J Neurosurg 137:1554–1561, 2022
Neurosurgical Forum
BROCA’S AREA
Complex cranial surgery and the
future of open cerebrovascular
training
Christopher S. Graffeo, MD, MS,1 Michael J. Link, MD,2 and
Michael T. Lawton, MD1
Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s
1 other devices that have resulted in a dramatic reduction
Hospital and Medical Center, Phoenix, Arizona; and 2Department of
Neurosurgery, Mayo Clinic, Rochester, Minnesota
The Evolving Landscape of Cerebrovascular Treatment
In less than a generation, the clinical practice and as-
sociated training opportunities in cerebrovascular neuro-
surgery have evolved dramatically. Numerous factors have
contributed to this profound transformation, including
trends in medical education, litigation, healthcare perfor-
mance tracking, and shifting perspectives on the physi-
cian-patient relationship. Notwithstanding these trends,
the single most important contributor to changes in cere-
brovascular training has been the widespread implementa-
tion of endovascular treatment.
Neurosurgical treatment of cerebrovascular diseas-
es has been an area of rapid innovation for more than 3
decades. During this time, microsurgery has been chal-
lenged in all quarters. Most aneurysms that would have
previously undergone surgical clipping are now managed
via endovascular intervention.1,2 Furthermore, although
data have been equivocal regarding several key scenarios,
an increase in the versatility and safety of the endovascu-
lar armamentarium has been noted, with initial trepida-
tion following the original description of detachable coils
by Guglielmi in 1991, ultimately giving way to more wide-
spread acceptance, particularly in the wake of the Interna-
tional Subarachnoid Aneurysm Trial (ISAT) in 1998 and
the International Study of Unruptured Intracranial Aneu-
rysms (ISUIA) in 2003.3–5
A retrospective review of the National (Nationwide)
ABBREVIATIONS ACGME = Accreditation Council for Graduate Medical Education; EEA = endoscopic endonasal approach; ISAT = International Subarachnoid Aneurysm
Trial; ISUIA = International Study of Unruptured Intracranial Aneurysms; NIS = National (Nationwide) Inpatient Sample; SRS = stereotactic radiosurgery.
1554 J Neurosurg Volume 137 • November 2022
Inpatient Sample (NIS) published in 2020 confirmed that
during the first 10 years following ISAT and ISUIA, in-
terventional procedures accounted for 56.3% of ruptured
aneurysm treatments overall and 65% of unruptured aneu-
rysms, with > 70% of all aneurysms undergoing primary
endovascular treatment in 2014, the last year of the study
sampling frame.2 Other recent analyses have demonstrated
an expanding role for flow diversion, Woven EndoBridge
(Microvention/Terumo) embolization, and a variety of
in the proportion of cerebrovascular cases preferentially
treated with open neurosurgical techniques.6
Although endovascular therapies have positively in-
fluenced key aspects of patient care and the outcomes of
certain cerebrovascular diseases, including subarachnoid
hemorrhage and ischemic stroke, the full range of second-
ary impacts that this shift has had on training and, there-
fore, on the care of future patients, is underappreciated.
Correspondingly, we sought to describe the effect that
changes in the culture and practice of cerebrovascular
neurosurgery have had on training pathways. As an al-
ternative to the dual vascular pathways, we describe the
complex cranial model, which emphasizes microsurgical
mastery in the treatment of both cerebrovascular and skull
base disorders while maintaining a focus on complemen-
tary operative techniques instead of a disease-specific
educational approach.
