Table Of ContentSurgical Neuroangiography 1
Springer-Verlag Berlin Heidelberg GmbH
The complete three-volume set consists of
Volume 1
Clinical Vascular Anatomy and Variations
Volume 2
Clinical and Interventional Aspects in Adults
Volume 3
Clinical and Interventional Aspects in Children
P. Lasjaunias Surgical
A. Berenstein
K.G. ter Brugge
Neuroangiography
1C linical Vascular Anatomy
and Variations
Second Edition
with 627 Figures in 1265 Separate Illustrations,
Some in Color and 77 Tables
Springer
Pierre Lasjaunias M. D., Ph. D.
Professeur des Universites en Anatomie
Chef de Service de Neuroradiologie Vasculaire Diagnostique et Therapeutique
Centre Hospitalier, Universitaire de Bicetre
78, rue du General Leclerc, 94275 Le Kremlin Bicetre, France
Alejandro Berenstein, M. D.
Professor of Radiology and Neurosurgery
Albert Einstein School of Medicine, NY
Director of the Hyman-Newman Institute of Neurology and Neurosurgery,
and The Center for Endovascular Medicine and Surgery
Beth Israel Medical Center New York
170 East End Avenue at 87th Street, New York, NY 10128, USA
Karel G. ter Brugge, M. D.
Professor of Radiology and Surgery
Head, Division of Neuroradiology University of Toronto /
University Health Network
Department of Medical Imaging, Toronto Western Hospital, FP3-210
399 Bathurst Street, Toronto, ON M5T 2S8, Canada
The first volume of the second edition of Surgical Neuroangiography
combines the previous volumes 1 and 3 in one book.
ISBN 978-3-642-07443-1
Library of Congress Cataloging-in-Publication Data
Lasjaunias, Pierre L. Surgical neuroangiography / Pierre Lasjaunias, Alejandro Berenstein, Karel G. ter
Brugge.-2nd ed.
p.; cm. Includes bibliographica1 references and index. Contents: 1. Clinica1 vascular anatomy and variations.
ISBN 978-3-642-07443-1 ISBN 978-3-662-10172-8 (eBook)
DOI 10.1007/978-3-662-10172-8
1. Nervous system-Blood-vessels-Radiography. 2. Nervous system-Blood vessels-Surgery. 3. Angio
graphy. L Berenstein, Alex, 1947-IL ter Brugge, Karel G. III. Title.
[DNLM: 1. Neuroradiography. 2. Angiography. WL 141 L344s 200 Il RDS94.2.L37 200 I 616.8-dc21
00-049688
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Originally published by Springer-Verlag Berlin Heidelberg New York in 2001
Softcover reprint of the hardcover 2nd edition 200 I
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To our families
Preface to the Second Edition
Anatomy is a language, and mastering this language is essential for physi
cians involved in the management of patients with vascular diseases of the
central nervous system. This language includes more than the recognition
of images; it also involves their interpretation in the unique arrangement
of the overall anatomy of the area, region, and individual, resulting in the
recognition of the difference between a normal variation and a pathologi
cal condition. Technological testing cannot replace anatomical knowledge.
Our ability to image the vascular system has expanded with the intro
duction of reconstructed 3-D images. Stereoscopy and virtual endoscopic
views demonstrate the inner orifice of an aneurysm in addition to its
extraluminal neck. New questions are being raised and new morphologi
cal views are being produced.
When therapies change, anatomy and anatomical perceptions change
with them. The internal carotid artery (ICA), for example, cannot be seen
as a simple, albeit essential, tube serving the brain. Embryological studies
and anatomical dissections have shown that in situations in which its
course is "aberrant" (through the tympanic cavity), the so-called ICA is in
fact the ascending pharyngeal artery, and the variant should be named
"cervical agenesis of the internal carotid artery". In the pig, the "ICA''
passes through the jugular bulb to join the rete mirabile. This so-called
ICA corresponds to another branch of the ascending pharyngeal artery,
which obviously supplies the brain but has a completely different origin
and biology. So even though a vessel can be named and its anatomical
relationships described, accepted, and perpetuated, our understanding of
the vessel should be completely reassessed.
