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Neurosurgical Classics--XXIV

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Neurosurgical Classics--XXIV Neurosurgical Classics--XXIV ROBERT H. WILKIN$, M.D. Division of Neurosurgery, Duke University Medical Center, Durham, North Carolina IGNIFICANT medical advancements usu- of this type, on June ~, 1808, was success- ally are based on preliminary observa- ful.6,7,22,3a S tions and experiments made by various After it had been shown that the common investigators over a period of many years. carotid artery could he ligated for hemor- Frequently, though, the final steps in the rhage or aneurysm, the operation was ap- process are not made until the introduction plied injudiciously in the treatment of a vari- of a key idea or technique. An example of ety of other conditions: epilepsy, exophthal- this is the development of the surgical treat- mos, tumors of the head and neck, pain in the ment of intracranial arterial aneurysms. Pro- head, psychosis, etc. 4,3~ The resulting opera- cedures for the treatment of other arterial tive mortality rates were so high that sur- aneurysms were known for centuries, but be- geons were stimulated to invent devices for cause aneurysms of the intracranial arteries the gradual occlusion of the artery23 were hidden within the skull, these lesions George W. Crile s introduced a spring-end were rarely diagnosed before the introduc- screw clamp, and William S. Halsted16 recom- tion of carotid arteriography in 19~7. Since mended aluminum bands for this purpose. then, intracranial aneurysms have been Rudolph Matas also emphasized the im- diagnosed frequently, and a variety of opera- portance of testing and increasing the col- rive procedures have been devised for their lateral circulation by the temporary occlu- treatment. sion of the carotid artery before its liga- Basic principles in the treatment of arterial tion.22,24--26,33,34 aneurysms have been advanced since the The history of man's experience with intra- time of the ancients. At first, attempts were cranial aneurysms, like his experience with made to empty or excise the aneurysmal sac carotid ligation, can also be traced back at after ligation of the artery, but during the least to the eighteenth century. Although it Middle Ages conservative therapy by com- is difficult to be certain about previous ob- pression became popular. With the introduc- servations, these lesions were definitely en- tion of the tourniquet in 1674, treatment countered at postmortem examination by by arterial ligation again came into vogue.2s,29 Francisci Biumi in 1763 and John Hunter in Arterial ligation for hemostasis was also 179~2 Surprisingly, aneurysms were not de- practiced early in the history of surgery.19 scribed by Fallopius, Casserius, Vesling, Exactly when the common carotid artery Wepfer, or Willis, whose studies during the was first ligated is not clear because of the sixteenth and seventeenth centuries estab- incomplete medical records of those times. lished the anatomy of the circle of This procedure has been credited to Ambrose Willis. 3,14,2~176 By 1851, about 40 well Par6 and to several surgeons of the late authenticated cases of cerebral aneurysm had eighteenth and early nineteenth cen- been reported, and in 1861 Jonathan Hutch- turies2S,~2,33 inson became the first to clinically diagnose a On November 1, 1805, Astley Cooper per- saccular, nontraumatic intracranial aneu- formed the first ligation of the common carot- rysm.3,21,22 id artery for an aneurysm of that artery. 5 Despite many later retrospective studies Hemiplegia developed on the eighth post- of the signs and symptoms associated with operative day and the patient died on the intracranial aneurysms, they were rarely twenty-first day. Cooper's second operation diagnosed during life until the advent of 892 Neurosurgical Classics--XXIV 893 carotid arteriography.9,12,22,23,26,31,32,35 Sur- Two other significant procedures for the geons therefore had few encounters with treatment of intracranial aneurysms also these lesions. were developed during those few years. Both The following four operations are illustra- can be attributed to Walter Dandy. In 1936 tive of the few attempts at surgical correc- he began to treat aneurysms of the internal tion of intracranial ancurysnls prior to 1933. carotid artery in or near the cavernous sinus At the turn of the present century, Victor by ligating this artery in the neck and intra- Horsley accidentally found an aneurysm in cranially, thus trapping the aneurysm be- the middle cranial fossa arising from the tween the proximal and distal points of right internal carotid artery, and success- ligation. 