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Neurovascular and Stroke

Authors

Anita Bhamidipati, MD
Emergency Medicine, Chief Resident 
Department of Emergency Medicine 
Cooper University Hospital

Sumaya Mekkaoui, MD
Emergency Medicine Resident
Department of Emergency Medicine
Cooper University Hospital

Special thanks to our 1st edition writing team

Anita Bhamidipati, MD
Sumaya Mekkaoui, MD
Tara Cassidy-Smith, MD, FAAEM

INTRODUCTION

Editor's Note
As of July 2018, the American Board of Medical Specialties has approved subspecialty certification in Neurocritical Care (NCC). Co-sponsored by the American Board of Emergency Medicine, NCC has become the 10th subspecialty available to ABEM-certified physicians.

Description of the specialty
Neurovascular fellowships have long been a pathway that board certified physicians in neurology complete in pursuit of continuing their careers in acute stroke care. More recently, emergency medicine physicians have undertaken this non-ACGME accredited fellowship in hopes of becoming experts in this niche area.

History of the specialty/fellowship pathway
While this is a fairly new area of fellowship and there are only a few programs accepting emergency medicine (EM) trained physicians, it is an expanding field since EM physicians are the first to evaluate these patients and activate neurovascular emergency protocols. In fact, as EM trained physicians have historically not pursued this type of fellowship, they are often coveted for these programs. Several new career paths and opportunities for the EM physician have arisen secondary to this fellowship in both the academic and community setting. While programs do not offer ACGME accreditation at this point, in the future we may see board certifiable positions being offered. 

Why residents choose to follow this career path
Residents choose to follow this career to increase their familiarity and expertise with acute neurovascular emergencies. In addition, those interested in directing stroke care and developing protocols for neurovascular emergencies at either an academic or community institution find this fellowship attractive. Those looking to advance the pre-hospital evaluation of neurovascular emergencies are also drawn to this path. Finally, residents looking to function as both clinicians and researchers undertake this fellowship with specific predilection for clinical or basic science research in acute stroke care. 

How do I know if this path is right for me?
If you have a specific interest in the care of neurovascular emergencies but are not sure if you want to pursue any fellowship, it may be best to plan rotations on a stroke service with your respective neurology colleagues. Alternatively, pursuing basic science or clinical research may help you gain a greater perspective. Generally, good candidates for this path include residents with a strong interest in being a leader in directing stroke/neurovascular care at either primary or comprehensive stroke centers or those pursuing an academic career with a focus on stroke/neurovascular emergency research and care.

Career options after fellowship
Career options vary depending on the particular program, as there is some variety between what each fellowship offers. Regardless, the idea is that after completion of this fellowship, you will be an expert in neurovascular emergencies forming a unique niche within whichever practice environment you choose to pursue. If any doubt exists on where to take your career after completion of the fellowship, the best idea is to find someone who has taken a similar path and ask for his or her guidance. There are not many EM trained clinicians who have gone down this route, so seeking out faculty mentors is crucial.

After completion of this fellowship, though you will not be board certified in the specialty, you will possess a unique skill set- whether that be an immense research background in acute neurovascular emergencies or that you are the leading expert in acute stroke care at your hospital. At primary or comprehensive stroke centers, you may be the most qualified to head committees or serve as directors of acute stroke care. Some examples are:

Primarily research/clinician

  • Clinical research focusing on acute stroke care, biomarkers of ischemia/TIA, novel antithrombotic agents
  • Basic science research focusing on intra-cerebral hemorrhage in rodents or other neurovascular emergencies

Primarily clinician/administrative

  • Teaching positions/clinical educators in medical school or residency programs regarding neurovascular emergencies
  • Directors of stroke at academic or community settings, either at primary or comprehensive stroke centers
  • Serve as members of stroke/neurovascular emergency committees, implementing new protocols in pre-hospital and early hospital care/ administrative work

Splitting time between departments
Splitting time between the ED and Stroke, Neurology, and Neuro-ICU services is very possible, if not encouraged. In fact, several programs fund the fellowship through shift work in the ED. As an EM- trained fellow, this is a great way to not only fund your fellowship, but also to stay involved in the acute initial management of neurovascular emergencies from the moment the patient hits the door. In addition, for those applicants interested in staying in the clinical spectrum after fellowship, it allows you to keep your emergency medicine knowledge fresh.

Academic vs. community positions
Most positions after fellowship are at academic institutions, though some graduates go on to become stroke/neurovascular directors at local community hospitals that are either comprehensive or primary stroke centers. The path you choose is entirely dependent on what you desire after graduation. It is important to keep this in mind throughout your training and when choosing a program that is right for you. You want to maximize exposure and tailor your CV to what best suits your interests.  It is important to know that some programs have more of a predilection for academics or research.

