Keywords
Europe - neurosonology - survey - education - standards
Introduction
Neurosonology is an outstanding diagnostic instrument in the hands of clinical
neurologists with unique selling points such as specific imaging technology, high
spatial resolution, online observation, non-invasiveness as well as broad and easy
availability in the clinical routine all over Europe.
Beside traditional vascular neurology, currently new fields of application such as
muscle and nerve imaging, brain parenchyma imaging, orbital ultrasound, and online
monitoring techniques in intensive care are booming.
We decided to conduct a survey to collect data on the current state of neurosonology
in Europe and beyond, as there is a definite need for a well-structured clinical
network to promote further technical progress, to offer an in-depth education and
training program, to test the usefulness of ultrasound in new fields, to implement
it in clinical trials, and to foster the application of sonography in daily
practice.
Methodology
A short 8-question survey ([Fig. 1]) covering
education, training, practice requirements, fields of application, and laboratory
organization was developed by the authors and distributed via e-mail to 46
countries. Each country representative is a respected expert and active promotor of
neurosonology in her/his country. The survey was launched on February 1 and the end
date was March 31, 2023. Descriptive statistics were used to report the data.
Fig. 1 Neurosonology questionnaire: set of questions asked of each
survey participant.
Results
Between February 1 and March 31, 2023, 42 out of 46 (91.3%) countries responded to
our questionnaire ([Fig. 2]). The completion rate
was 100% (8/8 questions answered) among respondents.
Fig. 2 Countries surveyed and percentage of respondents.
Question 1: Is neurosonology part of the medical program in your country?
In the majority of the countries surveyed (69.1%), neurosonology is not part of the
medical program. A few countries (11.9%) have it as an elective course, while
neurosonology is compulsory in less than one fifth (19%) ([Fig. 3]).
Fig. 3 Answers to questions 1-3 of the survey.
Question 2: Is neurosonology part of the neurology residency program?
In most countries (71.4%), neurosonology is part of the neurology residency training
program and is mandatory in almost half (47.6%) of the countries ([Fig. 3]).
Question 3: Do you have a national neurosonology society?
In 50% of the countries, neurosonology is organized in a society, either on its own
(19%) or as part of a larger society, such as the National Neurological Society
(31%) ([Fig. 3]).
Question 4: Who certifies neurosonologists?
In the majority of the countries surveyed (52.4%), there is no national
certification. In 42.8% of the countries, certification in neurosonology is offered
by a larger society, such as the National Neurological Society. Certification is
under the direct supervision of a national neurosonology society only in a few
countries (4.8%) ([Fig. 4]).
Fig. 4 Answers to questions 4-5 of the survey.
Question 5: What are the certification requirements?
In 23.8% of the surveyed countries, there are no requirements to practice
neurosonology. Candidates are assessed by a board examination (theoretical and
practical assessment) in 50% of the countries, while they just need to document
their practice in 26.2% ([Fig. 4]).
Question 6: Who accredits neurosonology centers?
Neurosonology centers are formally accredited only in a few countries (21.4%): in
2.4% by a national neurosonology society and in 19% by another regulatory body such
as the National Neurological Society or the Chamber of Physicians ([Fig. 5]).
Fig. 5 Answers to questions 6-7 of the survey.
Question 7: What are the accreditation requirements?
Just a few countries (26.2%) require certified personnel and appropriate equipment.
Adequate teaching and research activities are only rarely (11.9%) also necessary
elements for laboratory accreditation ([Fig.
5]).
[Fig. 6] displays the answers to survey questions 1
to 7 for each participating country.
Fig. 6 Answers to survey questions 1 to 7 for each participating
country. Light blue response: no/no/no/nobody/none/nobody/none. Yellow
response: optional/optional/yes, but part of a larger society/larger
society/certified practice only/other society/certified neurosonologist and
appropriate equipment. Red response: compulsory/compulsory/yes and
independent/neurosonology society/certified practice and formal
exam/neurosonology society/certified neurosonologists, appropriate
equipment, teaching activities and research activities.
Question 8: How is your neurosonology laboratory organized?
Half of the neurosonology laboratories surveyed are run only by neurologists, some
(29%) have technologists, and few (21%) also have trained nurses. With regards to
fields of application, vascular ultrasound is performed in all laboratories,
followed by critical care ultrasound (67%), brain parenchyma imaging (39%), and
neuromuscular ultrasound (36%). About 45% of the experts surveyed also assess
pediatric patients. Laboratories are mostly equipped with both duplex and
transcranial Doppler (TCD) systems (92%). Many (76%) have more than one duplex and
TCD machine with headframe for monitoring in stroke units/ICUs/operating rooms. Few
laboratories (8%) have only a duplex system. The majority of neurosonologists
operate in stroke units, followed by general neurology, neurosurgery wards, and
neuro-ICU.
Discussion
The results of this survey on neurosonology depict a very heterogeneous reality
across 42 mainly European countries.
To our knowledge, this is the first international survey on neurosonology education.
An earlier initiative by the European Federation of Neurological Societies reported
in 2001 evaluated the teaching of neuroimaging in neurology [1].