Clinical, Cultural, and Legislative Influences on
Neurosurgical Training
In tandem with these clinical changes, the typical train-
ing experience for neurosurgery residents in the United
States has also undergone a marked reduction in exposure
to open cerebrovascular operations. A study published by
Piazza et al. in 2017 using NIS data indicated that from
2002 to 2011, in the United States, teaching opportuni-
ties for both ruptured and unruptured aneurysm clippings
decreased significantly.7 Their analysis demonstrated that
the probability of a patient undergoing open treatment
decreased by 15.6% for those with ruptured aneurysms
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and 9.8% for those with unruptured aneurysms during
each year of the study period. In contrast, endovascular
interventions increased by 18.7% and 10.8% per year, re-
spectively, over the same interval. Similar findings were
confirmed by Yaeger et al. in a study of resident case log
data published by the Accreditation Council for Graduate
Medical Education (ACGME) during the sampling frame
of 2009 to 2019.8 Over that time, the fractional proportion
of endovascular aneurysm treatments involving trainees
increased from 11.7% to 39.6%, while craniotomies for
aneurysm decreased from 88.3% to 60.4%. As of 2019, the
mean number of open aneurysm treatments completed by
graduating residents during their 7-year training was 32.5
cases. These trends are anticipated to accelerate, a reality
that is now reflected by formal accreditation requirements,
which no longer include a case minimum requirement for
open aneurysm treatments as of 2018.9
Several other broad influences have affected the open
vascular experience for neurosurgical trainees. Since 2003,
all residents in ACGME-accredited programs have been
restricted to 80 hours of weekly clinical duties. Although
studies interrogating the effect of these changes on neuro-
surgery have been controversial, several observational and
survey-based assessments have indicated that duty-hour
restrictions could have reduced trainee case volume and
operative autonomy.10 Simultaneously, trends in malprac-
tice litigation both within neurosurgery and throughout
medicine have demonstrated significant increases in case
filings, settlements, and plaintiff decisions over the past 2
decades, further contributing to a decrease in trainee in-
dependence during complex procedures.11 Although these
changes are not specific to cerebrovascular neurosurgery,
when coupled with dwindling open case volumes, the net
effect has been markedly fewer open aneurysm, arterio-
venous malformation, or bypass operations per trainee, as
well as less autonomy per case.9
These forces have substantially increased the barriers
to developing advanced microsurgical skills during neu-
rosurgical residency, particularly for open cerebrovascular
operations. Encouragingly, the ongoing development of
diverse and comprehensive simulation technologies could
eventually offset some of these educational disadvantag-
es, including those based on virtual or augmented real-
ity, animal or cadaveric tissue models, or 3D printing.12–14
Current evidence suggests that these tools may shorten the
learning curve for acquisition of basic skills among neu-
rosurgical trainees. However, they are not anticipated to
replace operative experience for advanced skill develop-
ment. Consequently, fellowship-level training is expected
to remain mandatory for all cerebrovascular neurosur-
geons, although the common pathways into the field have
evolved in an unexpected fashion and are approaching an
inflection point.
Two Roads Diverged
Apprenticeship has been a core aspect of neurosurgical
training since its inception. Although the legacy of mod-
ern microsurgery can be traced through several lineages,
most of the leading modern neurosurgeons originate with
Gazi Yaşargil and his contemporaries or protégés. Follow-
ing in Yaşargil’s tradition, many first- and second-gener-
Neurosurgical forum
ation leaders in cranial neurosurgery practiced broadly,
often working in cerebrovascular, skull base, and neuro-
oncology.15 The list of neurosurgeon innovators practic-
ing in multiple subspecialties is extensive and includes
Evandro de Oliveira, Vinko Dolenc, Raymond Donaghy,
Charles Drake, Takanori Fukushima, Roberto Heros,
Peter Janetta, Laligam Sekhar, Robert Spetzler, Bennett
Stein, Thoralf Sundt, John Tew Jr., and Charles Wilson,
among many others.
Evolution in medicine is often marked by an inverse dy-
namic, with individual practices narrowing and deepening
while the terrain of their parent specialty broadens. Within
neurosurgery, this pattern was observed as microsurgical
expertise proliferated and individual neurosurgeons fo-
cused on narrower ranges of disease.16 Although this trend
benefited surgeons and patients alike, it also resulted in
the prioritization of fellowship and practice structures that
were disease focused, the contemporary consequences of
which were not anticipated in the pre-endovascular ther-
apy era.
Many neurosurgeons are drawn to innovation and have
a savvy understanding of novel tools or techniques that
may influence practice. Similarly, many neurosurgeons
are driven by the desire to provide safer and more effec-
tive treatments, ultimately motivating the development of
novel therapies, such as endovascular devices or stereo-
tactic radiosurgery (SRS). Correspondingly, as endovas-
cular therapies have matured and their indications have
expanded over the past 2 decades, the dominant training
and practice model for cerebrovascular neurosurgeons
has become the dual vascular approach oriented around
fellowship-level training in both endovascular and open
vascular surgery.17 Although several variations in the se-
quencing of these fellowships are considered acceptable
entrées into the field, their end goal is shared: the genera-
tion of individual neurosurgeons who are disease-oriented
specialists with competency in both disciplines.18
The principal benefit of dual training is a theoretical
reduction in incentive-based bias toward either open or
endovascular treatment, given that the same neurosurgeon
would be completing the procedure, regardless of the
recommended modality. In practice, whether combined
training actually eliminates bias remains controversial.19,20
More importantly, the assumption that consolidating de-
cision-making in a single individual is desirable has not
been explicitly interrogated. Rather, mounting evidence
suggests that a team of individuals with diverse skill sets
and training would be better equipped to make difficult
decisions and execute complex treatment plans, as shown
with multidisciplinary tumor boards.21,22
The psychology literature supports these findings and
reports that teams consistently outperform isolated individ-
uals in decision-making and are less vulnerable to bias, es-
pecially when team membership is intellectually diverse.23
The putative benefits of investing in a single neurosurgeon
with multiple skills may be negligible compared to the po-
tential advantages of a multidisciplinary team comprising
members with complementary perspectives.
