In the process of medical education, there are three essential principles of knowledge that trainees must learn: know, know how, and know to be [1]. These pillars allow the development of communication skills, professional attitude, medical judgment, clinical dexterity when performing a physical examination and medical history, and technical capacity when performing a diagnostic or therapeutic procedure, orientating them towards the resolution of the patient's condition [1,2]. The acquisition and refinement of these skills comprise the core of what medical education should represent [3]. The integration, specifically of knowing how medical training allows the learner to acquire both rational and practical abilities, including the development of clinical reasoning and the capacity to formulate an integrated action plan for the management of the patient, an archetype to clinical practice. This is essential to promote the quality of healthcare professionals and the improvement of their techniques [2].

Currently, many trainees point to learning gaps in their educational processes, particularly in the practical component [1]. In neurology, this problem is more common, translating into the fear of facing cases involving neurocritical medicine. This is attributable to both the diagnostic and therapeutic challenges that they imply and the level of knowledge that one must possess to treat them [4]. Similarly, fewer and fewer people have been interested in neurosurgical and neurointensive specialties. This is a growing concern and a problem for the health system since many patients attend to the emergency room with acute neurological pathologies but the supply of medically trained personnel is limited [4]. Therefore, education models that consolidate the necessary knowledge for both students and medical professionals should be implemented to increase their confidence, security, and competence when managing cases in neurocritical care.

A solution to this issue is the incorporation of simulation-based education, which has been very well received in the educational field since its inclusion in aviation for pilot training and in medicine in 1960 through the introduction of the Rescue Annie dummy to train people in cardiopulmonary resuscitation [4]. Simulation provides an ideal, effective, and safe learning environment for medical learners when acquiring clinical knowledge and skills [5]. Hence, the objective of this review is to provide evidence related to the utility of medical simulation in neurocritical care, especially in neurovascular care.

Simulation is a method used to recreate a situation without having to participate in a real event, and its main objective is to optimize the learning process and develop skills to improve professional performance [6-9]. This model is called experience-based learning because it offers a common practice scenario, followed by feedback and analysis of what has been learned and what could improve the results [10,11]. Although encounters with patients are an important component for learning in medicine, simulation grants previous exposure in different complex circumstances that may pose a risk to the patient, providing the trainee with a safe environment to develop their capability, acquire skills, and reflect on mistakes without putting their professional reliability at risk [6,12,13]. Furthermore, it can be used as a complement to experiences seen in patient care, providing educational opportunities that are not available in real events [6,14].

Learners are partially responsible for their education. To be able to access simulation-based learning, the apprentice must first acquire prior theoretical notions about basic sciences to confront clinical scenarios [15]. In addition, the habit obtained when treating the patient will accredit the trainee to act efficiently, professionally, and empathically, that is, to treat the patient satisfactorily [16,17]. The integration of the three aforementioned principles allows educating individuals who are capable of dealing with clinical problems with cleverness. When learners are competent, they are more confident with their abilities and proficient in correctly executing procedures because their knowledge has solid foundations [3,18].

Moreover, a responsible and well-trained instructor is in charge of participating in the improvement of the students’ capacities by evaluating their performance in an impartial manner, providing information, pointing out errors, and offering support and guidance during the debriefing. All of which focus on the abilities of the evaluated person. The instructor also leads the discussion where it is necessary to fulfill the learning objectives [19,20]. Ahmed et al. [21] conducted a cross-sectional observational study to evaluate the point of view of medical professors on the integration of simulation-based medical education and found that the majority of respondents recognized that simulation is an effective tool that can benefit teaching outcomes. Furthermore, its inclusion in the curriculum is indispensable and should not be conceived as an isolated activity. Roze et al. [22] proposed a simulation exercise in which trainees represented a patient suffering a neurological syndrome, and the attending physician supervised by a tutor. Student motivation, learning, topic understanding, communication skills, and learner confidence were found to be considerably improved [22,23].

As mentioned earlier, one of the main features of simulation is feedback. In fact, it is one of the most studied and has the most evidence related to effective learning based on this method of education [14,24,25]. van de ridder et al. [26] described feedback in clinical education as a "specific information about the comparison between the performance of an apprentice and a standard, given with the intention of refining the management of the apprentice.” Feedback ensures that the teaching objectives are met and provides a post-event reflection process [14]. In addition, debriefing is proposed as an exchange or discussion following the medical simulation, allowing learners to receive feedback, understand their actions, and better the results of their intervention. This helps incorporate new information into previous knowledge [19,27]. This method also enhances technical and behavioral skills [19]. Other characteristics of simulators that lead to proficient education include repetitive practice, range of levels of difficulty, diverse learning strategies, controlled environments, and individualized learning [25].

