I frequently tell our residents and fellows that if they want to make a mark in neurosurgery they should consider the remaining ‘growth’ fields in our subspecialty and pursue those career paths. Obviously, I am biased in the belief that neurointervention is at the top of that list. However, the rapid growth of our field, based largely on quantum advances in technology, renders it unwieldy and difficult to conscribe to our perceptions of how ‘evidence based medicine’ should be conducted. For example, there is a good chance that many of the devices we use today will be replaced in a year by better products. Should we then be held accountable and perhaps restricted in our practice as a result of poor or less than optimal results achieved through the use of these inferior devices? Furthermore, what is the role of randomized controlled trials in steering our field forward when technologic advancements continually redefine it?

The cerebrovascular community is encountering these dilemmas in rapid succession. Specifically, the recent publication of the SAMMPRIS (Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis trial), COSS (Carotid Occlusion Surgery Study), ISAT (International Subarachnoid Aneurysm Trial) and BRAT (Barrow Ruptured Aneurysm …