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SNI, Surgical Neurology International, with Nancy Epstein, its editor-in-chief, and SNI Digital, a new multimedia interactive digital resource for selected medical information in video audio
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print and podcast, with James Osmond as its editor-in-chief
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He's pleased to present another in the Skull Bay Surgery series from the University of California, Irvine, Department of Neurosurgery and Interdisciplinary Skull Bay Surgery team.
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The topic of this meeting is how we manage to giant intracranial arterial artery aneurysm. The
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anatomy, molecular biology, and clinical judgment behind the surgery.
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This multidisciplinary team includes people from neurosurgery, from molecular biology, from otolaryngology, and from other associated specialties. Frank Sew is a professor of neurologic surgery
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biomedical engineering and otolaryngology, and the chair of the department of neurosurgery at the University of California at Irvine.
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Danny Malkasian is a professor emeritus of neurologic surgery, director of the neuroanatomy and skull-based laboratory at the University of California at Irvine.
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And Alex Hender-Himps said he is a resident physician.
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Who's achieved many awards as a senior student with the most honors, and also graduated Summa Cum Laude at Chapman University.
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The guest commentator is Eric Nussbaum, who's the chair of the National Brain Aneurysm and Tumor Center and director of Complex cranial neurosurgery at the Midwest Spine and Brain Center in
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Minneapolis, St. Paul, and he is Associate Editor-in-Chief of SI and SI Digital. Besides the number of scientific publications on PubMed, he's written several books on aneurysms and malformations
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and cerebral vivascularization available from Amazon or theme.
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And the moderator is James Hausmann, the creator and founder and CEO of SI and SI Digital, former professor at the University of Minnesota, Michigan, Illinois, and UCLA, former head of
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neurosurgery and in-reforged health system, and then the University of Illinois at Chicago. It's a future-stomped or an healthcare consultant.
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All right. Very good. Well, thanks again for having us back on the podcast It's going to be another good session, we're on the journal.
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So today we're going to be talking about an interesting case, a little bit unique. It's a
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thrombost, a particular artery aneurysm. So this is a 53-year-old male with a history of hypertension, cigarette use, pryromphetamines, who presented to an outside hospital back in 2022, so a
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few years back with left hemibody numbness. He was found to have this - Do you want to get a little closer to the microphone? Oh, sorry. Yes, that's okay
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faintly see the mesh flow diverter being placed across the wide neck of the aneurysm. It's pretty faint in there. Yeah. So then after the procedure, he didn't get better. Initially, he was
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stable in his symptoms, but then he had one and a half years of progressive worsening left-sided weakness, gait imbalance, difficulty walking, and he was referred to Dr. Sue to discuss other
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options On exam at that time, he was alert and oriented. He had a rightward tongue deviation and some left hammy body weakness with some hyperoflexia, but no sensory deficits. You wanna take a
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crack at that, Eric? Do you have a new MR or any type of new cross-sectional imaging to see what the
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aneurysm's doing? Yes, we do. We have a new MR right here.
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And on the angiogram? and then we have an angiogram.
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And it's right here
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So
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They did a good job treating the aneurysm, but it doesn't feel anymore. But now we have this problem of worsening mass effect.
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So now you're on the mass compressing on the brainstem.
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Okay.
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I want to make a quick comment You know, the flow diverter is really not FDA approved for this posterior circulation. However, you know, people have been doing these cases with a fair result of
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excluding the blood flow to the aneurysm.
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And the angiogram showed that, you know, the result was pretty good And here, this is somehow the aneurysm sac got bigger after the flow
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diverter
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And I think, you know, over time, flow diversion.
