Training the cerebrovascular surgeon for the 21st century

INTRODUCTION First of all, I would like to apologize in advance for writing this chapter more as an essay reecting my personal biases rather than as a scientic paper. In this context, the following will be devoid of scientic quotations. I would also apologize for my personal lack of vision for what the future would be like beyond the next few years. Like Yogi Berra, I do have major difculties with predictions, particularly if they refer to the future. Clearly, those of us who lived through the ‘golden days’ of cerebrovascular surgery cannot help but be somewhat nostalgic about the past, which does not necessarily mean that we are pessimistic about the future. I would roughly date the beginnings of the golden era of cerebrovascular surgery to the early 70s when two dening trends entered neurosurgery. Firstly, the microscope and microsurgical techniques began to be applied widely in neurosurgery. Secondly, neurosurgeons became adept at microvascular suturing techniques and the EC–IC bypass graft operation was developed and began to be used widely by neurosurgeons. Before the 70s, several pioneers began to use the microscope and microsurgical techniques in neurosurgery and there were already a number of individuals who had developed a reputation as cerebrovascular surgeons. However, in general, all of these individuals did more than cerebrovascular surgery and in fact, were generally very well respected already as excellent and experienced neurosurgeons who could, in addition to doing many other things, clip an aneurysm or extirpate an AVM with good results. What was so important about the early 70s, in my opinion, was the emergence of a cadre of dedicated cerebrovascular surgeons. The microscope allowed this generally young group of surgeons to become technically procient in a short period of time. Before that time, it took many years of experience to be able to clip an aneurysm successfully. With the microscope, many if not most neurosurgeons could clip a ‘routine’ aneurysm satisfactorily during their chief residency or during the rst few years in practice. The introduction of microvascular suturing techniques, which was rapidly mastered by those of us who became interested in the vascular area, dened those young surgeons (there were a few ‘older’ ones, but by and large they were the exception) as being doted with unique surgical talent. Our professors simply found it incredible that we were able to complete successfully an anastomosis to a vessel that was less than 1 mm in diameter. Coupled with these factors was the rich opportunity for doing cerebrovascular research allowed to those individuals who became interested in this area early on in their career. Cerebrovascular physiology was then, as it remains now, a fascinating topic to those of us interested in the nervous system and a young neurosurgeon at that time had opportunities in research that unfortunately are less prevalent today. To a large degree, this was due to the reimbursement system which was generous enough to allow academic departments to invest some of the clinical revenues in the support of research laboratories. It was in this fashion that many of us had the opportunities to develop the substantial preliminary data that was necessary for successful future NIH funding. This coupling of the perception of unique surgical technical talent and a track record of investigation in the laboratory opened the door to substantial academic opportunities for the majority of this early cadre of dedicated cerebrovascular surgeons. It is interesting that as important as the bypass was in the early career of these individuals, the ending of the bypass era, with the publication of the EC–IC study, did very little to discourage or terminate the dedication to cerebrovascular surgery of this early cadre of individuals. There were still plenty of aneurysms, AVMs and carotid endarterectomies to go around and the research opportunities continued to abound. There were still extremely important questions to be answered in the clinic and in the laboratory about vasospasm, the causes and thresholds of ischemic damage, the value of neuroprotective agents, etc. Even after the publication of the bypass study, I recall that a good number of the better qualied resident applicants were still interested in the cerebrovascular eld. Obviously, to dene a ‘golden era’, one must have seen its decline. What, then, are the factors involved in the decline of this golden era? They are obvious, but not irreversible and in fact, some of these very factors may lead to a revitalization of cerebrovascular surgery. Radiosurgery came into being and, following the trend Correspondence and reprint requests to: Roberto C. Heros, MD, Department of Neurosurgery, University of Miami School of Medicine, 1095 NW 14th Terrace, Miami, FL 33136, USA. Accepted for publication December 2001.