On Aneurysmal Rupture and Rerupture.

A warning leak is a curious phenomenon attributed to cerebral aneurysms. Once the leak occurs, it has been postulated it could lead to a more catastrophic rebleeding. The designation "warning leak" trickled into neurosurgery vocabulary as early as the 1950s. The phenomenon has been poorly understood and characterized, but its presence spurs emergency physicians and neurointensivists to take action to secure the aneurysm. Rapid treatment of a recently discovered aneurysm is now commonplace, but it has not always been so. Antifibrinolytic agents spawned particular interest in the late 1970s, when many neurosurgeons postponed surgery after a recent hemorrhage. This historical vignette reviews the early views on aneurysmal rupture, rerupture, and the role of fibrinolysis.

Cardiac standstill and circulatory flow arrest in surgical treatment of intracranial aneurysms: a historical review.

Since the first surgery for an intracranial aneurysm in 1931, neurological surgeons have long strived to determine the optimal methods of surgical correction. Significant challenges of aneurysm clipping include intraoperative rupture and complex dome morphology. Hypothermia, cardiopulmonary bypass, pharmacologically induced hypotension, and cardiac standstill are a few of the methodologies historically and currently employed in the management of these issues. In the 1980s, significant advances in pharmacology and anesthesiology led to the use of agents such as adenosine for chemically induced hypotension and eventually complete circulatory arrest. Since the institution of the use of these agents, the traditional methods of circulatory arrest under conditions of hypothermia and cardiopulmonary bypass have fallen out of favor. However, there still exists a subset of technically difficult aneurysms for which cardiac standstill, both chemical and hypothermic, remains a viable therapeutic option. In this paper, the authors describe the history of cardiac standstill by both hypothermic and chemically induced means as well as provide examples in which these techniques are still necessary.

The ventral route to intracranial aneurysm: from the origin towards modern transsphenoidal surgery. An historical review and current perspective.

OBJECTIVE: A review of the main studies that have explored the use of the ventral pathway for treatment of intracranial aneurysms,including the recent reported extended transsphenoidal approaches. METHODS: A comprehensive literature review was performed using the PubMed database. We recovered 48 cases of cerebral aneurysms, approached via the transcervical-transclival, transoral-transclival, transfacial-transclival ventral pathways and the extended transsphenoidal route. The overall rates of complications and surgical success were evaluated and compared for both traditional ventral and transsphenoidal approaches. RESULTS: For traditional routes, the overall complications and surgical success rates were 74% (26/35) and 87% (13115), respectively.For extended transsphenoidal approaches were 44% (4/9) and 78% (7 /9), respectively. CONCLUSION: Our paper is a reconnaissance of what has been done via "the anterior route" and a notification of the existence of this "surgical window': Present and future of cerebral aneurysm treatment is represented by the endovascular technique. A few selected cases in specialized centers, where transsphenoidal approaches with the aid of the endoscope are routinely performed,may be treated with such techniques alone or in combination with other different procedures. Further studies in large numbers of patients will be required to validate the full benefit of this approach.

Petrosal approaches to posterior circulation aneurysms.

Complex posterior circulation aneurysms are formidable lesions with an abysmal natural history. Their management continues to present a challenge to both endovascular and open microsurgical approaches. Affording an expansive, combined supra- and infratentorial exposure, the petrosal approaches are well suited for these challenging lesions when located along the basilar trunk or at a low-lying basilar apex. This report evaluates the evolution and application of petrosal approaches to these lesions. Excluding transsigmoid, infratentorial, or labyrinth-sacrificing approaches, the authors found 23 reports with 61 posterior circulation aneurysms treated via a petrosal approach. Although early morbidity was not negligible, rates of aneurysm occlusion (95% overall) and long-term outcome were quite laudable in light of the challenge posed by these lesions. Moreover, with accumulating experience with petrosal approaches, rates of complications are likely to wane, as neurosurgeons capitalize on the expansive exposure afforded by these indispensable approaches.

A view on the current and future therapy of brain aneurysms.

While in clinical practice the use of endovascular and microsurgical methods retained relative levels by 2010, since 2008 the research activity has lagged behind that in other medical disciplines. Particularly research on neuroprotection, such as hypothermia and pharmacological measures, has lost impetus, and clinical applications of specific neuroprotective interventions have been largely abandoned. The last substantial advancement for aneurysm surgery was the introduction of intraoperative indocyanine green (ICG) angiography. The technical evolution of endovascular therapy has been somewhat more active than that of microsurgery. It is our conviction that microsurgical methods need to develop a focus particularly on minimal invasiveness and also cosmetic aspects. Teaching remains an important consideration. It appears that an explicit framework is necessary in order to communicate the specific do's, don'ts and hows of aneurysm surgery, i.e., a set of rules addressing general perioperative management, principles of exposure and dissection of the typical configurations, clipping technique and the specific issues concerning very small and very large aneurysms. Quality management has become an unconditional requirement also in neurovascular surgery. At our department we have established a system of identification of complications and monthly case analysis. Despite these efforts combined management morbidity and mortality for ruptured and unruptured aneurysms remains around 10%, which appears to be the achievable degree of safety in unselected patients with the current technology.

