J. Lawrence Pool, MD
It is an honor to be asked to contribute to the Archives for Intracranial Aneurysm Surgery. Matters of special interest to me are:
Intracranial surgery. Rather than carotid ligation in the neck, intracranial surgery gradually became the treatment of choice during the 1950s. I favored this development and also the later use of temporary clip occlusion of nutrient vessels to an aneurysm prior to its exposure and treatment.
Vasospasm. Many neurologists and those of allied fields in the 1950s did not believe that cerebral arteries were capable of vasospasm, or that it frequently occurred following subarachnoid hemorrhage from a bleeding aneurysm. I found that vasospasm could be artificially induced in vessels of the Circle of Willis in cats, dogs, and monkeys, as well as humans, and that it was a frequent occurrence after subarachnoid hemorrhage from an aneurysm (NEJM, 1958, and other papers).
Cardiac Arrhythmias. In hypothermic patients, I found cardiac arrhythmias could be induced by manipulation of vessels of the Circle of Trellis as well as by other stimuli and could be prevented or alleviated by IV sodium pentathal JNS, 1958).
Microsurgery. I was a pioneer, if not the first, to operate on cerebral aneurysms with the aid of a binocular dissecting microscope (in 1961, as published in the JNS, 1963).
Extracranial - cortical arterial shunt. Performed with a plastic tube in 1951, following aneurysm occlusion, this procedure is reported in my book on "Aneurysms and AVM's" with photos, in 1965. Dr. Yasargil, at one of Dr. Bennett Stein's Scarsdale Conferences, publicly stated that this was the first time any kind of an extracranial shunt had been made to an artery of the cerebral cortex.
Pulsating Exophthalmos (see my 1994 book "Brain Surgeon", Anecdotes). For these A-V fistulas, as part of a trapping procedure, I routinely plugged the entire length of the ipsilateral internal carotid artery in the neck by introducing a rubber catheter and tying it in place, to prevent collateral circulation. No recurrence of pulsation took place in any cases so treated.
Pregnancy and ruptured aneurysms. For a long while, considerable confusion and debate existed as to how best to treat a bleeding aneurysm during pregnancy. Bed rest until after delivery, immediate Cesarean section, or ligation of a cervical carotid artery were the commonest options. My review of the literature and personal experience convinced me that a high maternal and/or infant mortality occurred unless prompt intracranial surgery was done, just as if the patient were not pregnant. The latter policy, I concluded, was and is the method of choice (JAMA, 1965).