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where does the pica come off on that side where does it want to come off it in here that a pica that
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goes to care about I don't think it does you don't see a pica
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Yeah, it's, if it is, it's just a shadow, just below Ayaka, but I'm not
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sure if that is, it's just not a brain stem, circumferential,
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yeah, the icon is pretty robust, yeah,
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probably crossfilling on that So, let me get the time sequence. Frank, he came to see you in the clinic, and you went ahead and did this procedure, and you must have compared the pre-procedure
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versus the post-procedure. Am I just see that it enlarged, or did you go on the basis of his clinical presentation? Like Alex showed in the beginning, I think the first MRI he showed was the
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pre-procedure, and the dimension was smaller, and the post-procedure,
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point and seeing whether, if you've really obliterated the inflow to the aneurysm, whether it would now thrombose and properly shrink down, but it's not a criticism, just. Yeah, we thought about
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that. But just looking at the MRI, it was just so huge. And it was hard to imagine this thing is going to show down over a short period of time. And the
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patient was very eager. I mean, I don't know. He had some sense that
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he wanted this done. And he was actually pushing for it. We pushed back and did exactly what you said, just tried it by a little time. But your point is very important. We didn't want to do that
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and wait. We did this because we were ready to do the procedure. So yeah, maybe that was a good option as well. It's just an option. I'll talk about it later. I have an almost identical case
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except it's probably almost twice as large the aneurysm, almost identical. Yeah. Literally right, dist over, just like this, sitting right in the midline, pushing the medulla back just with
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significantly more compression. But anyway, go ahead, I'm curious to see what you did. Well, you know, I think if you remember, if they have large
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carotid aneurysms or posterior communicating aneurysms, excuse me, pressing on the third nerve,
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it's false, I think the studies were showed that it recovers after three months if it's a giant aneurysm, because it shrinks. So you were trying to follow what was experienced as my guests and take
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the least risky approach, but it wasn't complying with you. Is that right, Frank? That's what you were saying. Yeah, we gave it a few months and this sometimes didn't really go away. No.
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I would not be able to make a judgment. Either way, I would have been pulled in both directions. I'm not sure what I would have concluded, but there's one aspect. There's a difference between a
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peripheral nerve recovering and if this is a problem of the brainstem, I'm not sure that recovery occurs with any rapidness and may never recover. Yeah, good point, Johnny.
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I rarely make good ones, but I appreciate your work.
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Okay. But I would know what to do. I would be flop-y about it until something may force my hands.
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low, right? But I wasn't 100 sure what if we get in there, there's bleeding and the pipeline, it would be hard to clip anything off if there's a right, right? So we coil that off, there's no
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blood flow. So the goal was just to open up the innerism, and kind of dissolve the clot with the tools, and break up the clot and just kind of decrease the massive effect. Okay, not not even
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clipping, you know, taking out any. Okay, no, see, your goal, again, was a conservative approach. And I just deal with the aneurys in the mass, open it up and take
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the cloud out and hope that that's it. You can maybe add some bleeding, you're gonna handle that, right? I mean, that was your thinking. Yes. Okay.
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So what happened? All right, let's take a look.
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So left is superior, right is inferior and then anterior is where he's drilling. So this is. Um, him, uh, as Dr. Seer drilling the, um, Condyle, uh, anteriorly taking the, um, at least a
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third of it down in order to improve the exposure. And we'll, we'll, we'll go over some of the, uh, anatomy of all this with Dr. Malkasian, um, in a few minutes.
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Okay. I just thinning that down. And then here we are opening the Dura, um, the medulla, uh, or, or the spinal cord, and then heading up towards the posterior fossa,
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I'm dissecting it free,
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attacking the Dura up with some poor neurons to, to improve the exposure and assist with the opening.
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sort of getting everything freed up and here we have a still shot where the aneurysm dome is here. You can see 9 and 10 coming off anteriorly there and 11 meeting up to go through the jugular frame
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and the duel is down below. And these are some of the probably C1, C1 efforts going anteriorly. And
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12, part of 12
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And so now it's exposing the aneurysm dome,
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kind of getting some of the different structures out of the way as best as possible. That was a little roulette that was sacrificed in order to gain adequate exposure. This is the microdoppler
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assessing for flow. There was no flow if you could hear it, but there's no sound. And then here's Dr. Sue cutting into the aneurysm dome
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Yeah, that was a moment of truth, but it's all it's all it's all it's all coagulated. coagulated blood, thrombois blood, nothing actively bleeding. And so the debulcan kind of proceeds almost in
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a similar fashion as with a tumor with sharpened bloods dissection, just taking out the pieces of clot that are able to come and then removing the capsule as it goes.
