Equipoise in the management of intracranial aneurysms

Despite the continued evolution of endovascular therapy (EVT), microsurgery will remain not only a viable option for aneurysm management into the foreseeable future, but for many aneurysms, the preferred treatment. However, reduction in surgical case volume in favor of EVT now represents a systemic threat to surgical proficiency by drastically reducing case volumes and creating a training challenge for the next generation, thereby degrading the proficiency of future surgeons. Surgeons who can safely and effectively manage the aneurysms for which surgery remains the superior or only option are at risk of extinction. This review addresses this critical issue as we reach an inflection point in the history of cerebrovascular surgery. The evidence to support EVT or surgical management of aneurysms is critically reviewed in the context of equipoise, a genuine state of uncertainty regarding the superiority of one therapeutic modality over another. This review is not an argument against the immense value of EVT, which has saved countless lives and remains the optimal treatment for many patients. Rather, it is a call for balance, for a recalibration of clinical equipoise, and for the preservation of a complete and robust therapeutic armamentarium.