Surgical 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 This work is subject to copyright. AII rights are reserved, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilm or in any other ways, and storage in data banks. Duplication of this publication or parts thereof is only permitted under the provisions of the German Copyright Law of September 9, 1965, in its current version, and permis sion for use must always be obtained from Springer-Verlag Berlin Heidelberg GmbH. Violations are liable for prosecution under the German Copyright Law. http://www.springer.de © Springer-Verlag Berlin Heidelberg 198711990,2001 Originally published by Springer-Verlag Berlin Heidelberg New York in 2001 Softcover reprint of the hardcover 2nd edition 200 I The use of general descriptive names, registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. Product liability: The publishers cannot guarantee the accuracy of any information about the application of operative techniques and medications contained in this book. In every individual case the user must check such information by consulting the relevant literature. Cover design: E. Kirchner, Heidelberg Typesetting: Fotosatz-Service Kiihler GmbH, Wiirzburg Printed on acid-free paper SPIN 10735681 21/3130/op 5432 1 O 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