The Task at Hand
Although there is little evidence to support the emphasis
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Neurosurgical forum
on consolidated decision-making in neurosurgery, numer-
ous studies have reinforced the concept that skill acqui-
sition benefits from frequent, deliberate repetition, espe-
cially for precise execution of complex manual tasks.24,25
Within surgical pedagogy, a randomized study involving
students demonstrated that baseline differences in ability
or experience were readily overcome by focused practice
with robotic surgery during the study period.26 Another
randomized study of general surgery residents observed
significant differences in trainees who underwent distrib-
uted skills acquisition programs rather than single mass
sessions.27 Still, other studies from the general, orthope-
dic, and plastic surgery literature have reported similar
findings among trainees who undergo serial skills training
exercises.28,29 Anecdotally, these results concur with ours
regarding procedural competence and confidence across
a broad base of activities, ranging from medical students
learning bedside procedures to cerebrovascular surgeons
mastering the art of basilar apex aneurysm clipping.30,31
Applying these concepts to neurosurgical training, one
can plot the range of manual tasks common to each sub-
specialty alongside various axes. Two useful concepts are
the working scale of common procedures within a partic-
ular domain and the extent to which those procedures are
dependent on skill with the operating microscope (Fig. 1).
Spine and trauma occupy the largest working scales.
They infrequently require the operating microscope, with
notable exceptions including microdiscectomy, cervical
foraminotomy, and certain minimally invasive or onco-
logical spine procedures. Although the precision target-
ing of functional and stereotactic neurosurgery is at the
microscopic level, the procedures are executed without the
need for magnification and with automated systems con-
FIG. 1. The neurosurgery microscopy matrix showing relative working
scales and microscopic dependence of major neurosurgical subspe-
cialty practices. MIS = minimally invasive surgery.
1556 J Neurosurg Volume 137 • November 2022
trolling final electrode advancement or collimator align-
ment. Toward the center of the spectrum, neuro-oncology
and epilepsy procedures frequently involve macroscopic
resections of large tumors or lobar domains, and the ex-
tent to which the microscope is used varies widely. Endo-
vascular and endoscopic skull base procedures are unam-
biguously microscopic domains. However, by definition,
neither incorporates the operating microscope, and the
physical skill sets of catheter- or endoscope-based opera-
tions are demanding but distinct from microneurosurgery.
Finally, at the extreme of working scale and micro-
scope integration, we encounter the overlapping domains
of open cerebrovascular and skull base surgery. A cursory
review of the diseases commonly treated within each sub-
specialty might suggest that the shared features between
these disciplines are superficial. However, a more granular
assessment demonstrates not only that the technical nu-
ances of aneurysm and arteriovenous malformation sur-
gery overlap substantially with skull base tumor resection
and microvascular decompression but also that training
and practice within each field have the potential to mark-
edly improve a surgeon’s abilities to perform complex cra-
nial operations across both domains.
The Prodigal Trainee
The potential benefits of a practice that incorporates
both cerebrovascular and skull base training are self-evi-
dent. Performing a higher volume of complicated or chal-
lenging cases using the operating microscope is more like-
ly to advance the surgeon’s dexterity and manual skills.
This training is essential in the case of an intraoperative
complication or anatomical variant that demands dynamic
thinking, steady hands, and broad familiarity with tech-
niques for managing the unexpected. Furthermore, the
treatment landscape is such that maintaining a busy prac-
tice of predominantly open cerebrovascular operations is
essentially impossible for a junior surgeon, emphasizing
the pragmatic advantages of a second referral base.