Over time, various types of simulations have been created and implemented to satisfy certain purposes, each having its own characteristics and level of complexity (Table 1) [28]. (1) Part task trainers: these consist of three-dimensional (3D) anatomical models whose objective is to represent a specific part of the human body and to educate as similar to reality as possible. With these structures, deliberate practice of regularly used procedures in the clinical setting for the acquisition of skills can be achieved [24,29]. (2) Full-body mannequins: 3D anatomical models with sizes and physiognomies very similar to a real human body. The complexity of these structures can vary depending on the age of the patient represented, ability to offer physiological responses, systemic reactions, and even present neurological signs, which can be controlled by electronic devices managed by an operator in real time or through responses programmed directly into the mannequin [29]. This type of simulator allows the development of teamwork skills, handling critical events, and offers a method for evaluation. Studies have shown that this type of simulation is helpful for learning in critical care [24]. (3) Standardized patients: this group consists of actors with previous training in the simulation of specific clinical situations. Their participation allows the trainee to obtain a real experience in their practical exercise. They are important in the training of medical learners for the acquisition of competencies, such as empathy and communication [24,29]. Professionals, amateurs, and sometimes "real" patients, called expert patients, perform this role [30]. (4) Computer-based simulation: it consists of virtual representations of specific medical situations whose objective is to develop skills in the trainee. Their level of complexity ranges from a basic computer program to virtual reality programs that permit interaction with patients [29]. This option offers the opportunity to recreate scenarios that cannot be carried out with other types of simulation, such as disaster scenarios or terrorist attacks [24]. (5) Hybrid simulators: the types of simulation previously mentioned can be combined and carried out simultaneously in a practical exercise, with the goal of enhancing the academic value of the activity and increasing the learning process for the apprentice [24,29].

Neurological diseases account for a large percentage of admissions to the emergency department. Consequently, the clinician who is going to perform the evaluation and management of the patient must do so optimally and quickly [31,32]. The care of patients with acute neurological disorders requires a set of techniques, skills, and aptitudes on the part of healthcare personnel because the severity of these disorders are at risk for high rates of mortality and morbidity, such as compromised motor function and disability [33].

Many physicians, residents, and students feel anxious when dealing with neurological patients, which may be related to the lack of knowledge and little contact with these specific groups of patients during their training [34]. These fears and insecurities can be observed when health personnel are unsure how to act when facing these types of situations, which has a negative impact on the health of the patient, given that the first hours in the management of neurocritical events are crucial. For this reason, proper neuroscience education is essential to avoid fatal outcomes [33-36].

Traditionally, teaching neurologic emergencies is often transmitted through lectures, assigned readings, self-study modules, or demonstration of important findings in patients with neurological diseases [10]. For instance, during their clinical practice rotations, medical learners know the basic principles of the neurological examination and its possible variations in patients with an acute event. However, this knowledge is acquired by consulting the books provided by the teacher, practicing with colleagues, and checking on patients with sequels of a previous episode. As such, they rarely confront the real situation, which can generate gaps and impede proper professional performance. In the same way, many learners report feeling incapable and uncomfortable in performing neurological examinations as a consequence of the lack of understanding of basic sciences, which decreases their efficiency and motivation. This also subsequently limits their clinical expertise in an environment where they might be in charge of providing the initial management in the future [35,37,38].

Several studies [2,3,5,6,9,13,39] have shown that "people give more significance to the knowledge they obtain from experience than to those they acquire passively.” Therefore, it is necessary to implement tools that mediate the acquisition of knowledge in an active manner; in this case, instructing the trainee in a pragmatic way during their learning process [39]. However, there are situations where there is little or no opportunity to practice, such as in neurocritical events, which are characterized by the rapid deterioration of patients and the need for rapid and effective intervention by a specialized team [39]. Evidence supporting this includes the Neurocritical Care Education During Residency: Opinions (​NEURON) study, which concluded that a significant number of neurology residents were concerned about training in neurocritical care, expressing that education within the neurocritical care unit is very restricted and should change to benefit the student’s experience [40]. For this reason, simulation is an essential tool to recreate these types of scenarios as similar to reality as possible.

Before being exposed to real situations, the inclusion of these simulated spaces in neurocritical care offers the opportunity to learn how to communicate effectively with a team during an emergency, make quick decisions, correctly identify patients with critical neurological conditions, and implement appropriate treatment algorithms that help develop the reliability of the staff and their expertise in patient management [8,10,41]. Similarly, by incorporating simulations, the learner can experience failure and recognize the limits of their capacities, which results in the reduction of errors and better care to the patient and their loved ones [6,42].

