Cerebrovascular Surgery: Past, Present, and Future

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Abstract
The lyrics expressed in the famous Lennon/McCartney song might easily have expressed the state of mind of the modern physician battling the managed care revolution. They might equally apply to those cerebrovascular surgeons among us who remember better times: days when, armed with talent, innovation, manual dexterity, and a microscope, we roamed supreme over the kingdom of aneurysms, vascular malformations, and occlusive disease. Today our “turf” is threatened from every direction. Incredibly, aneurysms can now be approached and obliterated from the inside, with utter indifference and disregard to the complex cisternal anatomy delineated by Yaşargil. Moreover, many aneurysms may not need to be treated at all. Arteriovenous malformations (AVMs), lesions that once needed to be meticulously extirpated one microvessel at a time, can now be embolized from the inside or irradiated in a semirobotic, highly relaxed atmosphere. As for arterial occlusive disease of the brain, for which the surgeon's skills once consisted of either “unjamming” the traffic or rerouting it, today there is no shortage of attempts at neuroprotection by pharmacological and molecular genetic methods, coupled with an exploding field of endovascular innovations. At first glance, to the traditional cerebrovascular surgeon, “yesterday” can look quite appealing indeed!