Concepts evolve towards a broader view of anatomy and physiology.
Today, anatomy and embryology need to be looked at as manifestations
and adaptations of a process that has led to the selection of biological
mechanisms which preserve the vessel wall over time. Multiple factors
influence the balance between potential familial defects, embryonic defects,
the phenotypes that can be enhanced with special triggers (e.g., viruses),
and the ageing process, which may alter or refine the diseases that cannot
be grossly grouped together simply because they seem to be alike.
Clinical experience has shown that certain diseases involve specific
areas of the vascular tree and remarkably spare others. Topographic dif
ferences in the vascular environment may already suggest a potential
regional specificity of the vascular tree. It creates an invisible discontinu
ity in an apparently anatomical, histological, and hemodynamic contigu
ous system. The vulnerability of these segments cannot be permanent in
both a qualitative and a quantitative way.
VIII Preface to the Second Edition
The anatomy of an individual is not the same over time: It differs in the
newborn, the infant, the child, the adult, and the aged. A simple functional
illustration is the resorption of cerebrospinal fluid. In newborns and
infants, the pacchionian granulations are not mature, so that the cerebral
veins, and not the dural sinuses, drain the brain water.
Functional anatomy is the introduction of time in anatomy; the anatomy
of life and function as we know and observe it in clinical practice. How
ever, anatomy was established prior to the era of modern imaging. Now,
a function such as speech can be imaged, and words which are heard, seen,
spoken, and thought can be shown as areas of the brain that are activated.
However, this is akin to describing a dream without explaining it. The
error would be to think that speech is understood because it has been
imaged. By nature, images convey past reality and knowledge in a modern
expression. They freeze a dynamic process in which shape, space, and
time are linked. Only analysis can provide the dimension of time to a pic
ture, be it 3-D or even virtual reality.
Comparative anatomy is also functional anatomy, but over a longer
period of time it represents the historical dimension. It does not represent
a collection of independent validated maps and morphological models of
other species, but rather demonstrates the landmarks in human anatom
ical and physiological evolution (selection).
All the variants that become apparent to our keen discrimination
follow the universal law of the genome. It cannot be ignored that some
genes control morphology (homeobox-containing genes, remodeling
processes, etc.), just as others control function and molecular renewal.
The genome is essential but does not supply all the keys to anatomy; it only
explains the general architectural map. The realization of the genetic pro
gram, the possibility of adaptation as a reflection of epigenetic phenomena,
may have unforeseen outcomes, in particular when epigenetic triggers are
repeated or multiplied. It is only then that this fuzzy logic and the edges
of "normality" can be appreciated and understood by the modern
anatomist.
Three-dimensional reconstructions are readily used nowadays, proba
bly because we have become accustomed to them. We are comfortable
with the imaging medium and benefit from them even without under
standing how they work. For the specialist who has learned anatomy, the
eloquence of these pictures is delightful. Following volume acquisition,
electronic manipulation will allow for simulation of a surgical route, carry
out dissection, and make it possible to enter inside the space with virtual
images. Despite the realism of the image, it can never integrate the exis
tence of the surrounding environment. Whatever the appeal of the image,
it can be constructed only from what is visible, even when displayed by a
computer. It will still need to be interpreted, which is a subjective process.
Truth is not figurative, and every piece of information should be looked at
as a question rather than as an answer.
Anatomy is not just an exercise aimed at naming the form and provid
ing some key words, but rather a reading process and a dialogue between
form and its related structure. It is not enough to possess the letters of the
alphabet to be able to read or write, it is not enough to reproduce several
letters to write words, nor is it true that stringing words together in a pre-
Preface to the Second Edition IX
determined order makes one capable of writing phrases that make any
sense.
