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  • Open Cerebrovascular Neurosurgery: Studying the Learning Curve in the Endovascular era

    Final Number:

    Kristine Ravina MD; Ben Allen Strickland MD; Robert Rennert MD; Vance Fredrickson; Joshua Bakhsheshian MD; Jonathan Russin MD; Steven L. Giannotta MD

    Study Design:

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2018 Annual Meeting

    Introduction: Endovascular techniques have resulted in diminishing case volumes for open cerebrovascular neurosurgeons. Straightforward cases are progressively substituted with technically demanding complex lesions, frequently failures and recurrences of endovascular treatment. The value of open cerebrovascular fellowship training in comprehensive, high volume centers has increased. Nevertheless, the impact of fellowship training on the learning curve steepness reflecting the ability to graduate proficient open cerebrovascular surgeons remains unclear.

    Methods: Cases of intracranial aneurysms treated by a neurosurgeon with a 30+ year experience (Surgeon 1) and an immediate fellowship graduate (Surgeon 2) were retrospectively reviewed. The last 100 consecutive aneurysms treated by Surgeon 1 and the first 100 aneurysm surgeries performed by Surgeon 2 were included. Patient demographics, rupture status, presenting subarachnoid hemorrhage grades, aneurysm location, temporary clip time, vasospasm status, modified Rankin Scale (mRS), and Glasgow outcome scale (GOS) scores at discharge and follow-up were analyzed and compared.

    Results: There were no significant differences in complication rate and outcomes at follow-up after adjustment for pre-operative rupture status, Hunt-Hess, Fisher and Glasgow Coma Scale scores. Result stratification based on rupture status, Hunt-Hess and Fisher scores, revealed a significantly larger decrease in mRS score from discharge to follow-up for patients with Fisher score 4 for Surgeon 2. There were no significant differences in the numbers of patients with outcome improvement at follow-up, vasospasm and complication rates between both surgeons. Although there was no significant change in mRS and GOS scores at discharge and follow-up over time for Surgeon 2, a steady downtrend in the number of complications over time was evident.

    Conclusions: Future graduating open cerebrovascular surgeons will likely face more complex cases than prior to the endovascular era. Current accredited fellowship training has the potential to meet the training demands. As with endovascular training, more rigorous accreditation standards will likely improve training results.

    Patient Care: Efficient training of open cerebrovascular neurosurgeons nowadays is a significant point of debate given the rate at which endovascular techniques are gaining popularity and indications. The presented study emphasizes the role of accredited open cerebrovascular fellowship training in comprehensive, large volume centers which has the potential to adequately prepare young cerebrovascular neurosurgeons. Our results show that the surgical results obtained by a young neurosurgeon after fellowship training are comparable to those of a neurosurgeon with an extensive experience indicating that proper open cerebrovascular training is possible even facing the challenges in the era of endovascular treatment.

    Learning Objectives: By the end of this session, participants should be able to: - To describe challenges open cerebrovascular surgeons are increasingly facing in the endovascular era - To understand the current state of open cerebrovascular neurosurgeon training - To understand the role of accredited open cerebrovascular fellowship training


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