Cerebrovascular Surgery: Volume I PDF
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Cerebrovascular Surgery Volume I Cerebrovascular Surgery Volume I Edited by Jack M. Fein and Eugene S. Flamm With 162 Illustrations in 180 Parts Springer-Verlag New York Berlin Heidelberg Tokyo JACK M. FEIN, M.D. Department of Neurological Surgery, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY 10461 USA EUGENE S. FLAMM, M.D. Department of Neurosurgery, New York University, 550 First Avenue, New York, NY 10016 USA Library of Congress Catalog in Publication Data Main entry under title: Cerebrovascular surgery. Includes bibliographies and index. I. Cerebrovascular disease--Surgery. I. Fein, Jack M. II. Flamm, Eugene S. [DNLM: I. Cerebrovascular Disorders --surgery. WL 355 C4138] RD594.2.C49. 1984.617' .481. 84-13869 ISBN-13: 978-1-4612-9531-0 e-ISBN-13: 978-1-4612-5030-2 001: 10.1007/978-1-4612-5030-2 © 1985 by Springer-Verlag New York Inc. Softcover reprint of the hardcover 15t edition 1985 All rights reserved. No part of this book may be translated or reproduced in any form without written permission from Springer-Verlag, 175 Fifth Avenue, New York, New York 10010, U.S.A. The use of general descriptive names, trade names, trademarks, etc., in this publication, even if the former are not especially identified, is not to be taken as a sign that such names, as understood by the Trade Marks and Merchandise Marks Act, may accordingly be used freely by anyone. While the advice and information of this book is believed to be true and accurate at the date 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 warranty, express or implied, with respect to material contained herein. Typeset by Bi-Comp, Inc., York, Pennsylvania. 9 8 7 6 5 4 3 2 1 Dedicated to our children Shari Fein Andrew and Douglas Flamm Foreword Considerable impetus was given to the study and understanding of cere brovascular anatomy by Thomas Willis and his contemporaries in the seventeenth century, yet almost two hundred years were to pass before further significant advances were made in this field. Then, from the mid nineteenth century onwards, the dark ages of cerebrovascular research gradually lifted through the efforts of such workers as Luschka, Heubner, and Windle, whose pioneering anatomical studies formed the basis of the present-day understanding of the morphology of the cerebral circulation. The turn of the century saw an increasing influence of the early neurolo gists in describing anatomy of cerebral vessels in relation to their areas of distribution and to the production of focal deficits through specific vascu lar lesions and anomalies. Later still, Padget and others made important observations concerning phylogenetic and developmental aspects of the cerebral circulation. These anatomical and clinical studies were remarkable enough but the real breakthrough in investigating cerebral pathophysiology and in devis ing appropriate corrective neurosurgical procedures had to await the re markable advances in technology of the past fifty years. These began with the advent of cerebral angiography with all its subsequent refinements and progress has been accelerated through establishing noninvasive Doppler and high resolution ultrasound imaging techniques, methods for the accu rate measurement of cerebral blood flow, CT scanning, PET scanning, and, most recently, imaging and metabolic NMR scanning. Also the elec tron microscope has facilitated investigation into the structural changes in brain blood vessels in various pathological conditions such as hemorrha gic stroke, cerebral infarction, and hypertension. In line with these nu merous technical advances the number of investigations into CNS func tion carried out by neurosurgeons, neurologists, neuropathologists, physiologists, biochemists, and cell biologists has blossomed. In contrast, cerebrovascular surgery might be considered still to be in its infancy. Early successes and advances in operative technique owed viii Foreword much to the individual brilliance and surgical expertise of surgeons such as Cushing and Dandy. Although cerebral arterial aneurysms have been operated upon directly for almost fifty years, and carotid occlusive dis ease since the 1950s, it is only in the past fifteen years that the introduc tion of the operating microscope, microtechniques, bipolar coagulation, and improved neuroanesthesia has brought about generally acceptable results for most surgeons in these fields. In spite of the overall development of neuroscience on such a massive scale, we have to ask ourselves just how big are the steps we have taken in the understanding of cerebrovascular disease? Are we really that much nearer to knowing the true relationships of hypertension and cerebral arteriosclerosis, the development of aneurysms and A VMs, carotid occlu sive disease, and the etiology and proper treatment of stroke and cere bral vasospasm? We are forced to admit that our therapeutic successes are still severely limited. The present-day worker in almost every discipline of neuroscience is constantly assailed by steadily increasing numbers of scientific papers, journals, and monographs on his own and allied subjects. Their relevance and relative merits become increasingly difficult to discern in the context of what has gone before and what is currently acceptable theory. These four volumes form a truly encyclopedic review of all aspects of cerebrovascular disease and its treatment yet remain uncluttered by irrel evant detail and yield so much more than simple lists of facts for refer ence. They present not only a remarkable perspective and clear review of what has been achieved so far in investigation and treatment of each subject considered, but each section reflects also a sensible and balanced opinion of current thinking in the field with some indication as to which direction we should next take. I feel that