History of Management of Cerebral Arteriovenous Malformations In Children

Understanding of Disease

• 19th century — First described: Hubert von Luschka, in 1854, was the first to describe a cerebral AVM (12). Rudolf Virchow, in 1863, gave an anatomical description and argued AVMs were congenital lesions (13).
• Mid-20th century — Detailed pathological descriptions: Noran (1945) (14) and McCormick (1966) (15) each provided a pathological classification system of AVMs. McCormick differentiated between AVMs and other intracranial vascular malformations.
• 1986 — Understanding of surgical risk: In 1986, Robert F. Spetzler and Neil A. Martin proposed the eponymous Spetzler-Martin grading system for AVMs, which predicts the morbidity and mortality risk of AVM surgery based on the nidal size, pattern of venous drainage, and eloquence of adjacent brain (16).
• Early 21st century — Molecular biology of AVMs: In the modern era, advances in cellular and molecular biology techniques have enabled the study of the developmental biology, genetics, epigenetics, and hemodynamics of AVMs in an effort to improve the surgical and nonsurgical treatment of these lesions (17,18).

Technological Development

• 1920s — Development of angiography: The introduction of cerebral angiography by Egas Moniz in the late 1920s facilitated the visualization and improved the diagnosis of AVMs (19).
• Late 1960s — Development of microneurosurgery: Microsurgical resection of AVMs was enabled in the late 1960s by the invention of the surgical microscope and instruments for microneurosurgery, including microclips (20).
• 1960s and 1970s — Development of endovascular embolization: The development of embolic agents and other endovascular technologies led to the use of neurointerventional techniques in the treatment of cerebral AVMs in the 1960s and 70s (21).
• 1968 — Development of radiosurgery: Advancements in radiosurgical technologies, including Gamma Knife radiosurgery, allowed for the use of radiosurgery in the treatment of AVMs, which was first done in 1968 (22).
• Late 20th and early 21st centuries — Advancements in imaging technologies: The evaluation and treatment of AVMs has been improved by the parallel development of CT, MRI, angiography, and the use of these technologies in the operating room for improved navigation (frameless stereotactic navigation) and intraoperative diagnosis (intraoperative and perioperative angiography).

Surgical Technique

• Late 19th and early 20th centuries — Early surgical approaches: Surgical treatment was first attempted in 1889 by Giordano (ligation of feeding artery) and Péan (extirpation) (23). Later, in 1928, Cushing (24) and Dandy (25) each published case series that described their use of similar (and rather unsuccessful) techniques. Olivecrona, in 1932, is believed to have performed the first successful resection of an AVM, essentially by eliminating all the feeding arteries (26).
• Late 1960s — Microsurgical resection: Pioneered by Yaşargil in the late 1960s and enabled by advancements in microsurgical technologies (20), microsurgical resection has become standard practice in the surgical treatment of AVMs.
• 1960s and 1970s — Endovascular embolization: First described in 1960 (27) and further developed in the 1970s (28,29), endovascular treatment of AVMs can involve preoperative (premicrosurgical/preradiosurgical) or curative embolization, the latter having a low rate of success (21).
• 1968 — Radiosurgery: First employed by Lars Leksell and colleagues in 1968 (30), radiosurgery has played a role in the treatment of AVMs for decades; however, optimal success depends on careful patient selection (22,31).