REVIEW

CURRENT
OPINION Education in neuroanesthesia and neurocritical
care: trends, challenges and advancements
Angela Builes-Aguilar a, Jose L. Diaz-Gomez b,c,d, and Federico Bilotta e

Purpose of review
We summarize the latest evidence in neuroanesthesia and neurocritical care (NCC) training. In addition,
we describe the newer advancements that clinical educators face in these subspecialties. Lastly, we
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highlight educational approaches that may lead to an enhanced learning experience and development of
necessary skills for neurosciences trainees.
Recent findings
Current neuroanesthesia and NCC training requires acquisition of specific skills for increasing complex
surgical cases, specialized neurosurgical practice and new perioperative technologies. Furthermore, there
is increasing international interest for standardization and accreditation of neuroanesthesia fellowship
programs. Recent evidence has demonstrated that well structured training using high-fidelity simulation
improves cognitive and technical skills in acute neurological crises.
Summary
High-fidelity simulation in perioperative care of neurosurgical patients can be part of formal
neuroanesthesia and NCC curricula, and potentially impact trainees’ proficiency. A research agenda is
needed to validate the assessment of most effective educational interventions in neurosciences trainees with
diverse medical backgrounds. Creative combinations of cost-effective interventions including traditional
teaching, specific technical skills workshops, low and high-fidelity simulation deserve to be assessed in
future studies.
Keywords
education, neuroanesthesia, neurocritical care, simulation

INTRODUCTION according to the authors’ opinion on their contri-

Advancements in neurologic surgery are driving
new challenges for an adequate education in neuro-
anesthesia and neurocritical care (NCC). A substan-
tial growth of NCC units is evident with 60 training
programs and over 1200 diplomates in the USA [1].
Nowadays, NCC and neuroanesthesia clinical prac-
tices are facing inherent limitations to trainee edu-
cation in their fields. The following factors can
impact contemporary NCC and neuroanesthesia
education: unpredictable fluctuation in patient acu-
ity and census, administrative pressure for higher
economical productivity, nonuniform workforce
scheduling, diverse operating room coverage mod-
els, trainee duty-hours regulation and increasing
documentation burden [2,3].
We searched for articles published between
October 2016 and April 2018. The authors selected
those articles summarized in this review after assess-
ing their quality and impression. The readings were
classified as: excellent (&) and outstanding (&&)
bution in both fields.
The article will address the latest results on
accreditation on both neuroanesthesia and NCC.
Then we will present studies on simulation and
educational strategies in both settings.
a
Department of Anesthesia & Perioperative Medicine, Schulich School of
Medicine & Dentistry, Western University, London, Ontario, Canada,
b
Department of Critical Care Medicine, cDepartment of Anesthesiology,
d
Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA and
e
Department of Anesthesiology, Critical Care and Pain Medicine,
‘Sapienza’ University of Rome, Rome, Italy
Correspondence to Angela Builes-Aguilar, MD, MSc, MsEpi, Department
of Anesthesia & Perioperative Medicine, Schulich School of Medicine &
Dentistry, Western University, 275 Regent Street, London, ON, Canada
N6A2H3. Tel: +1 519 671 0313; e-mail: Angelitabuiles@gmail.com
Curr Opin Anesthesiol 2018, 31:520–525
DOI:10.1097/ACO.0000000000000628

www.co-anesthesiology.com Volume 31  Number 5  October 2018

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 Education in neuroanesthesia and neurocritical care Builes Aguilar et al.
KEY POINTS
 The evidence surveyed from the last 18 months reflects
increasing need to standardize neuroanesthesia
training. In response to this, accreditation of the
subspecialty is underway.
 The NCC fellowship accreditation system has been
under review and is currently being changed to reflect
more specific standards.
 There is evidence that having neurocritical training
improves patient outcomes and now we need to make
education, acquisition and maintenance of competence
match the standards.
 Four studies in neuroanesthesia and one in NCC
reported in the last 18 months reflect the increasing use
of simulation-based educational methods for training
residents and fellows. There is still a very long way to
go, but we are starting to incorporate educational
modalities to the traditional teaching to our
subspecialties.
 There is a call for all educators in neuroanesthesia and
NCC to incorporate high-fidelity simulation to their
curriculums. This is a wakeup call for those hesitating
on the implementation of simulation.
 We need to increase research in education and
simulation training within our fields.
REPORTS ON STANDARDIZATION AND
ACCREDITATION OF NEUROANESTHESIA
FELLOWSHIP PROGRAMS
Three international surveys were conducted in the
last 18 months. First, Sewell et al. [4] published the
Canadian survey. Although 10 of 17 anesthesia
departments responded [59% response rate (RR)],
50% of them had a neuroanesthesia fellowship.
