gms | German Medical Science

Objective: The management of ruptured and unruptured aneurysms has always been one of the core competencies in Neurosurgery. Intracranial surgery for aneurysms requires high skill and level of experience. This study evaluates the incidence and outcome of clipping and coiling procedures in a single institution and the impact on training in open neurovascular surgery. How high is the probability of clipping an aneurysm as a resident with respect to patient safety and outcome?

Methods: We identified all patients with ruptured and unruptured intracranial aneurysms between 2008 and 2016. Angiogram-negative subarachnoid hemorrhage was excluded. Clinical grading was assessed by the Hunt&Hess classification. We reviewed the mode and frequency of treatment according to elective (unruptured) or emergency (ruptured) cases. We evaluated the data of 0° MCA aneurysms and defined the outcome after treatment by determinants of new and the severity of persistent neurological deficits. We estimated the probability of numbers of unruptured 0° MCA aneurysms treated by a resident.

Results: 327 patients presented, 90 electively, 237 with ruptured aneurysms between 2008 and 2016, 220 female, 107 male, median age 53 years. 146 patients (61,6%) received endovascular treatment and 69 (29,1%) patients underwent surgery in the emergency group. Due to the high surgical requirements operations on ruptured aneurysms were performed by the head of department. In the elective group 43 patients (47,8%) received endovascular treatment, 42 patients (46,7%) underwent surgery. In the group of unruptured aneurysms 0° MCA aneurysms permit the easiest surgical access with minimal brain retraction and can be treated by 5th year and 6th year residents under the supervision of an experienced surgeon. In total 23 unruptured 0° MCA aneurysms received surgical and 6 endovascular treatment. In average 3-4 unruptured 0° MCA aneurysms are treated surgically per year. In the surgery group 1/23 (4,3%) patient and in the endovascular group 1/6 (16,7%) patient suffered from severe complication with a high grade of disability after treatment. No mortality occurred in both groups. Restitutio ad integrum could be achieved in about 65% of the cases in both groups.

Conclusion: According to the official German training charter no respective operative experience is required for trainees during residency. The future of microsurgical expertise in the field of the management of aneurysms depends on the quality and frequency of training. Our study and training program for experienced residents show that the selection of unruptured 0° MCA aneurysms for the microsurgical management results in good prognosis compared to the outcome of the endovascular technique. To maintain competence in aneurysm surgery changes in training requirements should be made.