IN-DEPTH FELLOWSHIP INFORMATION

Number of programs
There are fewer than 10 well-cited fellowship programs, but as these are non-ACGME accredited, some institutions may be open to having a research fellow in neurovascular emergencies if funding can be attained.

Differences between programs
While there are slight differences between any fellowship program, most offer similar curriculums, combining both research and clinical duties. Some programs are more research based than others, devoting more time to basic or clinical research. Rotations are similar amongst the programs. As mentioned previously, these programs are not used to having EM trained candidates, so do not be surprised if you are the first - you offer a unique perspective on these disease processes and their immediate treatment and management protocols. 

Length of time required to complete fellowship 
Most programs vary between 1-2 years in length. This distinction is often made based on either the interests of the candidate or the specific program itself. Candidates strongly interested in research generally take an additional year to complete this. Fellows looking to be primarily clinical can complete programs in 1 year.

Skills acquired during fellowship 
Depending on the program, you will gain experience with either clinical or basic neurovascular research, largely depending on your interest and the program you choose. Additionally, you will spend time on the Stroke Service, in the Neuro Intensive Care Unit and with Neuroradiology, honing your clinical skills as a diagnostician as well as your ability to interpret various forms of imaging in neurovascular emergencies. Some programs additionally offer the ability to serve on stroke committees and implement or augment existing policies.

Typical rotations/curriculum
This is dependent on the fellowship program. Fellowships usually offer the following: Stroke Service (inpatient and outpatient), Neuroradiology, PM&R, Neuro-ICU, Research. 

Board certification afterwards? 
Fellowships are not ACGME accredited for EM physicians and thus do not grant board certification afterwards. However, as highlighted above, this does not mean that they do not afford a wide variety of career opportunities after completion. 

Average salary during fellowship 
Salary will be that of a PGY-4, 5, 6, and comparable to other residents/fellows in your geographic area.

PREPARING TO APPLY

How competitive is the fellowship application process?
Most programs take a maximum of 1-2 fellows per year, and these spots are shared with neurology and vascular residents. These spots are limited; however, historically there are few EM candidates interested in these positions, and programs are typically looking for more EM trained candidates. The best way to be competitive is to have strong academics and supportive letters of recommendation. As these are non-ACGME accredited for EM residents, the rate-limiting step may be funding. In this case, grants, moonlighting or other shift work may fund the curriculum and an additional fellow spot. 

Requirements to apply
The only strict requirement is that applicants complete an accredited residency in EM.

Research requirements
Though some require it, generally there are no strict research requirements; however, most departments are involved in research and may even be participating in national trials. Thus, it is likely that you will have exposure to or be involved in some form of research throughout your rotations. Most programs encourage additional research if you have an interest in specific ongoing trials. 

Suggested elective rotations to take during residency
If possible, the following rotations may be beneficial to the interested applicant, but are not required: Stroke Call, Neurology Elective Month (both inpatient or outpatient), and/or Neuroradiology. 

Should I complete an away rotation?
There are no specific requirements for applicants to complete away rotations. However, if you are interested or want to get a better feel of a program and how neurovascular emergencies are run at that particular hospital, an away rotation may help. 

What can I do to stand out from the crowd?
There are few EM trained candidates applying for these fellowship positions, so you already stand out from the crowd! Other things to consider are, of course, completing research specifically in neurovascular emergencies or serving on stroke committees. In the end, you already are an exception to the rule, and the best thing you can do is get strong recommendation letters and build your CV to showcase a distinct interest in this area. 

How many recommendations should I get? Who should write these recommendations?
Get 2-3 recommendation letters from core EM or Neurology faculty and/or faculty from your away rotations and elective months. Core faculty includes core EM faculty or those responsible for neurology away rotations. The most important thing is that these faculty know you well. 

What if I decide to work as an attending before applying? Can I still be competitive when I apply for fellowship?
Yes, definitely! Most applicants are encouraged/required to continue clinical work in the ED at least several shifts per month at the institution. They are encouraged to work at outside hospitals during fellowship as well. Any additional experience is generally a good thing. 

What if I’m a DO applicant?
DO applicants are accepted to some, but not all, neurovascular fellowships. In some institutions they are not eligible to do shift work in the ED and may be limited to the research aspect of the fellowship.

Requirements are generally the same; these applicants need to complete an EM residency to qualify for fellowship. Research and away rotations may be more beneficial to this type of applicant. 

What if I am an international applicant?
Some international candidates may be accepted but may not be allowed to perform clinical shift work in the ED of that institution. 

APPLICATION PROCESS

How many applications should I submit?
In terms of number of programs applied to, interviews to go on or typical questions asked, there is no great consensus. As stated previously, neurovascular fellowships are largely non-accredited, and historically EM candidates have not pursued these positions. There are only a few programs throughout the country, so applicants would probably do best by applying to all of them.