Only one neuroanesthesia fellowship director sup-
ported formal subspecialty accreditation. The
authors indicated that the majority of neuroanes-
thesia fellows are international graduates and that
there is low interest in neuroanesthesia fellowship
program across Canada. The same year Valero et al.
[5] addressed in an editorial the current training,
implementation and standardization of neuroanes-
thesia fellowships in Europe. With a response of 45%
(14 representative), the accreditation was supported
by 79%. Of note, one program in Finland is currently
in the process of nationwide neuroanesthesia fel-
lowship accreditation. Later, Rajan et al. [6 ] pre-
&
sented the American survey during the 45th Annual
Society for Neuroscience in Anesthesiology and
Critical Care (SNACC) meeting. The main findings
include strong support for an accredited body to
accredit the neuroanesthesia fellowship (66% of
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attendings, 56% of fellows and 55% of residents).
Most of the 457 respondents felt that the SNACC
guidelines would be adequate for formal accredita-
tion. In addition, Farag et al. [7] published the
current demographic patterns for neurosurgical
anesthesia practice in the United States through
the Anesthesia Quality Institute report. They
describe the demographics of 486 588 neurosurgical
anesthesia cases in 210 centers within the United
States between 2010 and 2014. The most frequent
surgery performed is the single-level spine surgery,
representing 45% of all procedures. Furthermore,
neurointerventional procedures (2.4%) and epilepsy
surgery had the lowest percentage (0.06%). The data
highlight the least frequent procedures which
demand high expertise such as deep brain stimula-
tors insertion and epilepsy surgery. It is our opinion
that in the fellowship accreditation, the distribution
of procedures according to center and geography
could help programs and committees to adjust their
needs and could use these data for training rotation
or case exposure.
As the editor of 2017 October’s issue at the
Current Opinion in Anesthesiology journal, Bilotta
[3] suggested raising the neuroanesthesia practice
from sub to supraspecialty. His main arguments for
necessary accreditation, and standardization of
neuroanesthesia fellowship are ‘low volume and
demand for high skill’ training, the specific required
knowledge, unique competences and inadequate
procedure exposure across centers. Bajwa et al. [8]
support Dr Billota’s proposal as they describe most
necessary skill sets and knowledge that make neuro-
anesthesia unique. This evidence reflects the
increasing awareness to standardize training and
the upcoming accreditation of the subspecialty
and possible impact of residents’ interest in the
neuroanesthesia subspecialty if a paradigm change
occurs. These efforts started a couple of decades ago
[9] and the SNACC has already created curricular
guidelines to move forward [10]. Looking into the
future, we should engage in answering different
questions: what are the criteria to assess compe-
tence?; what is the quality of the education we are
providing?; how are we going to effectively deliver
it?; how are we going to train the educators on these
new educational methods?; or could we even impact
patient outcomes with other education modalities?
REPORTS ON STANDARDIZATION AND
ACCREDITATION OF NEUROCRITICAL
CARE FELLOWSHIP PROGRAMS
The three articles reflect imminent changes in
accreditation and certification of NCC programs
in the United States. They reflect the need for better
www.co-anesthesiology.com 521
Neuroanesthesia
refinement in the standards and criteria to assess the
level of proficiency across programs. On the other
side, editorials were published to support and
empower NCC specialty and abdicate for neuro-
teams working together to improve patients’ out-
comes. Napolitano et al. [1] published an update on
the number of US critical care fellowship training
programs. Data were obtained from the last 16 years
by the Accreditation Council for Graduate Medical
Education (ACGME) and the specialty boards. It
showed how the NCC education is rising and grow-
ing with 60 programs and over 1200 diplomates. It
describes the two entities that provide accreditation
and the pathways to certification in NCC: The
United Council for Neurologic Subspecialties and
Committee on Advanced Subspecialty Training
under the Council of the Society of Neurological
Surgeons. Parallel to the former, Dhar et al. [11]
presented a survey of NCC fellowship program
directors. They explored the current state and the
perception of the program accreditation, the gradu-
ate certification and the transition to the (ACGME)/
American Board of Medical Specialties (ABMS) path-
way. As a result, 33 of the 54 program directors
completed the survey; 68% of the respondents indi-
cated that ACGME accreditation would help for the
future growth of the subspecialty as a field and the
majority favored the ACGME–ABMS pathway.
