Vascular Neurosurgery

Vascular neurosurgery is one of the most popular and rapidly evolving subspecialties within neurosurgery. Using cutting-edge technology, vascular neurosurgeons treat conditions of the brain and spinal cord involving blood vessels (arteries and veins).

Within vascular neurosurgery, many techniques are utilized including traditional surgical approaches (open vascular techniques) and minimally invasive approaches through blood vessels (endovascular techniques).

These techniques allow specialists to treat a wide variety of disorders and restore function to their patients. Herein, we’ll discuss many aspects of neurovascular surgery and answer many commonly asked questions by patients and caregivers alike.

Open cerebrovascular neurosurgery refers to the use of traditional surgical techniques, such as a craniotomy, to treat vascular pathology. Endovascular neurosurgery is a minimally invasive technique which uses specialized catheters (wires) to enter blood vessels in the wrist or groin.

These catheters can be used to perform advanced diagnostic imaging to gather pictures of the network of blood vessels using contrast dyes. Endovascular techniques utilize these catheters to treat strokes, aneurysms, and even to seal off the blood supply (embolize) to the tumors of the brain and spine.

Vascular neurosurgeons often undergo additional fellowship training to learn skills pertinent to vascular disorders of the brain and spine. Traditional neurosurgery residency is now 7 years long. Fellowship training can occur during the traditional neurosurgery residency (known as an enfolded fellowship) or after graduation from a neurosurgery residency program.

Even with a specialized fellowship training, many vascular neurosurgeons continue to treat many different types of brain and spinal cord pathology. Vascular disorders are commonly intertwined with these pathologies and the use of specialized techniques can enhance certain diagnostic and treatment modalities.

While open vascular techniques can only be performed by neurosurgeons in an operating room setting, endovascular techniques can be performed by physicians in other specialties. Fellowship training in endovascular intervention allows neurologists and radiologists to diagnose and treat certain vascular diseases.

It is not uncommon for a hospital to employ interventional neurologists and interventional neuroradiologists to work in tandem with a team of neurosurgeons. Each specialist provides additional perspective to facilitate the care of the patient. 

Most commonly, vascular neurosurgeons focus on disorders of the blood vessels (arteries and veins), such as:

• Stroke: Acute ischemic stroke is one of the most time sensitive and common interventions handled in endovascular neurosurgery. Ischemic strokes occur when a portion of the brain loses blood flow. This typically occurs when a clot or other debris blocks the passage of blood flow through a major vessel in the brain. Endovascular neurosurgeons can retrieve the clot and restore flow.
• Intracranial aneurysms: Balloon-like outpouchings of blood vessels in brain that can rupture and cause symptoms. If an aneurysm ruptures, it requires an immediate attention and possible intervention to stop the site of bleeding.
• Arteriovenous malformations (AVMs): AVMs are often congenital (present at birth) abnormalities of blood vessels. High-pressure arteries normally diverge into capillaries before converging into veins. In AVMs, these high-pressure arteries connect directly with low-pressure veins. This phenomenon can result in a mass of engorged blood vessels leading to a risk of rupture and bleeding within the brain. Endovascular intervention can block these abnormal arteries and surgery can remove the AVM. Surgery remains the most definitive way to cure an AVM.
• Cavernous malformation: Cavernous malformations are similar to AVMs, except the blood flow within cavernous malformations is much slower. Surgical removal in certain symptomatic cases is recommended.
• Brain tumors: Certain brain tumors, specifically meningiomas, may benefit from pre-treatment with endovascular embolization of the tumor’s blood supply. This can minimize blood loss during surgery and may have benefits to patient outcomes.

It is important to understand the cardinal signs and symptoms that should alert patients to the possibility that they are experiencing the effects of cerebrovascular disease. Listed below are several clusters of signs and symptoms that are important for patients to be aware of:

1. Ischemic Stroke:

• Sudden numbness or weakness in the face, arm, or leg, especially on one side of the body.
• Sudden confusion, trouble speaking, or difficulty understanding speech.
• Sudden trouble seeing in one or both eyes.
• Sudden trouble walking, dizziness, loss of balance, or coordination.
• Sudden severe headache with no known cause.

2. Hemorrhagic Stroke:

• Sudden severe headache that is often described as the worst headache of one’s life.
• Some individuals refer to this headache as a “thunderclap” headache, unlike anything they have ever experienced before.
• Sudden weakness or numbness, especially on one side of the body.
• Sudden difficulty speaking or understanding speech.
• Sudden vision changes or loss of vision in one or both eyes.
• Loss of consciousness or fainting.

3. Carotid Stenosis:

• Transient ischemic attacks (TIAs), also known as “mini-strokes”, which may cause temporary weakness, numbness, or paralysis on one side of the body.
• Sudden weakness or numbness, usually on one side of the body.
• Sudden difficulty speaking or understanding speech.
• Sudden vision changes or loss of vision in one eye.
• Facial drooping or asymmetry.

4. Aneurysms:

• Sudden severe headache, often described as a thunderclap or the worst headache ever experienced.
• Nausea and vomiting.
• Stiff neck or neck pain.
• Sudden vision changes, such as double vision or loss of vision.
• Seizures.

Individuals should recognize these signs and symptoms and seek immediate medical attention if they or someone else experiences them. Time is critical in treating cerebrovascular diseases, and prompt intervention can significantly improve outcomes.

There are roughly 3,500 neurosurgeons practicing in the United States. Vascular neurosurgeons represent only a fraction of this already limited workforce. Given the need for costly technology involved with endovascular imaging and intervention, vascular neurosurgeons are typically in academic university hospitals or large urban areas.

These specialists are rarely, if ever, seen in rural settings. Their placement in teaching hospitals makes them available to the community, frequently seeing patients brought into the emergency department by ambulance or helicopter from smaller or rural hospitals.

Commonly, patients with severe and obvious signs of stroke and other vascular disorders including brain hemorrhage come to the emergency department and are seen by a vascular neurosurgeon. In other cases, non-symptomatic vascular disease may be inadvertently discovered by radiologists, neurologists, family practitioners, and internists (internal medicine physicians) during a workup for an unrelated condition.

Large cancer centers may also consult vascular neurosurgeons in cases where blood supply to tumors or high-risk areas may be problematic. As one of the fastest growing sub-specialties in neurosurgery, vascular neurosurgery offers many advantages in the care of a wide variety of patients and pathologies.

• Vascular neurosurgery is a critical sub-specialty with true promise and major contributions to the future of neurosurgery.
• Endovascular techniques are minimally invasive and gaining further traction with the neurosurgical community for a wide variety of treatment scenarios.
• Open vascular techniques, while more invasive, are necessary for certain complex and difficult to access vascular diseases.

• American Association of Neurological Surgeons Cerebrovascular Section
• Brain Aneurysm Foundation
• The Aneurysm and AVM Foundation 
• American Stroke Association