infections and surgical wound infections; demonstrate basic knowledge of antibiotic therapy, groups of antibiotics, neuro-specific considerations e.g. CSF-penetration
  • Specific considerations for patients with coexisting critical illness, e.g. ARDS, and intracranial pathologies
  • Endocrine consequences of pituitary tumors
  • Brain death
  • Ethical considerations for end-of-life decisions
  • Exhibit safe order writing and closed-loop communication

 

Apply the above knowledge for the diagnosis and treatment of patients with:

  • Coma, including post cardiac arrest
  • Delirium
  • Herniation syndromes
  • Acute hydrocephalus
  • Moderate and severe traumatic brain injury (Subdural and epidural hematomas, hemorrhagic contusions)
  • Ischemic and hemorrhagic strokes
    • Administration and management of intravenous thrombolysis or intra-arterial therapies with Neurointerventional team
    • Cardiogenic brain embolism
    • Large vessel cerebral atherosclerosis
    • Management of patients pre and post CEA or stenting
    • Aortic arch cerebral and spinal embolism and spinal infarctions
    • Small cerebral artery occlusive disease
    • Hemodynamic brain ischemia
    • Migraine
    • Hereditary and acquired hypercoagulable states, including antiphospholipid antibody syndromes
    • Disseminated intravascular coagulation, thrombotic thrombocytopenic purpura, other hematological disorders
    • Substance abuse and drug toxicities
    • Hypertensive encephalopathy/Posterior Reversible Leukoencephalopathy Syndrome
    • Cervical and intracranial artery dissection
    • Vasculopathies including genetic (i.e. Moya-moya), inflammatory (i.e vasculitis), and infectious
    • Cerebral venous thrombosis
    • Genetic and metabolic disorders
    • Aneurysmal subarachnoid hemorrhage and vasospasm
    • Vascular malformations (AVM, cavernous malformations, fistulas,etc)
    • Indications for surgical management of brain ischemia and hemorrhage
  • Encephalitis/meningitis/brain abscess
  • Acute neuromuscular illness
  • Peri-operative care after neurosurgical or interventional neuroradiology procedures
  • Concurrent critical medical or surgical illness
  • Complications of vascular disease, including raised intracranial pressure, sepsis and venous thrombosis
  • Management of extra-ventricular drains and multimodal monitoring
  • Seizures and status epilepticus
  • Neurological complications of pre and post organ transplant patients

 

Faculty

Stanford Neurocritical Care program currently has five faculty neurointensivists:

Karen Hirsch, MD, Stanford Neurocritical Care Program Director

Anna Finley Caulfield, MD, Neurocritical Care Fellowship Director

Marion Buckwalter, MD, PhD, Associate Professor

Chitra Venkatasubramanian, MBBS, MD, Clinical Associate Professor

Prashanth Krishnamohan, MBBS, MD, Clinical Assistant Professor

Fellows receive training and education in a multi-disciplinary method not only from neurointensivists, but also anesthesia and pulmonary intensivists, vascular neurologists, neurosurgeons, epilepsy neurologists, trauma-surgical intensivists, neurointerventionalists, and neuroradiologists.

How to Apply

We are participating in the San Francisco Match - www.sfmatch.org - process. All applications should be submitted through the SF Match approximately two years prior to the applicants anticipated residency graduation date. Applications start at the beginning of October. Interviews occur the following spring and the match occurs mid-June.  

Applicants must be graduates of an ACGME-accredited residency and eligible for medical licensure in the state of California. Stanford University is committed to increasing representation of women and members of minority groups and particularly encourages applications from such candidates.

General inquiries about the fellowship should be sent to our Fellowship Coordinator, Valerie Berland at vberland@stanford.edu.

Salary and Benefits

In summary, the salary amount will be reflective of your level of post-graduate training. More information on salary and benefits may be obtained from the Stanford Graduate Medical Education website.  

Anna Finley Caulfield, MD
Clinical Associate Professor, Neurology and Neurological Sciences