There is a wide variation in institutional structures,
procedural requirements, competencies assessment
and level of independence for the fellows. Indeed,
there is room for improvement in the institutional
support and changes in administrative tasks. More-
over, Marcolini et al. [12] compared the NCC train-
ing in the United States with the other critical care
medicine (CCM) training programs. They showed
both NCC and CCM programs having similar core
requirements with variations on the length of train-
ing. In contrast, the NCC training includes proce-
dures and competencies focus on multimodal
monitoring, placement and management of exter-
nal ventricular drains and continuous electroen-
cephalography. The authors found the goals for
each procedure were unclear about the degree of
proficiency needed and how to demonstrate each
competency. Bithal [13] reminded some of the char-
acteristics of the neurointensivists. He presented
some of the evidence showing improvement in
patient’s outcomes when NCC teams are imple-
mented and trained personnel come together to
&
treat complex neurocrtically ill patient [14,15 ,16].
He listed some factors that may explain beneficial
results: specific knowledge, full attention to
critical neurological conditions, multidisciplinary
approach with neurology team and implementation
of advanced monitoring. Furthermore, Manno et al.
522 www.co-anesthesiology.com
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[17] responded in to the editor against the argument
that subspecialty units are unnecessary as proposed
by Vincent [18]. They present the evidence that has
shown that specialized units improve patient’s out-
comes by decreasing mortality, resource utilization
and getting better outcomes. In a very eloquent
article, the authors quest for a patient-centered care
model to transmit this expertise to those who bene-
fit the most, whereas very specialized teams and
experts get to individualize and treat very complex
patients.
ADVANCEMENTS IN NEUROANESTHESIA
AND NEUROCRITICAL CARE EDUCATION
Simulation-based studies in neuroanesthesia
The four simulation-based studies in neuroanesthe-
sia reported in the last 18 months reflect the increas-
ing use of this educational method to train residents
&
and fellows. Recently, Brockerville et al. [19 ] deter-
mined the degree of difficulty managing an emer-
gency airway on headframe in situ. Here authors
asked 30 anesthesia providers (residents, fellows
and faculty) to insert a laryngeal mask (LMA), intu-
bate with direct laryngoscopy and video laryngo-
scope into a mannequin both with and without
using the Leksell stereotactic headframe. When
the mannequin had a headframe, the intubation
success rate was 97 and 93% with video laryngo-
scope and direct laryngoscopy, respectively. This
study shows that under controlled conditions, inser-
tion of the LMA seems to be the fastest technique to
manage the airway independently of who is the
anesthesia provider is. Hence, simulation can be
incorporated into the acquisition of skills to manage
airway intraoperatively in difficult scenarios during
neurosurgical procedures.
&
In another intriguing study, Ciporen et al. [20 ]
created a simulation course with three scenarios in
which neurosurgical and anesthesia residents man-
aged cases of cavernous carotid artery injury. Several
technical and nontechnical skills were recorded,
and all were surveyed for satisfaction, realism, teach-
ing and development of crisis resources manage-
ment algorithms. A total of seven neurosurgical
and six anesthesia residents participated in the
study. Overall, both technical and nontechnical
skills improved. Specifically, interdisciplinary com-
munication showed the most improvement. How-
ever, scores for leadership were higher among
surgical residents, whereas gathering information
and considering options were higher in the anesthe-
&&
sia residents. In 2016, Rajan et al. [21 ] evaluated
screen-based case scenarios to determine if they
were more effective than problem-based learning
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 Education in neuroanesthesia and neurocritical care Builes Aguilar et al.
discussion in improving test scores 1 and 2 months
after training 22 residents during their first neuro-
anesthesia rotation. Each resident participated in
one learning activity during the 4-week rotation.
Then study cases were alternated for the next 4
weeks. The outcomes were short and long-term
score improvement and resident’s satisfaction.
There was no statistical difference in the median
score for short or long term, between the two meth-
ods. However, 88% of surveyed residents agreed that
simulated-based training should be incorporated in
&
the curriculum regularly. Niciu et al. [22 ] described
the creation of two high-fidelity interprofessional
simulations and the process they had to go through
to start this training in their department. Also, they
were able to teach how to practice the guidelines in
the neurosurgical theater and quantified and raised
awareness their team had on the neurosurgical car-
diac arrest guidelines published in 2014.
Simulation brings many advantages to educa-
tion: it is learner-centered, could help to imprint
certain behaviors of neuroanesthesiologist as leaders
with unique expertise, trainees can be exposed to
and manage rare events, helps to assess competence,
implement safe practices and address the evaluation
of learning curves of residents to provide anesthesia
for very specific neuroanesthesia procedures [23,24].