One of the giants of neurological surgery left us more than a decade ago, and neurosurgical literature did not show much interest.

One of the giants of neurological surgery left us over a decade ago. Charles George Drake died September 15, 1998 in London, Ontario after an extended bout with lung cancer. Although he will always be identified with taking posterior fossa aneurysm surgery from the realm of the daring to the domain of the routine, his contributions were much broader. Clinical neurosciences have been blessed in the past century by the life and works of Drake. In the neurosurgical world, the achievements of Drake are very well known and have been well recorded. Unfortunately, in the past decade since his passing, only one paper has been published about him and his contributions to neurosurgery. This is a historical paper regarding Charles George Drake that attempts to (1) remember Drake as a pioneer; (2) to evaluate lessons that we have learned from him; and (3) to address the question 'What made him great?'. As per Drake's teachings, this paper is meant to articulate the unique perspectives Charlie provided with respect to how we learn our craft, maintain the integrity of reporting, and implement suggestions as to how we may progress into the future. In conclusion, it is our hope that this paper will bring to life the unique character of Drake and his unprecedented blend of genius, creativity, technical skill, introspection, and ever-present humility for all international neurosurgeons to appreciate.

Dominique Anel, John Hunter, and the Eponymous Hunterian Ligation of Aneurysms: Conception to Current Practice.

The contributions of both Dominique Anel and John Hunter in the development of the eponymous Hunterian ligation of aneurysms are presented. John Hunter, the "father of scientific surgery" lent his name to the eponymous practice of applying ligatures to aneurysmal dilatation of arteries. However, evidence suggests that the operation might antedate him by decades. Dominique Anel was a surgeon in the time of Louis XIV who, after his initial apprenticeships in Toulouse and Montpellier, subsequently served in the French navy. He famously described the lacrimal syringe that bears his name but was also interested in diseases of the bones and arteries. Anel described his technique of ligating an aneurysm of the brachial artery in the winter of 1709-1710 in Turin. His description of ligating just the upper end of the aneurysm without touching the sac was described in his collected works in 1714. This technique was exactly the same as that used by Hunter. However, Hunter had based his decision not to excise the sac on his own research. Hunterian ligation was used routinely before endoaneurysmorrhaphy, after which its popularity declined. Hunterian ligation has been superseded by development of surgical clips and endovascular techniques for intracranial aneurysms. However, the technique is still described occasionally in vascular and neurosurgical literature in the context of treating large aneurysms not amenable to traditional treatment modalities.

History of the genesis of detachable coils. A review.

The genesis of detachable coils and the background of this genesis are described in this article. To frame the beginning developmental stages of the discovery of detachable coils, the previous extravascular-intravascular and endovascular techniques are presented, as well as the development of the various delivery systems. The experimental studies, initial clinical application, and crucial moment of the conception of detachable coils are also reported.

[A century of intracranial aneurysm treatment: from carotid ligation to endovascular procedures]. / De la ligature de carotide aux techniques endovasculaires ou un siècle de traitement des anévrismes intracrâniens. Historique du traitement des anévrismes.

Intracranial aneurysm treatment began in the 20th century. Treatment remained anecdotal for a long time because these lesions could not be visualized. This was the period of hunterian ligation of the carotid and trapping. After the discovery of the carotid angiography at the end of the 1920s, a new direct clipping approach started. Other techniques were used, such as wrapping and coating. Finally, in the 1980s, endovascular procedures appeared and are now in constant progress. The advantages, problems and improvements of these treatments are briefly reviewed.

Francesco Rizzoli (1809-1880) and the elusive case of Giulia: the description of an ''arteriovenous aneurysm passino through the wall of the skull''.

The improved knowledge of clinical and emodynamical aspects of extracranial arteriovenous malformations in the 18 th century provided a foundation for the understanding and treatment of cerebrovascular pathology. It was not until the late 19 th century that detailed clinicopathological reports of intracranial arteriovenous malformations were published. In this historical context, a seminal report written by the Italian surgeon Francesco Rizzoli is worthy of notice, the Giulia case. A 9-year-old girl presenting with seizures and an occipital pulsanting swelling was examined in 1873 by Rizzoli. He was able to use Giulia's signs and symptoms to predict the complex angioarchitecture of her ''arteriovenous aneurysm passing through the wall of skull''. The postmortem dissection completely confirmed the supposed diagnosis, disclosing a direct communication between the hypertrophic branches of the ocipital artery and the transverse sinus. The clinical course of that case is briefly reviewed in this article and the diagnosis of this unusual arteriovenous shunt is discussed in light of the current neurosurgical knowledge.