Generally speaking, applicants contact the appropriate program director expressing interest in the fellowship along with a CV and 2 letters of recommendation. If the applicant is deemed eligible, an interview would follow and then positions are offered. There is no strict application process for most of these programs as they operate outside of the match process. 

How do I pick the right program for me?
It seems that positions are largely filled based on how well the applicant and program fit together and the similarity in academic interests. The best way to pick the “right” program is to pick one that will serve as a foundation for the type of career you want (research, academics, clinical education or as stroke directors at community hospitals). It is important to take into account the collaboration between neurology, neurosurgery, and radiology, but in the end a program should be chosen based on what best suits your desires. 

Application deadlines
This fellowship operates outside of the match. Contact program directors with your CV and letters of recommendation by January before the start of the fellowship. 

Tips for writing your personal statement
Personal statements are not officially required: only a CV and letters of recommendation are required. An “interest letter” or email to the respective program director should go along with the above but is not necessarily a personal statement. As this fellowship is based on fit between you and the program it is less formal than fellowships that operate within ERAS or the match.

Is this a match process?
No. 

What happens if I don’t obtain a fellowship position?
Unfunded positions may be available at specific institutions that can be funded through outside clinical work/moonlighting. Research opportunities may still be available in neurovascular/stroke at the desired program for 1 year, with re-application the following cycle. 

INTERVIEW PROCESS

How do I stand out from the crowd?
Be yourself! This is your time to let your personality shine and show that you would be a great fit in their program. Make sure you know your application well and research the program prior to your interview. Try and practice a mock interview prior to the real interview so that you can make sure you present your best self. Finally, make sure you are able to clearly vocalize why you are interested in this fellowship and your tentative career goals post-fellowship. 

What types of questions are typically asked?
There is no real consensus on the types of questions typically asked on these interviews. Program directors will have genuine conversations with you regarding your interests in neurovascular emergencies and inquire as to why you have chosen this particular type of fellowship, what are you looking to gain from this program, and what particular skills do you hope to leave with? They most likely will want to know what direction you want to take your career whether that be strictly research, clinical education, stroke director, etc. 

How many interviews should I go on?
It is recommended that you attend as many as are offered, as there are not that many eligible programs in the country. 

PREPARING FOR FELLOWSHIP

Textbooks to consider reading
There are no real tips on textbooks to read prior to fellowship. It is useful to keep up on the latest in neurovascular care, however, via journal articles, etc. 

Important skills to practice while in residency to prepare for fellowship
The competitive applicant should try to broaden his or her knowledge of neurovascular emergencies, making sure to include both acute and chronic management of these disease processes. Unlike general emergency medicine residency, during fellowship you will likely be focused on the inpatient or clinic care of these patients, and it is important to keep that in mind during residency if you desire this type of fellowship. Patient care will not end with diagnosis and acute stabilization. Most EM trained residents are fairly skilled in basic neuroradiology, but any additional training, exposure or expertise would be a great skill to acquire, especially since some of your colleagues will be neurology trained with expertise in advanced imaging.

Tips on how to succeed as a fellow
Fellowship is a unique time to expand your skill set under the guidance of mentors. Take advantage of any opportunity to further your education during fellowship not just as an EM physician, but also an expert in acute neurovascular care. Also make sure to stay balanced, making time do things that you enjoy outside of work and to spend time with your family and friends to help prevent burnout. 

CONCLUSION

Additional resources
Because EM trained applicants generally have not followed this path, there are few additional resources. National organizations affiliated with neurovascular study are geared toward neurology and vascular surgery residents and would probably not prove very useful. The best resource you have is other clinicians who have taken a similar path and word of mouth. This is a very small network where connections go a long way so all the better to start forming them now. 

Journals:

  • Journal of Stroke and Cerebrovascular Diseases Stroke

Podcasts:

National organizations

  • No consensus opinion exists on recommended national organizations.

Conferences
No consensus opinion exists on conferences to consider attending. Consider attending the lectures at ACEP that are on neurovascular and stroke topics as these are not only educational but can be potential networking opportunities as well.

How to find a mentor
The best way to find a mentor is to try to find someone within your institution that has gone down the path that you intend on pursuing. This may prove difficult in the sense that there are few EM-trained physicians who have completed neurovascular fellowships. However, if there are faculty that are clinical educators in neurovascular emergencies, serve on stroke committees, or have strong connections with the stroke protocol teams, it may be useful to have their opinions or guidance. Remember, this opportunity wouldn’t exist if there weren’t EM physicians around the country that have also pursued this path. So find them, and reach out to them! Most emergency medicine physicians are passionate about their fields and happy to help future generations; this is no exception to that tenet.