Management of Subarachnoid Hemorrhage in Two

See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/290480989

Management of Subarachnoid Hemorrhage in Two Important Italian Political Leaders: A Paradigm of Ethical and Technological Evolution of Neurosurgery During the Past Half-Century

Article in World Neurosurgery · January 2016 DOI: 10.1016/j.wneu.2015.12.089

5 authors, including:

Pierluigi Longatti Giacomo Pavesi University of Padova Azienda Unità Sanitaria Locale Modena

82 PUBLICATIONS 716 CITATIONS 35 PUBLICATIONS 100 CITATIONS

SEE PROFILE SEE PROFILE

Alberto Feletti Azienda Unità Sanitaria Locale Modena

44 PUBLICATIONS 317 CITATIONS

SEE PROFILE

All in-text references underlined in blue are linked to publications on ResearchGate, Available from: Giacomo Pavesi letting you access and read them immediately. Retrieved on: 07 August 2016 Historical Vignette

Management of Subarachnoid Hemorrhage in Two Important Italian Political Leaders: A Paradigm of Ethical and Technological Evolution of Neurosurgery During the Past Half-Century Pierluigi Longatti1, Ermanno Giombelli2, Giacomo Pavesi3, Alessandro Carteri1, Alberto Feletti3

Key words For a curious and extraordinary coincidence, 5 of the 7 most relevant leaders of - Cerebral aneurysm the Italian Communist Party (Partito Comunista Italiano, which was established - History of neurosurgery - Italian in 1921, has been the biggest Communist Party in Western Countries) suffered a - Neurosurgery evolution cerebral stroke. Cerebrovascular diseases afflicted also Stalin and Lenin, and a - Political leaders number of Presidents of the United States. - SAH We present the stories of 2 important Italian political leaders who shared both Abbreviations and Acronyms the leadership role of the major left Italian Party and the dramatic experience of MCA: Middle cerebral artery a subarachnoid hemorrhage. Retracing their medical incidents, separated by 50 SAH: Subarachnoid hemorrhage years of history, we show how a fatal medical disease has become neurosur-

From the 1Department of Neurosurgery, Treviso gical and successfully cured thanks to the advances of neurosurgery, neurora- Hospital e University of Padova, Padova; 2Department of diology, and hospital organization. A neurologic disease that was disgraceful 50 Special Surgeries, Unit of Neurosurgery, University Hospital years ago has lost any disquieting and embarrassing significance in the present of Parma, Parma; and 3Department of Neurosciences, Unit of Neurosurgery, NOCSAE Modena Hospital, Baggiovara, Italy time to the light of evolution of vascular neurosurgery. To whom correspondence should be addressed: Alberto Feletti, M.D., Ph.D. [E-mail: [email protected]] 2 Citation: World Neurosurg. (2016). consequences. This observation, however, Internal Medicine Department initially in http://dx.doi.org/10.1016/j.wneu.2015.12.089 is a mere curiosity and does not represent Padova and later in Rome. In his memoirs, Journal homepage: www.WORLDNEUROSURGERY.org the major theme of this article, nor has Cesare Frugoni writes about many of his Available online: www.sciencedirect.com this coincidence seemed to have patients, mostly renowned personalities 1878-8750/$ - see front matter ª 2016 Elsevier Inc. All discouraged politicians from contesting between the 2 World Wars, such as King rights reserved. the leadership of hon. Bersani’s Party. Fuad of Egypt, King Alphonse XIII of Nowadays, when a political leader or a Spain, the musician and conductor Arturo very important person is hospitalized, the Toscanini, the Nobel Prize Gugliemo INTRODUCTION public expects to receive thorough infor- Marconi, Benito Mussolini, and many other On January 5, 2014, Panorama, a wide- mation regarding the patient. In contrast, in members of the jet society of that time.3 circulation Italian weekly magazine, ran the past conventional medicine was very In particular, he was the doctor who the headline “Bersani and the Curse of the imaginative in avoiding certain words and managed the most critical illness of Pal- Communist Leaders—After Togliatti and adjectives, especially those indicating a lack miro Togliatti, the powerful 4 deca- Berlinguer, also Bersani Suffers a Brain of remedy, such as cancer, coma, heart deÀlasting General Secretary of the Italian Hemorrhage.”1 Pier Luigi Bersani, the attack, hemorrhage, etc. With better un- Communist Party (Figure 1). Togliatti’s General Secretary of the Democratic Party, derstanding of the disease progression and neurosurgical story is very interesting had suffered a subarachnoid hemorrhage successful treatments, people have restored and worthy of description. On July 14, (SAH) after the rupture of a middle the real and less-terrifying meaning of these 1948, in one of the most critical periods cerebral artery (MCA) aneurysm. Why a words. Such changes in both medical and of the newly established Italian Republic, curse? In a curious and extraordinary social communication and disease man- a young right-wing student attacked coincidence, 5 of 7 most relevant leaders agement are highlighted by speciﬁcstories Togliatti. A bullet became lodged in the of the Italian Communist Party (Partito that narrate similar cases in different his- external occipital protuberance without Comunista Italiano, which was established torical epochs. This train of thought is a penetrating the skull and was removed in 1921, has been the largest Communist good chance for neurosurgeons to trace the with no clinical consequences. To reassure Party in Western Countries) suffered a tremendous evolution that neurosurgery has millions of followers who were ready to cerebral stroke (Table 1). This is an odd undergone during the last half century. unleash a communist revolution that fate that even Lenin and Stalin, the top would have radically changed the political founders and leaders of the Soviet Union, geography of Europe after the Second did not escape. Stroke also seems to have CASE 1: PALMIRO TOGLIATTI World War, that evening Togliatti, lying plagued many Presidents of the United Professor Cesare Frugoni (1881À1978) was on his bed in the Clinic, greeted his sup- States, and not without political a famous clinician and the chairman of the porters despite his physical condition.

