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Why is surgical neurology publishing a series on surgery for cerebral aneurysms?
Surgical Neurology 67 (2007) 5 www.surgicalneurology-online.com
Editorial
Why is surgical neurology publishing a series on surgery for cerebral aneurysms? Over the years, I have written editorials proclaiming the bDeath of aneurysm surgeryQ (Surg Neurol 1997;48:98-100; Surg Neurol 2001;56:348) and the benefits of endovascular approaches to cerebral aneurysms. When I first wrote about the subject, I was severely criticized by my neurosurgical colleagues as being wrong and was not invited to speak on this subject. Over the years, even the most severe critics have adopted interventional procedures to cerebral aneurysms. Neurosurgeons are even being trained as interventionalists, as I suggested in the 1997 article. In some places, greater than 90% of cerebral aneurysms in the community are being treated by interventional approaches. Hence, why is Surgical Neurology publishing a series on the surgery of cerebral aneurysms? The reason is based on a fundamental principle of medicine taught to me by my friend and colleague, Gerard Debrun, an interventional neuroradiologist. Our primary goal was to provide our patients the lowest-risk treatment with the best outcome with every choice we made in our treatment. We would continuously ask each other, as we decided on what to do for each patient we saw, bWhat are the risks and outcomes of surgical treatment, interventional treatment, or other alternatives, even no treatment?Q We would try to develop new creative approaches to the complex problems we faced, weighing the risks and benefits versus the conventional approaches. Even if Gerard could not coil an aneurysm, we would consider the next treatment and its risks and benefits. I remember on New Year’s Eve, while operating on a patient with a large ruptured basilar tip aneurysm, we chose surgery because it appeared that the neck was too large for coiling. At surgery, the aneurysm was too large for a clip. As a surgeon, I could have done it with temporary clipping and other measures but was still concerned that I would not be able to see the perforators well enough to make sure they were not trapped in the clip blades, leaving the patient with a devastating infarction. So, I called Gerard to the operating room, showed him the aneurysm, and asked him if he could offer a lower-risk treatment than I could. I told him that surgery had a high risk of catching important perforators, and before I proceeded, I wanted to make sure there were no other alternatives. The next day, he coiled the aneurysm using the balloon remodeling technique. The patient did well. At each 0090-3019/$ – see front matter D 2007 Published by Elsevier Inc. doi:10.1016/j.surneu.2006.11.030
step, we chose the lowest-risk treatment with the best outcome. This does not mean that we were biased for or against surgery or coiling. What we wanted was what was best for the patient. We were honest enough to admit what we could do and what we could not. One year ago, I was invited to give the First Snellman Lecture at the annual meeting of the Finnish Neurosurgical Society. We had never seen Finland. I had read and admired the work of the Finnish neurosurgeons, particularly Juha Hernesniemi. Then, I had a chance to see him operate on several aneurysms, meet his bRainbow Team,Q as he calls all the people who work with him, from anesthesiologists to nurses to neurosurgeons. I appreciated the excellence of their work and results. Hernesniemi worked with Yasargil, Drake, and Peerless and even published the final volume of the outstanding work of Drake and Peerless. Juha Hernesniemi has done over 3000 aneurysm surgeries. His experience, knowledge, surgical technique, and scholarship are outstanding. I believe that our readers and neurosurgeons around the world should know more about his work. So, over the next 2 years, he and his Rainbow Team will summarize their experience with these aneurysms, all accompanied by videos, so that every neurosurgeon can see their excellent work. So, have I changed my mind about surgery for cerebral aneurysms? If that is your question, you have missed the point of this editorial and all the previous editorials, and probably a fundamental principle of medicine. The choice we have to make is: What is best for the patient, and not what is best for the doctor. With the work of Hernesniemi and the Rainbow Team, we have more options to offer our patients. In places without interventional experts or expensive technology, the Finnish neurosurgeons have provided us with a better way to approach these aneurysms surgically. In those places with interventional expertise, this same principle of medicine applies. Pick what is best for the patient. This principle will endure for all time.