11,~2 Two years later Dandy also fully treated it by ligating the common carot- introduced the important technique of di- id artery in the neck. 17,2~,26 In 19~4, Wilfred rectly occluding the neck of a saccular Trotter performed the first planned opera- aneurysm with a silver clip. 1~ tion for an intracranial aneurysm diagnosed The publications describing these two pro- preoperatively when he ligated the right cedures mark the end of the period when internal and external carotid arteries for several new techniques were rapidly intro- a traumatic aneurysm of the intracranial duced for the treatment of intracranial portion of the internal carotid artery. ~,22 aneurysms. They also mark the beginning of Four years later a saccular aneurysm of the present comparative evaluation of these the left middle cerebral artery in another pa- techniques in large numbers of patients. tient was correctly diagnosed preoperatively, References and treated by Walter Dandy by partial oc- 1. ALBRIGHT,F. The syndrome produced by aneu- clusion of the internal carotid artery in the rysm at or near the junction of the internal carotid neck.~,22 Finally, in 1931 the first planned in- artery and the circle of Willis. Johns Hopk. Hosp. tracranial operation for aneurysm was per- Bull., 1929, ~: 215-245. s BIaLEY, J.L. Traumatic aneurysm of the intra- formed when Norman Dott wrapped muscle cranial portion of the internal carotid artery. With around an aneurysm at the bifurcation of the a note by Wilfred Trotter. Brain, 1928, 51 : 184-208. left anterior and middle cerebral arteries. 13,22 3. BULL,J. A short history of intracranial aneurysms. Lond. clin. med. J., 1962, 3: 47-61. Then in 1933 Dott became the first to 4. CHEVERS,N. Remarks on the effects of oblitera- operate on an aneurysm previously demon- tion of the carotid arteries upon the cerebral circu- strated by carotid arteriography. With the lation. Lond. med. Gaz., 1845, n.s. 1: 1140-1151. 5. COOPER, A. A case of aneurism of the carotid use of this diagnostic technique, a new era in artery. Med.-chir. Trans., 1809, 1: 1-12. the treatment of intracranial aneurysms 6. COOPER, A. Second case of carotid aneurism. Med.-chir. Trans., 1809, 1: 222-233. was initiated. ~3,22 Many of the modern intra- 7. COOPER, A. Account of the first successful opera- cranial procedures for the correction of these tion, performed on the common carotid artery, for ancurysms were developed during the follow- aneurism, in the year 1808: with the post-mortem ing five years. examination, in 1821. Guy's Hosp. Rep., 1836, 1 : 58-58. "The first intracranial operation involving the 8. CHILE, G. W. An experimental and clinical re- actual excision of an aneurysm was reported by search into certain problems relating to surgical operations. Philadelphia: J. B. Lippincott Co., 1901, German[1~] to the Harvey Cushing Society in 19~8. 200 pp. German excised a posterior cerebral aneurysm 9. CvsaIna, H. Contributions to the clinical study with recovery. of intracranial aneurysms. Guy's Hosp. Rep., 192S, "The difficulty in ascribing credit to the first 73: 159-168. person to do a particular procedure is illustrated 10. DANDY, W.E. Intracranial aneurysm of the in- by the discussion which followed German's re- ternal carotid artery. Cured by operation. Ann. port to the Harvey Cushing Society. N[cKcnzic Surg., 1938, 107: 654--659. mentioned excising an aneurysm; Wilkins de- ll. DANDY, W.E. The treatment of internal carotid scribed opening an aneurysm by error; ])oppen aneurysms within the cavernous sinus and the cranial chamber. Report of three cases. Ann. Surg., stated that he preferred to surround an aneurysm 1939, 109: 689-709. with strips of muscle; Lyerly described a case in 12. DANNY, W. E. Intracranial arterial aneurysms. which he ligated the artery and removed the sac; Ithaca, N. Y.: Comstock Publishing Co., Inc., 1944, and Fay related removing an aneurysm under the viii, 147 pp. impression that it was a meningioma."22 13. DoTT, N. ]Y[. Intracranial aneurysms: cerebral .
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