Northeast Florida Medicine
Vol. 66, No. 3 2015
15
Endovascular Neurosurgery
Introduction
Neuroendovascular surgery is a very young subspecialty.
It has been only recently that we have overcome the
technical challenges to operate effectively within the
cerebral vasculature. Still, it is hard to imagine a vascular
neurosurgery practice today without an endovascular
section, or without a neuroendovascular partnership.
While neurovascular disease was not the first application
of endovascular therapy, it is perhaps the most intriguing.
The complexity of the intracranial vascular and bony
anatomy, the very small vessel diameters (less than 1 mm
in diameter,) and the unforgiving nature of brain tissue
make the endovascular approach to the brain a distinct
engineering challenge. However, it is these same features
that make such a compelling case for endovascular
solutions.The principles which underlie neuroendovascular
treatment actually stretch very far back in history. As with
every advancement in medicine, progress in this field has
benefited from the inspiration of individuals and continued
technological innovation.
Early Efforts at Intervention
The idea of treating vascular lesions, particularly
aneurysms, with nonsurgical methods is not new.Treatment
of aneurysms by the insertion of foreign bodies such as
needles and wire, and even the application of electrical
current, was reported in the late 18
th
century.
1
While the
emphasis was generally on thoracic aortic aneurysms,
other peripheral aneurysms and the occasional carotid or
cerebral aneurysm were treated. In the 1800s, Phillips in
London and Velpeu in France reported inducing thrombus
formation in aneurysms by introducing a foreign body
(generally long pins).
2
In 1864, C.H. Moore recovered
a bullet from the ascending aorta during an autopsy and
discovered it was covered with fibrin. Based on this he
introduced 26 yards of metal coil into a thoracic aortic
aneurysm in another patient, on the theory that this would
promote thrombus and reduce flow into the aneurysm sac.
2
Almost immediately after treatment, he noted a decrease
in the pulsation and the size of the aneurysm, as well as a
reduction in the patient’s pulse from 116 to 92 beats per
minute. The patient died several days later from sepsis,
but this “packing” technique caught on, with a number
of other investigators packing aneurysms with everything
from horse hair to watch springs.
2
Electrothrombosis (also
referred to as galvanopuncture) was practiced widely in the
latter part of the 1800s in Europe, and into the early 20
th
century in the United States. With this technique, needles
are inserted into an aneurysm, and an electric current is
applied to promote thrombosis. In 1856, Ciniselli published
50 cases of galvanopuncture of aortic aneurysms, with a
cure rate of 50 percent.
3
However, there was a procedure
associated mortality of 14 percent. While an improvement
over the results of other treatments at the time, it could
not be recommended for most patients. In 1879, Corradi
described a technique combining the two approaches: a
permanent coil was placed and electric current applied.
2
The technique gained a number of proponents, but a lack
of consistent success eventually led to this technique also
falling out of favor.
These treatments all shared one great flaw. There was no
visualization of what the physician was placing. X-rays were
not discovered until 1895, and a workable angiogram was
not developed until well into the 20
th
century. Still, these
earnest and well documented attempts to treat diseases
with no good surgical options laid a foundation for the
sophisticated endovascular treatments of today.
Address correspondence to:
David A. Miller, M.D.
Assistant Professor of Radiology and Neurosurgery
Director Comprehensive Stroke Center at Mayo Clinic Florida
4500 San Pablo Road
Jacksonville, FL 32266
Office: (904) 953-6349
Fax: (904) 953-1044
After Hours: (904) 953-2000
E-mail:
Thinking Small: The Evolution of Neuroendovascular Therapy
By David A. Miller, MD
Assistant Professor of Radiology and Neurosurgery
Director Comprehensive Stroke Center at Mayo Clinic Florida
Abstract:
The sub specialty of Neuroendovascular therapy has
become a prominent feature of neurosurgical practice. It arose from
the origins of cerebral angiography in the early 20
th
century, and has
developed with a wave of advances in biology and technology.