Given the shared origin of these subspecialties and
their noted historical overlap among first- and second-gen-
eration neurosurgeons, many of the common skull base
techniques have an established utility for cerebrovascular
operations, such as the anterior clinoidectomy for access-
ing ophthalmic aneurysms, the orbitozygomatic cranioto-
my for high anterior communicating artery or basilar apex
aneurysms, or the far-lateral approach to vertebrobasilar
lesions, among others. Additionally, minimally invasive or
“keyhole” craniotomies, developed predominantly within
the realm of skull base surgery, have proven their versa-
tility in minimizing the morbidity associated with open
approaches to cerebrovascular lesions, such as the lateral
supraorbital and minipterional craniotomies for clipping
of unruptured anterior circulation aneurysms.32 These fa-
miliar examples provide a useful template for understand-
ing the rich opportunities for crosstalk between the train-
ing pathways.
Taking the approach discussion to the next level of so-
phistication, one appreciates that the craniotomies com-
monly used by neurosurgeons with skull base training
have the potential to permit more individualized treatment
across a range of challenging cerebrovascular diseases.
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 Neurosurgical forum

Skull base surgery is often conceptualized as a modular
system for bone removal that attempts to optimize the
operative corridor while minimizing brain retraction.33
Although neuroanatomically defined, the skull base trian-
gles also provide an important heuristic for understanding
disease and tailoring approaches to each patient and le-
sion. This skull base framework has proven so valuable to
cerebrovascular neurosurgery that it has, in turn, inspired
the conceptualization and development of several addi-
tional sets of triangles, including those for tackling ante-
rior communicating and vertebrobasilar aneurysms.34,35
Brainstem cavernomas are another key example of how
cerebrovascular operations benefit from skull base exper-
tise, particularly for lesions that come to the pial surface in
an area that is difficult to access via traditional corridors
(Fig. 2A). For example, a ventral pontine lesion that comes
to the surface laterally would require significant retraction
and an unfavorable working angle if the standard retrosig-
moid craniotomy were used (Fig. 2B). In contrast, the ex-
tended retrosigmoid approach opens access to the petrous
fissure and transmiddle cerebellar peduncle approach, and
the posterior petrosectomy offers a presigmoid corridor
that has both a shorter working distance and more lateral
angulation with respect to the ventral brainstem (Fig. 2C
and D).
Similarly, basilar apex aneurysms demand a range of

FIG. 2. A: Overview of relative access provided by candidate approaches considered for posterior fossa access, such as for
resection of brainstem cavernous malformations, highlighting the value of a skull base skill set in treating cerebrovascular patholo-
gies. B–D: Craniotomy, dural opening, and intradural access are compared from the surgeon’s perspective for standard retrosig-
moid (B), extended retrosigmoid (C), and posterior petrosectomy (D) approaches. Panels A–C used with permission from Barrow
Neurological Institute, Phoenix, Arizona. Panel D upper reprinted from Operative Techniques in Neurosurgery, Vol 4, Issue 1,
Zubay G, Porter RW, Spetzler RF, Transpetrosal approaches, pp 24–29, Copyright 2001, with permission from Elsevier. Panel D
lower reproduced from Horgan MA, Delashaw JB, Schwartz MS, Kellogg JX, Spektor S, McMenomey S. Transcrusal approach to
the petroclival region with hearing preservation. J Neurosurg. 2001;94:660–666. ©AANS, published with permission.

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treatment strategies, depending on their morphology and
conformation to the skull base (Fig. 3A). Although early
microsurgical treatments for basilar apex aneurysms that
could not be accessed via a pterional craniotomy and trans-
sylvian approach (Fig. 3B) relied on the subtemporal ap-
proach (Fig. 3C), the exposure it affords is relatively lim-
ited. Skull base approaches markedly improve safe access
to basilar artery aneurysms, with high-riding aneurysms
accessible via the orbitozygomatic craniotomy or transcav-
ernous approach (Fig. 3D) and low-lying aneurysms acces-
sible via Kawase’s anterior petrosectomy (Fig. 3E).36
These examples are representative of the many ways in
which the complex cranial model can markedly enhance
the depth and breadth of an individual’s training experi-
ence. Rather than 2 discrete years focused on important but
discrete skill sets, a fellow who undertakes serial fellow-
ships in skull base and cerebrovascular neurosurgery may
gain more exposure to an overlapping set of approaches
and techniques, as well as a deeper understanding of how
they can be technically adapted across a broader range of
diseases.
