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Year : 2018  |  Volume : 66  |  Issue : 3  |  Page : 892--893

Current trends in the management of intracranial aneurysms and how neurosurgical residency programs in India are falling behind in this revolution

Krishna Chaitanya Joshi 
 Division of Endovascular Neurosurgery, Department of Neurosurgery, Rush Medical Center, Chicago, Illinois, USA

Correspondence Address:
Dr. Krishna Chaitanya Joshi
Division of Endovascular Neurosurgery, Department of Neurosurgery, Rush Medical Center, Chicago, Illinois

How to cite this article:
Joshi KC. Current trends in the management of intracranial aneurysms and how neurosurgical residency programs in India are falling behind in this revolution.Neurol India 2018;66:892-893

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Joshi KC. Current trends in the management of intracranial aneurysms and how neurosurgical residency programs in India are falling behind in this revolution. Neurol India [serial online] 2018 [cited 2019 Dec 12 ];66:892-893
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I am a neurosurgeon trained in India and currently doing a clinical fellowship in neuroendovascular neurosurgery at a high-volume tertiary care institute in a large metropolitan city in the USA. I wanted to share my unbiased perspective of the current trends in the management of intracranial aneurysms and how India, having some of the most skilled neurosurgeons and great institutes for residency training, has fallen far behind in the treatment of aneurysms. Maingard et al., recently published the 100 most cited articles in endovascular treatment of aneurysms from all over the world and not a single one was from India.[1] The International Subarachnoid Aneurysm Trial (ISAT) comparing surgical clipping and endovascular coiling was published in Lancet in 2002,[2] which showed that disability-free survival at 1 year is significantly better with endovascular coiling and has led to a paradigm shift in the way we treat aneurysms. Since the trial, numerous newer devices have come up, including flow diverters and low profile stents. If there would be a new ISAT, endovascular treatment would be shown as far superior in terms of disability-free survival and prevention of rebleed. The newer devices have also allowed the treatment of previously inoperable aneurysms or those requiring tedious surgeries, for example, giant aneurysms or aneurysms of the posterior circulation, to be possible with minimal morbidity and mortality. The current industry estimate of clip versus endovascular procedure ratio in the USA and Europe exceeds 95% in favor of endovascular therapy (ET). Another important aspect to consider is the rising incidence of incidental aneurysms, both in the West and India. ET is undoubtedly the first line of treatment for incidental aneurysms and is also the preferred choice of the patient.

Thus, the last decade has seen the birth of a new breed of cerebrovascular surgeons – the comprehensively trained or dual-trained surgeon. It is well past the period of debate for clip versus coil. It is now imperative that we concentrate on treating the disease and not the modality of treatment. But unfortunately, none of our institutes of advanced neurosurgical training are currently offering training programs for this breed of surgeons. Most leading neurosurgical departments are very adamant in not introducing this concept into the residency training program and the results are already showing. Two important reasons are stated for this by most heads of the department: (1) Endovascular treatment is more expensive. (2) There are ancillary departments who can take care of this. Both these reasons are far from the reality. Chang et al.,[3] used healthcare data analysis to compare the hospital costs between ET and neurosurgical clipping (NC) in 31,422 unruptured intracranial aneurysms and 14,247 ruptured aneurysms, which showed that the cost of ET was significantly lower than that of NC. The ET group had a significantly shorter hospital stay. It is also often questioned whether or not a surgeon can perform both open and endovascular techniques successfully and safely. In a study of 3247 patients undergoing clipping for cerebral aneurysms, it was shown that there was no difference in rehabilitation or readmission rates between hybrid neurosurgeons and surgeons performing only clipping.[4] Management of intracranial aneurysms needs a thorough training in the anatomy and physiology of the brain, procedural skills, and neurocritical care management, and this combination can only be found in neurosurgeons, thus making them the ideal choice to take over as leaders in treating this pathology.

The neurosurgical residency training leadership in India is eschewing reconsideration of the traditional approach to neurovascular diseases. Progress in developing neuroendovascular centers, especially in the institutes, is slow and lacks dedication from the senior faculty. Currently, residents trained in India need to take the laborious path of going to the western countries to acquire this knowledge and skill. There is also a dangerous middle path that many young neurosurgeons are taking, where they visit foreign countries for a couple of weeks of observership and declare themselves as endovascular surgeons. This could be dangerous for the patients and detrimental to the field of cerebrovascular surgery.[5] Collaboration and cross-pollination from industry and other specialties have driven the growth of the field of neuroendovascular surgery at a rapid pace, and it is very important that young neurosurgeons get on board this ship before it is too late. Among the various specialties in therapeutic neurosciences, the highest numbers of randomized controlled studies are currently being done and published in the field of neuroendovascular surgery. New and emerging studies, such as the recently published DAWN study, have expanded the limits of treating previously untreatable conditions, such as stroke.[6] It is the need of the hour that neurosurgical programs across the country develop neuroendovascular programs and take the lead in the 'cath labs' just like they do in the operating rooms. It is also very important to set training standards for surgeons who can call themselves hybrid surgeons; if this is not done soon enough, there will be an army of poorly trained and poorly informed hybrid neurosurgeons. Unfortunately, many institutes still reject the notion of a neurosurgeon spending time in an angiography suite and treating complex pathologies through the femoral artery, but it is high time we neurosurgeons in India join this revolution and take leadership in it before it is too late.

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Conflicts of interest

There are no conflicts of interest.


1Maingard J, Phan K, Ren Y, Kok HK, Thijs V, Hirsch JA, et al. The 100 most cited articles in the endovascular management of intracranial aneurysms. J Neurointerv Surg 2018. doi: 10.1136/neurintsurg-2017-013688.
2Molyneux A, Kerr R, Stratton I, Sandercock P, Clarke M, Shrimpton J, et al. International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: A randomised trial. Lancet 2002;360:1267-74.
3Chang HW, Shin SH, Suh SH, Kim BS, Rho MH. Cost-effectiveness analysis of endovascular coiling versus neurosurgical clipping for intracranial aneurysms in Republic of Korea. Neurointervention 2016;11:86-91.
4Bekelis K, Gottlieb D, Bovis G, Su Y, Tjoumakaris S, Jabbour P, et al. Unruptured cerebral aneurysm clipping: Association of combined open and endovascular expertise with outcomes. J Neurointerv Surg 2016;8:977-81.
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6Nogueira RG, Jadhav AP, Haussen DC, Bonafe A, Budzik RF, Bhuva P, et al. Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. N Engl J Med 2018;378:11-21.