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

  • Helen Huang
    Affiliations
    Department of Neurosurgery, Monash Health, Level 5, Block D, 246 Clayton Road, Clayton, Victoria 3168, Australia
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  • Rebecca Limb
    Affiliations
    Department of Neurosurgery, Monash Health, Level 5, Block D, 246 Clayton Road, Clayton, Victoria 3168, Australia
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  • Leon T. Lai
    Correspondence
    Corresponding author at: Department of Neurosurgery, Monash Health, Level 5, Block D, 246 Clayton Road, Clayton, Victoria 3168, Australia.
    Affiliations
    Department of Neurosurgery, Monash Health, Level 5, Block D, 246 Clayton Road, Clayton, Victoria 3168, Australia

    Department of Surgery, Monash Medical Centre, Level 5, Block E, 246 Clayton Road, Clayton, Victoria 3168, Australia
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      Highlights

      • 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.
      • As significantly more endovascular procedures are performed, there is an increasing expectation for trainees to manage post-procedural endovascular treatment.
      • As most endovascular cases are performed by interventional radiologists in Australia, it is reasonable to assume that neurosurgery trainees' overall exposure to the disease is incomplete.
      • Endovascular treatment should be considered a core component of the neurosurgical SET curriculum and an essential modality in the skillset of a cerebrovascular neurosurgeon.

      Abstract

      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.

      Abbreviations:

      aSAH (aneurysmal subarachnoid haemorrhage), EVT (endovascular treatment), IA (intracranial aneurysm), ICD-10 AM (International Statistical Classification of Disease, 10th edition, Australian modification), NHMD (National Hospital Morbidity Database), RACS (Royal Australasian College of Surgeons), SET (Surgical Education and Training), UIA (unruptured intracranial aneurysm)

      Keywords

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