In less than a lifetime, the treatment of neurovascular disease has progressed at a dizzying pace. Much of this progress has occurred in the last 40 years as technology, improved critical care, and subspecialization have resulted in continuous improvement in patient outcome. Many of the individual practitioners and scientists in the disciplines of neurology, neurosurgery, and radiology who have been responsible for advancing the field are still with us today. A number of us are privileged to count them as our mentors and colleagues. Our ability to treat complex neurovascular disease on a daily basis is due in large part to the efforts of those who struggled before us and have shared their passion, wisdom, and failings with us. In neurosurgery, these recent pioneers include Drake, Yasargil, Sugita, and a bevy of colleagues too numerous to list. Their contributions continue to influence the daily care of neurosurgical patients the world over. Likewise, neuroendovascular surgery owes much of its current status to Serbinenko, Hieshima, Berenstein, Djindjian, Merland, Moret, and Guglielmi. The contributions in devices, techniques, and experience influence the daily practice of endovascular therapy. Many of the 'pioneers' of endovascular therapy are working today and continuing to define the field.
The tremendous clinical successes of neuroendovascular techniques have led to an increase in the number of practitioners with a substantial number coming from specialties outside radiology. Best estimates worldwide suggest that nearly 50% of practitioners in neuroendovascular surgery come from specialties outside radiology, predominantly neurosurgery and neurology. interventional radiologists and neurosurgeons in North America have recognized this growing hybrid subspecialty through the establishment of joint guidelines for the training of neuroendovascular specialists1.
Historically, the first description of a vascular anomaly was an aneurysm from an autopsy case report by the British physician Gilbert Blane in 1800(2). The pre-morbid diagnosis of intracranial aneurysms did not occur until the introduction of lumbar puncture by Quincke in 1891(3). Egas Moniz, the father of modern cerebral angiography, introduced the technique in 1927 for the localization of tumors(4,5). In spite of the relatively recent introduction of methods for identifying vascular lesions, the first successful treatment of an aneurysm was in 1808 by Cooper who performed carotid ligation6. Zeller performed the first direct approach to a carotid cavernous fistula in 1911 and Dott successfully wrapped an intracranial aneurysm in 1931 7,8. The first aneurysm clipping was performed by Dandy in 1937 with a silver clip9. The subsequent introduction of the operating microscope and the development of aneurysm clips in their modern form brought neurovascular surgery into the modern era. One of the first technological improvements in aneurysm clips was Mayfield's introduction of clips that could be reapplied. Heifetz later added a reliable spring mechanism, and Yasargil and Sugita improved upon the early clips with designs that have become the standard the world over10,11. Modern neurosurgery subsequently trained a generation of neurosurgeons in microsurgical techniques12,13.
The origins of endovascular therapy can be traced to the first attempt to induce thrombosis of an aneurysm as reported in 1831 and 1832 by Velpeu and Phillips, respectively 14,15. Each independently placed needles within aneurysms to induce thrombosis. In 1941, Werner and colleagues reported treatment of an aneurysm by filling it with yards of silver wire through a spinal needle16. Mullen was one of the early neurosurgical pioneers in endovascular techniques. Mullen and coworkers induced electrothrombosis in aneurysms by the introduction of an electrode into aneurysms17. The first successful catheterization of intracranial vessels was reported by Lussenhop and Velasquez. Latex detachable balloons were created by Serbinenko, allowing the endovascular occlusion of vessels. The concept of magnetic navigation of microcatheters within the intracranial circulation was introduced by a group led by Askenasy. They prognosticated that some day a magnetically driven catheter would be used in the treatment of aneurysms18-20. This was subsequently expanded upon by Alksne and colleagues as well as Hilal21,22. This pioneering work was the harbinger of the current research involving magnetic field direction of catheters for interventional procedures.
