Elsevier

World Neurosurgery

Volume 93, September 2016, Pages 413-420
World Neurosurgery

Historical Vignette
Endovascular Neurosurgery: Personal Experience and Future Perspectives

This manuscript is the transcription of the Luessenhop Lecture (original title: “On the possibility of using past experiences as the servant, not the master, of the mind”) presented at the Joint Cerebrovascular Section of the American Association of Neurological Surgeons and the Congress of Neurological Surgeons in Los Angeles on 16 February 2016.
https://doi.org/10.1016/j.wneu.2016.06.071Get rights and content

Background

From Luessenhop's early clinical experience until the present day, experimental methods have been introduced to make progress in endovascular neurosurgery.

Methods

A personal historical narrative, spanning the 1980s to 2010s, with a review of past opportunities, current problems, and future perspectives.

Results

Although the technology has significantly improved, our clinical culture remains a barrier to methodologically sound and safe innovative care and progress.

Conclusions

We must learn how to safely practice endovascular neurosurgery in the presence of uncertainty and verify patient outcomes in real time.

Introduction

Alfred J. Luessenhop (1926–2009) has been regarded as the father of endovascular neurosurgery.1 After completing his residency (Massachusetts General Hospital in June 1959), he performed a landmark procedure (September 1959) in Georgetown University Medical Center (Washington, DC), reported in the Journal of the American Medical Association in March 1960.2 He called the procedure “artificial embolization of cerebral arteries.” The case was “to a large degree, a trial of the theoretical considerations that an embolus” would travel, “excluded from smaller branches to normal brain … to arrest at a point proximal to the malformation …. The carotid artery was exposed, and 4 spherical emboli, made of methyl methacrylate, were introduced under local anesthesia. Immediately after the 4th embolus, the patient became drowsy ….”2

A summary of Luessenhop's life and work was published in 2014.1 Perhaps even more interesting is to read his own perspective, published in 1990.3 There he recognizes the important contribution of Russian surgeons, such as Serbinenko4 and Romodanov and Shcheglov,5 as well as of Gerard Debrun,6 who had to reinvent detachable balloons (because communication was restricted between Russian surgeons and the Western world). Luessenhop also recognized René Djindjian7 as the pioneer in initiating selective catheterization techniques, referring to a 60-case series reported in 1973.

Section snippets

Enthusiasm (the Early Years)

Enthusiasm literally means “having the god enter into the worshipper ….” It came with the rituals devoted to Bacchus. “Much of what is greatest in human achievement involves some element of intoxication, some sweeping away of prudence by passion. Without enthusiasm, life would be uninteresting; with it, it is dangerous. In the sphere of thought, sober civilization is roughly synonymous with science”.8

One of Djindjian's students (and co-author of Ref.7), Jacques Théron, had been invited to

Perhaps We Can Get Better Prepared: The Laboratory

“Most people know what they do. They even know why they do what they do. What they don't know is what what they do does.”

—Foucault

In those days, we were manufacturing our own tools with whatever was available. Tubing was bought by the kilometer, on large spools. The particles we used were obtained by putting chunks of polyvinyl alcohol foam pillows in a kitchen blender.15 Elastic ligatures were made from the elastic waistband of men's underwear (one pair of briefs provided enough fibers for an

Learning from Experience

“Experimental science means the possibility of using past experiences as the servant, not the master, of mind.”

—J. Dewey (Democracy and Education)

Going back to the early 1980s, shortly after being introduced to what Jacques and others could do in the angio suite, I began to avidly read all I could find in the literature at the time. For some reason, I got married and spent most of my honeymoon reading Drake's articles. In passing, I would like to emphasize that reading old articles during your

The Good Practice: Care Trials

“Voltaire is said to have stated that the price of liberty is eternal vigilance. I often feel that the same applies to defending the use of randomized clinical trials (RCTs) because there are incessant attempts to replace them with other forms of investigation for various reasons.”36

I will shortly run out of time for this presentation, and soon we shall all be dead. Thus the matter is urgent. The lesson you can bring home from this lecture is to experience by yourself how it is possible to

Acknowledgments

I thank Tim Darsaut for correcting the manuscript and for countless challenging discussions on these matters over the last 10 years.

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      Endovascular treatments have revolutionized the management of common neurovascular diseases such as intracranial aneurysms and ischemic stroke. These advances would not have been possible without the visionary explorations of pioneers [1], but if these endovascular interventions are now considered progress, it is because they have convincingly been shown to improve patient outcomes in pragmatic trials [2,3]. Many other endovascular innovations have changed practice, but they cannot (yet) qualify as progress because they have never been properly assessed.

    Conflict of interest statement: The author declares that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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