Is it time to rethink microsurgical training for the treatment of intracranial aneurysms in Australia?

[BACKGROUND] Case volume and complexity for microsurgical treatment of cerebral aneurysms have changed due to the growing use of endovascular therapy in clinical practice. The authors sought to quantify the clinical exposure of Australian neurosurgery trainees to cerebral aneurysm microsurgery.

[METHODS] This observational, retrospective cross-sectional study examined the Australian National Hospital Morbidity database for all admissions related to microsurgical and endovascular treatment of aneurysmal subarachnoid haemorrhage (aSAH) and unruptured intracranial aneurysms (UIAs) for the years 2008 to 2018. Procedural volumes were compared with neurosurgical trainee figures to investigate the rate of procedural exposure relative to the neurosurgical workforce.

[RESULTS] A total of 8,874 (41.6%) microsurgical procedures (3,662 for aSAH, 5,212 for UIAs), and 12,481 (58.4%) endovascular procedures (6,018 for aSAH, 6,463 for UIAs) were performed. Trainee exposure to microsurgery in aSAH declined from 9.1 to 7.3 cases per trainee per annum (mean 7.7), with case complexity confined mostly to simple anterior circulation aneurysms. There are significant state-by-state differences in the preferred treatment modality for aSAH. During the same study period, the number of microsurgical cases for UIAs increased (from 8.9 to 13.5 cases per trainee per annum, mean 11.0). Significantly more endovascular procedures are performed than microsurgery (10.7 to 17.0, mean 12.7 cases, for aSAH; 8.0 to 21.5, mean 13.7 cases, for UIAs).

[CONCLUSIONS] Trainee exposure to open aneurysm surgery for aSAH have significantly declined in both case volume and complexity. There is an overall increase in the number of surgeries for elective aneurysms, but this varies widely from state-to-state.