WORLD NEUROSURGERY - [-]: ---,MONTH 2016 www.WORLDNEUROSURGERY.org 1

certainly understood what the problem Table 1. General Secretaries of the Italian Communist PartyeDemocratic Party was” (excusatio non petita.). He also Diagnosed with Cerebrovascular Disease blamed the fact that “Togliatti and his Years of Service collaborators did a serious imprudence as Secretary Year of Age, Age at when they decided to keep the speech Name General Disease Disease years Death, years outdoors, bareheaded under the sun.” Nine years later, the 83-year-old Prof. C. Amadeo Bordiga 1921À1924 1969 Cerebral stroke 80 81 Frugoni was on vacation in Switzerland Antonio Gramsci 1924À1927 1937 Cerebral hemorrhage 46 46 when he received an urgent call. The 72- Palmiro Togliatti 1927À1964 1964 SAH 71 71 year-old hon. Togliatti was in deep coma after an apoplectic stroke in Yalta. Prof. C. À Luigi Longo 1964 1972 1968 Cerebral hemorrhage 68 80 Frugoni was asked to provide medical Enrico Berlinguer 1972À1984 1984 Cerebral hemorrhage 62 62 consultation to hon. Togliatti and travelled fi Pier Luigi Bersani 2009À2013 2014 SAH 62 to Yalta with Communist Party of cials. Yalta was the site of collective holidays SAH, subarachnoid hemorrhage. organized by the Soviet State, where the fun was alternated by the acculturation of young people. Hon. Togliatti was in Yalta Two years later, on August 22, 1950, he first to confirm the diagnosis of in this capacity. He was holding a con- was involved in a car accident while on hematoma,” although we don’t know ference in Russian to young pioneers of vacation. He suffered a head trauma with a which side, “and to evacuate it, with the Communist Party of the Soviet Union, frontal fracture and a fracture of the such a wonderful and prompt result that “also this time bareheaded and directly twelfth dorsal vertebra. After an initial hon. Togliatti, still on the operating bed, under the sun,” notes Prof. C. Frugoni: spontaneous improvement, a progressive regained consciousness.” “Togliatti suffered a stroke exactly as in deterioration ensued. The neurologist On May 1, 1955, in the late morning of a Trieste nine years before.” Prof. C. Fru- Professor Ugo Cerletti (1877À1963, known very sunny day, hon. Togliatti was giving a goni and Prof. Mario Spallone, a fervent for the invention of electroshock therapy lively and long political speech outdoors, Communist and the personal doctor of for mental disturbances, and a member of bareheaded under the sun in Trieste. He hon. Togliatti, reported Togliatti’s neuro- the Italian Communist Party)4 diagnosed suddenly noticed that he was not able to surgical history to their Russian col- Togliatti with a possible subdural chronic voluntarily move his right hand and leagues, emphasizing the former hematoma purely by clinical examination immediately later he started vomiting and intervention for the chronic subdural he- and suggested surgical evacuation. had a severe headache. After the injection matoma and the previous SAH. No warn- Professor Valdoni, Chair of General of a pain reliever, he found the strength to ing sign had appeared in the previous Surgery, and Professor Piero Frugoni take up the subject for a few minutes and days, when hon. Togliatti had been performed the surgery in the private conclude his speech. The chief of the involved in writing the “Yalta Memorial” clinic “Villa Salus.” They made “four Neurology and Psychiatry Department of about the future of Communism in the drillings, two on each side, that allowed Trieste, Professor Francesco Maria Donini, Soviet Union and in Europe, which he had made the diagnosis of SAH after a lumbar planned to discuss with Brezhnev. puncture. Cesare Frugoni reports that “in Everything needed for medical care had the meantime the appropriate actions had been minutely prepared and functionally been taken, but I did not want the word organized in one of the lodges for the young hemorrhage to be shown in the bulletin. Communist Party of the Soviet Union pio- Actually I did not consider appropriate to neers. At 1 AM on August 19, 5 days after the give too precise technical explanations event, the following medical bulletin was because we were talking about a issued: “The general state of Comrade politician, whose future position had to be Togliatti endures severe. According to the protected, also avoiding the use of words, program decided with the participation of as hemorrhage, that could have led to Prof. Cesare Frugoni, a consultation was misunderstandings and incorrect as- held with the neurosurgeon Prof. Alexei sumptions.” Furthermore, he specifies Arutiunov. An exploration of the cranial “the location of the SAH is certainly vault was decided for clarifying the subdural intracranial, but its importance and im- space. The intervention performed by Prof. plications are very different compared to a Arutiunov was well tolerated. The post- cerebral hemorrhage.” Nevertheless, Prof. operative course is normal at the moment.” C. Frugoni must have had some doubts Hon. Togliatti died on August 21. The about the correctness of his conduct number of resuscitations that were under- because he added, “however, doctors who taken for 2 hours after his cardiac arrest, a Figure 1. Hon. Palmiro Togliatti. have carefully read the bulletin would have length of time we would nowadays define as

