How do we maintain competence in aneurysm surgery

Abstract

The article by Le Reste et al. [7] addresses a very important topic in our current cerebrovascular practice. In order to deliver to our patients the best quality of care, a certain level of proficiency and competence needs to be attained and maintained. This is true for all areas of neurosurgery and constitutes a realistic objective in the treatment of most pathologies.The authors have looked at a particular subset of patients for whom surgery remains the recommended form of treatment. In fact, in high-grade SAH patients with intracerebral space-occupying hematomas, surgical decompression of the mass effect may be warranted, and along with it the clipping of the bleeding aneurysm. The authors suggest a correlation between cumulative surgical experience and lower intraoperative aneurysm rupture, although mortality and final outcome did not reach statistical significance. This can in fact be due to the sample size and the lower number of cases treated by surgeons with less cumulative experience. Five surgeons operated on these difficult patients on an emergency basis, one of them with minimal experience in the elective surgical treatment of aneurysms (surgeon 1 with only ten cumulative cases, nine of them within the study). There is no reference as to who was assisting these surgeons and what kind of experience these assistants had.Of course the surgical scenario in such challenging cases is far from being favorable. The brain is angry and edematous, intracranial pressure is flying high, not always with dilated ventricles enabling ventricular drainage, arachnoid spaces are collapsed with opercula overlying each other, which makes the dissection significantly more difficult than usual because the brain and veins become rather more friable. The surgeon has to constantly worry, control, and override all these difficulties, draining the hematoma, securing space and surgical conditions, which will enable him to control the circulation and deal with the ruptured aneurysm. In emergency cases like these, there is little time and room for the usual discussion regarding the size and shape of the sac and neck, the existence of calcified walls, and whether there are arteries taking off directly from the sac. In other words, all considerations that are pertinent in the context of an elective choice between a surgical or an endovascular treatment are cast away by the need to surgically decompress the hematoma, secure the aneurysm, and control ICP. As wisely pointed out by the authors, the surgeon needs to be prepared to circumvent all these difficulties, having as background the particularly adverse scenario of an urgent or emergent procedure in an unstable patient with poor medical condition. Both very important technical and also non-technical factors are at play. The technical gesture will only be perfect if the psychological condition of the surgeon and his resilience to act in severe adversity exists. The conjunction of the former and latter factors will only occur if the acting surgeon has acquired and maintained a level ...

Treatment and diagnosis of cerebral aneurysms in the post-International Subarachnoid Aneurysm Trial (ISAT) era: trends and outcomes

“…These types of aneurysms carry a higher morbidity related to their treatment and often require open surgical techniques 26. Furthermore, as indications for EVT have expanded, surgeons have become less proficient with clipping leading to worse perioperative morbidity 27 28…”