The future of neurovascular surgery. Part I: Intracranial aneurysms.

T o neurosurgeons in countries all over the world, the challenge of cerebral aneurysm surgery is exhilarating and gratifying. To successfully clip a difficult aneurysm which can at any instant explode in front of the surgeon’s eyes, threatening the patient’s life, produces the feeling of fulfillment of one’s dream of saving lives that is most satisfying to a physician. It is akin to the “good guy” winning the “shoot-out” in an old western movie. However, this era is fading for neurosurgeons, just as the time of the “Wild West” has become so distant that it has been replaced by space exploration and the marvels of computers. And just like the “Wild West” with which so many are familiar, it is hard to see it go. But it is surely passing. The advances in science have produced fantastic technology, currently in its infancy, but still the beginning of a new era in the treatment of nervous system diseases using endovascular or interventional techniques. Reports from centers in France and the U.S. have demonstrated that selected aneurysms can be successfully obliterated by endovascular techniques, which are less stressful and invasive to the patient than traditional surgery. In selected cases, 70% of aneurysms can be completely obliterated without a craniotomy and with a hospital stay notably shorter than that of an operated patient. The treatment is not perfect; some aneurysms (20%) recanalize or have neck remnants-but this also occurs with traditional surgical approaches. A very small number of patients (3%) suffer complications from endovascular treatments. Yet, as 1 have watched these aneurysms being obliterated with less morbidity than I could achieve surgically, I am convinced that endovascular treatments are an essential approach to the successful cure of this disease. Other uses of interventional techniques include the treatment of vasospasm. Intra-arterial papaverine or angioplasty offer excellent therapeutic op-