Surgical Versus Endovascular Management of Ruptured and Unruptured Intracranial Aneurysms: Emergent Issues and Future Directions

Abecassis, Isaac Josh; Zeeshan, Qazi; Ghodke, Basavaraj; Levitt, Michael R.; Ellenbogen, Richard G.; Sekhar, Laligam N.

doi:10.1016/j.wneu.2019.12.127

Cited by 16 publications

(21 citation statements)

References 41 publications

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“…endoscopic surgery support the safety and efficacy of these modern alternatives. 1,2 Bypass surgery remains a useful tool for complex aneurysms requiring revascularization, but it is a rare procedure utilized in only approximately 0.4% of cases across the United States. 16 The current guidelines for resident education hours and competition among tertiary centers 3 contribute to the shrinking microsurgical operative training exposure for residents.…”

Section: Discussionmentioning

confidence: 99%

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A lArge number of overlapping factors currently contribute to creating a challenging environment for neurosurgical residents seeking to develop psychomotor skills in microsurgical technique, including increased treatment of neurological disease with minimally invasive modalities. [1][2][3] Yet, microsurgery remains an important tool for the neurosurgeon. Patients referred for open microsurgical treatment often have highly complex lesions not always amenable to endovascular or minimally invasive technologies, 4 while the in-hospital time required for residents to master the necessary skills is limited by appropriate Accreditation Council for Graduate Medical Education (ACGME) concerns about patient safety and resident well-being.Motivated by the further decrease in available training opportunities due to the unfortunate COVID-19 pandemic, 2 residents (I.J.A.

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confidence: 99%

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Developing microsurgical milestones for psychomotor skills in neurological surgery residents as an adjunct to operative training: the home microsurgery laboratory

Abecassis

Sen

Ellenbogen

et al. 2020

Journal of Neurosurgery

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OBJECTIVEA variety of factors contribute to an increasingly challenging environment for neurological surgery residents to develop psychomotor skills in microsurgical technique solely from operative training. While adjunct training modalities such as cadaver dissection and surgical simulation are embraced and practiced at our institution, there are no formal educational milestones defined to help residents develop, measure, and advance their microsurgical psychomotor skills in a stepwise fashion when outside the hospital environment. The objective of this report is to describe an efficient and convenient “home microsurgery lab” (HML) assembled and tested by the authors with the goal of supporting a personalized stepwise advancement of microsurgical psychomotor skills.METHODSThe authors reviewed the literature on previously published simulation practice models and designed adjunct learning modules utilizing the HML. Five milestones were developed for achieving proficiency with each graduated exercise, referencing the Accreditation Council for Graduate Medical Education (ACGME) guidelines. The HML setup was then piloted with 2 neurosurgical trainees.RESULTSThe total cost for assembling the HML was approximately $850. Techniques for which training was provided included microinstrument handling, tissue dissection, suturing, and microanastomoses. Five designated competency levels were developed, and training exercises were proposed for each competency level.CONCLUSIONSThe HML offers a unique, entirely home-based, affordable adjunct to the operative neurosurgical education mandated by the ACGME operative case logs, while respecting resident hospital-based education hours. The HML provides surgical simulation with specific milestones, which may improve confidence and the microsurgical psychomotor skills required to perform microsurgery, regardless of case type.

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Section: Discussionmentioning

confidence: 99%

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confidence: 99%

Developing microsurgical milestones for psychomotor skills in neurological surgery residents as an adjunct to operative training: the home microsurgery laboratory

Abecassis

Sen

Ellenbogen

et al. 2020

Journal of Neurosurgery

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“…Evidence shows that high-volume cerebrovascular centers of excellence with both microsurgery and endovascular surgery specialists produce superior patient outcomes. 1,[8][9][10] Medical bills are the leading cause of personal bankruptcy in the United States. 11 Healthcare costs contribute to approximately 18% of the gross domestic product ($3.6 trillion or $11 172/ person).…”

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confidence: 99%

“…13 Earlier cost comparisons between microsurgery and endovascular treatment report contradictory findings. 1,14-17 Furthermore, most earlier cost analyses were published before the latest endovascular therapy advancements. We used a propensity-adjusted analysis to compare the total healthcare cost of endovascular vs microsurgical treatment of aSAH at a single quaternary center.…”