2 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2015.12.089

CASE 2: PIER LUIGI BERSANI In the past 50 years, the Italian Communist Party has undergone a number of changes. With internal divisions and fusions with other parties that originated from the dissolution of the Christian Democracy Party, Partito Comunista Italiano ultimately adopted the name of Democratic Party. Hon. Pier Luigi Bersani, who has been the General Secretary of the Democratic Party from 2009 to 2013, also suffered a SAH, just like hon. Togliatti, at the age of 62. On January 5, 2014, he complained about a sudden and strong headache with vomiting while he was in his house in Piacenza, Italy (Figure 2). His wife drove him immediately to the local hospital, where he arrived at 11 AM. As soon as a computed tomography scan showed the presence of a SAH, hon. Bersani was transferred to the more-equipped Ospedale Maggiore in Parma, where a Department of Neurosurgery is available,at 1 PM. A cerebral angiography confirmed the presence of an aneurysm of the right MCA. The first medical bulletin was released by the Hospital Director of the Ospedale Maggiore of Parma: “Today, Sunday, January 5, 2014, honorable Pier Luigi Bersani has been transferred to the Department of Neurosur- gery of the University Hospital of Parma because of a sudden SAH. The hemorrhage was diagnosed this morning at the Hospital of Piacenza. After the first examinations Figure 2. Hon. Pier Luigi Bersani. confirming the diagnosis, a cerebral