the authors have achieved their aim in presenting these books not simply as reference volumes but in affording the discerning reader with an opportunity to open his mind to new perspectives which may thus stimulate further improvements in the understanding and treatment of cerebrovascular disease. M. G. YA§ARGIL Preface In the last decade, cerebrovascular surgery has emerged as a distinct subspecialty within neurological surgery. Given the variety of diseases which involve the cerebral circulation and the large number of patients affected, cerebrovascular disorders are an important public health prob lem. A number of neurosurgeons now devote ,a major portion of their time to the study and treatment of these problems. Several centers of excel lence have developed worldwide and a variety of innovative surgical ap proaches to these problems have been proposed. Clinical and basic re search has widened the cerebrovascular horizon. There have been major advances in our understanding of the pathophysiology of ischemia, sub arachnoid hemorrhage, vasospasm and the hypertensive vasculopathies. Noninvasive imaging techniques such as digital subtraction angiography and quantitative metabolic and hemodynamic studies are becoming more important clinically. Intraoperative monitoring techniques have been re fined and microvascular surgery is now a way of life for many surgeons. Many of these advances are described in journal publications, topical monographs and symposium proceedings. With the growth of interest and concentration in this surgical subspecialty, however, there is a need for a more comprehensive treatment of cerebrovascular surgery. Cerebrovascular operations require precise surgical skills. These skills are an amalgam of technical facility, knowledge, judgment, experience, and discipline. All four volumes of Cerebrovascular Surgery describe technical innovations which have been found useful through trial and error. They provide the fundamental concepts and facts which should form the basis for surgical judgments. The experience required to formulate a logical surgical plan and the discipline required to carry it through to completion is difficult to de scribe. Given the variety of approaches to the various cerebrovascular disorders, we felt that this should be a multiauthored work. By pooling such a fund of knowledge the reader is given the opportunity for a broad education in cerebrovascular surgery. x Preface Cerebrovascular surgery cannot be carried out in a vacuum. A sophisti cated appreciation of the heart as a pump and the brain as a functional organ are requisite ingredients. This volume was therefore designed to address these issues and to provide the reader with the insights into the anatomy and physiology of the cerebral circulation. Since microsurgery has become an important component in the treatment of all cerebrovascu lar disorders, the concluding chapters in this volume describe the funda mental principles, instrumentation, and techniques utilized in microvas cular surgery. Volume II describes the specific management of patients with cerebrovascular occlusive disease. Volume III describes the surgery of arterial aneurysm. Volume IV completes the series with a description of the surgical treatment of arteriovenous malformations, spontaneous hematomas, and surgery of the sagittal sinus. The editors would like to acknowledge the efforts of the senior sur geons and their staff who participated in this effort. These individuals will undoubtedly continue to provide the creative leadership needed to reduce the morbidity and mortality due to cerebrovascular disease. JACK M. FEIN EUGENE S. FLAMM Contents of Volume I Foreword by M. G. Ya§argil............................ vii Preface.... ... . ... . ... . .. . .. . .. ... . .. . . .. . . ... . .. . ... . IX Contents of Volume II . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . XIII Contents of Volume III . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv Contents of Volume IV ................................ XVII Contributors to Volume I. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . XIX Contributors to Volumes I-IV. . . . . . . . . . . . . . . . . . . . . . . . . . XXIII Historical Introduction Jack M. Fein ........................................ . 2 The Vascular Anatomy of the Cerebral Hemispheres Georges Salamon, Andre Gouaze, Sharon E. Byrd, and Jean-Marie Corbaz .................................... 11 3 Vascular Anatomy of the Posterior Fossa Ajax E. George and In-Sup Choi ........................ 49 4 Cerebrovascular Physiology Niels A. Lassen and Jens Astrup ........................ 75 5 Hematologic Considerations in Cerebrovascular Surgery Charles A. Owen, Jr. and E. J. Walter Bowie ............ 89 6 Cardiovascular Considerations in Cerebrovascular Surgery William H. Frishman, Jack M. Fein, and Marc Kirschner. 117 7 Neurological Evaluation in Cerebrovascular Disease o. M. Reinmuth and P. N. Karanjia .................... 129 8 Clinical Evaluation of Cerebral Hemodynamics Robert H. Ackerman ................................... 181 9 Anesthesia for Neurovascular Surgery James E. Cottrell and Philippa Newfield ................. 213 xii Contents of Volume I 10 The Operating Microscope in Microvascular Surgery Jack M. Fein ......................................... 233 11 Instrumentation for Microvascular Neurosurgery Leonard I. Malis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245 12 Photodocumentation in Microvascular Neurosurgery Ronald I. Apfelbaum .................................. 261 13 The Microsurgical Laboratory Norman Chafer, Z. Szabo, and H. J. Buncke. . . . . . . . . . . . . 273 14 Acquisition of Technical Skills in Microvascular Neurosurgery Jack M. Fein and Rodney Olinger. . .. . ... . .. ... . .. .... .. 279 Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-1
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