Table Of ContentThe complete four-volume set consists of
1 Functional Anatomy
of Craniofacial Arteries
2
Endovascular Treatment
of Craniofacial Lesions
3
Functional Vascular Anatomy of Brain,
Spinal Cord and Spine
4 Endovascular Treatment of Brain,
Spinal Cord and Spine Lesions
P. Lasjaunias A. Berenstein
Surgical
Neuroangiography
2
Endovascular Treatment
of Craniofacial Lesions
With 244 Figures in 648 Separate Illustrations
Springer-Verlag
Berlin Heidelberg New York
London Paris Tokyo
PIERRE LASJAUNIAS, M.D., Ph.D.
Chef de travaux d'Anatomie, Professor of Radiology (Adj.) NYU
Service de Radiologie, H6pital de Bicetre,
Universite Paris XI, 78 Rue du General Leclerc,
94275 Le Kremlin Bicetre, France, and·
Department of Radiology, Toronto Western Hospital,
399 Bathurst Street,
M5T 2S8 Toronto, Ont., Canada
ALEJANDRO BERENSTEIN, M.D.
Professor of Radiology, Director of Surgical N euroangiography Service
New York University and Bellevue, Medical Center, 560 First Avenue,
New York, NY 10016, USA
ISBN-13: 978-3-642-71190-9 e-ISBN-13: 978-3-642-71188-6
DOl: 10.1007/978-3-642-71188-6
Library of Congress Cataloging-in-Publication Data. Lasjaunias, Pierre L. Surgical neuroangiography.
Includes bibliographies and indexes. Contents: v. 1. Functional anatomy of craniofacial arteries-v. 2.
Endovascular treatment of craniofacial lesions. 1. Nervous system-Blood-vessels-Radiography. 2. Ner
vous system-Blood-vessels-Surgery. 3. Angiography. 1. Berenstein, Alejandro, 1947-II. Title. [DNLM:
l. Angiography. 2. Neuroradiography. WL 141 L344s] RD594.2.L37 1987 617'.4807572 86-26028
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© Springer-Verlag Berlin Heidelberg 1987
Softcover reprint of the hardcover 1s t edition 1987
The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of
a specific statement, that such names are exempt from the relevant protective laws and regulations and
therefore free for general use.
Product liability: The publisher can give no guarantee for information about drug dosage and application
thereof contained in this book. In every individual case the respective user must check its accuracy by
consulting other pharmaceutical literature.
Reproduction of the figures: Gustav Dreher GmbH, D-7000 Stuttgart
2127/3130-543210
To Pascale, losee, Estelle, Erica, Vanessa, and Aude,
and to the teams of vascular technicians and nurses of both
Bicetre and New York University for their invaluable
assistance.
Preface
Embolization has been performed in many European countries and in
North America for over 20 years and is now beginning to gain accep
tance in other countries. At first, experience with these techniques was
shared in the form of individual case reports; today some centers have
treated enough patients to be able to transform this anecdotal material
into more concrete data. For the last 10 of these 20 years, the two of us
have been deeply involved~ encouraged, and stimulated by the interest
created by the few pioneers in endovascular techniques.
In 1978, when we first met, our discussion on embolization could
have been summarized as disagreement. It soon became obvious that
these differences were primarily related to our different individual back
grounds. One of us having a strong orientation toward anatomy, and the
other toward technique. We realized that these apparently opposing
approaches complement each other and decided to combine them to our
mutual benefit. This collaboration has matured into the search for
improvements in patient care and for the safest, most reliable, and most
responsible manner of treatment.
The goal of these volumes is to share what we feel useful to the
performance of endovascular surgery. Vascular lesions and tumors con
stitute the traditional targets of embolization. Following advances in
knowledge and in materials, proximal arterial endoluminal occlusion has
been succeeded by the ability to produce an effect at the cellular level by
means of microemboli and cytotoxic agents. The technical challenge to
preserve as much as possible of the healthy tissue has led to superselec
tivity in the embolization of brain vessels and fourth divisions of the
external carotid system. Miniaturization of devices allows us to use all
our tools in newborns and infants without femoral arterial damage. The
possibility of further enhancing the selectivity of delivery system place
ment by selective recognition of the target will create further applications
of surgical neuroangiography. The development of rational protocols for
specific lesions and territories, as well as guaranteed reliability and safety
constitute the other objectives in the maturation of this specialty.
