Aneurysm treatment practice patterns for newly appointed dual-trained cerebrovascular/endovascular neurosurgeons: Comparison of open surgical to neuroendovascular procedures in the first 2 years of academic practice

Integrating endovascular techniques into established open neurosurgery practice: a temporal analysis of treatment evolution in a dual-trained neurosurgical unit

OBJETIVE

In Europe, units with Dual-trained Neurovascular Surgeons (DTNS) skilled in both open neurosurgery (ON) and endovascular neurosurgery (EN) are scarce. For instance, in Spain, our unit is unique within the public health system, where all neurovascular procedures are carried out by DTNS. Our study aims to evaluate the evolution in treating ruptured intracranial aneurysms (rICAs) and assess the impact of this evolution on clinical outcomes.

METHODS

A retrospective cohort study was performed on rICAs treated in our unit from October 2012 to June 2023. We reviewed clinical and radiological data to analyze the evolution of ON and EN over time, as well as their impact on patient outcomes. Univariate, multivariate, and mixed-effects models were utilized to discern temporal changes.

RESULTS

The modified Fisher Scale (mFS) and the modified World Federation of Neurological Surgeons scale (mWFNS) showed strong correlation with the outcome at 6 months outcomes, both with p < 0.00001. However, the surgical intervention method, ON versus EN, did not significantly affect outcomes (p > 0.85). In adjusted multivariate logistic regression, mFS (-1.579, p: 0.011) and mWFNS (-0.872, p < 0.001) maintained their significance. rICAs location was significant when comparing ON to EN p = 0.0001. A significant temporal trend favored the selection of EN p = 0.0058). Mixed-effects time series modeling indicated that while patient characteristics and rICA specifics did not predict treatment choice, the year of treatment was significantly correlated (0.161, p = 0.002). Logistic regression with interaction terms for time and treatment type did not produce significant results.

CONCLUSION

Our findings suggest that despite an increased adoption of EN techniques, there has been no change in patient outcomes. Even with the rise of EN, our unit continues to perform ON for a higher proportion of rICAs than most national hospitals. We propose that a "dual approach" offers advantages in a patient individualized treatment decision protocol in the European context.

Training Cerebrovascular and Neuroendovascular Surgery Residents: A Systematic Literature Review and Recommendations

Background: The rapid evolution of neuroendovascular intervention has resulted in the inclusion of endovascular techniques as a core competency in neurosurgical residency training. Methods: We conducted a literature review of studies involving the training of neurosurgical residents in cerebrovascular and endovascular neurosurgery. We reviewed the evolution of cerebrovascular neurosurgery and the effects of these changes on residency, and we propose interventions to supplement contemporary training. Results: A total of 48 studies were included for full review. Studies evaluated trainee education and competency (29.2%, 14/48), neuroendovascular training models (20.8%, 10/48), and open cerebrovascular training models (52.1%, 25/48), with some overlap. We used a qualitative analysis of reviewed reports to generate a series of suggested training supplements to optimize cerebrovascular education. Conclusion: Cerebrovascular neurosurgery is at a crossroads where trainees must develop disparate skill sets with inverse trends in volume. Continued longitudinal exposure to both endovascular and open cerebrovascular surgical fields should be mandated in general resident education, and blended learning tactics using adjunct simulation systems and models should be incorporated with didactics to both optimize learning and alleviate restraints placed by decreased volume and autonomy.

Endovascular embolization versus surgical clipping in a single surgeon series of basilar artery aneurysms: a complementary approach in the endovascular era

Background

Currently, most basilar artery aneurysms (BAAs) are treated endovascularly. Surgery remains an appropriate therapy for a subset of all intracranial aneurysms. Whether open microsurgery would be required or utilized, and to what extent, for BAAs treated by a surgeon who performs both endovascular and open procedures has not been reported.

Methods

Retrospective analysis of prospectively maintained, single-surgeon series of BAAs treated with endovascular or open surgery from the first 5 years of practice.

Results

Forty-two procedures were performed in 34 patients to treat BAAs—including aneurysms arising from basilar artery apex, trunk, and perforators. Unruptured BAAs accounted for 35/42 cases (83.3%), and the mean aneurysm diameter was 8.4 ± 5.4 mm. Endovascular coiling—including stent-assisted coiling—accounted for 26/42 (61.9%) treatments and led to complete obliteration in 76.9% of cases. Four patients in the endovascular cohort required re-treatment. Surgical clip reconstruction accounted for 16/42 (38.1%) treatments and led to complete obliteration in 88.5% of cases. Good neurologic outcome (mRS ≤ 2) was achieved in 88.5% and 75.0% of patients in endovascular and open surgical cohorts, respectively (p = 0.40). Univariate logistic regression analysis demonstrated that advanced age (OR 1.11[95% CI 1.01–1.23]) or peri-procedural adverse event (OR 85.0 [95% CI 6.5–118.9]), but not treatment modality (OR 0.39[95% CI 0.08–2.04]), was the predictor of poor neurologic outcome.