In addition to approaching mastery, complication man-
agement highlights another high-yield area of complex
cranial synergy. Although advanced approach training is
partially provided by isolated fellowship training in either
field, certain techniques for complication management are
substantially less represented across the disciplines.
The most feared complication in skull base microneu-
rosurgery is a stroke from inadvertent vascular injury.
Although stroke is uncommon when an experienced sur-
geon performs the procedure, it is an unambiguous risk
associated with certain skull base resections, particularly
for large, deep-seated tumors that envelop critical struc-
tures, such as petrous apex meningiomas. Although skull

FIG. 3. A: Overview of relative access provided by candidate approaches considered for basilar artery aneurysm access,
highlighting the value of a skull base skill set in treating cerebrovascular pathologies. B–D: Access to the basilar apex via the
pterional craniotomy and transsylvian approach is relatively limited, which historically prompted the development of the subtempo-
ral approach (C). Modern skull base approaches, including the orbitozygomatic craniotomy (D) and anterior petrosectomy (E, e.g.,
Kawase’s approach), have further empowered treatment of high- and low-riding basilar aneurysms. Used with permission from
Barrow Neurological Institute, Phoenix, Arizona.

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base surgeons are well versed in techniques for controlling
bleeding, cerebrovascular bypass expertise is much rarer.
Thus, experience and comfort with a wide range of cere-
brovascular bypasses equip the skull base surgeon with a
dramatically larger array of techniques for repairing ar-
terial injuries and replacing blood flow following vessel
injury.
Similarly, although every neurosurgeon learns the fun-
damentals of CSF leakage management, skull base opera-
tions are fraught with challenging CSF and wound care
issues. These challenges are partly attributable to the ex-
tensive skull base drilling most operations require. How-
ever, numerous other factors also contribute, including
dependent wounds involving the posterior fossa or trans-
sphenoidal regions, the frequent need for dural resection
and grafting, and commonplace indications for postop-
erative irradiation or chemotherapy.37 Skull base training
correspondingly provides deep familiarity with advanced
reconstructive techniques. Common tools are familiar to
most neurosurgeons, such as the nasoseptal flap, or fron-
tal sinus cranialization and skull base reconstruction with
a pedicled pericranium.38 Others are more esoteric but
highly effective mechanisms for preventing or resolving
CSF leakage, including the “yo-yo technique” for muscle
pledget occlusion of a communication into the sphenoid si-
nus after anterior clinoidectomy, the tack hole–based scalp
flap suspension technique for far-lateral reconstruction,
and the full range of rotational and free flap options.39,40
Indirectly, skull base surgery has already provided
2 salient models for demonstrating how the relationship
between open and endovascular domains should evolve
for cerebrovascular neurosurgeons. First, SRS has proven
safety and efficacy across a wide variety of benign skull
base diseases such that it is almost universally accepted
as a core component of the treatment paradigms for ves-
tibular schwannoma, meningioma, pituitary adenoma,
paraganglioma, and some cases of trigeminal neuralgia.41
Almost all skull base surgeons recommend SRS for some
of their patients. Yet, a minority of surgeons participate
directly in radiation planning or delivery. Instead, these
surgeons focus predominantly on surgical cases and defer
SRS responsibilities to interested colleagues and radiation
oncologists.
Second, the advent and refinement of the endoscopic
endonasal approach (EEA) within skull base surgery have
led to marked improvements in treating several important
entities, including pituitary adenoma and craniopharyn-
gioma.42 Although initially met with resistance by some
skull base surgeons, EEA techniques have improved in
safety and efficacy, resulting in their emergence as a front-
line treatment for many midline lesions.43 Nevertheless,
larger tumors extending beyond the carotid arteries still
require transcranial techniques, emphasizing another ex-
ample of critical synergy between contemporary and tra-
ditional schools of training.
With these resonant examples in mind, our perspective
is that all cerebrovascular neurosurgeons should be fully
committed to engagement with the academic and clinical
dimensions of endovascular treatments, just as their skull
base peers are with SRS or EEA. Simultaneously, we en-
courage more widespread recognition that intellectual en-
Neurosurgical forum
gagement does not require one to perform those interven-
tions personally.
Finally, as has been shown with multidisciplinary team
dynamics, the potential for creativity appears to be en-
hanced by diverse surgeon experiences and backgrounds.