Embolizer, interventional neuroradiologist, surgical neuroradiologist,
and neuroangiographer are the most commonly used names for the
radiologists or surgeons performing embolization in lesions of the head,
neck, brain, and spine. Their search for an identity may appear futile;
however, it constitutes a strong psychological lever against medical
bureaucracy, which often unfortunately constitutes a factor limiting inno
vation. The current use of "interventional" in connection with
neuroradiology is too restrictive. It focuses attention on the technical
aspect of our work and its imaging support. Pejorative names, such as
"embolizers of pictures", enhance this feeling even more. Such a name
may also convey to the public and patients the notion of an innocuous
VIII Preface
treatment. This notion is entirely untrue. As embolization techniques
have become more efficacious, they have also become more aggressive
and invasive. Poorly performed, they have the same potential to do harm
as a poorly conceived or executed surgical maneuver. Consequently, it is
imperative that operators have a sound background in functional
neuroanatomy and clinical evaluation, as well as adequate technical
training.
For this reason we are introducing the term "surgical neuroangiogra
phy" in the context of endovascular approaches. The adjective "surgical"
refers to the use of hands and tools in treatment, and therefore better
describes both our procedures and the additional clinical competence
that should be acquired by the conventional neuroradiologist. The title
"neuroradiologic surgery" would put a different emphasis on the link
between the surgical and neuroradiological communities. Although we
do not perform open surgery in a conventional sense, our treatments
(therapeutic neuroradiology) or our interventions (interventional
neuroradiology) require competence in certain clinical areas in addition
to the actual technical skill, for example, outpatient consultation, hospi
tal care, postoperative care and follow-up, and seminars with referring
and related specialties.
Is there anything radiological in surgical neuroangiography? The
angiosuite, our most expensive tool, is only a tool, and like the neurosur
gical operating theaters, it can be used by others and for other purposes.
Thus, concepts in surgical neuroangiography should be derived from
clinical content and not from the technical surroundings. Even the
angiosuite may not remain a link with radiology since ultrasound, CT,
and MRI already provide much the same information as intravenous
digital angiography. This type of "global angiography" will soon disap
pear as a diagnostic examination, leaving the angiosuite to be used
almost exclusively for sophisticated invasive (surgical) measures for pre
therapeutic or therapeutic purposes.
What is the persisting radiological element in surgical neuroangiogra
phy? What remains is the capability of using an image of existing condi
tions to make decisions and of performing therapeutic interventions
without direct visual control. Stereotaxic neurosurgery uses precisely the
same concept, and therefore constitutes the closest link with traditional
neurosurgery.
Should we be "neurosurgeons"? We do not think so, since surgical
training has to achieve specific clinical and technical goals during a
difficult training program. However, there is definitely an overlap be
tween our knowledge and that of neurosurgeons. Ideally, academic train
ing should incorporate a common trunk, gathering all future neurosci
ence specialists where surgical neuroangiography and neurological
surgery share certain problems. An example of such problems are the
types of complications that can be encountered. Firstly, complications
may be related to treatment in a general sense and correspond to the
topography of the lesion and the nearness of fragile tissues (for neurolog
ical surgery) or sensitive territories (for the surgical neuroangiography).
Such complications represent a real therapeutic risk which can (and
should) be explained to patients in advance. Their diminution over time
is due to improvements in endovascular techniques and in the selection
Preface IX
of patients; differences in results can be attributed to the human charac
ter of surgical neuroangiographic techniques in general, and to the differ
ence between proper and excellent patient care. Secondly, complications
may be due to technical mistakes or incorrect intraoperative decisions;
these represent the difference between proper and inadequate patient
care. Their constant decrease in frequency is an expression of the success
of modern training. Their persistence in many places emphasizes the
need for individual operators to update their knowledge and skills.
We hope that these volumes will be a useful tool for those involved in
surgical neuroangiography. However, one should not believe that a
specifically designed instrument may compensate for insufficient
training.
Surgical neuroangiography is a difficult specialty for those who
choose to learn it now, and a gratifying one for those who are fortunate
enough to practice it full time. The development of cytotoxic agents,
techniques for the treatment of aneurysms, endovascular prostheses, and
the use of lasers and angioscopes are a few of the fascinating aspects
which will influence the future of the endovascular approach.
