Table Of ContentContemporary Perspectives in Neurosurgery
Series Editor: Robert N.N. Holtzman
Contemporary Perspectives in Neurosurgery
Series Editor: Robert N.N. Holtzman
Surgery of the Spinal Cord: Potential for Regeneration and Recovery,
Robert N.N. Holtzman and Bennett M. Stein, Editors
Spinal Instability, Robert N.N. Holtzman, Paul C. McCormick,
Jean-Pierre C. Farcy, Editors
Endovascular Interventional Neuroradiology, Robert N.N. Holtzman and
Bennett M. Stein, Editors
Robert N.N. Holtzman Bennett M. Stein
Editors
Heidi Winston
Associate Editor
Endovascular
Interventional
Neuroradiology
With 127 Figures in 280 Parts
Springer-Verlag
New York Berlin Heidelberg London Paris
Tokyo Hong Kong Barcelona Budapest
ROBERT N.N. HOLTZMAN, MD
Assistant Clinical Professor of Neurological Surgery, College of Physicians and
Surgeons of Columbia University, The New York Neurological Institute, New York,
NY 10032. Associate Neurosurgeon, Lenox Hill Hospital, New York, NY 10021,
USA
BENNETT M. STEIN, MD
Byron Stookey Professor of Neurological Surgery, College of Physicians and Sur
geons of Columbia University; Chairman of the Department of Neurological Sur
gery, The New York Neurological Institute, New York, NY 10032, USA
Library of Congress Cataloging-in-Publication Data
Stonwin Conference (7th: 1989: Winston Estate)
Endovascular interventional neuroradiologyjRobert N.N.
Holtzman, Bennett M. Stein, editors; Heidi Winston, associate
editor.
p. cm.-(Contemporary perspectives in neurosurgery)
"Stonwin Medical Conference; Harry Winston Medical Foundation."
Includes bibliographical references and index.
ISBN-13:978-1-4612-7548-0
I. Cerebrovascular disease-Interventional radiology-Congresses.
2. Cerebrovascular disease-Endoscopic surgery-Congresses.
I. Holtzman, Robert N.N. II. Stein, Bennett M.
III. Winston, Heidi. IV. Harry Winston Medical Foundation.
V. Title. VI. Series.
[DNLM: I. Cerebrovascular Disorders-radiography-congresses.
2. Radiography, Interventional. WL 355 S881e 1989J
RD594.2.s76 1994
616.8'I-dc20
DNLMjDLC 93-35499
Printed on acid-free paper.
© 1995 Springer-Verlag New York, Inc.
Softcover reprint of the hardcover 1st edition 1995
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if the former are not especially identified, is not to be taken as a sign that such names, as
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of going to press, neither the authors nor the editors nor the publisher can accept any legal
responsibility for any errors or omissions that may be made. The publisher makes no war
ranty, express or implied, with respect to the material contained herein.
Production managed by Natalie Johnson; manufacturing supervised by Jacqui Ashri.
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9 8 7 6 5 4 3 2 1
ISBN-13:978-1-4612-7548-0 e-ISBN-13: 978-1-4612-2464-8
DOl: 10.1007/978-1-4612-2464-8
This volume is dedicated to
Mrs. Edna Winston
Guest of Honor: Juan M. Taveras, M.D., Professor of Radiology,
Harvard Medical School; Former Chief of Neuroradiology,
New York Neurological Institute, Columbia-Presbyterian Medical Center.
Mrs. Edna Winston
This woman endured great suffering during her life because of medical problems that
today could have been diagnosed more easily and the years of suffering alleviated.
She managed to raise a family of two sons with much love, attention, and adoration.
My mother was a woman of exquisite aesthetics and a vibrancy of humor bordering
on satire. She bore her suffering nobly. It is to her memory and the atmosphere she
created in this house and home that this volume of the Stonwin Medical Conference
is dedicated.
Ronald H. Winston
Harry Winston Research Foundation, Inc.
Foreword
This book is composed of individual chapters based on talks given at the
Seventh Annual Stonwin Medical Conference. The subject, endovascular
interventional neuroradiology, was proposed by Professor A.N. Konovalov,
Chairman of the N.N. Burdenko Neurosurgical Institute during an informal
dinner at his home in Moscow. Dr. Bennett M. Stein, Chairman of the
Department of Neurosurgery of the New York Neurological Institute, sug
gested the names of prospective guests, in particular Professor Juan M.
Taveras, who subsequently agreed to preside as our guest of honor. The
participants included a hematologist and vascular physiologist, neuroradio
logists, neurologists, and neurosurgeons from a number of countries in
cluding Canada, France, the People's Republic of China, the former Soviet
Union, and the United States of America. They represented that small group
of individuals who are actively pursuing the problems of aneurysmal and
vascular malformation evolution and rupture with the intention of managing
these lesions endovascularly. Their efforts were scrutinized and contrasted
with present-day optimum neurosurgical therapies.
The Stonwin Estate, purchased by Harry Winston in 1940 in exchange for
a precious gemstone, provided the idyllic setting for the three-day meeting
that convened on those grounds. The exchange of ideas was accompanied by
great enthusiasm and brought to the forefront the technological and physio
logical problems that must be faced and overcome in the development of this
new specialty.
We acknowledge with deep gratitude the efforts of Mr. Ronald H.