James I. Ausman, MD, PhD (Editor) E-mail address: [email protected]
Editorial
Why is surgical neurology publishing a series on surgery for cerebral aneurysms? Over the years, I have written editorials proclaiming the bDeath of aneurysm surgeryQ (Surg Neurol 1997;48:98-100; Surg Neurol 2001;56:348) and the benefits of endovascular approaches to cerebral aneurysms. When I first wrote about the subject, I was severely criticized by my neurosurgical colleagues as being wrong and was not invited to speak on this subject. Over the years, even the most severe critics have adopted interventional procedures to cerebral aneurysms. Neurosurgeons are even being trained as interventionalists, as I suggested in the 1997 article. In some places, greater than 90% of cerebral aneurysms in the community are being treated by interventional approaches. Hence, why is Surgical Neurology publishing a series on the surgery of cerebral aneurysms? The reason is based on a fundamental principle of medicine taught to me by my friend and colleague, Gerard Debrun, an interventional neuroradiologist. Our primary goal was to provide our patients the lowest-risk treatment with the best outcome with every choice we made in our treatment. We would continuously ask each other, as we decided on what to do for each patient we saw, bWhat are the risks and outcomes of surgical treatment, interventional treatment, or other alternatives, even no treatment?Q We would try to develop new creative approaches to the complex problems we faced, weighing the risks and benefits versus the conventional approaches. Even if Gerard could not coil an aneurysm, we would consider the next treatment and its risks and benefits. I remember on New Year’s Eve, while operating on a patient with a large ruptured basilar tip aneurysm, we chose surgery because it appeared that the neck was too large for coiling. At surgery, the aneurysm was too large for a clip. As a surgeon, I could have done it with temporary clipping and other measures but was still concerned that I would not be able to see the perforators well enough to make sure they were not trapped in the clip blades, leaving the patient with a devastating infarction. So, I called Gerard to the operating room, showed him the aneurysm, and asked him if he could offer a lower-risk treatment than I could. I told him that surgery had a high risk of catching important perforators, and before I proceeded, I wanted to make sure there were no other alternatives. The next day, he coiled the aneurysm using the balloon remodeling technique. The patient did well. At each 0090-3019/$ – see front matter D 2007 Published by Elsevier Inc. doi:10.1016/j.surneu.2006.11.030
step, we chose the lowest-risk treatment with the best outcome. This does not mean that we were biased for or against surgery or coiling. What we wanted was what was best for the patient. We were honest enough to admit what we could do and what we could not. One year ago, I was invited to give the First Snellman Lecture at the annual meeting of the Finnish Neurosurgical Society. We had never seen Finland. I had read and admired the work of the Finnish neurosurgeons, particularly Juha Hernesniemi. Then, I had a chance to see him operate on several aneurysms, meet his bRainbow Team,Q as he calls all the people who work with him, from anesthesiologists to nurses to neurosurgeons. I appreciated the excellence of their work and results. Hernesniemi worked with Yasargil, Drake, and Peerless and even published the final volume of the outstanding work of Drake and Peerless. Juha Hernesniemi has done over 3000 aneurysm surgeries. His experience, knowledge, surgical technique, and scholarship are outstanding. I believe that our readers and neurosurgeons around the world should know more about his work. So, over the next 2 years, he and his Rainbow Team will summarize their experience with these aneurysms, all accompanied by videos, so that every neurosurgeon can see their excellent work. So, have I changed my mind about surgery for cerebral aneurysms? If that is your question, you have missed the point of this editorial and all the previous editorials, and probably a fundamental principle of medicine. The choice we have to make is: What is best for the patient, and not what is best for the doctor. With the work of Hernesniemi and the Rainbow Team, we have more options to offer our patients. In places without interventional experts or expensive technology, the Finnish neurosurgeons have provided us with a better way to approach these aneurysms surgically. In those places with interventional expertise, this same principle of medicine applies. Pick what is best for the patient. This principle will endure for all time.
James I. Ausman, MD, PhD (Editor) E-mail address: [email protected]