WORLD NEUROSURGERY - [-]: ---,MONTH 2016 www.WORLDNEUROSURGERY.org 3

Downloaded from ClinicalKey.com at GOT-CILEA-Italian Center for Evaluation Health Care (CeVes) August 04, 2016. For personal use only. No other uses without permission. Copyright ©2016. Elsevier Inc. All rights reserved. HISTORICAL VIGNETTE PIERLUIGI LONGATTI ET AL. SAH AND THE ITALIAN COMMUNIST PARTY CURSE of history and development not only of the the episode of the subdural chronic he- countries, especially Sweden with the civil society but also of neurosurgery. Two matoma is emblematic. In the 1950s, the precious work of Olivecrona and Norlen, threads connect these 2 politicians: they neurologist was the diagnostician who therefore became the leaders in this field have been General Secretary of the Italian used to indicate to the surgeon where to until the introduction of the intraoperative Communist Party/Democratic Party, and operate, as had been customary for cen- microscope in the beginning of the 1960s. they have both been affected by the same turies. Neuroradiologic examination was Conversely, Italy and Germany were disease, SAH. not used routinely and usually reserved for isolated from the rest of the world during The case of hon. Bersani is part of the those cases when the clinical presentation the war and because of emigration over- contemporary history. SAH is now well of a supposed subdural hematoma was seas after the war. Italian neurosurgery known, and it was diagnosed immedi- unclear and questionable.5 Nevertheless, advanced gradually thanks to the help of ately. The computerized telemedicine the intervention was a success. many young doctors, especially from the system allowed the forwarding of Togliatti’s first SAH episode that occurred South, which was first freed by the Allied computed tomography scan images to the in Trieste is even more interesting. The forces, who were trained by Olivecrona.8,9 specialists working in a different hospital, story clearly confirmsthatSAHwasconsid- Possibly, Germany founded its neurosur- with the consequent optimization of the ered as a medical disease in 1955. It was gical renaissance through the technology treatment timing. The neurosurgeon is actually called “serous meningitis.”6 All the of the legendary Zeiss intraoperative mi- nowadays the leader of the medical team, precautions against its occurrence are croscopes that became the main tool of assisted by the neuroradiologist and not coherent with a medical treatment (absolute every neurosurgical room. The years be- the neurologist, who is not part of the bed rest, long convalescence.). Therefore, tween 1955 and 1964 are the foundation of team managing this disease. Angiography Togliatti’s SAH was performed entirely by vascular neurosurgery. Actually, the first showed an MCA aneurysm whose confor- medical specialists and even by a clinical papers about aneurysms clipping with mation required an immediate clipping. doctor. A neurosurgical consultation was microneurosurgical technique were pub- The medical bulletins, which the political certainly possible. Piero Frugoni, Prof. C. lished in 1964À1965. word was waiting for, express the severity Frugoni’s son, was a professor of Interestingly, Prof. Frugoni banned the of the disease and the aptness of the Neurosurgery in Padova at that time. word “hemorrhage” from being written in therapeutic maneuvers in a technical and Moreover, cerebral angiography was the medical bulletin. This behavior is understandable form. available in Padova and in other main considered very strange and questionable Conversely, the case of hon. Togliatti centers in Italy. The Portuguese physician nowadays. Nevertheless, this action was offers many hints and dramatically marks and neurologist Egas Moniz introduced common then. Stalin’s cerebral hemor- the social and medical advancements of cerebral angiography in 1927. Cerebral rhage was announced with a 2-day delay, the past half-century that perhaps we do angiography has been performed after SAH and Lenin’s stroke officially was hidden not clearly perceive (“Tempora mutantur et since 1931.6,7 Advancements in diagnosis and discussed only informally even in the nos mutamur in illis,” i.e., “The times and treatment of cerebral aneurysms were highest circles of the Party. Nowadays, the change, and we change with them”). First, obviously hindered by the war. Neutral possibility of a prompt and precise diagnosis with angiography and the better understanding of the physiopathology of SAH have helped to identify patients with ruptured aneurysms. Furthermore, the advent of the microneurosurgical era, a standardized early surgical intervention, and the attention for delayed complica- tions as vasospasm have helped decrease the mortality and improve final outcomes. The introduction of computerized telemedicine and a proper organization of regional hospitals are other crucial steps towards the optimal treatment of SAH. The immediate visualization of neuroradiologic examinations performed at pe- ripheral hospitals allows neurosurgeons to promptly diagnose and decide the appropriate treatments. The hub-and-spoke model for hospital organizations not only rationalizes resources but also rapidly di- rects patients to the proper hospital to be treated. Along with surgical advances, Figure 3. Hon. Pier Luigi Bersani returns to the House of Representatives on February 25th, 2014 (Copyright ANSA). technology and organization have helped to shorten the time to treatment and