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So just slowly debulking, coming around, taking out pieces of of clotted blood.
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The wall was still very kind of a heron, it is digging into the medulla, the brainstem. So we tried to kind of peel that up, but it was difficult. So we decided just to leave that capsule on.
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And the internal content was all gone. So I was hoping over time it will kind of shovel up a little bit and retract a little.
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First, dentate where the nerve roots of the posterior roots of C1 are dorsal along with this final accessory. What is the developmental question here? These come from either the occipital or the
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cervical
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and segmented parts of our development there, where our somites are segmented the rest of our para-sagittal distance flanking, the spinal cord. There's something that nobody talks about, the 12
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cranial nerve
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and C1, and the ascending part of the spinal accessory, none of these have a dorsal root ganglion I don't know what that means, but it's a developmental observation that doesn't seem any
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physiological interest. It's beating up a horse for clinical, it has, I can't figure out any clinical importance, but it is an observation. So what's my point? My point is that these upper
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cervical nerves, C1, and the hypoglossal, they really come from the similar movements of somites that are mesodermal and neurocress. And
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I think they have variations because of that.
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And I think the clinical importance of that is during surgery, they don't always look the same. This final accessory is pretty consistent, but C1,
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both dorsal and ventral, don't forget, C1, they've never found the dorsal or ganglion on it and we know the high-fogloss was. absolutely motor, other than what may come as connections with the
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other sensory nerves. Surgically, it would mean that you have less freedom to manipulate that nerve because it's attached and it's intimately related to the C1, you said, right? And the vertebral
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artery. So you don't have much, if you're trying to move it, it's probably not very, that's not gonna have much leeway That's the whole point. It's a common denominator that I make about
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operating in this area. You can draw all the pictures, you can take all of the discussions. There's no room here. Out of all the para-clival approaches, which I go a little bit into, I think
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this is the most difficult. I think you have no freedom here. Eric, let me ask you something up to this point. Would you do anything differently or what are your thoughts?
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I think the operation was done very well. I totally agree with not trying to peel that off of the front of the medulla. I think you did a good job. I think you probably facilitated or hastened the
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recovery of mass effect. I mean, again, don't take this at all as a criticism I do believe that with that artery sacked, it would have shrunk down over time. So as long as you do the surgery and
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you don't hurt him or her, I think that you have, as I said, hastened the decreased mass effect in the recovery. But I think if you give this a year in theory, now in theory, it doesn't always
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work that way. You can have a completely thrombo-standeurism looking and you can't tell where blood flow is getting in You can still have these giant aneurysms grow and it's not exactly why. But in
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theory, with the coils all the way across the inflow, I suspect it would have shrunk down over time.
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I think you may be right. It's hard for me to tell without a lot of experience in this particular thing.
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But when we were working inside, chipping out the
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thrombus, the few kind of the giant thrombus aneurysm we've done taking out the thrombus, it's very organized, it's very gritty, it's like very hard. And I'm sure there's some inflammation going
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on in there over time. And maybe that would actually accelerate the degradation of the cloth. I'm not, I don't know if I can say for sure. I was very,
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the cloud was very hard.
