Norman E. Chase, MD
Comments
on Interventional
I
was asked to make some editorial comments relating to the excellent article in this issue of Radiology by Hi gashida et al (1). My attitudes and opin ions about interventional neuroradiol ogy have been shaped in part by my
own minuscule contributions
to the
field early in its development, but more importantly by my long associa tion as chairman of a department of ra diology that has been extraordinarily active in interventional neuroradiolo
Neuroradiology'
brated leak balloon and was the first to introduce the use of acrylics as an en dovascular embolization material.
stated earlier, the endovascular therapy
The development of interventional neuroradiology accelerated in the
for this type of aneurysm is probably definitive and, in the right hands, has
1980s, largely through the contribu tions of individuals such as the authors of the accompanying article (17), as
well as Berenstein (18-20), Fox (21,22), Vinuela (23,24), and others in North America; Lasjaunias (25-28), Merland (29), and Picard (30), among others, in
France; and many other investigators
gy.
Interventional neuroradiology owes a great debt to the pioneers in the field, a few of whom are cited below. Lues senhop (2) introduced the concept of endarterial embolization of cerebral ar teriovenous malformations. Djindjian and coworkers (3,4), as well as Di Chiro and Doppman (5,6), developed subse lective angiography and introduced therapeutic embolization of arteriove nous malformations of the spinal cord. Newton (7) as well was an early inves tigator in attempts to embolize arterio
venous malformations
of the spinal
cord. Hilal (8,9) and Kricheff (10) used different approaches to embolize arte riovenous malformations of the brain with use of catheter techniques and a variety of embolic materials. Serbi nenko (11)—as well as Scheglov (12)— in the Soviet Union and Debrun (13,14)—working first with French and then Canadian coworkers—indepen dently introduced the use of detachable balloons for the treatment of intracra nial aneurysms and arteriovenous fistu las. Kerber (15,16) introduced the cali
in the Americas,
conditions that were not amenable to surgery or in which surgical therapy did not have particularly good end re suits, such as aneurysms of the intraca vernous carotid artery, carotid cavern ous fistulas, and inoperable arteriove nous malformations of the brain, spinal cord, and dura, as well as arteriovenous malformations of the head and neck.
Other almost universally accepted roles for interventional neuroradiology include presurgical embolization of tu mors, treatment of cervical arteriove nous fistulas, treatment of intractable epistaxis, obliteration of vein of Galen aneurysms (previously an almost uni versally lethal disease) either with or without associated surgery, and presur gica! or definitive treatment of vascular neoplasms of the head and neck. Endovascular therapies have made some cerebral arteriovenous malforma tions that were once inoperable amena ble to surgical cure, even in instances in which
Index terms: Aneurysm, intracranial, 10.73 •¿ Aneurysm, therapy, 10.1299 •¿ Arteriovenous malformations, cerebral, 10.75 •¿ Catheters and catheterization •¿ Cerebral blood vessels, thera peutic blockade, 10.1299 •¿ Editorials •¿ Nervous system, therapeutic radiology Radiology
1991; 178:624-626
‘¿Fromthe Department of Radiology. New York University MedicalCenter,550 First Aye, New York, NY 10016. Received December 14, 1990; accepted December 17. Address reprint requests to the author. c RSNA,
1991
See alsothearticle by Higashidaetal(pp 663-670) and the editorial by Kobrine (pp 627628) in this issue.
624
Europe, and Japan.
To date, the greatest successes have been achieved in the therapy of those
they
could
not be totally
primarily those involving the cavern ous portion of the carotid arteries. As
excellent results. Those cases of intra dural aneurysms treated with detach able balloons in this and most other se ries outside of those in the Soviet Union and some in France include pa tients who have been rejected for sur gery either because of the location of the aneurysm, the type of aneurysm, or the medical condition of the patient. It is obvious that this group of preselect ed patients can be expected to have a much higher morbidity and mortality
rate than those patients considered good candidates for surgery. It is probably good practice that, at least at this time, endovascular detach able balloon therapy of intradural an eurysms is reserved for this type of high-risk patient, since the surgical ap proach has very respectable morbidity and mortality figures. As Luessenhop (31) stated
in an earlier
editorial,
fol
low-up studies are necessary to corn pare the !ong-term results of endovas cular therapy of intradural aneurysms
with those of surgical therapy. I do not feel that detachable balloon therapy of intracranial, intradural an eurysms will remain the therapy of
choice. I do believe, however, that most intracranial
aneurysms
will ultimately
be treated with endovascular tech niques, possibly with the use of stents or some type of membrane that can be
utilized to occlude the origin of the an eurysm.