4 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2015.12.089

Downloaded from ClinicalKey.com at GOT-CILEA-Italian Center for Evaluation Health Care (CeVes) August 04, 2016. For personal use only. No other uses without permission. Copyright ©2016. Elsevier Inc. All rights reserved. HISTORICAL VIGNETTE PIERLUIGI LONGATTI ET AL. SAH AND THE ITALIAN COMMUNIST PARTY CURSE ultimately improve the patients’ outcome. means.17 Another Italian, Guido Guglielmi, procedures; 4) how a fast file-sharing Moreover, the spreading of communica- later improved this technique with the system has removed some images of the tions like newspapers, television, and the creation of endovascular detachable coils in remote past, as VIP patients’ rooms are Internet leads to a consequent increased 1991.18,19 Undoubtedly, the neurosurgical now overcrowded by physicians from interest of the population about diseases departments in Moscow could certainly everywhere examining the files; 5) how impacting politics and cultural and social provide proper diagnostic angiography in immediate the communication to the life. For these reasons, in the case of hon. the early 1960s20; however, hon. Togliatti’s world is about the clinical diseases of Bersani it was not necessary to hide or clinical condition was obviously severe. persons on whom the fate of millions of avoid the words “hemorrhage” or “aneu- Even the diagnostic angiography would people depends; and 6) how a fatal event rysm” as it happened with Togliatti. have required a transfer to Moscow, concerning an important politician could There is little to say about the cause of impossible with the means of that time. have been a novel hint that has shifted the hon. Togliatti’s death in Yalta. Of course Moreover, surgery of cerebral aneurysms treatment of cerebral aneurysms toward the definitive diagnosis is not clear, with microsurgical technique initially the most conservative endovascular neu- because neuroradiologic examinations and was indicated days or weeks after SAH, roradiologic procedures. an autopsy were not performed. However, and the results of direct attack on anamnesis and symptoms directly reported ruptured intracranial aneurysms before REFERENCES by doctors who assisted him indicate a the introduction of the intraoperative 1. Panorama. Bersani e la maledizione dei leader comunisti. second SAH as the most likely cause of his microscope were not satisfactory. Milano, Italy: Panorama; 2014. Available at: death, 9 years after the first hemorrhage. Actually, the first randomized neurosur- http://www.panorama.it/news/politica/spifferi- Even nowadays, a similar case would gical trial carried out by McKissock et al.21 dal-transatlantico/bersani-emorragia-cerebrale- parma/. Accessed January 5, 2014. probably not benefit from any treatment. demonstrated that the results of Because of his nonpartisan and authori- conservative therapy were better than those 2. Meschia J, Safirstein BE, Biller J. Stroke and the tative esteem, Prof. C. Frugoni’s consulta- of direct attack on anterior communicating American presidency. J Stroke Cerebrovasc Dis. 1997; tion had the function of a validation of the aneurysms. The first and better results of 6:141-143. Soviet medical management of the case. microneurosurgical technique would have 3. Frugoni C. Ricordi e incontri. Milano: A. Mondadori; The Russian doctors who rushed from been published shortly after the Yalta 1974. Moscow immediately realized that there events (Adams JE, Witt J. The use of the 4. Aruta A. Shocking waves at the museum: the Bini- was no possibility for treatment. The futile otologic microscope in the surgery of Cerletti electro-shock apparatus. Med Hist. 2011;55: use of cranial trepanation to search for a aneurysms. Presented at the Neurosurgical 407-412. questionable subdural hematoma can have Society Meeting on January 25, 1964).22,23 In 5. Bergman PS, Nathanson M, Friedman ED. Results many explanations; however, it is possible any case, only Pool was claiming the need of exploration in patients with clinical diagnosis that Prof. Arutiunov could have been for an early aneurysm treatment, which was of subdural hematoma. J Am Med Assoc. 1952;149: prompted by political reasons to show the usually performed at least 10À15 days after 1529-1532. 24 Soviet Union prestige to the world. bleeding. At any rate, hon. Togliatti never 6. Todd NV, Howie JE, Miller JD. Norman Dott’s Khrushchev himself deemed so precious recovered consciousness and died on contribution to aneurysm surgery. J Neurol Neuro- the life of the Italian leader that he August 21. surg Psychiatry. 1990;53:455-458. entrusted its preservation to Prof. Mario The strange leitmotiv connecting 7. Perrett LV, Bull JW. Some aspects of subarachnoid Spallone, the personal physician of hon. Communist leaders during the span of haemorrhage: a symposium. III. The accuracy of Togliatti. Prof. Arutiunov was 60 years old several decades offers a diachronic para- radiology in demonstrating ruptured intracranial at the time, and we do not have references digm not only of the treatment of an aneurysms. Br J Radiol. 1959;32:85-92. showing he had any particular interest in infamous disease but also of the commu- 8. Cantore G, Riccio A. Obituary Prof. Beniamino cerebrovascular surgery before 1964. His nication style related to the disease itself. Guidetti 1918-1989. Acta Neurochir (Wien).1989;101:91. previous publications showed his interest 9. Neurochirurgia2000. Prof. Francesco Castellano. in head trauma, intervertebral disc pathol- Napoli, Italy: Neurochirurgia2000; 2009. Available 10-13 ogy, and chronic subdural hematomas. CONCLUSIONS at: http://www.neurochirurgia2000.com/cardarelli/ Interestingly, the story of hon. Togliatti is Turning back to the series of the Italian castellano.htm. Accessed February 10, 2015. fl likely to have triggered his interest in ce- Communist leaders so frequently af icted 10. Arutiunov AI. Closed cerebrocranial injuries. Vopr rebrovascular surgery. Actually, as the new by cerebral stroke, we presented the Neirokhir. 1955;19:4-9. Director of the Burdenko Institute of emblematic stories of 2, showing: 1) how a “ ” 11. Arutiunov AI. Subdural encapsulated hematomas, Neurosurgery, Prof. Arutiunov soon after neurologic disease that was disgraceful their clinical aspects and surgical treatment. Vopr published 2 significant papers on diag- 50 years ago has lost any disquieting sig- Neirokhir. 1961;25:16-21. nostic and vascular surgery.14-16 nificance in the present time to the light of Moreover, hon. Togliatti’s death seems to evolution of vascular neurosurgery; 2) how 12. Arutiunov AI. On some principal questions in the pathology and surgical treatment of intervertebral be temporally correlated with the develop- a fatal medical disease has become a disks. Vopr Neirokhir. 1962;26:21-24. ment of interventional neuroradiology in neurosurgical one and can be successfully the Union of Soviet Socialist Republics, with cured; 3) how the novel neuroimaging 13. Arutiunov AI, Brotman MK. Contrast methods of examination in the clinical diagnosis of degener- the increase of the attempts to exclude ce- technology has reduced the relevance of ation processes in the intervertebral disks. Vopr rebral aneurysms through endovascular clinical neurologists in neurosurgical Neirokhir. 1964;28:44-50.