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Here's our post-op MRI, which I think looks quite good. I mean, you can see like the rind of - Can you go back to the operative picture for a minute? I had my sound up. Yeah, oh, no, when he
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had the
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aneurysm, oh. What we did - we did, I think, the first time when they were called - we did not a coiling out
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in the '90s. And there were some times where the coils
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were misplaced and so forth, and that would lead to thrombosis of the artery and so forth. So - and I worked with Gerard de Pranigai, who was a terrific technician. And so we had to go and take
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them on, take the coils out, and then close the artery. And we didn't have to do it in the vertebral. We did it in mostly supertentorial. And
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that's a much more difficult problem. I'm bringing it up because of this
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because if you start to take the coils out. They're coming out, not only the collet, they're coming out of the afferent and efferent vessel. So you have to be prepared to close them off. And then
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you have to be prepared to essentially clip the aneurysm. And
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so you have to leave a neck to do that. You're gonna think about all those things ahead of time. And here you double checked and triple checked and there was no flow somehow in the back of my mind
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that maybe it's caused my experience I'm not sure I ever believed that. It was, I mean, there was nothing you could do, that you had all the evidence you could. But if you get in there and you
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start pulling on them, caught you, didn't do that. You use the cusa and you're just your goal is to decrease the mass effect. That was your goal. And you did that. And then you got out of there,
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which is, and that's a problem with sometimes with surgery. And that is, gee, I think I can do better And done.
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pipeline, right? The pipeline, I understand that. Right. I don't know. I don't know if it happens. I don't think people have a lot of experience. I don't know, Eric, maybe you do like
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operating after pipeline. I would try to avoid that. We then coil removal. And that's okay, right? As long as you have a healthy segment of the vessel. But once pipeline is in there, it's stuck.
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And then it doesn't close. You can't put a clip on it. You can't put a clip next to it. There's been any pathologic studies with pipeline on people who've died and looked at what happens
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histologically between the pipeline and the vessel. Anybody know that? Yeah, there are lots of studies like that. And they supposedly endotheialize. Well, okay. Very well. And it becomes like
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a cover that's okay. Okay, that would be important, I know. Yeah, but if there is a branch, there's outflow, pipeline allows that because it's fenestrated so. but there's no flow laterally and
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you should should not flow.
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I'm sorry, go ahead, Eric. No, I apologize. I agree with you trying not to operate. I think it's a bad idea to be operating in and around a pipeline. I have had to sacrifice the parent artery
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on one occasion, and
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a clip will close the pipeline. Solid aneurysm clip will close the vessel with the pipeline But I think what you did was smart because I totally agree with you, even though it was probably
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endothelialized. I would have been very nervous that as you're taking out clot, you pull some
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of that endothelium or something away, and all of a sudden you've got bleeding back into the aneurysm I don't think you can rely on that pipeline to necessarily
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better. Right.
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As an aneurysm surgeon, you've got to you've got to you've got to done beats perfect because people want to take the clip off. They want to replace it and they keep doing that. And eventually you
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blow the you tear the neck. And so done beats perfect. But I think you did it. Those are very wise, very thoughtful, very careful job Frank. And all these things were going through your mind.
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I'm sure of that. Yeah, it's a nerve wracking process. Now a question. Why didn't you get better? Why don't we miss him? So he got better. He got better. Oh, he did get better. So look at
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the post up. Am I Alex is showing you, you know, it's it's empty now. It's like an eggshell. Yes.
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So just the wall that was stuck to the brain stem, we didn't decided not to peel off So the mass effect, you know, is less. It's not perfect. there. And he did get better right away. Like he
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was able to,
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but over time, though, I think his improvement kind of settled a little bit. It's not as good as we thought he thought it was going to get. I'll go back in one more, to go back one more slide.
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If you look at it, you still, you can still see the capsule of the aneurysm, or the right against the brainstem. The brainstem and the
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lateral view. Oh, yeah. So, when you look at the surgical video, the wall of the aneurysm is not as flimsy as one would think. Yeah, that's the point I'm making And I think it's because it's
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not a very aneurysm without a elastin to some abnormal collagen.
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I'm not 100 sure that would happen here because the war itself is really hard. Denny, from a biological point of view, is the body going
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to eat away and to just some of the aneurysm all with time or not?
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No, I don't think so. I think that the dynamics of pulsation have been removed and that's where there'll be credibility for improvement. But I
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just don't think that this is something that the body's going to digest like some pathologies. I could be wrong about that. I could be wrong about almost everything I say.