Many innovations across medical practice have arisen by
applying an outside perspective to established tools or
techniques. Famously, Andreas Raabe encountered the
technology that would become indocyanine green video-
angiography while perusing the vendor hall at a general
trauma meeting, where he saw a tool for liver surgeons that
would ultimately revolutionize intraoperative cerebrovas-
cular imaging.44 Particularly salient to the complex cranial
model is “macrovascular decompression,” an innovative
procedure at the intersection of skull base and cerebrovas-
cular practice. In these unusual operations, large dolicho-
ectatic vertebrobasilar loops are elevated off the cranial
nerves and retained in a noncompressive position via sling,
clip, or complete rerouting with cerebrovascular bypass.45
These elegant and challenging operations highlight the
power of intellectual and technical crossover between the
disciplines, as their successful execution relies on mastery
of skull base techniques, as well as comfort with poten-
tially unstable cerebrovascular abnormalities.
The Complex Cranial Surgeon
A survey of the current microneurosurgical landscape
invites an essential and fundamental question: What is the
best strategy to provide future generations of residents and
fellows with the resources needed to master and advance
the increasingly rarified craft of cerebrovascular micro-
neurosurgery, ensuring that patients who require open
treatments continue to have excellent outcomes? The com-
plex cranial route presents an important and compelling
training model when considered in light of the growing
list of endovascular tools, the influx of practitioners from
radiology and neurology into the endovascular space, the
advantages of diverse perspectives on the treatment team,
and the benefits of frequent and focused repetition for
high-level manual skill development. Several pathways
into complex cranial specialization are reasonable. All
share the notion of fellowship-level education in operative
management of both skull base and open cerebrovascu-
lar diseases. As we have highlighted, this paired training
experience reflects a strong tradition from neurosurgical
history, innovation enhancement, and technical synergy.
Without question, endovascular treatments will become
safer and more dominant in the future, and patients will
benefit from the leadership of neurosurgeons with endo-
vascular expertise on their teams. However, for individuals
who are motivated to take on the uncommon and techni-
cally challenging operations that will continue to mandate
open microsurgical treatment, the complex cranial train-
ing pathway is more likely to provide a critical volume of
microsurgical cases and to empower the lifelong evolution
of technical excellence.
Acknowledgments
We thank the staff of Neuroscience Publications at Barrow
Neurological Institute for assistance with manuscript preparation.
Dr. Graffeo thanks his peers, Dr. Perry, Dr. Carlstrom, and Dr.
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Srinivasan, for the spirited discussions that continue to inform his
perspective on complex cranial surgery.
References
1. Lawton MT, Lang MJ. The future of open vascular neuro-
surgery: perspectives on cavernous malformations, AVMs,
and bypasses for complex aneurysms. J Neurosurg. 2019;​
130(5):1409-1425.
2. Luther E, McCarthy DJ, Brunet MC, et al. Treatment and di-
agnosis of cerebral aneurysms in the post-International Sub-
arachnoid Aneurysm Trial (ISAT) era: trends and outcomes.
J Neurointerv Surg. 2020;12(7):682-687.
3. Wiebers DO, Whisnant JP, Huston J III, et al. Unruptured
intracranial aneurysms: natural history, clinical outcome,
and risks of surgical and endovascular treatment. Lancet.
2003;362(9378):103-110.
4. Lindgren A, Vergouwen MDI, van der Schaaf I, et al. Endo-
vascular coiling versus neurosurgical clipping for people with
aneurysmal subarachnoid haemorrhage. Cochrane Database
Syst Rev. 2018;8:CD003085.
5. Molyneux A, Kerr R, Stratton I, et al. International Sub-
arachnoid Aneurysm Trial (ISAT) of neurosurgical clipping
versus endovascular coiling in 2143 patients with ruptured
intracranial aneurysms: a randomised trial. Lancet. 2002;​
360(9342):1267-1274.
6. Walcott BP, Stapleton CJ, Choudhri O, Patel AB. Flow diver-
sion for the treatment of intracranial aneurysms. JAMA Neu-
rol. 2016;73(8):1002-1008.
7. Piazza M, Nayak N, Ali Z, et al. Trends in resident operative
teaching opportunities for treatment of intracranial aneu-
rysms. World Neurosurg. 2017;103:194-200.
8. Yaeger KA, Munich SA, Byrne RW, Germano IM. Trends in
United States neurosurgery residency education and training
over the last decade (2009-2019). Neurosurg Focus. 2020;​
48(3):E6.