Obviously,
a great deal of
obliterated with endovascular tech
work must be done before techniques
niques. Other arteriovenous malforma tions have been partially treated with endovascular techniques, making ste reotactic radiosurgery a therapeutic possibility. The study by Higashida et al report ed in this issue of Radiology represents the largest personal experience of en dovascular treatment of intracranial an eurysms by any North American inves tigators. The authors are to be congrat ulated for their excellent overview and thoughtful, intelligent approach to what must still be considered experi mental therapy. The largest component of this pub lished series is extradural aneurysms,
can be developed and proved. Coopera tion from neurosurgical colleagues will
be essential to enable selection at the appropriate time of patients who are somewhat
better candidates
than those
who have been chosen for endovascu lar treatment of aneurysms up till now. A great deal of laboratory experimenta tion is necessary before these tech niques can be perfected, and they cer tainly should be attempted only in those centers that have the greatest ex perience and the greatest support for endovascular therapies. I also expect that the success rate for treatment and, indeed, cure of arterio venous malformations of the brain will
cular therapy, surgery, and/or stereo tactic radiosurgery. The recent contri bution by interventional neuro radiologists of angioplasty treatment of intracranial arterial spasm has im proved the outcome considerably in those patients with subarachnoid hem orrhage secondary to aneurysm who undergo surgical treatment of their an
is so small a field at the present time that it certainly does not warrant spe cia! board examinations or separate clinical departments. There are also ar guments about what specialty these in dividuals represent. I would agree with Bryan (32) that these practitioners are neuroradiologists who require an un derstanding of radiologic techniques and equipment and of neuroanatomy, pathology, and neurologic diagnosis, with additional training and experi ence in the difficult techniques of in terventional neuroradiology. Many of these neuroradiologists may, indeed,
eurysm.
have backgrounds in neurosurgery
There is indeed a very promising fu ture for interventional neuroradiology. As neurosurgery is becoming more and
neurology, as many have had in the past; but functionally they will be neuroradiologists working intimately with their neurosurgical and neurolog ic colleagues. The performance of these procedures will most certainly remain in the neu roradiology section if only because of the capital investment for equipment, the understanding of the technology, the need to communicate with the manufacturers to optimize equipment, and the scarcity of trained radiologic paraprofessionals. The field should have an inclusionary pathway for neu rosurgeons or others who become in terested in this field so that they may receive the necessary training in radio!ogy and neuroradiology, as well as in terventional radiology. They will add their own specific skills and perspec tives to this developing clinical science. The necessary training for interven tional neuroradiology must include a basic understanding of diagnostic radi ology and neuroradiology and addi tional training and experience in inter ventional neuroradiology. It will be useful if the interventional neuroradi ologist also has some training beyond that of the average radiologist in the clinical care of this group of patients, so as not to burden clinical colleagues with aspects of routine care for those patients who may be primarily the pa tients of the interventional neuroradi ologist. All neuroradiologists should have some training in the treatment of con ditions that are either immediately life threatening or sufficiently common place, so that skills can be maintained. I would include the treatment of epista.x is and the presurgical embolization of tumors in the group of conditions in which all neuroradiologists should be competent. In conclusion, the work of Higashida et al is a milestone in the development
improve considerably as experience is gained and new techniques are ap plied. Certainly, many more arteriove nous malformations can be cured in the future by a combination of two or more
of the available techniques—endovas
more physiologic in its approach and techniques, endovascular therapy should follow and sometimes lead. The techniques of the endovascular thera pist can be used to further elucidate the functionings of the nervous system. Endovascular therapies for conditions such as Parkinson disease, Alzheimer disease, epilepsy, and stroke are not be yond expectations.
