Network Optimization - Ep.2/2 - SLICE Worldwide 2022


Is simulation-based training useful for neuro-intervention?


The natural history of large vessel acute ischemic stroke is devastating. Several studies have proven that endovascular treatment is highly efficient, with a number needed to treat of 2-3 patients to obtain 1 functional independence. While these results have been outstanding and revolutionized acute stroke treatment, a vast majority of patients worldwide do not yet benefit from adequate treatment due to a lack of trained physicians. Simulation training has been proposed as a means of shortening the learning curve and improving the technical skills of physicians.

Drawbacks of the classical learning method in neuro-intervention[1]:

1) Long duration of treatment: residents/fellows are gradually introduced to more difficult tasks in vivo until they reach greater independence and can perform procedures independently. Optimal training period varies on the volume of the center and the number of trainees, but in high-volume centers (>300 thrombectomies, >2000 neurointerventional procedures per year), it should be at least one year until a trainee can safely perform thrombectomies.

2) Financial difficulties: many fellowship programs are not sponsored by the public healthcare systems, and fellows must subside on their own or search for funding during the long time they spend training; Moreover, this implies additional personal costs as fellows are physicians that accept less payment to learn new skills and to develop.

3) Low case volume: Healthcare systems with low-case volumes due to an inadequate number of physicians who can cover 24/24/7/7 service will face a “chicken-and-egg” problem as it will be great difficulty to raise the number of physicians due to lack of training opportunities and these will discourage young doctors from pursuing a career in what they see as long, difficult and uncertain pathway. In turn, this will perpetuate a low number of cases.

4) Lack of patient safety: training directly on patients, despite supervision, may lead to a higher overall complication rate.

5) Lack of procedural standardization: each procedure being taught in a mentor-trainee model will be more prone to personal beliefs and less evidence-based. This may result in perpetuating the same errors in centers from professor to a young physician to future professor without critically analyzing procedural steps ( “We always do it like that” )

6) Lack of discussion about learning points during procedures: during a procedure, it is difficult to stop and explain several steps that one has to do and why one does those steps as the concentration of the operator regards the case itself and the well-being of the patient and is less sensitive to the needs of the trainee.

7) Lack of an objective method to assess the trainee’s progress.

Potential benefits of simulation-based training[2,3]:

1) Simulation-based training may offer a safe and easy way to accelerate the learning curve of young physicians.

2) By accelerating the learning curve and by obtaining adequate feedback from the simulator, physicians may be more rapidly introduced to new steps of the procedure, and overall training period may shorten given the high number of virtual cases that a trainee can perform in a given time frame;

3) Simulation-based training, can be used to help physician training in low-volume settings where any additional case is a teaching opportunity and where a simulator may offer doctors the chance to experience cases that they otherwise would rarely see.

4) Simulation-based training, can be highly standardized, and the simulator may spot – and adequately report intra-operator and inter-operator progress;

5) Simulation-based training, permits the partitioning of each procedure into several small steps that the expert performs as a whole. These are rarely thought of as separate steps, difficult to learn at the start, and forgetting some during the initial practice may raise the risk of complications.

6) Simulation-based training allows one to retry different techniques in the same anatomy, thereby comparing between “empiric optimal strategies”’.

7) In-vitro procedures may lead to more optimal standardization of neurointerventional procedures and thus eliminate several small individual errors that are prone to individual center experience and habits.

8) Simulation-based training for stroke procedures may help healthcare systems facing low-procedural volume due to an inadequate number of interventionalist to accelerate the number of physician training and thus to offer overall better outcomes at a populational level.


Current training standards in neuro-intervention result from a historic teaching model that disregards modern approaches that have been proven efficacious in various other domains. By disregarding these options, not pursuing them, and/or further developing them, our specialization may be subject to perpetuating errors that will not be easily evident without adequate standardization of training. With adequate development and implementation of modern simulators, it is not just the physicians but the whole community that stands to gain a lot of disability adjusted life years.

Further reading:

1. Kurz, M.W.; Ospel, J.M.; Advani, R.; Sandset, E.C.; Aamodt, A.H.; Tennøe, B.; Ersdal, H.L.; Fjetland, L.; Ajmi, S.; Kurz, K.D.; et al. Simulation Methods in Acute Stroke Treatment. Stroke 2020, 51, 1978–1982, doi:10.1161/STROKEAHA.119.026732.

2. Patchana, T.; Wiginton, J.; Ghanchi, H.; Favre, A.W.; Tayag, E.C.; Schiraldi, M.; Miulli, D.E. Use of Endovascular Simulator in Training of Neurosurgery Residents - A Review and Single Institution Experience. Cureus 2020, 12, e11931.

3. Ospel, J.M.; Kashani, N.; Mayank, A.; Liebig, T.; Kaesmacher, J.; Holtmannspötter, M.; Shankar, J.; Almekhlafi, M.A.; Mitha, A.P.; Wong, J.H.; et al. Current and future usefulness and potential of virtual simulation in improving outcomes and reducing complications in endovascular treatment of unruptured intracranial aneurysms. J. Neurointerv. Surg. 2021, 13, 251 LP – 254, doi:10.1136/neurintsurg-2020-016343.


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