9. ACGME Program Requirements for Graduate Medical
Education in Neurological Surgery. Neurological Surgery
Program Requirements and FAQs. Accreditation Council
for Graduate Medical Education. Accessed March 11, 2022.
https://www.acgme.org/Specialties/Program-Requirements-
and-FAQs-and-Applications/pfcatid/10/Neurological%20
Surgery
10. Bina RW, Lemole GM Jr, Dumont TM. On resident duty hour
restrictions and neurosurgical training: review of the litera-
ture. J Neurosurg. 2016;124(3):842-848.
11. Mukherjee S, Pringle C, Crocker M. A nine-year review of
medicolegal claims in neurosurgery. Ann R Coll Surg Engl.
2014;96(4):266-270.
12. Graffeo CS, Perry A, Carlstrom LP, et al. 3D printing for
complex cranial surgery education: Technical overview and
preliminary validation study. J Neurol Surg B Skull Base.
Published online February 22, 2021. doi:10.1055/​s-0040-
1722719
13. Perry A, Graffeo CS, Carlstrom LP, Anding WJ, Link MJ,
Rangel-Castilla L. Novel rodent model for simulation of syl-
vian fissure dissection and cerebrovascular bypass under sub-
arachnoid hemorrhage conditions: technical note and timing
study. Neurosurg Focus. 2019;46(2):E17.
14. Belykh E, Giovani A, Abramov I, et al. Novel system of
simulation models for aneurysm clipping training: descrip-
tion of models and assessment of face, content, and construct
validity. Oper Neurosurg (Hagerstown). 2021;21(6):558-569.
15. Flamm ES, Professor M. Professor M. Gazi Yaşargil: an ap-
preciation by a former apprentice. Neurosurgery. 1999;​45(5):​
1015-1018.
16. Gottfried ON, Rovit RL, Popp AJ, Kraus KL, Simon AS,
Couldwell WT. Neurosurgical workforce trends in the United
States. J Neurosurg. 2005;102(2):202-208.
1560 J Neurosurg Volume 137 • November 2022
17. Harbaugh RE, Agarwal A. Training residents in endovascular
neurosurgery. Neurosurgery. 2006;59(5)(suppl 3):S277-S281,
S3-S13.
18. Todnem N, Ward A, Alleyne CH Jr. How hybrid/dual training
influences cerebral aneurysm management. Contemp Neuro-
surg. 2019;41(3):1-8.
19. Jiang B, Bender MT, Hasjim B, et al. Aneurysm treatment
practice patterns for newly appointed dual-trained cerebro-
vascular/endovascular neurosurgeons: Comparison of open
surgical to neuroendovascular procedures in the first 2 years
of academic practice. Surg Neurol Int. 2017;8:154.
20. Volovici V, Verploegh ISC, Vos JC, et al. Can young vascu-
lar neurosurgeons become proficient in microsurgical clip
reconstruction in the endovascular era? A Rotterdam cohort
spanning 2 decades with propensity score matching for com-
plexity. World Neurosurg. 2020;144:e780-e788.
21. Carlson ER. Collective wisdom and multidisciplinary tumor
boards. J Oral Maxillofac Surg. 2014;72(2):235-236.
22. Lamb BW, Brown KF, Nagpal K, Vincent C, Green JS,
Sevdalis N. Quality of care management decisions by mul-
tidisciplinary cancer teams: a systematic review. Ann Surg
Oncol. 2011;18(8):2116-2125.
23. Brodbeck FC, Kerschreiter R, Mojzisch A, Schulz-Hardt
S. Group decision making under conditions of distributed
knowledge: the information asymmetries model. AMRO.
2007;32(2):459-479.
24. Friedrich MJ. Practice makes perfect: risk-free medical train-
ing with patient simulators. JAMA. 2002;288(22):2808-2812.
25. Jonides J. How does practice makes perfect? Nat Neurosci.
2004;7(1):10-11.
26. Shee K, Ghali FM, Hyams ES. Practice makes perfect: cor-
relations between prior experience in high-level athletics and
robotic surgical performance do not persist after task repeti-
tion. J Surg Educ. 2017;74(4):630-637.
27. Moulton CAE, Dubrowski A, Macrae H, Graham B, Grober
E, Reznick R. Teaching surgical skills: what kind of practice
makes perfect? A randomized, controlled trial. Ann Surg.
2006;244(3):400-409.