Dr. Norman Chater and Chater's Point.

Dr. Norman Chater, a University of California San Francisco-trained microvascular neurosurgeon, dedicated his career to the development of surgical bypass techniques. His work contributed to advancements in microvascular anatomy and the development of cerebral revascularization techniques. He identified Chater's point, an extracranial landmark that marks the posterior extent of the Sylvian fissure, which on craniectomy reliably exposes vessels of the angular gyrus, the vasculature found to be most appropriate for bypass procedures owing to its accessibility and vascular diameter. This surgical landmark continues to be essential for the successful execution of bypass surgeries to this day.

History, Evolution, and Continuing Innovations of Intracranial Aneurysm Surgery.

Evolution in the surgical treatment of intracranial aneurysms is driven by the need to refine and innovate. From an early application of the Hunterian carotid ligation to modern-day sophisticated aneurysm clip designs, progress has been made through dedication and technical maturation of cerebrovascular neurosurgeons to overcome challenges in their practices. The global expansion of endovascular services has challenged the existence of aneurysm surgery, changing the complexity of the aneurysm case mix and volume that are referred for surgical repair. Concepts of how to best treat intracranial aneurysms have evolved over generations and will continue to do so with further technological innovations. As with the evolution of any type of surgery, innovations frequently arise from the criticism of current techniques.

The transition from hunterian ligation to intracranial aneurysm clips: a historical perspective.

The description of cerebral aneurysms dates back to antiquity. Little was known, however, about the pathological mechanisms of aneurysm formation and treatment options for this disease until 200 years ago. The modern era of aneurysm treatment began with the hunterian ligation of the proximal artery, followed by clip and coil occlusion. In this article, the authors describe the transition from conservative therapy to internal carotid artery (ICA) ligation and gradual occlusion of the ICA to the direct placement of clips on aneurysms. The driving forces and rationale behind each major advancement are summarized, and the authors attempt to predict what these innovations mean for the future of intracranial aneurysm management.

History of surgery for cerebrovascular disease in children. Part I. Intracranial arterial aneurysms.

Intracranial aneurysms are rare in children, and their origins and treatment methods tend to be different from those in these same entities in adults. These lesions tend to be congenital or to have an infectious or traumatic origin. In the current paper the authors trace the historical evolution of the diagnosis and treatment of intracranial aneurysms in children. Based on the literature, these lesions appear to occur in children in less than 3% of all series. The literature also supports the suggestion that symptoms from these aneurysms are often from mass effect and that giant aneurysms and lesions in the posterior cranial fossa are relatively more common in children than in adults. The termination of the carotid artery and the anterior cerebral artery seem to be disproportionately common sites of aneurysm formation in this cohort. Interestingly, surgical outcomes in children appear to be moderately better than in adults. Based on the literature, the claim can be made that a multidisciplinary approach to the management of such aneurysms can yield good outcomes in a very high percentage of children treated.

Historical Landmarks in the Management of Aneurysms and Arteriovenous Malformations of the Central Nervous System.

OBJECTIVE: To describe the history of vascular and endovascular neurosurgery. METHODS: A literature research was conducted including historical events from 2000 bc to the twenty-first century ad, and a timetable was filled with information regarding the most representative historical landmarks regarding vascular and endovascular neurosurgery. RESULTS: Starting from approaches limited to the cervical carotid artery, vascular neurosurgery gained its way through the intracranial and finally endovascular space thanks to the introduction of both innovative and progressively less invasive procedures. With the invention of cerebral angiography in 1927, Egas Moniz paved the way for modern endovascular neurosurgery. CONCLUSIONS: Numerous pioneers have been described through this historical reconstruction. Their genius, effort, dedication, and passion brought a massive contribution to vascular and endovascular neurosurgery as we know it today.

Evolution of endovascular therapy for aneurysm treatment. Historical overview.

The endovascular treatment of intracranial aneurysms has recently become an established therapeutic option. The foundation of this treatment modality was laid by the work done in ground-breaking cases, combined with technological advances since the first half of the 19th century. In this historical overview the authors describe the steps taken by the early pioneers and the results of their work, which was often done under challenging circumstances. The work of these predecessors established the stepping-stones for constant development and refinement for those who have come after them, eventually evolving into the procedures used today. Endovascular treatment of intracranial aneurysms is only possible because of the work of these innovators.