A brief history of arteriovenous malformation radiosurgery.

Stereotactic radiosurgery was first described by Leksell in Stockholm, Sweden in 1951. In 1967, Leksell introduced the 'Gamma Knife' for clinical use in carefully selected patients. A major role for radiosurgery further emerged in 1972 after its application for brain arteriovenous malformations. Radiosurgery was initially used for high risk or deep seated AVMs that were unsuitable for resection or embolization. Several additional pioneers contributed towards its continued development. Stereotactic radiosurgery is now considered as an important option for patients with brain vascular malformations, including AVMs, cavernous malformations, and dural AV fistulas.

Legacy and current understanding of the often-misunderstood Foix-Alajouanine syndrome. Historical vignette.

Foix-Alajouanine syndrome has become a well-known entity since its initial report in 1926. The traditional understanding of this clinical syndrome is as a progressive spinal cord venous thrombosis related to a spinal vascular lesion, resulting in necrotic myelopathy. However, spinal venous thrombosis is extremely rare and not a feature of any common spinal vascular syndrome. A translation and review of the original 42-page French report revealed 2 young men who had presented with progressive and unrelenting myelopathy ultimately leading to their deaths. Pathological analysis demonstrated endomesovasculitis of unknown origin, including vessel wall thickening without evidence of luminal narrowing, obliteration of cord vessels, or thrombosis. Foix and Alajouanine also excluded the presence of intramedullary arteriovenous malformations. At the time, dural arteriovenous fistulas (dAVFs) had not been described, and therefore this type of lesion was not specifically sought. In retrospect, it seems possible that both patients had progressive myelopathy due to Type I dAVFs. In the decades since that original report, numerous authors have included spinal cord venous thrombosis as a central feature of Foix-Alajouanine syndrome. The inclusion of thrombosis in the clinical picture of this syndrome is not only incorrect but may leave one with the impression of therapeutic futility, thus possibly preventing successful surgical or endovascular therapy.

Vascular lesions of the spinal cord: history and classification.

Vascular lesions of the spinal cord are uncommon causes of myelopathy. Although recognized for more than 100 years, only slightly more than 100 cases were reported in the literature by midcentury. With recognition of the clinical syndrome and the development of selective spinal angiography in the 1960s and 1970s, a systemic classification of these diverse lesions has been made, allowing rational treatment using modern microsurgical and endovascular therapy.

The influence of Harvey Cushing on neuroradiologic therapy.

Harvey Cushing was largely responsible for the establishment of neurosurgery as a separate discipline. He demonstrated how careful attention to technique could make surgery acceptably safe, established classifications and clinical-pathologic correlations of a wide variety of tumors, and trained dozens of future neurosurgical department heads. Less well known, however, is Cushing's contribution to the early clinical use of radiation therapy for a variety of intracranial disorders. With the aid of his meticulous clinical follow-up, large case volume, and willingness to try new treatment methods, he demonstrated the utility of therapeutic radiation in patients with pituitary tumor, medulloblastoma, and arteriovenous malformation. His less impressive results with the irradiation of patients with glioma are also worthy of note and include trials of brachytherapy. Neurosurgeons and radiation oncologists exploring new methods of delivering therapeutic radiation to the central nervous system should be aware of the lessons learned from Cushing's experience.