It is no coincidence that the greatest strides in interventional neuroradiolo gy have been made at those centers that have some of the strongest depart ments of neurologic surgery in North
America. The field could not have de veloped support, geons.
without the encouragement, and backing of the neurosur
I feel that I must credit a few of these individual neurosurgeons in this edito rial. Ransohoff, of New York Universi ty; Drake, in London, Ontario; and Wil son, at the University of California in San Francisco, all played major roles in support and development of these fields. Without their courage and vi sion, this work could not have been done. It must be emphasized that inter ventional neuroradiology cannot be an isolated effort. It requires the backing,
the support, and the intelligence of many others in related fields—most notably neurosurgery, neurology, vas cular surgery, anesthesiology, otolaryn gology, plastic surgery, and radiation oncology. This team approach permits
objective decisions, appropriate target ing of therapies, and the absence of therapy
where
indicated.
It is needless
to add that any center that is active in these techniques must have adequate case material to maintain skills and add to the store of knowledge. There has been some discussion as to
what these practitioners
of interven
or
I am not a great believer in adding spe
of this young field. Additional contri butions from other investigators will
cialty classifications. Despite the need for these workers to communicate, meet, and exchange experiences and ideas at seminars and conferences, this
continue to appear in the literature, adding to the geometric progression in the development of interventional neuroradiology. Whether or not the
tional neuroradiology
should
Volume 178 •¿ Number 3
be called.
number
of practitioners
tional neuroradiology
of interven
grows signifi
cantly, the field will remain a challeng ing, exhilarating, demanding, and ful filling activity for many years. U
References 1.
Higashida RT, Halbach VV, Dowd CF. Barnwell SL, Hieshima GB. Intracranial aneurysms: interventional neurovascular treatment with detachable balloons—re suits in 215 cases. Radiology
2.
3.
1991;
178:663-670. Luessenhop AJ, Spence WI. Artificial em bolization of cerebral arteries: report of use in a case of arteriovenous malforma tion.JAMA 1960; 172:1153-1155. Djindjian R, Dumesnil M, Faure C, Lefebre
J, Levegue P. Etude angiographique d'un 4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
angiome intra-rachidien. Rev Neurol 1962; 106:278-285. Djindjian R, Houdart R, Cophignon J, Hurth M. Premiers essais d'embolisation par voie femorale dans un cas d'angiome medullaire et dans un cas d'angiome au mente par Ia carotide externe. Rev Neurol 1971;125:119—130. Di Chiro C, Doppman JL, Ommaya AK. Selective arteriography of arteriovenous aneurysms of the spinal cord. Radiology 1967;88:1065-1077. Doppman JL, Di Chiro C, Ommaya AK. Obliteration of spinal cord arteriovenous malformations by percutaneous emboliza tion (letter). Lancet 1968; 1:577. Newton TH, Adams J. Angiographic demonstrated and nonsurgical emboliza tion of a spinal cord angioma. Radiology 1968; 91:873-876. Hilal 5K, Michelsen JW. Therapeutic per cutaneous embolization for extraaxial vas cular lesions of head, neck, and spine. Neurosurg 1975; 43:275-287. Hilal 5K, Sane P, Michelson WJ, Kossein A. The embolization of vascular malfor mations of the spinal cord with low-vis cosity silicone rubber. Neuroradiology 1978; 16:430—433. Kricheff II, Madayag M, Braunstein P. Transfemoral catheter embolization of cerebral and posterior fossa arteriovenous malformations. Radiology 1972; 103:107111. Serbinenko FA. Balloon catheterization and occlusion of major cerebral vessels. Neurosurg1974;41:125-145. Romadanov AP, Scheglov VI. Intravascu lar occlusion of saccular aneurysms of the cerebral arteries by means of a detachable balloon catheter. In: Krayenbuhl H, Sweet WH, eds. Advances and technical stan dards in neurosurgery. Vol 2. Berlin: Springer-Verlag, 1982; 25-49. Debrun C, Lacour P. Carson JP, et al. De tachable balloon and calibrated leak bal loon technique in the treatment of cere brovascular lesions. J Neurosurg 1978; 49:635-649. Debrun C, Fox A, Drake C, et al. Giant unclippable aneurysms: treatment with detachable balloons. AJNR 1981; 2:167173. Kerber C. Balloon catheter with a cali bratedleak:a new systemforsuperselec tive angiography and occlusive catheter therapy. Radiology 1976; 120:547-550. Kerber C. Intracranial cyanoacrylate: a new catheter therapy for arteriovenous malformation. Invest Radiol 1975; 10:536538. Heishima GB, Higashida RT, Wapenski J. et al. Balloon embolization of large distal
Radiology
625
18.