According to our survey, formal education in neurosonology during the MD program is
rare. Conversely, neurosonology is very often part of the neurology residency
program although it is mandatory in less than half of the surveyed countries. The
current situation might be due to a lack of qualified teachers in neurosonology, or
a lack of interest in the subject. Instead, neurologists should be motivated to deal
more intensively with neurosonology, for example in the acute phase of stroke, and
obtain an image themselves, in order to monitor in real time what's happening with
their patients so that they can immediately act accordingly [2].
It is internationally recognized that the use of ultrasound by neurologists should be
encouraged in the fields of neurovascular, neuro-intensive, neuromuscular, and
point-of care ultrasound [2]
[3]
[4]
[5]
[6]. Guidelines
for competency and quality assurance in the different fields of neurosonology have
already been reported and can readily be implemented [3]
[4]
[7]
[8]. Meanwhile, to increase the
motivation of postgraduates to proactively deal with ultrasound, several programs
aim to include hands-on ultrasound courses in the rotations of medical students
[9]
[10]
[11]. These efforts might enhance the education in
neurosonology as long as the various structural deficits highlighted by the present
survey are overcome.
The lack of a specific neurosonology society in most countries complicates
post-university training and continued medical education (CME) which are crucial for
growth within a specialty.
Even more important is the lack of national certification as only half of the
countries surveyed have a formal assessment with a theoretical and practical
examination. This means that an unacceptably low percentage of neurosonologists are
certified. There should be a supra-national pan-European or international
accreditation council for CME in neurosonology to ensure that neurosonologists have
access to quality learning opportunities and solid means to obtain and meet
licensing and credentialing requirements.
In most countries there is no accreditation of neurosonology laboratories. Indeed,
only a few countries require certified personnel, appropriate equipment, and
research activities as necessary elements for laboratory accreditation. There should
be an international accreditation council to ensure that neurosonologists and
neurosonology laboratories meet rigorous, high standards.
The last question of the survey, the only open-ended question, dealt with laboratory
organization and was specifically addressed to the national representative. All
laboratories are run by neurologists, but surprisingly a neurovascular technologist
and/or a trained nurse is part of the lab personnel only in a minority of cases.
This means that in most labs the exams are performed directly by the neurologist who
is also responsible for the final report. This results in the issue of internal
quality control in the case of a one-man show infrastructure.
With regards to ultrasound systems, most labs are fully equipped with adequate
instrumentation, i. e., duplex and TCD systems with a headframe for monitoring
patients in stroke units/ICU/operating rooms.
Concerning fields of application, all laboratories perform neurovascular ultrasound,
which is expected since the majority of neurosonologists operate in stroke units.
The second most frequent field of application is neurocritical care ultrasound, as a
good percentage of neurosonologists work in neurosurgery wards and the neuro-ICU.
Just over one third of laboratories also perform brain parenchyma imaging – mainly
for movement disorders – and neuromuscular ultrasound. Surprisingly less than half
of the survey respondents assess pediatric patients, even though there are several
indications for performing ultrasound in children, especially in sickle cell disease
(SCD). This is a major drawback considering the pivotal role of TCD in stroke
prevention and the increasing number of SCD patients in Europe, due to a rise in
global human population movement and reduced child mortality thanks to advances in
diagnosis and treatment [12].
This survey has some limitations that need to be addressed: 1. The national
representatives were asked to provide information regarding the current state of
neurosonology in their country, considering the average laboratory. Of course, we
are aware that some labs are excellent in terms of practice standards and qualified
personnel in spite of national requirements, but the objective was to get a global
picture. 2. Although this survey does not require the input of new data by the
respondents, which makes it very attractive, it is based on the personal judgment of
experts and a change of the respondents can yield different results. However, the
respondents were selected because they are also aware of the current
neurosonological situation in their country. 3. Although in some countries there is
no neurosonology society, there is a strong ultrasound society which includes
neurosonologists and offers excellent training. However, these are exceptions. 4.
Single neurosonologists might have received education and training in excellent
institutions abroad and might be known worldwide. Yet, an island on its own, even if
it is beautiful, always remains an island. We are much more interested in
connectivity and networking between laboratories. 5. Finally, considering that a
national representative is proud to represent her/his country, the responses to the
survey must be viewed as an optimistic representation of the current situation.
Therefore, any negative response cannot be underestimated. Rather, action must be
taken to improve the current situation by promoting in different countries courses,
training, and international certification in the main fields of neurosonology for
teachers and for experts.
Conclusion
The results of this survey indicate that there is a substantial need for
transnational harmonization of neurosonology standards to guarantee uniformity and
quality of performance. This survey will also provide guidance to promote an
international accrediting council and create a quality-controlled laboratory network
for implementing neurosonology in clinical trials.
Bibliographical Record
Claudio Baracchini, Elsa Azevedo, Uwe Walter, João Sargento-Freitas, Branko Malojcic. Neurosonology Survey in Europe and Beyond. Ultrasound Int Open 2024; 10: a22439625.
DOI: 10.1055/a-2243-9625