Technical advances in endovascular therapy have moved the field rapidly in a few short years. Guglielmi and his colleagues from UCLA first reported their clinical experience using the technique of electrothrombosis and detachable coils to treat a carotid cavernous fistula in 1992 23. In 1995, the Guglielmi Detachable Coil (GDC) was approved for use in the US and is now used to treat more than 1100 aneurysms per month worldwide. It is now considered the treatment of choice for most posterior circulation aneurysms. The use of the GDC system for a particular aneurysm is dictated by aneurysm morphology, rather than surgical accessibility. It is generally unsuitable as a stand-alone treatment for large necked or fusiform lesions. However, many investigators have introduced techniques for extending the range of the GDC system. Moret popularized the balloon remodeling technique in which a microcatheter is placed within the aneurysm sac and a microballoon is used to hold the catheter within the aneurysm and protect the vessel lumen from coil herniation 24. Others have used highly navigable coronary stents to reconstruct fusiform arterial lumens and wide-necked aneurysms25-28. Stents provide a barrier for preventing coil herniation into the parent vessel lumen and physically alter blood flow across the aneurysm inflow tract. Within the next few years, prospective randomized trials will compare open surgery to endovascular therapy for the treatment of intracranial aneurysms. Such trials are necessary to better define the role of both surgery and endovascular treatment.
Stroke is the number one cause of adult disability in the industrialized world. As a public health issue, stroke prophylaxis yields tremendous dividends. Carotid endarterectomy (CEA) has been shown by multiple prospective randomized trials to diminish the risk of stroke in carefully selected patients with hemodynamically significant lesions 29. The roles of carotid artery stenting (CAS) and surgical bypass procedures are less clear. Anecdotal case series suggest strongly that CAS may be beneficial in those patients deemed high-risk surgical candidates. Repeat CEA, surgically inaccessible bifurcations, severe coronary artery disease, and radiation induced stenosis are a few of the indications for which CAS may be appropriate 30-32. The role of CAS will be defined in the coming years as it is compared directly and indirectly to surgery in prospective trials. Extracranial-intracranial (EC-IC) bypass was shown to be ineffective by prospective randomized trial in the past33. However EC-IC bypass will be revisited in the coming years as the Carotid Occlusion Surgery Study (COSS) compares best medical therapy to superficial temporal artery to middle cerebral artery bypass in patients with carotid occlusion and documented hemodynamic compromise. Most suspect that EC/IC bypass will be shown to diminish stroke in this high-risk group. Endovascular intracranial angioplasty and stenting for occlusive disease is typically reserved for inoperable or 'high-risk' patients. The past results are variable and anecdotal. Recent series have shown a marked decline in the historically high complication rates and suggest that it may have a role in the future treatment of intracranial atherosclerotic disease34,35.
The role of intravenous tissue plasminogen activator (TPA) has been established for the treatment of acute stroke for patients presenting within 3 h of symptom onset by the National Institute of Neurological Disorders Stroke trial (NINDS)36. In a recent meta-analysis, Brott and colleagues demonstrated greater benefit to those patients receiving intervention within 90 min, reinforcing the widely held perception that time is of the essence. Intra-arterial (IA) therapy has been reserved for those patients presenting outside the intravenous TPA window of 3 h. The efficacy of IA therapy has been proven conclusively in the Prourokinase for Acute Ischemic Stroke Trial37. Acute stroke therapy has been aided by better understanding of the pathophysiology of stroke and the coagulation cascade. Currently, less than 5% of all patients with acute stroke are treated with thrombolytics due to a combination of factors including community education and in-hospital delays. Many institutions capable of delivering i.v. therapy are unable to provide IA therapy to those patients in whom the i.v. therapeutic window has passed. Acute stroke therapy in the future will likely be aided by neuroprotective agents to diminish secondary reperfusion injury as well as thrombolytics and platelet inhibitors delivered by the intravenous and/or intra-arterial route.
