Ricardo A. Hanel, MD, PhD, Editor

Ciarán J. Powers, MD, PhD, Editor

Eric Sauvageau, MD, Editor

Endovascular treatment of cerebral aneurysms is now a commonplace procedure and has largely superseded the former gold standard of craniotomy for clipping. The primary advantage of endovascular surgery over microsurgery is the minimization of approach-associated morbidity. Even at the hands of the best neurosurgeons, the approach-associated morbidity of a craniotomy is significantly greater than endovascular approach. The liabilities of endovascular treatment, namely, lack of control at the operative site and questionable long-term durability, are increasingly being addressed with incremental innovation in support catheter, balloon technology, and coil/stent technologies. More recently, the advent of flow diverters, a disruptive technology when compared with endosaccular devices, is changing the paradigm of aneurysm treatment and allowing safe treatment of extraordinary lesions with much lower recurrence rates. The immediate future holds the promise for better tools to help us provide the best care for our patients, which should always be at the center of all considerations.

For this reason, we must approach this future with our eyes open and maintain a little skepticism. While the advances of technology in endovascular neurosurgery are impressive, for some pathologic processes, the indications for treatment remain undefined. Nowhere is this more evident than in the treatment of acute ischemic stroke from large vessel occlusion (LVO). With advances in stentriever and suction thrombectomy devices, successful angiographic recanalization rates are now consistently greater than 80%. However, as recent prospective randomized studies have shown, thrombectomy has yet to show a significant improvement in patient outcomes. While there are many valid criticisms of these prospective, randomized trials (especially the poor representation of current technology), the key issue is likely patient selection. Simply put, we do not yet know which patients will benefit from thrombectomy for acute LVO. As the practitioners capable of providing these remarkable endovascular treatments, it is incumbent on us to lead the research that will determine which patients are the best candidates for therapy.

Arteriovenous malformation also represents an area where patient selection is of the essence to improve patient outcomes. Endovascular therapy definitely represents a valid option or adjunct but the benefit could be nullified by inexperienced hands or if the procedure is directed toward the wrong kind of patient toward the wrong patient.

In summary, it remains primordial to educate present and future generations to be neurovascular specialists and not only mere technological savants. We hope this issue of Neurosurgery Clinics of North America will serve as a high-level topic review and keep the readers updated on current and future neurointervention directions.