Introduction: The New Era of Endovascular Treatment

This introductory chapter provides the readers with an insight into the history of neuroendovascular surgery. Acknowledging the past is of the utmost importance to understanding and interpreting present dynamics and future directions in such a young, yet quickly evolving medical field. Starting from ancient history with the first descriptions of cerebral aneurysms, we describe the era of the extravascular approach to cerebrovascular disease with a focus on the main techniques conceived such as arterial ligation, aneurysm wrapping, trapping and packing. With the invention of the aneurysmal clip, the direct surgical approach to cerebral aneurysms gained a privileged place in the management of intracranial vascular disease which it retained throughout most of the second half of the 20th century. Nevertheless, marked by the invention of cerebral angiography, the endovascular era symbolically began in 1927. Ingenious, sometimes bizarre and hazardous, endovascular approaches to cerebrovascular disease are recounted, touching the history of the evolution of endovascular techniques, embolic materials and navigation devices. Modern neuroendovascular surgery is described with a focus on the development of coil technology which represents an essential milestone as it gave a massive impulse toward the birth of a new subspecialty in neurosurgery. At the end of the chapter we discuss how the training of young neurosurgeons is changing and should cope with these new acquisitions. The role of neuroendovascular surgery in neurosurgical residency programs is summarized for the United States, Japan and Europe. Should this be part of the neurosurgeon’s armamentarium? Could it be delegated completely to the neurointerventional radiologist or might it be best part of a completely new specialty?

Keywords: Cerebrovascular disease, history, interventional, neuroradiology, stroke, subarachnoid hemorrhage.