Intracranial arteriovenous malformations (AVMs), described as early as 1887 by Pfannenstiel38, remain an often vexing pathology. The first complete excision of an AVM was performed by Pean in a young boy presumed to have a right frontal-parietal tumor 39. Early neurosurgeons advocated extreme conservatism with regard to AVMs. It was not until the introduction of cerebral angiography that surgery became more common as surgeons were able to identify AVMs preoperatively. Pitcher, Olivecrona and Riives, Penfield and Erickson, had all published successful case series by the late 40S 40-42. From 1932 to 1957, nearly 500 patients underwent surgery for AVMs with remarkable success rates. Mortality for small AVMs was approximately 5% and moderate lesions 6%-10%. As complications ensued in patients with incomplete removal of their lesions, the concept of complete removal of AVMs became accepted 43. The first AVM embolization was reported in 1960 by Luessenhop and Spence 44. Several large series of embolizations appeared in the literature reporting varying degrees of success 45,46. In 1977, Stein and Kjellberg et al.43 , presented series of patients treated with radiotherapy. Today, both surgery and radiosurgery play a prominent role in AVM therapy with embolization utilized as adjunctive treatment in specific cases. Endovascular embolization has been greatly aided in North America by the recent FDA approval of NBCA.
The diagnostic state of the art 50 years ago relied on angiographic methods, pneumoencephalography (discovered by Jacobeacus, applied clinically by Dandy), and clinical examination. Hounsfield's introduction of X-ray computed tomography transformed the diagnostic landscape in neurosurgery and neurology. Relative to previous imaging modalities, CT was effectively without complication and allowed brain pathology to be visualized directly rather than by its secondary effects on normal morphology47. Today, we can localize disease and functionality with a combination of noninvasive studies based on the physical and physiologic properties of the central nervous system and its diseased states. While endovascular therapy and cerebral angiography have seen renewed growth, the role of diagnostic cerebral angiography may well diminish as 3-dimensional reformatting of magnetic resonance angiographic and computed tomographic images improves.
In 75 years, neurovascular surgery has progressed in directions which could hardly have been imagined by physicians performing the first angiograms. What the next 75 years will bring is likely to be equally remarkable. The trend towards minimally invasive techniques will undoubtedly continue as budgets for health care strain to cover an increasingly aged population in North America. The ability to minimize morbidity and length of stay in hospital will become ever more important. Some lesions will be deemed best treated by open surgery and others by endovascular methods. This will ultimately be decided by prospective study. We will become better at controlling and minimizing secondary injury during stroke. This may begin simply by applying principles already appreciated by our colleagues caring for those with head injury-- avoidance of hypoxia and control of blood pressure. Arguably, a patient in need of IA thrombolysis should always be under anesthesia for their own benefit in terms of safety, ease of operation, and cerebral protection. Bioactive implants will play an ever increasing role in treatment. Already, our colleagues in cardiology are beginning to utilize coated stents with positive outcomes and soon neuroendovascular surgeons will be able to place bioactive coils within aneurysms to improve neck obliteration. Such treatments are harbingers of the future, encouraging vessels to remodel and repair by controlling local physiologic responses. Just as 75 years ago, some of the future directions of vascular surgery are apparent, but the ultimate destinations are unknown.
ACKNOWLEDGMENTS
Thanks are due to the many authors who have contributed to this issue. The authors are representative of the current state of neurovascular therapy. They are neurologists, neurosurgeons, neurointerventionalists, and basic scientists with often similar interests, complementary and occasionally overlapping skills, whose sole aim is to provide the best possible care to patients. They represent the present and future of our specialties. I must also acknowledge and thank my own mentors and colleagues, Fernando G. Diaz, Manuel Dujovny, and L. Nick Hopkins for their support, wisdom, and encouragement.
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Richard D. Fessler, MD Assistant Clinical Professor Director of Neuroendovascular Surgery Harper University Hospital
Departments of Neurosurgery and Radiology Wayne State Univedrsity School of Medicine Detroit, MI, USA
Copyright Forefront Publishing Group 2002
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