19.
20.
21.
basilar arteryaneurysms.J Neurosurg 1986; 65:413-416. Berenstein A. Flow controlled silicone fluid embolization. Am J Neuroradiol 1980; 1:61-77. Berenstein A. Technique for catheteriza tion and embolization of the lenticulo striate arteries. J Neurosurg 1981; 54:783789. Berenstein A, Ransohoff J, Kupersmith M, et al. Transvascular treatment of giant aneurysms of the cavernous carotid and vertebral arteries: functional investigation and embolization. Surg Neurol 1984; 21:312. Fox AJ, Vinuela F, Pelz DM, et al. Use of detachable balloons for proximal artery occlusion in the treatment of unclippable cerebral aneurysms. J Neurosurg 1987; 66:40-46.
22.
23.
24.
25.
26.
27.
626 •¿ Radiology
Fox AJ, Lee DH, Pelz DM, Brothers MF. Deveikis JP. Thrombotic mixture as a po lymerizing agent (abstr). AJNR 1988; 9:1029. Vinuela F, Fox AJ, Debrun C, et al. Pro gressive thrombosis of brain arteriove nous malformations after embolization with isobutyl-2-cyanoacrylate. AJNR 1983; 4:1233-1238. Vinuela F, Fox AJ, Kan 5, et al. Balloon occlusion of a spontaneous fistula of the posterior inferior cerebellar artery. Neurosurg 1983; 58:287-289. Lasjaunias P, Berenstein A. Surgical neuroangiography. Vol 1, Functional vas cular anatomy of the craniofacial area. New York: Springer-Verlag, 1987. Lasjaunias P. Berenstein A. Surgical neuroangiography. Vol 2, Endovascular treatment of the craniofacial area. New York: Springer-Verlag, 1987. Uasjaunias P. Berenstein A. Surgical neuroangiography. Vol 3, Functional
28.
29.
30.
31.
32.
anatomy of the brain, spine and spinal cord. New York: Springer-Verlag (in press). Uasjaunias P. Berenstein A. Surgical neuroangiography. Vol 4, Endovascular treatment of the brain, spine and spinal cord. New York: Springer-Verlag (in press). Merland JJ, Reizine D. Treatment of arte riovenous spinal cord malformations. Semin Intervent Radiol 1987; 4:281-290. Picard U, Moret J, Uepoire J. Endovascu lar treatment of intracerebral arteriove nous angiomas. J Neuroradiol 1984; 11:928. Luessenhop A. Interventional neuroradi ology: a neurosurgeon's perspective. AJNR 1990; 11:625-629. Bryan RN. Remarks on interventional neuroradiology. AJNR 1990; 11:630-632.
March 1991
Comments
on Interventional
I
was asked to make some editorial comments relating to the excellent article in this issue of Radiology by Hi gashida et al (1). My attitudes and opin ions about interventional neuroradiol ogy have been shaped in part by my
own minuscule contributions
to the
field early in its development, but more importantly by my long associa tion as chairman of a department of ra diology that has been extraordinarily active in interventional neuroradiolo
Neuroradiology'
brated leak balloon and was the first to introduce the use of acrylics as an en dovascular embolization material.
stated earlier, the endovascular therapy
The development of interventional neuroradiology accelerated in the
for this type of aneurysm is probably definitive and, in the right hands, has
1980s, largely through the contribu tions of individuals such as the authors of the accompanying article (17), as
well as Berenstein (18-20), Fox (21,22), Vinuela (23,24), and others in North America; Lasjaunias (25-28), Merland (29), and Picard (30), among others, in
France; and many other investigators
gy.
