Technical development does not come from reading a book; it comes from operating. Neurosurgeons develop microsurgical skills through a combination of repetition, technical mistakes, outside learning, and high standards.

The secret of success with aneurysm surgery is case volume. Splitting fissures, drilling clinoids, deciphering aneurysm anatomy, dissecting perforators, and applying clips all get easier with practice. Therefore, aneurysm surgery is no different from any other art or sport that combines physical and cognitive training. Aspiring neurosurgeons do not shy away from high case volume; they covet it, make personal sacrifices to acquire it, and endure its side effects. Aneurysm surgery is exhausting and stressful, and repetition can blunt the thrill and add pressure from rising personal expectations. However, high volume helps in developing efficiency, confidence, and experience. A steady stream of patients often requires an academic practice, subspecialization in vascular neurosurgery, a collaborative team of endovascular surgeons and vascular neurologists, and regional prominence that will attract referrals.

Mistakes are unavoidable. Master neurosurgeons who train residents teach them to clip aneurysms, but seldom make “rookie” mistakes. As a result, residents do not see the missteps the mentor might have made when he or she was a young neurosurgeon, and residents may not appreciate the nuanced techniques of their mentor that avoid these mistakes. Technical errors with aneurysms often result in morbidity or death. These cases are dark and indelible moments that call for introspection. These cases replay in the mind, or on intraoperative video, to determine better moves for next time. Notes from similar cases are reviewed, sifting through past lessons and searching for new ones. The advice of other neurosurgeons may help. Preoperative and postoperative angiograms may clarify intraoperative findings. This process illuminates where improvement is needed. Failures, more than successes, stimulate technical development. Success becomes an expectation and good outcomes are quickly forgotten, but failure is the catalyst that transforms and matures young neurosurgeons, advancing them forward along the learning curve. Poor outcomes and dead patients are impossible to forget and can be haunting. Neurosurgeons ill equipped to absorb these blows react with fear and avoidance at one extreme, or callous insensitivity at the other extreme. In between are humility, introspection, and discipline. Neurosurgeons redeem themselves by maintaining their confidence, committing themselves to learning, and applying what they have learned to future patients.

Outside learning is important in cognitive development. There will be those aneurysms that are too difficult, beyond the neurosurgeon’s ability. These cases call for time spent in the cadaver laboratory, course work with experts, and reading. This book is meant to help with this learning process.

Clipping an aneurysm is the prototypical neurosurgical operation. It is the classic confrontation between surgeon and pathology; it requires manual dexterity, knowledge of anatomy, and a delicate touch rather than gadgetry and high technology. The stakes are high—patients live or die depending on the neurosurgeon’s skill. This iconic operation has made aneurysm surgeons into icons of neurosurgery: Dandy, Yasargil, Drake, Sundt, Spetzler, and others. These acknowledged masters have been mentors to many aneurysm surgeons, and an important part of technical development is adopting their high standards of excellence. These lofty standards require dedication, commitment, and some of our very best neurosurgeons. The end result is technical skill, grateful patients, personal fulfillment, and the perpetuation of aneurysm surgery. Aneurysm surgery is and should remain an important element of neurosurgical culture, even as endovascular techniques advance in popularity and sophistication. More importantly, neurosurgeons will be needed to deal with the complex aneurysms that cannot be managed any other way. The complexity of open aneurysm surgery will continue to increase as endovascular therapy addresses the simpler cases. Modern aneurysm techniques offer excellent solutions for the seven types of aneurysm discussed in this book, and must be saved for those aneurysms that require them.