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confidence: 99%

Cost Comparison of Microsurgery vs Endovascular Treatment for Ruptured Intracranial Aneurysms: A Propensity-Adjusted Analysis

et al. 2022

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BACKGROUND:In specialized neurosurgical centers, open microsurgery is routinely performed for aneurysmal subarachnoid hemorrhage (aSAH).OBJECTIVE:To compare the cost of endovascular vs microsurgical treatment for aSAH at a single quaternary center.METHODS:All patients undergoing aSAH treatment from July 1, 2014, to July 31, 2019, were retrospectively reviewed. Patients were grouped based on primary treatment (microsurgery vs endovascular treatment). The primary outcome was the difference in total cost (including hospital, discharge facility, and all follow-up) using a propensity-adjusted analysis.RESULTS:Of 384 patients treated for an aSAH, 234 (61%) were microsurgically treated and 150 (39%) were endovascularly treated. The mean cost of index hospitalization for these patients was marginally higher ($9504) for endovascularly treated patients ($103 980) than for microsurgically treated patients ($94 476) (P = .047). For the subset of patients with follow-up data available, the mean total cost was $45 040 higher for endovascularly treated patients ($159 406, n = 59) than that for microsurgically treated patients ($114 366, n = 105) (P < .001). After propensity scoring (adjusted for age, sex, comorbidities, Glasgow Coma Scale score, Hunt and Hess grade, Fisher grade, aneurysms, and type/size/location), linear regression analysis of patients with follow-up data available revealed that microsurgery was independently associated with healthcare costs that were $37 244 less than endovascular treatment costs (P < .001). An itemized cost analysis suggested that this discrepancy was due to differences in the rates of aneurysm retreatment and long-term surveillance.CONCLUSION:Microsurgical treatment for aSAH is associated with lower total healthcare costs than endovascular therapy. Aneurysm surveillance after endovascular treatments, retreatment, and device costs warrants attention in future studies.

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“…However, further study is needed to evaluate longer-term efficiency.ABBREVIATIONS: SL ¼ single-layer; WEB ¼ Woven EndoBridge S ince the publications of the results of the International Subarachnoid Aneurysm Trial (ISAT), in many centers, endovascular therapy has become the first-line treatment for intracranial aneurysms. 1,2 With an annual rupture rate of 0.36% per year, the…”

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Endovascular Treatment of Small and Very Small Intracranial Aneurysms with the Woven EndoBridge Device

Girot

Caroff

Cortese

et al. 2021

AJNR Am J Neuroradiol

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BACKGROUND AND PURPOSE:The Woven EndoBridge has proved to be a safe and effective treatment, especially for wide-neck intracranial aneurysms. The recent fifth-generation Woven EndoBridge came with smaller devices. The purpose of this study was to assess the safety and efficiency of Woven EndoBridge treatment of small and very small aneurysms. MATERIALS AND METHODS:Between September 2017 and March 2020, all consecutive patients treated with a 3-or 3.5 mmwidth Woven EndoBridge device were included in this retrospective intention-to-treat study. Clinical and radiologic findings were evaluated at immediate and last-available follow-up. Angiographic outcome was assessed by an external expert reader.RESULTS: One hundred twenty-eight aneurysms were treated with a fifth-generation Woven EndoBridge device including 29 with a width of #3.5 mm. Ten aneurysms were ruptured (34%). In 3 cases (10%), Woven EndoBridge treatment could not be performed because the aneurysm was still too small for the smallest available Woven EndoBridge device and another endovascular strategy was chosen. The median follow-up time was 11.2 months. Complete and adequate occlusion was obtained in 71% and 90% of the treated aneurysms, respectively. Retreatment was needed in 2 cases (10%). Symptomatic ischemic complications leading to transient neurologic deficits occurred in 2 cases (7%) (1 procedure-related and 1 device-related) but with full spontaneous recovery at discharge. CONCLUSIONS:The fifth-generation Woven EndoBridge device seems to be a safe and technically feasible treatment for both ruptured and unruptured small and very small intracranial aneurysms, with satisfactory occlusion rates on midterm follow-up. However, further study is needed to evaluate longer-term efficiency.ABBREVIATIONS: SL ¼ single-layer; WEB ¼ Woven EndoBridge S ince the publications of the results of the International Subarachnoid Aneurysm Trial (ISAT), in many centers, endovascular therapy has become the first-line treatment for intracranial aneurysms. 1,2 With an annual rupture rate of 0.36% per year, the

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Surgical Versus Endovascular Management of Ruptured and Unruptured Intracranial Aneurysms: Emergent Issues and Future Directions

Cited by 16 publications

References 41 publications

Developing microsurgical milestones for psychomotor skills in neurological surgery residents as an adjunct to operative training: the home microsurgery laboratory

Developing microsurgical milestones for psychomotor skills in neurological surgery residents as an adjunct to operative training: the home microsurgery laboratory

Cost Comparison of Microsurgery vs Endovascular Treatment for Ruptured Intracranial Aneurysms: A Propensity-Adjusted Analysis

Endovascular Treatment of Small and Very Small Intracranial Aneurysms with the Woven EndoBridge Device

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