Conclusions

Complementary implementation of both endovascular and open surgery facilitates individualized treatment planning of BAAs. By leveraging strengths of both techniques, equivalent clinical outcomes and technical proficiency may be achieved with both modalities.

Intraoperative 3-Dimensional Rotational Angiography in Cerebrovascular Surgery: A Case Series

OBJECTIVE

Intraoperative imaging is critical in cerebrovascular surgery to assess the technical success of the operation. This case series aimed to evaluate the safety and efficacy of 3-dimensional rotational angiogram (3D-RA) in addition to 2-dimensional intraoperative angiography (2D-IOA) during cerebrovascular surgery in the hybrid operating room.

METHODS

All consecutive patients who underwent open cerebrovascular surgery and intraoperative 2D-IOA with 3D-RA in a hybrid operating room at 2 academic centers between August 2018 and December 2019 were identified from a prospectively maintained institutional database. Medical charts and operative videos including intraoperative angiography were reviewed, and clinical and angiographic outcomes assessed.

RESULTS

A total of 40 cerebrovascular surgeries in 39 patients (mean age, 53 ± 13 years; 51% female) were carried out with the addition of 3D-RA to 2D-IOA in the hybrid operating room. After 3D-RA in addition to 2D-IOA, 1 (2.5%) surgical alteration occurred in an aneurysm clipping. Other procedures were not altered with the addition of 3D-RA to 2D-IOA. There were no complications from the addition of 3D-RA to 2D-IOA.

CONCLUSIONS

Using a combination of 3D-RA and 2D-IOA in the hybrid operating room may enhance the likelihood of achieving an optimal result when employing microsurgical cerebrovascular surgery and avoid unanticipated incomplete outcomes, complications, and returns to the operating room. Whereas the addition of 3D-RA elucidated residual aneurysm not otherwise visualized on the 2D-IOA, in other cerebrovascular procedures studied, there was no additional value of the 3D-RA over the 2D-IOA.

Procedural complexity independent of P2Y12 reaction unit (PRU) values is associated with acute in situ thrombosis in Pipeline flow diversion of cerebral aneurysms

Background

Acute in situ thrombosis is an ischaemic phenomenon during Pipeline embolisation device (PED) procedures with potentially high morbidity and mortality. There is controversy regarding the role of platelet function testing with P2Y12 assay as a predictor of intraprocedural thromboembolic events. There is limited knowledge on whether procedural complexity influences these events.

Methods

Data were collected retrospectively on 742 consecutive PED cases at a single institution. Patients with intraprocedural acute thrombosis were compared with patients without these events.

Results

A cohort of 37 PED cases with acute in situ thrombosis (mean age 53.8 years, mean aneurysm size 8.4 mm) was matched with a cohort of 705 PED cases without intraprocedural thromboembolic events (mean age 56.4 years, mean aneurysm size 6.9 mm). All patients with in situ thrombosis received intra-arterial and/or intravenous abciximab. The two groups were evenly matched in patient demographics, previous treatment/subarachnoid hemorrhage (SAH) and aneurysm location. There was no statistical difference in postprocedural P2Y12 reaction unit (PRU) values between the two groups, with a mean of 156 in the in situ thrombosis group vs 148 in the control group (p=0.5894). Presence of cervical carotid tortuosity, high cavernous internal carotid artery grade, need for multiple PED and vasospasm were not significantly different between the two groups. The in situ thrombosis group had statistically significant longer fluoroscopy time (60.4 vs 38.4 min, p<0.0001), higher radiation exposure (3476 vs 2160 mGy, p<0.0001), higher rates of adjunctive coiling (24.3% vs 8.37%, p=0.0010) and higher utilisation of balloon angioplasty (37.8% vs 12.2%, p<0.0001). Clinically, the in situ thrombosis cohort had higher incidence of major and minor stroke, intracerebral haemorrhage and length of stay.

Conclusions

Predictors of procedural complexity (higher radiation exposure, longer fluoroscopy time, adjunctive coiling and need for balloon angioplasty) are associated with acute thrombotic events during PED placement, independent of PRU values.