Winston in the creation and furthering of these conferences and those of his
wife Mrs. Heidi Winston. Particularly valuable were Mrs. Winston's sense
of organization, her concern for the participants and their wives, and her
assistance with the editing of the publications.
Henry B. Roberts Jr.
Publishing and Editorial Consultant
Stonwin Medical Conference
ix
Preface
In 1974 F.A. Serbinenko of the Burdenko Neurosurgical Institute published
his work on balloon catheterization of major cerebral vessels in the Journal
of Neurosurgery. It officially established endovascular interventional neuro
radiology as both a therapeutic adjunct to existing surgical procedures and
an independent means of treating vascular lesions of the cerebral circulation.
At about the same time, superselective angiography was emerging as a
natural outgrowth of cerebral angiography. The development and availabil
ity of coaxial microcatheters was a major factor contributing to this techno
logical advance. Initially, a variety of materials, including muscle, Silastic
spheres, and glues, were utilized to bring about the occlusion of carotid
cavernous fistulas, aneurysms, and arteriovenous malformations. Detach
able balloons and platinum coils later supplanted these early techniques. In
this setting, lesions arising from tertiary branch vessels could now be reached
with minimal morbidity, and outcomes approximating those derived from
surgical excision and clipping could be attained.
Herein are detailed descriptions of these endovascular achievements, con
trasting the results with present-day surgical technology. Experts from
North America, Europe, the People's Republic of China, and the former
Soviet Union contributed detailed accounts of their work in both the text
and the discussions. The field of endovascular interventional neuroradiology
is presently undergoing the flux of development characteristic of a new spe
cialty, and changes are taking place continuously as technological advances
and successes permit deeper, atraumatic endovascular access.
This volume begins with an analysis of the blood's coagulation mecha
nisms and the physiology of the circulation as it relates to thrombosis. Basic
concepts presented include a discussion of the platelet and fibrin systems as
they are implicated in the formation and lysis of a thrombus. Also discussed
are the possibilities for reepithelialization without platelet aggregation and
endovascular/endosaccular thrombosis followed by recanalization after clot
formation. The applicability of such processes was considered in terms of
aneurysmal occlusion. Similarly, the role fluid mechanical factors play in the
focal deposition of platelets resulting in thrombosis and the formation of
aneurysms in human circulation using isolated segments of arteries and veins
xi
xii Preface
is discussed in terms of streamlines, fluid velocities, and wall shear stresses by
analyzing the motion of particles and red blood cells on 16 mm cinefilm.
Descriptions of specialized technologies designed to bring about changes
in the vascular bed that may be curative for life-threatening occlusive and
embolic problems follow: Detailed information is provided on (1) the evalua
tion of arteriovenous malformations (A VMs) by the transcranial Doppler
technique, comparing pre- and postembolization and postsurgical changes;
(2) the "smartlaser," which can be guided endovascularly to vaporize athero
sclerotic plaques, thereby achieving recanalization of blocked arteries in
the coronary and carotid systems; and (3) intravascular placement of Hilal
platinum coils for successful management of A VMs, giant aneurysms, and
fistulas.
The risks of endovascular surgery over a to-year period at New York
University Hospital, with the use of present-day techniques-including the
newest generation of variable-stiffness microcatheters assisted by deflecting
microguide wires, small balloons, current-generation acrylics, and digital
subtraction angiography (DSA)-have led to improved results as noted by
Alex Berenstein, with mortality less than 1.0% and severe morbidity less
than 2.3%. John Pile-Spellman has, through a team approach at the Massa
chusetts General Hospital, confirmed these conclusions and demonstrated
that these techniques may be of value for treating vasospasm and arterioscle
rotic occlusions of cerebral blood vessels.
The endovascular experience at various institutions is presented: This
includes the superior orbital vein approach of Gerard Debrun for traumatic
and other carotid cavernous fistulas and dural A VMs at The Johns Hopkins
Hospital stands in contrast to arterial balloon catheter occlusion of those
lesions, which was performed successfully in 98.4% of 630 patients by Fedor
Serbinenko and coworkers at the N.N. Burdenko Neurosurgical Institute.
Similarly, the latter institute's experience with aneurysms, AVMs, and other
vascular lesions treated by endovascular neurosurgery since 1964 is discussed
by A.N. Konovalov. Chung-cheng Wang of the Beijing Neurosurgical Insti
tute offers his experience in intravascular embolization, and Alan Fox of the
University of Western Ontario discusses his experience and offers a proposal
for a scale of neurological outcome following endovascular intervention.
The specific management of aneurysms from a surgical standpoint is pre
sented by Robert Solomon, who stresses the need for collaboration between
endovascular neuroradiologists and neurosurgeons to develop the criteria
for endovascular approaches and to develop strict indications for both surgi
cal and endovascular approaches. Victor Scheglov presents the endovascular
experience of 725 cases during the past 14 years at the Neurosurgical Insti
tute of Kiev, where all aneurysms are now being managed by the endo
vascular technique, regardless oftheir location. Grant Hieshima presents the
transluminal angioplasty technique for intracranial arterial vasospasm that
he used in 27 vessels in 13 patients (all but one vessel remaining in its dilated
state). In addition, 250 aneurysms were managed by intravascular balloon
