Neurovascular surgery: a narrative review of the way forward from the UK perspective

Background and Objective: Neurovascular disorders, including brain aneurysms, arteriovenous malformations (AVMs) and intracranial atherosclerosis, are a significant burden on healthcare systems globally. They can result in significant morbidity and mortality. Over the past two decades, advancements in neurovascular surgery, particularly in endovascular techniques, have reshaped treatment approaches and the International Subarachnoid Aneurysm Trial (ISAT), which demonstrated the superiority of endovascular coil occlusion over microsurgical clipping for ruptured intracranial aneurysms, catalysed this change. In the UK, endovascular surgery, primarily performed by interventional neuroradiologists (INRs), is the treatment of choice for most brain aneurysms and is also beginning to be advocated in the treatment of other neurovascular pathologies. Consequently, many have questioned the long-term viability of open neurovascular surgery in the UK. More recently, the introduction of mechanical thrombectomy (MT) for acute ischemic stroke and the promising results of middle meningeal artery embolisation (MMAE) for chronic subdural haematomas have highlighted the demand for endovascularly trained practitioners and may represent an opportunity for dual (open and endovascular) neurovascular training in the UK. This review aims to explore the current state of neurovascular training in the UK and to examine the potential challenges for the future of neurovascular surgery.

Methods: Key databases, including PubMed, Embase, and Web of Science, were searched for articles published from January 2000 to September 2025. Search terms included “neurovascular surgery OR neuroendovascular surgery”, “endovascular techniques”, “microsurgery OR open neurovascular surgery” and “training in vascular neurosurgery”. Inclusion criteria focused on studies written in the English language and relevant to the United Kingdom (UK) healthcare context, though selected articles from high-income countries were included for comparison.

Key Content and Findings: This review explores the evolving landscape of neurovascular surgery in the United Kingdom (UK), focusing on training pathways, workforce challenges, and the integration of emerging technologies. We explore the differences between neurosurgical and INR training in the UK and how this has limited the number of dual-trained practitioners, in contrast to practices in North America. The introduction of MT and MMAE has created increased demand for endovascularly trained practitioners.

Conclusions: We highlight the necessity of adapting training models to ensure a balanced and competent neurovascular workforce, ultimately improving patient outcomes and sustaining the future of both open and endovascular neurovascular surgery.