The most frequently reported cause of neurological emergencies, and consequently, the main reason for consultation faced by neurologists on call is acute cerebrovascular disease [32,43]. According to the World Health Organization, stroke is the second leading cause of death worldwide, accounting for approximately 11% of deaths in 2019 [44,45]. Additionally, it is the leading cause of acquired physical disability in adults, the leading cause of epilepsy in older people, and the second most common cause of late-onset dementia. Likewise, cerebrovascular accidents have been ranked as the first or second most common cause of death in South American countries, which was aggravated by the poor system of care in neuroemergencies [46].

Based on the previous information, the implementation of simulation programs in neurovascular critical care can increase the life expectancy of patients who arrive at hospital centers due to stroke and other neurological conditions as it will provide them with the opportunity of better care in the hands of trained personnel, who are not necessarily specialists, for these situations. In addition, it also promotes the process of learning and education (Table 2) [46-49].

In London, simulated education has been practiced for several years and has been useful in professional stroke training and in establishing the acute stroke unit model. It has also been utilized to train first response personnel to perform thrombolysis [8]. In stroke, there is an important correlation between the time of onset of symptoms to the time of recanalization of the affected blood vessel. Simulation is used in this case as an educational technique to ensure prompt attention and assessment. Tahtali et al. [50] proposed to train the subjects based on the data collected regarding the care provided to the patient, over conferences given to the health workers and suggested that a well-structured team generally consists of a neurologist, radiologist, resident, and nurse, who coordinate strategies to reduce the patient waiting time for treatment.

In addition, Ospel et al. [51] conducted an international multidisciplinary survey, with the intention of determining the point of view of neurointerventionalists about the errors regularly committed in the endovascular treatment of unruptured intracranial aneurysms. They found that the faults that most regularly caused complications were related to technical execution and suggested that these faults can be prevented by strengthening the abilities of medical personnel through training in simulation settings. As a result, it would be ideal for simulation to be widely available to physicians and to become a part of the equipment in intervention centers, similar to surgical specialties that use this learning modality permanently in their academic training program [51-53].

To meet the requirements for appropriate therapy in cases of neurovascular events, educational programs and hospital centers resort to strategies that guarantee a better level of qualification, surgical success, and efficient ways to pass on knowledge to their staff. In an attempt to promote education and training in neurocritical care, the Neurocritical Care Society developed an emergency neurological life support course, which teaches health professionals the correct management of patients during the first hours of a neurological urgency [54]. The course provides a series of guidelines and protocols for the care of patients with acute neurological conditions, including acute ischemic stroke and intracerebral and subarachnoid hemorrhage, which are some of the main cerebrovascular pathologies [54].

Other learning and simulation modalities that can be included in different medical schools as a strengthening method in the area of vascular neurocritical care are as follows.

There is very limited literature on the expenses incurred in the implementation of simulations in a medical setting [25]. However, the common point in most studies is the high cost, since mannequins, virtual reality simulators, and other types of simulators do not have very accessible prices. In addition, these equipment require adequate personnel for their management and maintenance, which greatly increases the costs of simulation in education [24]. Technological advances come in giant steps, and what today seems to be a great simulation equipment can quickly become obsolete. Therefore, it may not be viable to make this investment [84].

Simulation has shown good results in medical scenarios in which the patient's problem can be solved following protocols previously established in clinical practice guidelines, such as cardiopulmonary resuscitation, a common practice among health professionals [85]. However, in neurological emergencies, the most important thing is to be able to obtain a diagnosis before implementing previously established protocols. The issue is not as simple as one might think, and the solution to that problem depends on the encounter between the physician and the patient [86].

Actors are trained to represent classical patterns of a specific disease. However, in reality, patients may show nonspecific signs. Simulation may not sufficiently teach some skills since the scenario will never be the same as the real one, and no matter how hard one tries, there are certain characteristics that could never be simulated by an actor or a mannequin [86]. Hocker et al. [86] stated in their study that learners will hardly succeed in maximizing their knowledge and skills until they experience dealing with a real patient.

Therefore, although simulation is an important component of knowledge acquisition, it does not replace intimate patient contact because it is a component that ultimately determines problem-solving, decision-making, and communication skills. Hence, it is necessary to complement both simulation and practice in real situations to train competent professionals.

Medical simulation in academic training programs for health sciences has a great impact on the development of specific skills, potentially reducing medical-legal and economic complications and improving care and results in the management of clinical events. Simulation is an essential educational tool that imparts knowledge from an interactive perspective and offers a broader vision in relation to the practice of medicine. In neurocritical care, specifically neurovascular care, the visualization of these environments represents an opportunity to develop rapid and accurate decision making, allowing the maintenance of neuronal integrity and functional capacity of the patient, and ultimately reducing morbidity and mortality.