Major advancements in cerebrovascular surgery
Today’s brain surgeries have historical roots that can be traced back to ancient times.
Neurosurgical procedures appear throughout the history of Ancient Egypt, Ancient Greece and Ancient Arabia, among other places. Likewise, in the Americas, Mayans and Incas used hand operated drills and tools to perform brain surgery thousands of years ago.
Methods for these procedures changed over the ages and in certain geographic areas, but some form of trepanation – that is, interventions that required drilling a hole in the skull – were used by many different civilizations at various times throughout history.
During the Renaissance, for instance, doctors used trepanation to treat a variety of conditions including seizures, mental disorders and skull fractures. Since then, a myriad of techniques and technologies have been used to advance the fields of neuro- and cerebrovascular surgery.
Here are some of the major milestones in cerebrovascular surgery to know about, starting from the turning point in neurosurgery safety to novel therapies. Every technological advancement, from the microscope to imagining tools to flow measurement solutions, has pushed cerebrovascular surgeries one more step further than what was previously thought possible.
Advancements in Cerebrovascular Surgery: A Short History
Dr. Harvey Cushing is known as the “father of modern neurological surgery” for his groundbreaking contributions to the field. Thanks to his surgical techniques and deep knowledge of the nervous system, Cushing was able to lower neurosurgery’s fatality rate.
But it wasn’t just his technique and knowledge that improved neurosurgical patient outcomes. Cushing was also the pioneer of the anesthesia chart and was the first to use electrocautery to reduce blood loss in neurosurgery.
Dr. Cushing’s techniques and knowledge made a vital impact on the field of neurosurgery, which were then followed by other foundational technology advancements that brought the field into the modern era.
Noteworthy advancements include a collaboration between optician Carl Zeiss and physicist Ernst Abbe that brought microscopes to the field of neurology.
In 1957, Dr. Theodore Kurze was the first neurosurgeon to use a microscope in the OR. In 1967, Dr. Gazi Yaşargil successfully performed a superficial temporal artery–middle cerebral artery bypass on a 5-year-old child using microscopic technology.
The microscope and its evolution provided surgeons with better illumination and magnification, which improved precision.
In 1910, Dr. Victor L’Espinasse used an endoscope to treat hydrocephalus. However, the technology was not enthusiastically received. Harold Hopkins made enhancements to the endoscope, which made it more widely used.
An endoscope combined with a YAG-laser provides better visualization of ventricles, bringing forth new possibilities in neuroendoscopy.
The introduction of computer tomography (CT) technology provided better diagnostics and presurgical results. Currently, CT can be used for angiography, follow-up, headaches, hemorrhage, tumors and intracranial pressure.
Magnetic resonance imaging (MRI) can be used intraoperatively. In the 1960s, the first two-dimensional ultrasound was used for brain imaging. Later, three-dimensional ultrasound could also be used intraoperatively.
Intraoperative technologies like video angiography and flowmetry are valuable elements of neurosurgery and cerebrovascular surgery. Flowmetry can be used to measure flow in cerebral aneurysm clipping to ensure that the clip did not compromise cerebral blood flow, for example. These technologies were used during a groundbreaking awake aneurysm clipping procedure in November 2018.
Micro flowprobes provide more objective volume flow measurement during cerebrovascular procedures. Furthermore, intraoperative flow measurement technology helps save time and reduces the risk of intraoperative and postoperative stroke.
The future of cerebrovascular surgery is vast.
Here’s what professionals are keeping an eye on:
Endovascular robotics: Surgical robots have been used across specialities to great advantage including fatigue and tremor reduction and the ability to perform small, scalable movements. A team led by Gavin Britz successfully performed cerebrovascular navigation, placement of coils, bare metal stents and microcatheters in vitro and in vivo animal models using a robotic device.
Simulation: Three-dimensional CT angiography (3D-CTA) and three-dimensional digital subtraction angiography have enabled the reproduction of craniotomy and vascular tree modeling. Simulators using this ability can allow students and surgeons to simulate aneurysm clipping.
As for future cerebrovascular simulation devices, P Marinho, et al state they will need to “integrate representation of the brain surface and biomechanical modeling of brain and aneurysm wall deformation under retraction or during clipping. They should contribute to training and maintenance of surgical skills, thereby optimizing the quality of surgical treatment in this field.”
New therapies: Functional neurosurgery and stereotactic delivery of treatments, while in limited practice today, will continue to evolve. It’s a rapidly growing specialty that has the ability to impact the treatment of post-stroke function, spinal cord injuries and more.