Vascular anatomy remains fundamental to the clinical practice of inter
ventional neuroradiology. The understanding of the development of the
vascular system in relation to its territories and adjacent structures facil
itates the anticipation of possible anatomical variations and clinical syn
dromes. Key components of managing patients with vascular disorders of
the central nervous system are: a commitment to acquiring knowledge of
the vascular anatomy, an emphasis on knowledge of the natural history of
vascular disorders, and the documentation of one's personal record when
treating these disorders.
The new edition of Surgical Neuroangiography has undergone several
significant changes. Volumes 1 and 3 have been combined in a single
book, and most of the text has been rewritten or edited. New figures have
been added, new variations have been illustrated and explained. The
addition of 3-D angiography has allowed us to depict in an eloquent way
many of the variations previously described or simply illustrated with a
schematic drawing. Several large and generic drawings have been includ
ed and repeated in the text to allow for a more comprehensive analysis of
the anatomy and variations without having to turn the pages back and
forth. The sequence of the seven chapters reflects the increasing anatom
ical complexity of the vasculature from the spine to the cervico-cranial
junction including the posterior fossa supply below the trigeminal origin.
The carotid system can then be analyzed from the extracranial to the
intracranial, to the intradural components. The distal basilar system is
described with the caudal division of the internal carotid artery, since
X Preface to the Second Edition
knowledge of the evolution of the circle ofWillis is prerequisite to under
standing its variations. The addition of Karel ter Brugge as an author has
offered a chance to enrich our shared vision and complement the clinical
applications of these anatomical axioms. Future volumes will deal with
such clinical applications in adults (Vol. 2) and children (Vol. 3). Surgical
Neuroangiography is not a multi-author book but rather the result of
25 years of shared experience between the authors who have been contin
ually working and researching together for the benefit of patients and
trainees in interventional neuroradiology.
April2001 P. Lasjaunias, A. Berenstein, and K. G. ter Brugge
Preface to the First Edition
Volume 1. Functional Anatomy of Craniofacial Arteries
Embolization has been performed in many European countries and in
North America for over 20 years and is now beginning to gain acceptance
in other countries. At first, experience with these techniques was shared
in the form of individual case reports; today some centers have treated
enough patients to be able to transform this anecdotal material into more
concrete data. For the last 10 of these 20 years, the two of us have been
deeply involved, encouraged, and stimulated by the interest created by the
few pioneers in endovascular techniques.
In 1978, when we first met, our discussion on embolization could have
been summarized as disagreement. It soon became obvious that these dif
ferences were primarily related to our different individual backgrounds.
One of us having a strong orientation toward anatomy, and the other
toward technique. We realized that these apparently opposing approaches
complement each other and decided to combine them to our mutual bene
fit. This collaboration has matured into the search for improvements in
patient care and for the safest, most reliable, and most responsible manner
of treatment.
The goal of these volumes is to share what we feel useful to the per
formance of endovascular surgery. Vascular lesions and tumors constitute
the traditional targets of embolization. Following advances in knowledge
and in materials, proximal arterial endoluminal occlusion has been
succeded by the ability to produce an effect at the cellular level by means
of micro emboli and cytotoxic agents. The technical challenge to preserve
as much as possible of the healthy tissue has led to superselectivity in the
embolization of brain vessels and fourth divisions of the external carotid
system. Miniaturization of devices allows us to use all our tools in new
borns and infants without femoral arterial damage. The possibility of
further enhancing the selectivity of delivery system placement by selective
recognition of the target will create further applications of surgical neuro
angiography. The development of rational protocols for specific lesions
and territories, as well as guaranteed reliability and safety constitute the
other objectives in the maturation of this specialty.
Embolizer, interventional neuroradiologist, surgical neuroradiologist,
and neuroangiographer are the most commonly used names for the radio
logists or surgeons performing embolization in lesions of the head, neck,
brain, and spine. Their search for an identity may appear futile; however,
it constitutes a strong psychological lever against medical bureaucracy,
which often unfortunately constitutes a factor limiting innovation. The
current use of "interventional" in connection with neuroradiology is
too restrictive. It focuses attention on the technical aspect of our work and