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This is exactly what I would have expected. I don't think you could have done better than this. This is a perfect result from surgery, by the way I would have been shocked if - Somehow the
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brainstem had quickly re-expanded, or if this had
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somehow nicely pulled away from the brainstem, I've operated on and opened up and decompressed a lot of giant aneurysms over the years. This is pretty much how it always is in my experience. Maybe
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I've been unlucky, but the giant middle cerebells, ACOMs that I've done, where we have more commonly opened them and evacuated the contents, this is exactly what you want. You actually did a
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perfect job here. And I believe that your patient will continue to improve. I really do.
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Okay, terrific experience. What happened with the case you had with an aneurysm in the same location that was twice as large arc? So it's a slightly different case. It was actually a patient that
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had been managed by,
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so an endovascular group, actually the group in Mayo had, could coils proximally in the vert end? distally in the vert, I think, trying to trap the aneurysm, but what happened was there was
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persistent filling of the aneurysm because they didn't put a pipeline in and they didn't put coils across, and and now you couldn't get coils across the neck, and so blood flow, and we could never
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figure out exactly how it was getting into the aneurysm, but this division. The pica reverse flow through the pica. I don't know. I don't think so. We checked. I mean, the suspicion was that it
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was probably coming through the distal coil mass, that little segment of distal vert, and you couldn't get additional coils in there, and it was very challenging because we knew that if we opened
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the aneurysm, there was going to be at least some bleeding because there was filling the aneurysm on the anjogram when you let it run out into the venous phase.
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most comfortably, but that got better. He's eating normally now. His walking is good and overall he's doing better at two months, but we can just improve. He still has a little bit of gain
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amounts, a little bit of symptoms, but as we've discussed, I think he's slowly improving. And it would be interesting to see, I don't know, Dr. Nussbaum, in your experience, if you follow
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these with serial MRIs over time, does anything change or does it kind of stay the same? I mean, you know, when it's going to get, I mean, in general, I've seen some giant aneurysms and they
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actually get much smaller over time. So for example, cavernous aneurysms where we've sacrificed the vessel and done a distal bypass or something where you've trapped it and there's no flow at all,
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but it's very slow. I mean, I have some cases where 10 years later, We have an MRI that went from a four centimeter aneurysm
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one centimeter mass. So I mean, they do shrink. So I'm sure this is going to shrink down. It just really has to. I can't imagine it won't. I think you're going to be pleased with your result in
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the long term. But I don't, I don't think if you check it again in a month, I don't think it's going to look better yet. It takes time, I'm sure, right? Yeah. It's the end of the return to
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work, Eric. Alex, Alex?
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I don't know if he, if he has at the two month mark, we have to check in with him at his next follow up about that. But I would, I would absolutely hope that he would be able to. I don't think I
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agree with Eric. I don't think you could do anything differently here, but I did a great job.
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And then we have
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There's a report that I put out many years ago, probably 20 years ago, we were talking about, you know, the stents and bleeding through the stents. There was, I get a few cases of head and neck
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cancer with ENT where they were wrapped around the carotid and considered therefore inoperable. And what we did is we put a stent, it didn't have pipelines back then, but it was an uncovered
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whatever stent they had It looked similar to a pipeline. Probably even less of a mesh, kind of a more open mesh. We put a stent in the carotid and then we waited a month. So we let it
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endothelialize and then we resected the tumor and as part of the resection, actually cut right down to the stent. So we removed the epithelium of the carotid artery, of the internal carotid artery,
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only the stent and peeled it off that way. And amazingly, yeah, and it doesn't, and it didn't bleed. So right now, that's different than an aneurysm where you like disrupting and pulling stuff
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out and you don't have that, you know, normal structure of the carotid, which is a thicker vessel, I guess. But so, I just thought that was kind of an interesting analogy that the stents do
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endothelialize to a degree that if you
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don't push and pull too much, you can actually leave only the stent with its endothelium. And we reported, we did that in a number of cases. So, you know, just interesting. Well, that's really
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useful to know. Yeah. Yeah. We hope you enjoyed this presentation. Legal disclaimer is the views and opinions expressed in this program are those of the author interviewee.
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