(1911), Astwazaturoff (1911), Cassirer and Mühsam1 (1911), Isenschmid2 (1912), Schmolck (1912), Wichern (1912), von Eiselsberg and Ranzi1 (1913), Kaiserling (1913), Wischnewski (1913), Castex and Bob (1914), Leunenschloss (1914), Maklakow1 (1914), Orbison1 (1915), Versé (1918), Bort (1920), Castex and Romano (1920), Schmidt (1920), Bannister (1921), Hammes (1921), Magnus1 (1921), Nonne1 (1921), Campbell and Ballance1 (1922), Deist (1922), Worster-Drought and Ballance (1922), Müller (1923), Wohak (1923), Elkin (1924), von Lehoczky (1924), Mühsam1 (1924), Rienhoff (1924), Esser (1925), Federoff and Bogorad (1925), Klimesch (1925), Laves1 (1925), Marx (1925), Reid (1925), Dowling (1926), Globus and Strauss (1926), Haenel2 (1926), Klimesch (1926), Leeser (1926), Bregman (1927), Eimer and Melhose (1927), Herzog (1927), Olivecrona and Lysholm1 (1927), Perthes1 (1927), Worster-Drought and Dickson (1927), Buckley (1928), Cushing and Bailey1,2 (1928), Dandy1 (1928), Ruehl (1929), Yates Paine Brockman1,2 (1930), Brock and Dyke (1932), Krug and Samuels (1932), Dimitri and Balado (1933), Levine (1933), Love (1933), Schaltenbrand (1938), Sattler (1939).
Surgical Treatment of Cerebral AVMs (1889–1930)
Most of these early procedures were carried out by general surgeons (Table 1.1). Giordano is credited to have operated upon the first cerebral AVM in 1889. Regarding his original paper, however, it is clear that he simply ligated a pathological vessel on the left parietal surface and did not expose the remainder of the AVM located in the deep subcortical tissue.
Jules Emile Péan (1830–1898)
(By kind permission of Prof. H. M. Koelbing, Director of the Institute of Medical History, University of Zurich)
The first complete excision of a cerebral AVM was made 98 years ago by the famous French surgeon Péan. He treated a 15-year-old boy who had suffered a left sided Jacksonian fit, and made a diagnosis of a right sided central tumor. The operation took place in May 1889 and was described thus by Péan:
“Au cours de l’opération, nous nous trouvâmes en présence d’un angiome des méninges en communication avec les sinus longitudinal supérieurs. Malgré sa richesse vasculaire, malgré son étendue, la tumeur put être enlevée en totalité, sans perte de sang, grâce au pincement temporaire et définitif des vaisseaux variqueux, dilatés, érectiles, dont elle était composée. A ce propos, nous avons recherché, dans la science les faits de ce genre, qui avaient été publies et nous n’en avons trouvé aucun qui fut exactement semblable, aucun surtout qui eût été opéré.” Péan’s conclusion is optimistic: “– De même qu’il existe des angiomes extracrâniens communiquants à travers la voute du crâne avec le sinus longitudinal supérieur, il existe une variété d’angiomes intracrâniens communicants également avec les sinus longitudinal supérieurs, mais développés dans l’épaisseur des méninges et situés entièrement à l’intérieure du crâne. Les tumeurs sont justiciables de la trépanation, l’hémorrhagie et notamment celle due à la communication avec les sinus, et facilement arrêstée par le pincement temporaire et définitif.”
Neurosurgical Approaches Prior to the Introduction of Angiography (1928)
Cushing (1909–1928) and Dandy (1921–1926) each described their operative experiences in 14 and 15 cases respectively, of venous and arteriovenous malformation and added cases from the literature. Both of their series were published in the same year (1928) and reading the original descriptions it seems likely that all their cases were true arteriovenous malformations. Dandy felt that the only way to cure an arteriovenous aneurysm was to ligate the entering arteries or to excise the whole vascular tumor. Earlier, he had lost one patient from hemorrhage during the operation and a second case from intracerebral hemorrhage following total extirpation and he wrote: “But the radical attempt at cure is attended by such supreme difficulties and is so exceedingly dangerous as to be contraindicated except in certain selected cases… As in most cerebral lesions, however, each case should be considered a law unto itself. There are large aneurysms and small ones; those which are mostly arterial, others mainly venous; some are superficial, others deep, some are in highly important areas of the brain, others in portions largely silent. All of these factors, and finally the patient’s wishes in the matter, must be weighed. An aneurysm in the left cerebral hemisphere in a right handed person is surely noli me tangere under all conditions. Any attempted cure, even if successful, would almost surely result in disturbances of speech or motor power, or of both… there is more reason to attempt to cure a patient who has an arteriovenous aneurysm in the right hemisphere.”
Cushing’s experience with operations for cerebral angiomas dated back to 1909. Some brief extracts from his excellent operative accounts follow:
Case 1: A 39-year-old patient presented with raised intracranial pressure thought to be due to a cerebral neoplasm and was operated upon on 3.2.1909: “Left subtemporal decompression was made… The dura was not particularly tense. When opened a large thin-walled venous lake was disclosed, from which branches spread in various directions… It seemed unwise to attempt it.”
Case 2: A 4-year-old child with right sided congenital exophthalmos and bulging in the right temporal area; September 4, 1920: “When the dura was reflected there came into view a mass of hugely dilated vessels, evidently veins, which covered the entire temporal lobe. Two of the main vessels were ligated but extirpation was obviously impossible.”
Case 3: 30-year-old male, operated on March 18, 1921: “A left osteoplastic exploration was made. When the dura was opened an enormous tangle of dilated veins was disclosed spreading upward from about the region of the arm-center. The larger vessels were fully as big as the little finger. The chief emerging vein was ligated but all attempts to get beneath or between the larger vessels were accompanied by so much bleeding that their ligation or extirpation was deemed impossible.”
Case 4: “April 25, 1921: … On reflecting the dura an exceedingly wet brain was disclosed with two huge veins on the surface, one running largely in the sylvian fissure. The other, more vertical, lay in the precentral fissure… Since the operator felt some regrets at not having been more radical in his attacks upon the lesion in the preceding case, a ligature was first thrown around the large descending vein at the point… A second ligature was then put on, which must have started trouble from stasis in the main varix which became hardened and swollen… Finally bleeding began to occur from around the sides of the varix and a rupture seemed imminent. There was evidently only one thing to do – to catch the base of the protruding lesion with a large curved clip and to throw a ligature around the whole mass. This desperate step was taken and the cavity, which continued to bleed after the ligature was placed, was finally filled with a slab of muscle taken from the patient’s leg, before the excessive venous hemorrhage could be controlled. There had been a sharp fall in blood pressure from which she finally recovered without transfusion… As was to be expected, the patient showed a postoperative right hemiplegia and aphasia… Nearly seven years since her operation, regards herself, aside from some remaining weakness of her right arm, as in normal health.”
Depressed following such an experience Cushing wrote:
“One could hardly have chosen a worse place than over the lower motor area of the leading hemisphere in which to attempt the surgical removal of a racemose varix.” The untoward results of the procedure in this case resulted in a more cautious attitude when a similar lesion was disclosed in the next patient (left postcentral region): “December 28, 1922: No attempt was made to treat the lesion by ligature or otherwise.”
Cushing reviewed the poor results of other workers and warned: “The surgical history of most of the reported
