Virginia Via Research Day Book 2026

Medical Student Research Clinical

13 REDEFINING SURGICAL INDICATIONS IN THE ENDOVASCULAR ERA: EARLY EXPERIENCE OF A DUAL-TRAINED NEUROSURGEON IN A PRIVATE COMMUNITY PRACTICE

Ramzi Badra, OMS-III; Kristine Ravina, MD; Benjamin Yim, MD Corresponding author: rbadra@vt.vcom.edu

VCOM-Virginia, Blacksburg, Virginia Department of Neurosurgery, Carilion Clinic, Virginia Tech School of Medicine, Roanoke, Virginia Neurosurgery Division, John Muir Health, Walnut Creek, California

treated endovascularly and 24 (11%) were clipped. Indications driving open over endovascular approach included aneurysm morphology (n=63%), failure of endovascular techniques (n=21%), and noncompliance with dual antiplatelet therapy (n=16%; p=0.0098). Subarachnoid hemorrhage (SAH) was present in 37 cases (17%), with 81% managed endovascularly and 19% clipped. Choice of clipping for ruptured aneurysms was most often due to limitations in aneurysm morphology followed by failure of endovascular techniques. Treatment modality varied significantly by aneurysm location (p < 0.001). Clipping was more common for middle cerebral artery (MCA; 50%) and anterior communicating artery (ACOM; 25%), while endovascular techniques predominated for internal carotid artery (ICA; 25%) and posterior communicating artery (PCOM; 22%) aneurysms. For aneurysm clipping, mini craniotomy was favored for MCA, while standard craniotomy was dominant for ACA clipping (p = 0.0018). Among endovascular treatments, flow diversion was most frequently used for ICA and PCOM, whereas stent-assisted and primary coiling were more

common for ACOM and MCA aneurysms (p = 0.00015). Conclusion: Microsurgical clipping skills remain essential for anterior circulation aneurysms - particularly the MCA and ACOM and is significantly influenced by aneurysm morphology. Additionally, anatomical considerations strongly influenced the specific technical strategies utilized within each modality.

Context: The emergence of dual-trained cerebrovascular and neuroendovascular (CVNV) neurosurgeons, along with advancements in endovascular technology have shifted and expanded the treatment landscape for intracranial aneurysms. However, the practice patterns of CVNV neurosurgeons in the non-academic setting remain poorly defined. Objective: To characterize treatment decision making and technical strategies employed by a CVNV neurosurgeon during the first three years of private practice. Identify key factors influencing treatment modality for intracranial aneurysms, including morphology, rupture status, and patient considerations. Methods: This is a retrospective cohort analysis of consecutive aneurysms treated by a single CVNV neurosurgeon during the first three years of practice. Cases were categorized by treatment modality (clipping vs. endovascular), technical strategy, aneurysm location, and rupture status. Results: Of the 218 aneurysms, 194 (89%) were

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184 Edward Via College of Osteopathic Medicine (VCOM)