WORLD NEUROSURGERY - [-]: ---,MONTH 2016 www.WORLDNEUROSURGERY.org 5

14. Arutiunov AI. On the clinical aspects and the 19. Guglielmi G, Viñuela F, Dion J, Duckwiler G. 24. Pool JL. Early treatment of ruptured intracra- surgical therapy of intracerebral hemorrhage. Electrothrombosis of saccular aneurysms via nial aneurysms of the circle of Willis with Khirurgiia (Mosk). 1965;41:103-107. endovascular approach. Part 2: preliminary clinical special clip technique. Bull N Y Acad Med.1959; experience. J Neurosurg. 1991;75:8-14. 35:357-369. 15. Arutiunov AI. Controversial problems of the surgery of vascular lesions of the brain. Vopr Neirokhir. 20. Serbinenko FA. Sectional puncture carotid angi- 1965;29:11-15. ography by means of a catheter. Vopr Neirokhir. Conflict of interest statement: The authors declare that the article content was composed in the absence of any 16. Konovalov AN, Yartsev VV, Likhterman LB. The 1960;24:35-38 [in Russian]. commercial or financial relationships that could be construed Burdenko Neurosurgery Institute: past, present, as a potential conflict of interest. future. Neurosurgery. 1997;40:178-185. 21. McKissock W, Richardson A, Walsh L. Anterior communicating aneurysms: a trial of conservative Received 1 August 2015; accepted 29 December 2015 17. Serbinenko FA. Balloon catheterization and oc- and surgical treatment. Lancet. 1965;1:873-876. Citation: World Neurosurg. (2016). clusion of major cerebral vessels. J Neurosurg. 1974; http://dx.doi.org/10.1016/j.wneu.2015.12.089 41:125-145. 22. Kurze T. Microtechniques in neurological surgery. Journal homepage: www.WORLDNEUROSURGERY.org 18. Guglielmi G, Viñuela F, Sepetka I, Macellari V. Clin Neurosurg. 1964;11:128-137. Available online: www.sciencedirect.com Electrothrombosis of saccular aneurysms via endovascular approach. Part 1: electrochemical 23. Pool JL, Colton RP. The dissecting microscope for 1878-8750/$ - see front matter ª 2016 Elsevier Inc. All basis, technique, and experimental results. intracranial vascular surgery. J Neurosurg. 1966;25: rights reserved. J Neurosurg. 1991;75:1-7. 315-318.

6 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2015.12.089