Interventional neuroradiology owes a great debt to the pioneers in the field, a few of whom are cited below. Lues senhop (2) introduced the concept of endarterial embolization of cerebral ar teriovenous malformations. Djindjian and coworkers (3,4), as well as Di Chiro and Doppman (5,6), developed subse lective angiography and introduced therapeutic embolization of arteriove nous malformations of the spinal cord. Newton (7) as well was an early inves tigator in attempts to embolize arterio
venous malformations
of the spinal
cord. Hilal (8,9) and Kricheff (10) used different approaches to embolize arte riovenous malformations of the brain with use of catheter techniques and a variety of embolic materials. Serbi nenko (11)—as well as Scheglov (12)— in the Soviet Union and Debrun (13,14)—working first with French and then Canadian coworkers—indepen dently introduced the use of detachable balloons for the treatment of intracra nial aneurysms and arteriovenous fistu las. Kerber (15,16) introduced the cali
in the Americas,
conditions that were not amenable to surgery or in which surgical therapy did not have particularly good end re suits, such as aneurysms of the intraca vernous carotid artery, carotid cavern ous fistulas, and inoperable arteriove nous malformations of the brain, spinal cord, and dura, as well as arteriovenous malformations of the head and neck.
Other almost universally accepted roles for interventional neuroradiology include presurgical embolization of tu mors, treatment of cervical arteriove nous fistulas, treatment of intractable epistaxis, obliteration of vein of Galen aneurysms (previously an almost uni versally lethal disease) either with or without associated surgery, and presur gica! or definitive treatment of vascular neoplasms of the head and neck. Endovascular therapies have made some cerebral arteriovenous malforma tions that were once inoperable amena ble to surgical cure, even in instances in which
Index terms: Aneurysm, intracranial, 10.73 •¿ Aneurysm, therapy, 10.1299 •¿ Arteriovenous malformations, cerebral, 10.75 •¿ Catheters and catheterization •¿ Cerebral blood vessels, thera peutic blockade, 10.1299 •¿ Editorials •¿ Nervous system, therapeutic radiology Radiology
1991; 178:624-626
‘¿Fromthe Department of Radiology. New York University MedicalCenter,550 First Aye, New York, NY 10016. Received December 14, 1990; accepted December 17. Address reprint requests to the author. c RSNA,
1991
See alsothearticle by Higashidaetal(pp 663-670) and the editorial by Kobrine (pp 627628) in this issue.
624
Europe, and Japan.
To date, the greatest successes have been achieved in the therapy of those
they
could
not be totally
primarily those involving the cavern ous portion of the carotid arteries. As
excellent results. Those cases of intra dural aneurysms treated with detach able balloons in this and most other se ries outside of those in the Soviet Union and some in France include pa tients who have been rejected for sur gery either because of the location of the aneurysm, the type of aneurysm, or the medical condition of the patient. It is obvious that this group of preselect ed patients can be expected to have a much higher morbidity and mortality
rate than those patients considered good candidates for surgery. It is probably good practice that, at least at this time, endovascular detach able balloon therapy of intradural an eurysms is reserved for this type of high-risk patient, since the surgical ap proach has very respectable morbidity and mortality figures. As Luessenhop (31) stated
in an earlier
editorial,
fol
low-up studies are necessary to corn pare the !ong-term results of endovas cular therapy of intradural aneurysms
with those of surgical therapy. I do not feel that detachable balloon therapy of intracranial, intradural an eurysms will remain the therapy of
choice. I do believe, however, that most intracranial
aneurysms
will ultimately
be treated with endovascular tech niques, possibly with the use of stents or some type of membrane that can be
utilized to occlude the origin of the an eurysm.