June 1987 P. LASJAUNIAS and A. BERENSTEIN
Acknowledgements
We would like to acknowledge the following for their help in providing
illustrative pictures: 1. S. Choi, A. Roche, G. Scialfa, and K. Terbrugge.
We also wish to thank P. Burrows, J. Escridge, B. Willinsky, and
J. Dion for their language editing assistance.
We are particularly grateful to C. Vachon for her help in producing
the original drawings for this volume, and to D. LacIef, A. Arce,
H.Helners, A. Jaladoni, and J. Scott for their photographic and secre
tarial assistance.
Contents
Chapter 1
Technical Aspects of Surgical Neuroangiography 1
I. Introduction . . . . . . . . 1
II. Patient Preparation. . . . . 1
Preoperative Medications 1
III. Anesthesia of Embolization 2
1. General Anesthesia . . 2
2. Neuroleptic Analgesia 2
3. Tracheostomy . . 3
4. Local Anesthesia 3
IV. Puncture Sites ... 3
Introducer Sheath 3
V. Catheters and Delivery Systems 5
1. Conventional Catheters 5
2. Balloon Catheters . . 9
3. Propelling Chambers . 13
4. Detachable Balloons . 13
5. Open End Guidewires . 19
6. Guidewires . . . . . 19
VI. Embolic Agents .... 19
1. Particle Embolization 19
2. Gianturco Coils . . . 29
3. Nonabsorbable Liquids 29
VII. Opacifying Agents . . . 39
1. Tantalum Powder . . . 39
2. Metrizamide Powder . 40
VIII. Ethyl Alcohol (95 % Ethanol) 40
1. EthanolInjection in the Arterial System. 41
2. Ethanol Injection in Venous Malformations 42
IX. Infusion Chemotherapy ........... 43
Time Released Microcapsules (Chemoembolization) 44
X. Other Potential Agents 44
1. Ethibloc . 44
2. Collagen 44
3. Estrogen 44
XI. Miscellaneous 45
1. Syringes . . 45
2. Stopcocks and "Y" Adaptors 45
3. Tray Containers . . . . . 46
4. Flushing Solutions. . . . . . 46
5. Systemic Heparinization 46
6. Activated Coagulation Time (ACT) Monitoring. 46
XII Contents
7. Corticosteroids . . . . . . . . . . . . . . . . . . . 47
8. Normal Physiology of the External Carotid Arteries . 47
XII. Flow Control . . . . . . . . . . . . . . . . . 48
1. Protection of a "Dangerous" Anastomosis . 48
2. Intralesional Flow Control ........ 52
3. Occlusive Balloon Flow Reversal . . . . . 54
4. Functional Rearrangement of the Supply to a Territory 54
5. Surgical Flow Control . . . . . . . . . 54
XIII. Provocative Test . . . . . . . . . . . . . 54
XIV. Electrophysiological Monitoring (EPhM) 55
XV. AngiographicEquipment 55
XVI. Postembolization Care . 56
XVII. Special Care . . . . . . 56
1. Neurological Deficit. 56
2. Post-Op Swelling 56
3. Skin Necrosis 56
XVIII. Follow-Up . . . . . 56
Chapter 2
Dural and Bony Thmors 57
I. Introduction . 57
II. Meningiomas. 57
1. Epidemiology 57
2. Pathology . . 64
3. Clinical Presentation 70
4. Pretherapeutic Evaluation 83
5. Therapeutic Strategy and Clinical Objectives 88
6. Technical Aspects of Embolization . . . . . 89
7. Special Considerations in Meningioma Embolization 91
III. Other Bony and Dural Tumors 97
1. Cerebral Tumors . . . . 97
2. Neurinomas. . . . . . . 98
3. Esthesioneuroblastomas 99
Chapter 3
Nasopharyngeal Thmors 101
I. Juvenile Angiofibromas (JAF) 101
1. Macroscopic Pathology 101
2. Microscopic Pathology . 104
3. Epidemiology . 105
4. Pathophysiology 106
5. Clinical Findings 109
6. NaturalHistory 110
7. Pre therapeutic Evaluation 110
8. Therapeutic Goals . . . . 117
9. Technical Aspects of Embolization . 119
10. Tumor Recurrence . . . . . 121
II. Other Nasopharyngeal Tumors . 122
III. Conclusion . . . . . . . . . . . 126
