Depressed following such an experience Cushing wrote:
“One could hardly have chosen a worse place than over the lower motor area of the leading hemisphere in which to attempt the surgical removal of a racemose varix.” The untoward results of the procedure in this case resulted in a more cautious attitude when a similar lesion was disclosed in the next patient (left postcentral region): “December 28, 1922: No attempt was made to treat the lesion by ligature or otherwise.”
Cushing reviewed the poor results of other workers and warned: “The surgical history of most of the reported cases shows not only the futility of an operative attack upon one of these angiomas, but the extreme risk of serious cortical damage which is entailed… How many less successful attempts, made by surgeons less familiar with intracranial procedures, have gone unrecorded may be left to the imagination.”
“The lesions, in short, when accidentally exposed by the surgeon, had better be left alone, and how much radiation may accomplish for them is undetermined though there are favourable experiences on record. So long ago as 1914 Wilhelm Magnus of Oslo unexpectedly exposed at operation a venous angioma of the left rolandic region, a decompression was made with the intention of treating the lesion with radium therapy which at that time was known favourably to influence cutaneous angiomas. After treatment, the decompression, which was bulging, receded, and the epileptiform attacks, from which the patient was suffering, became infrequent and finally disappeared …”
The publication of Reichert (1946) is unique, as he reported 15 cases of premotor vascular anomalies causing Jacksonian epilepsy, which were treated successfully by coagulation of the dural and pial vessels of the lesion (1935 to 1941).
Neurosurgical Treatment of Intracranial AVM Following the Introduction of Angiography (1930)
As we have seen, surgical excision of AVMs was carried out between 1889 and 1930, both by general surgeons and neurosurgeons. Some of these cases met with success, others ended disastrously. After one or two bad results most surgeons did not risk further attempts at excision.
With the advent of cerebral angiography the position began to change, for it became possible not only to diagnose the AVM but also to obtain some idea as to its location, its size and construction and the number of feeding and draining vessels. Angiography, however, was still somewhat primitive and the contrast material imperfect. Only a few angiographic demonstrations of cerebral AVMs were published before 1936 (Dott 1929, Löhr and Jacobi 1933, Moniz 1934 and 1951, Olivecrona and Tönnis 1936). Dott provided the first demonstration of the angiographic aspects of cerebral AVMs at the Neurosurgical Conference in Stockholm in 1935. However, the full benefits of cerebral angiography came only with improved techniques which were not widely available until the 1950s.
Olivecrona had a disappointing experience in 1923 when exploring for an infratentorial tumor (case 65). He was confronted with a highly vascular AVM and the patient died. In another case (66), with right parietal AVM, two surgical attempts remained unsuccessful. In future years Olivecrona (1927) urged caution in attempting surgery for an AVM found unexpectedly at operation. In this respect, his attitude was similar to that of Cushing and Dandy.
Left carotid angiogram showing a frontoparietal AVM. In the monograph of Egas Moniz, “L’Angiographie Cérébrale”, Masson, Paris 1934.
On May 5, 1932 Olivecrona carried out his first successful radical removal of a left cerebellar AVM on a 37-year-old male. The preoperative diagnosis was tumor or tuberculoma. The stormy operation was performed under local anesthesia, took 8 hours and the patient needed a transfusion of 2000 ml. The postoperative course was uneventful and the patient left the hospital 3 months later. In the next case (a 52-year-old female with right temporal AVM) diagnosis had been made preoperatively and verified on angiography. Olivecrona’s 16 cases together with 6 cases operated upon by Tonnis and 4 venous angiomas were presented in their classical monograph in 1936 (Bergstrand et al. 1936). Out of 26 cases only 2 dural and 3 parenchymal AVMs could be extirpated. They were cautions in advising operation saying that “Some polar AVMs and those in silent areas of the right hemisphere have been declared to be extirpable and curable, but in most cases the situation seemed to be unfavourable. A successful removal can be accomplished if all the feeders are eliminated, but this is only possible in a few cases.” The authors did not recommend techniques of cerebral decompression or ligature of the internal carotid artery.
Twelve years later Olivecrona published his extensive experience in 64 cases and mentioned also the surgical results of Penfield and Erickson (1941) and Pilcher (1946 a, b) together with the 7 successfully extirpated cases described by Dott in a personal communication Olivecrona and Riives (1948). By 1954 Olivecrona had removed 81 cerebral AVMs with quite exceptional results (Table 1.2).
The overall mortality for the series was 9% (7 cases), but most of these were early cases. In between 1951 and 1956 there was only a single operative death.
The opinion that small to moderate sized AVMs in silent areas of the brain should be operated upon while, others in nonsilent areas were better left untouched, found general acceptance among neurosurgeons. Within 25 years (1932–1957) approximately 500 patients with cerebral AVMs had undergone surgery; Olivecrona and Lysholm 1927, Dott 1929, Tönnis 1934, Puusepp 1935, Bergstrand, Olivecrona and Tönnis 1936, Röttgen 1937, Moniz 1938, Seeger 1938, Sorgo 1938, Singleton 1939, Northfield 1940/1941, Krayenbühl 1941, Penfield and Erickson 1941, Asenjo and Uiberall 1945, Jaeger and Forbes 1946, 1950, Pilcher 1946, Dott 1948, Olivecrona and Riives 1948, Pluvinage 1948, Trupp and Sachs 1948, Norlén 1949, Olivecrona 1949, 1950, Sorgo 1949, McKissock 1950, Pilcher et al. 1950, Sunder-Plassmann 1950, Basset 1951, Gros and Martin 1951, Kraus 1951, Petit-Dutaillis and Guiot 1951, 1953, Thiébaut et al. 1951, Wechsler et al. 1951, Whitney 1951, Amyot 1953, Arné et al. 1953, Druckemiller and Carpenter 1953, Ebin 1953, Gillingham 1953, Krayenbühl and Yaşargil 1953, Laine and Delandsheer 1953, 1956, Lazorthes and Géraud 1953, McKenzie 1953, Montrieul et al. 1953, Pompeu and Niemeyer 1953, Selverstone and White 1953, Tönnis and Lange-Cosack 1953, Falconer 1954, Logue and Monckton 1954, Martin and Brihaye 1954, Milletti 1954, Pimenta and da Silva 1954, Pluvinage 1954, Scott et al. 1954, Carton and Hickey 1955, Gould et al. 1955, Olsen and Wood 1955, Potter 1955, Hayne et al. 1956, Leppo et al. 1956, Lundberg et al. 1956, Paillas et al. 1956, Paterson and McKissock 1956, Philippides et al. 1956, Asenjo et al. 1957, Baker 1957, Hamby 1957, Krayenbühl and Yaşargil 1957, 1958 (90 cases, 26 radical removal), Ley 1957 (23 cases, 9 extirpations), McKissock and Hankinson 1957 (100 cases, 68 operated), Milletti 1957, Niemeyer 1957, Norlén 1957, Olivecrona and Ladenheim 1957 (100 cases, 81 operated), Paterson 1957, Tolosa 1957, Tönnis 1957, Af Bjorkesten 1959, Paillas et al. 1959, Tönnis et al. 1958.
Diagram of a temporooccipital AVM. Published in “An Introduction to Clinical Anatomy”, 1932, London, by Traquair. The angiography was performed