Simulation-based studies in neurocritical
care
There was one simulation-based study reported by
&&
Braksick et al. [25 ]. They evaluated changes in the
level of knowledge and confidence of critical care
fellows after going through a simulation course in
which they had to manage three neurologic emer-
gencies. A total of 16 fellows participated. The med-
ical knowledge score statistically increased with the
simulation course and went from 5.2 to 6.4 (out of
8). Learners reported a significant increase in the
level of confidence managing patients with the
same neurological conditions in comparison with
conditions they did not have simulation training.
The satisfaction and the perception of relevance of
the course was rated highly.
Albin and Malaiyandi [26] raised the question if
NCC is behind integrating simulation into the train-
ing curriculum. They presented a proposal of four
arguments for how high-fidelity simulation training
benefits NCC: The exposure to rare but important
diseases, direct observation and timely feedback,
learner evaluations consistently higher for simu-
lated curricula and the possibility that simulation
can be made via an online platform. They also listed
three limitations for the use of simulation in NCC
environment: challenge to accurately simulate
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Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
neurological findings, neurological emergencies
often comanifested with other diseases and insuffi-
cient data to demonstrate that high-fidelity simula-
tion in NCC improves clinical performance or
outcomes beyond traditional reaching methods.
CHALLENGES FOR NEUROANESTHESIA
AND NEUROCRITICAL CARE EDUCATION
Three studies address different educational strate-
gies: the first one is a survey on the residents’ per-
ception on the NCC rotation and the challenges
they face. The second describes the learning of
participants in the Emergency Neurological Life
Support (ENLS) course and ways to take it to the
next level, and the third one reports the creation
of an app for learners to improve the manage-
ment when transporting patients with neurological
emergencies.
The communication committee and resident
and fellow taskforce within the Neurocritical Care
Society (NCS) created a survey to assess the neurol-
ogy residents’ knowledge on the NCS and the expo-
sure to NCC during the residency [27]. The RR was
36.5%, and 85% of the respondents got exposure to
NCC rotations with a mean length of 9  4 weeks
mainly during the 2nd and 3rd year of residency.
When the investigators asked how the residents
could improve their NCC experience, the major
finding was that residents request improvement in
their education. They address some barriers to the
education in the NCC unit, including increasing
patient census and acuity, more timely decision-
making, resident duty hours and the demand from
the staff.
&
McCredie et al. [28 ] evaluated the impact of the
ENLS course on knowledge and skills to manage
neurological emergencies in a low-income country.
They surveyed 34 participants before, immediately
after and 6 months after the course. There was a
statistically significant increase in the acquisition of
knowledge (from a median score of 38–61% and
46%) before, immediately after and 6 months after
the course, showing the retention was maintained.
At 6 months, 77% reported that they have changed
their practice and clinical decisions. One of the
feedback findings was that adding a 2nd day for
hands-on training will improve the skills and
knowledge.
Lastly, Melvin and Kiernan [29] presented their
creation of a smartphone app for personal trans-
porting neurosurgical patients, so they do not forget
crucial steps. The NeuroT App; Dublin Ireland was
developed with their group of experts. It provides
information during emergency transfers. The report
describes a survey on 13 anesthesia trainees and
www.co-anesthesiology.com 523
Neuroanesthesia
their experience transporting patients and their rec-
ollection on the management of emergency neuro-
surgical patients.
Technology innovations are increasing in
healthcare and medical education. It will be inter-
esting for the future to evaluate the implementation
stage on the proper use of apps, patient outcomes
and trainee perceptions on learning with new edu-
cation modalities. We anticipate more educational
innovation like mobile applications, artificial intel-
ligence and simulation-based training will be devel-
oped and evidence on how best to introduce them
both to the trainees learning experience and imple-
mentation for patient care remains to be addressed.
CONCLUSION
Given the current paradigm change in medical edu-
cation, it is necessary to seek plausible strategies to
emphasize and enhance education despite well
described limitations. Nevertheless, there are mean-
ingful opportunities to advance the clinical practice
with the current surgical technique advancements
and widespread technological resources for peri-
operative patient care. Lastly, there is increasing
international interest for standardization and
accreditation of neuroanesthesia and NCC fellow-
ship programs. Thus, it is necessary to develop more
creative and long-lasting educational approaches
(i.e. low and high-fidelity simulation), whereas
the assessment of (ACGME) core competencies for
fellowship training programs can be enhanced.
Acknowledgements
We would like to thank Department of Anesthesia &
Perioperative Medicine, Schulich School of Medicine &
Dentistry, Western University, London, Ontario,
Canada for their support.
Financial support and sponsorship
None.
Conflicts of interest
There are no conflicts of interest.
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& of special interest
&& of outstanding interest
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