Obviously,
a great deal of
obliterated with endovascular tech
work must be done before techniques
niques. Other arteriovenous malforma tions have been partially treated with endovascular techniques, making ste reotactic radiosurgery a therapeutic possibility. The study by Higashida et al report ed in this issue of Radiology represents the largest personal experience of en dovascular treatment of intracranial an eurysms by any North American inves tigators. The authors are to be congrat ulated for their excellent overview and thoughtful, intelligent approach to what must still be considered experi mental therapy. The largest component of this pub lished series is extradural aneurysms,
can be developed and proved. Coopera tion from neurosurgical colleagues will
be essential to enable selection at the appropriate time of patients who are somewhat
better candidates
than those
who have been chosen for endovascu lar treatment of aneurysms up till now. A great deal of laboratory experimenta tion is necessary before these tech niques can be perfected, and they cer tainly should be attempted only in those centers that have the greatest ex perience and the greatest support for endovascular therapies. I also expect that the success rate for treatment and, indeed, cure of arterio venous malformations of the brain will
cular therapy, surgery, and/or stereo tactic radiosurgery. The recent contri bution by interventional neuro radiologists of angioplasty treatment of intracranial arterial spasm has im proved the outcome considerably in those patients with subarachnoid hem orrhage secondary to aneurysm who undergo surgical treatment of their an
is so small a field at the present time that it certainly does not warrant spe cia! board examinations or separate clinical departments. There are also ar guments about what specialty these in dividuals represent. I would agree with Bryan (32) that these practitioners are neuroradiologists who require an un derstanding of radiologic techniques and equipment and of neuroanatomy, pathology, and neurologic diagnosis, with additional training and experi ence in the difficult techniques of in terventional neuroradiology. Many of these neuroradiologists may, indeed,
eurysm.
have backgrounds in neurosurgery
There is indeed a very promising fu ture for interventional neuroradiology. As neurosurgery is becoming more and
neurology, as many have had in the past; but functionally they will be neuroradiologists working intimately with their neurosurgical and neurolog ic colleagues. The performance of these procedures will most certainly remain in the neu roradiology section if only because of the capital investment for equipment, the understanding of the technology, the need to communicate with the manufacturers to optimize equipment, and the scarcity of trained radiologic paraprofessionals. The field should have an inclusionary pathway for neu rosurgeons or others who become in terested in this field so that they may receive the necessary training in radio!ogy and neuroradiology, as well as in terventional radiology. They will add their own specific skills and perspec tives to this developing clinical science. The necessary training for interven tional neuroradiology must include a basic understanding of diagnostic radi ology and neuroradiology and addi tional training and experience in inter ventional neuroradiology. It will be useful if the interventional neuroradi ologist also has some training beyond that of the average radiologist in the clinical care of this group of patients, so as not to burden clinical colleagues with aspects of routine care for those patients who may be primarily the pa tients of the interventional neuroradi ologist. All neuroradiologists should have some training in the treatment of con ditions that are either immediately life threatening or sufficiently common place, so that skills can be maintained. I would include the treatment of epista.x is and the presurgical embolization of tumors in the group of conditions in which all neuroradiologists should be competent. In conclusion, the work of Higashida et al is a milestone in the development
improve considerably as experience is gained and new techniques are ap plied. Certainly, many more arteriove nous malformations can be cured in the future by a combination of two or more
of the available techniques—endovas
more physiologic in its approach and techniques, endovascular therapy should follow and sometimes lead. The techniques of the endovascular thera pist can be used to further elucidate the functionings of the nervous system. Endovascular therapies for conditions such as Parkinson disease, Alzheimer disease, epilepsy, and stroke are not be yond expectations.
It is no coincidence that the greatest strides in interventional neuroradiolo gy have been made at those centers that have some of the strongest depart ments of neurologic surgery in North
America. The field could not have de veloped support, geons.
without the encouragement, and backing of the neurosur
I feel that I must credit a few of these individual neurosurgeons in this edito rial. Ransohoff, of New York Universi ty; Drake, in London, Ontario; and Wil son, at the University of California in San Francisco, all played major roles in support and development of these fields. Without their courage and vi sion, this work could not have been done. It must be emphasized that inter ventional neuroradiology cannot be an isolated effort. It requires the backing,
the support, and the intelligence of many others in related fields—most notably neurosurgery, neurology, vas cular surgery, anesthesiology, otolaryn gology, plastic surgery, and radiation oncology. This team approach permits
objective decisions, appropriate target ing of therapies, and the absence of therapy
where
indicated.
It is needless
to add that any center that is active in these techniques must have adequate case material to maintain skills and add to the store of knowledge. There has been some discussion as to
what these practitioners
of interven
or
I am not a great believer in adding spe
of this young field. Additional contri butions from other investigators will
cialty classifications. Despite the need for these workers to communicate, meet, and exchange experiences and ideas at seminars and conferences, this
continue to appear in the literature, adding to the geometric progression in the development of interventional neuroradiology. Whether or not the
tional neuroradiology
should
Volume 178 •¿ Number 3
be called.
number
of practitioners
tional neuroradiology
of interven
grows signifi
cantly, the field will remain a challeng ing, exhilarating, demanding, and ful filling activity for many years. U
References 1.