28. Applebaum MA, Doren EL, Ghanem AM, Myers SR, Har-
rington M, Smith DJ. Microsurgery competency during
plastic surgery residency: an objective skills assessment of an
integrated residency training program. Eplasty. 2018;18:e25.
29. Dammerer D, Putzer D, Wurm A, Liebensteiner M, Nogler
M, Krismer M. Progress in knee arthroscopy skills of resi-
dents and medical students: a prospective assessment of
simulator exercises and analysis of learning curves. J Surg
Educ. 2018;75(6):1643-1649.
30. Barr J, Graffeo CS. Procedural experience and confidence
among graduating medical students. J Surg Educ. 2016;​73(3):​
466-473.
31. Lawton MT. Basilar apex aneurysms: surgical results and
perspectives from an initial experience. Neurosurgery.
2002;50(1):1-10.
32. Esposito G, Dias SF, Burkhardt JK, et al. Selection strategy
for optimal keyhole approaches for middle cerebral artery
aneurysms: lateral supraorbital versus minipterional crani-
otomy. World Neurosurg. 2019;122:e349-e357.
33. Jean WC. Skull Base Surgery: Strategies. Thieme; 2019.
34. Ivan ME, Safaee MM, Martirosyan NL, et al. Anatomical tri-
angles defining routes to anterior communicating artery an-
eurysms: the junctional and precommunicating triangles and
the role of dome projection. J Neurosurg. 2019;132(5):1517-
1528.
35. Tayebi Meybodi A, Borba Moreira L, Zhao X, Preul MC,
Lawton MT. Anatomical analysis of the vagoaccessory tri-
angle and the triangles within: the suprahypoglossal, infra-
hypoglossal, and hypoglossal–hypoglossal triangles. World
Neurosurg. 2019;126:e463-e472.
36. Tayebi Meybodi A, Benet A, Rodriguez Rubio R, et al.
Unauthenticated | Downloaded 03/28/24 03:51 PM UTC
 Neurosurgical forum

Comparative analysis of orbitozygomatic and subtemporal 44. Raabe A, Beck J, Gerlach R, Zimmermann M, Seifert V.
approaches to the basilar apex: a cadaveric study. World Neu- Near-infrared indocyanine green video angiography: a new
rosurg. 2018;119:e607-e616. method for intraoperative assessment of vascular flow. Neu-
37. Fraser S, Gardner PA, Koutourousiou M, et al. Risk factors rosurgery. 2003;52(1):132-139.
associated with postoperative cerebrospinal fluid leak after 45. Srinivasan VM, Labib MA, Furey CG, Catapano JS, Lawton
endoscopic endonasal skull base surgery. J Neurosurg. 2018;​ MT. The “binder ring” bypass: transection, rerouting, and
128(4):1066-1071. reanastomosis as an alternative to macrovascular decom-
38. Gagliardi F, Boari N, Mortini P. Reconstruction techniques in pression of a dolichoectatic vertebral artery. Oper Neuro-
skull base surgery. J Craniofac Surg. 2011;22(3):1015-1020. surg (Hagerstown). Published online February 11, 2022.
39. Ali MS, Magill ST, McDermott MW. Far lateral craniotomy doi:10.1227/ONS.0000000000000099
closure technique for preservation of suboccipital muscula-
ture. J Neurol Surg B Skull Base. 2021;82(5):562-566. Disclosures
40. Chi JH, Sughrue M, Kunwar S, Lawton MT. The “yo-yo” The authors report no conflict of interest.
technique to prevent cerebrospinal fluid rhinorrhea after
anterior clinoidectomy for proximal internal carotid artery Correspondence
aneurysms. Neurosurgery. 2006;59(1)(suppl 1):ONS101-
ONS107. Michael T. Lawton: neuropub@barrowneuro.org.
41. Kondziolka D. Current and novel practice of stereotactic ra-
INCLUDE WHEN CITING
diosurgery. J Neurosurg. 2019;130(6):1789-1798.
Published online April 29, 2022; DOI: 10.3171/2022.3.JNS212939.
42. Gardner PA, Prevedello DM, Kassam AB, Snyderman CH,
Carrau RL, Mintz AH. The evolution of the endonasal ap-
proach for craniopharyngiomas. J Neurosurg. 2008;108(5):​
1043-1047.
43. Cavallo LM, Somma T, Solari D, et al. Endoscopic endonasal
transsphenoidal surgery: history and evolution. World Neuro-
surg. 2019;127:686-694.

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