Neurovascular surgery: a review of the way forward from the American perspective

摘要

Abstract: The United States (U.S.)’ neurovascular surgery landscape has evolved significantly over recent decades, with advancements in both endovascular and microsurgical techniques to address the varied and complex nature of cerebrovascular diseases. As neurovascular disorders continue to impose substantial public health and economic burdens, innovations in minimally invasive interventions have been particularly transformative. Endovascular techniques now dominate the landscape, offering effective, lower-risk treatments for conditions such as intracranial aneurysms, stroke, chronic subdural hematomas, and more. This shift in procedures and workforce is complemented by a marked number of neuroendovascular training fellowships in the U.S., with 117 positions available annually across 84 programs, compared to 18 programs for open neurovascular surgery fellowships. Notable advancements include the development of flow diverters, thrombectomy devices, and novel endovascular approaches for communicating hydrocephalus. Concurrently, the need for open surgical methods persists for complex lesions where endovascular options are insufficient, emphasizing the importance of training and maintaining a skilled microsurgical workforce. However, challenges such as regional disparities in access to care, exemplified by the distribution of neurovascular-capable stroke centers, and decreasing case volumes for open procedures persist. Additionally, emerging technologies continue to shape the practice of neurovascular surgery into an era of precision surgery, including the use of artificial intelligence (AI) to diagnose, plan surgery, and prognosticate neurovascular patients, robotic-assisted interventions to improve patient outcomes, and virtual reality (VR) technologies to integrate simulation-based and competency-driven training methods. While previous reviews have discussed specific aspects or global trends in neurovascular surgery, this review presents the unique American perspectives in neurovascular surgery, examining key innovations in endovascular devices and advances in open microsurgical techniques. We also explore workforce dynamics and training challenges in the U.S., focusing on the balance between the evolving role of neuroendovascular interventionists with concomitant declining surgical case volumes. Finally, we present the future directions of neurovascular surgery to meet the diverse needs of the American population, emphasizing the role of advancing technology in personalized neurovascular surgery through AI algorithms in precise patient selection, sustained neurovascular expertise with the use of robotic telementoring and VR platforms, and the expansion of neurovascular indications to include neuromodulation and beyond.