Higashida RT, Halbach VV, Dowd CF. Barnwell SL, Hieshima GB. Intracranial aneurysms: interventional neurovascular treatment with detachable balloons—re suits in 215 cases. Radiology
2.
3.
1991;
178:663-670. Luessenhop AJ, Spence WI. Artificial em bolization of cerebral arteries: report of use in a case of arteriovenous malforma tion.JAMA 1960; 172:1153-1155. Djindjian R, Dumesnil M, Faure C, Lefebre
J, Levegue P. Etude angiographique d'un 4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
angiome intra-rachidien. Rev Neurol 1962; 106:278-285. Djindjian R, Houdart R, Cophignon J, Hurth M. Premiers essais d'embolisation par voie femorale dans un cas d'angiome medullaire et dans un cas d'angiome au mente par Ia carotide externe. Rev Neurol 1971;125:119—130. Di Chiro C, Doppman JL, Ommaya AK. Selective arteriography of arteriovenous aneurysms of the spinal cord. Radiology 1967;88:1065-1077. Doppman JL, Di Chiro C, Ommaya AK. Obliteration of spinal cord arteriovenous malformations by percutaneous emboliza tion (letter). Lancet 1968; 1:577. Newton TH, Adams J. Angiographic demonstrated and nonsurgical emboliza tion of a spinal cord angioma. Radiology 1968; 91:873-876. Hilal 5K, Michelsen JW. Therapeutic per cutaneous embolization for extraaxial vas cular lesions of head, neck, and spine. Neurosurg 1975; 43:275-287. Hilal 5K, Sane P, Michelson WJ, Kossein A. The embolization of vascular malfor mations of the spinal cord with low-vis cosity silicone rubber. Neuroradiology 1978; 16:430—433. Kricheff II, Madayag M, Braunstein P. Transfemoral catheter embolization of cerebral and posterior fossa arteriovenous malformations. Radiology 1972; 103:107111. Serbinenko FA. Balloon catheterization and occlusion of major cerebral vessels. Neurosurg1974;41:125-145. Romadanov AP, Scheglov VI. Intravascu lar occlusion of saccular aneurysms of the cerebral arteries by means of a detachable balloon catheter. In: Krayenbuhl H, Sweet WH, eds. Advances and technical stan dards in neurosurgery. Vol 2. Berlin: Springer-Verlag, 1982; 25-49. Debrun C, Lacour P. Carson JP, et al. De tachable balloon and calibrated leak bal loon technique in the treatment of cere brovascular lesions. J Neurosurg 1978; 49:635-649. Debrun C, Fox A, Drake C, et al. Giant unclippable aneurysms: treatment with detachable balloons. AJNR 1981; 2:167173. Kerber C. Balloon catheter with a cali bratedleak:a new systemforsuperselec tive angiography and occlusive catheter therapy. Radiology 1976; 120:547-550. Kerber C. Intracranial cyanoacrylate: a new catheter therapy for arteriovenous malformation. Invest Radiol 1975; 10:536538. Heishima GB, Higashida RT, Wapenski J. et al. Balloon embolization of large distal
Radiology
625
18.
19.
20.
21.
basilar arteryaneurysms.J Neurosurg 1986; 65:413-416. Berenstein A. Flow controlled silicone fluid embolization. Am J Neuroradiol 1980; 1:61-77. Berenstein A. Technique for catheteriza tion and embolization of the lenticulo striate arteries. J Neurosurg 1981; 54:783789. Berenstein A, Ransohoff J, Kupersmith M, et al. Transvascular treatment of giant aneurysms of the cavernous carotid and vertebral arteries: functional investigation and embolization. Surg Neurol 1984; 21:312. Fox AJ, Vinuela F, Pelz DM, et al. Use of detachable balloons for proximal artery occlusion in the treatment of unclippable cerebral aneurysms. J Neurosurg 1987; 66:40-46.
22.
23.
24.
25.
26.
27.
626 •¿ Radiology
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