How Hybrid/Dual Training Influences Cerebral Aneurysm Management

Abstract

continue to evolve rapidly. The neurosurgeon’s armamentarium has grown tremendously with a vast array of microsurgical and endovascular techniques. Advancements in knowledge and technology have helped to reduce the high morbidity and mortality historically associated with this disease. To take full advantage of our modern technology, technical skill, and clinical knowledge, the training of neurosurgeons who treat aneurysms has also become more complex. In our opinion, the modern-day neurosurgeon best equipped to treat cerebrovascular disease is going to be one who has obtained hybrid or dual training in both endovascular and microsurgical techniques. Neurosurgeons comfortable with both open microsurgical and endovascular techniques can use these skills interchangeably and safely to treat a broad spectrum of disease and hopefully reduce complications by not leaning too far toward to one particular treatment strategy. Historically, the term “aneurysm” has been attributed to Galen in ad 2, who combined the 2 Greek words, ana (across) and eurys (broad). It was Buimi of Milan in 1765 who gave the fi rst documented clinical account and autopsy report of the disease. After clinical medicine became more sophisticated, Hutchinson in 1875 accurately diagnosed an aneurysm in a live patient followed by Quincke in 1891, who demonstrated blood in cerebrospinal fl uid after subarachnoid hemorrhage. As neurosurgical techniques improved, the ligation of ruptured aneurysms became feasible but remained technically challenging with very high morbidity and mortality rates. The fi eld continued to advance as Harvey Cushing fi rst described a metal clip for aneurysms not amenable to suture ligation in 1921, and Walter Dandy operated on a 43-year-old woman with a right third nerve palsy and an unruptured aneurysm in 1937. As clip ligation techniques were refi ned, the fi eld of angiography began to blossom with Moniz, who performed the fi rst angiogram in 1927 and then later, in 1933, reported angiographic localization of a ruptured aneurysm. By 1954, angiograms began to be described as routine procedures for diagnosis and localization of aneurysms. A decade later interventional techniques were already being used to treat aneurysms, such as balloon occlusion of aneurysms in 1964 by Luessenhop and Velasquez, and in 1965 J. F. Alksne reported using a magnetic fi eld to guide iron microspheres into aneurysms. The precursor to today’s coil