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SNI Digital, Innovations in Learning, a 3D Live video journal, which is interactive with discussion,
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and now offers this program and others on podcasts on Apple, Amazon, and Spotify. In association with SNI,
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Surgical Neurology International, a 2D Internet Journal
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are pleased to present another in the SNI Digital series of interviews with clinical neuroscience leaders.
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This program will be a discussion with Rafael Tamargo about an updated review of open microsurgical versus endovascular management of un ruptured and ruptured brain aneurysms.
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Dr. Tamago is the Walter E. Dandy professor of neurosurgery, the director of the division of cerebral vascular neurosurgery, the vice chairman of the department of neurosurgery, and the
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neurosurgical co-director of the neurosciences critical care unit at the Johns Hopkins University
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The paper I'll be discussing in this program is open micro-surgical versus endovascular management of un ruptured and ruptured brain aneurysms published in operative neurosurgery in
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November of 2024.
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The discussion will include Eric Nussbaum, who's the chair of the National Brain Aneurysm and Tumor Center, and the Director of Complex Cranial Neurosurgery and
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the Midwest Spine and Brain Center in Minneapolis and St. Paul, Minnesota, and the Associate Editor-in-Chief of SI, and Board Member of SI Digital.
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Dr. Nusbaum has published a number of books and scientific papers in PubMed and SNI. These books on aneurysm and AVM surgery are available at amazoncom and
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from theme publishers at themecom
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So in this discussion is James Iausmann
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So, why don't you just talk to me? Yeah, absolutely. Well, first of all, I would like to thank my old friend and mentor, Dr. Ausman, for inviting me to speak and for Surgical Neurology
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International to give me this opportunity. Dr. Ausman asked me to give a brief
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synopsis of my background I was born in Cuba and grew up in the Caribbean, most of Puerto Rico. I went to Princeton University for college, Columbia University for medical school. And then I did
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one year of general surgery at Columbia Presbyterian. And after that, moved to Johns Hopkins, where I did my residency in neurosurgery. And I've been there since then And I got to Hopkins in 1985
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And my focus has been on this. been vascular neurosurgery. I do open neurosurgery. I have never done endovascular, but I have a great team
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when we all work together. And I've been at Hopkins since then. And so today I would like to talk about, currently how we think about treating aneurysms, whether we treat them endovascularly or
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microsurgically. So why don't we just start with, we'll get into the various aneurysms, it's pretty straightforward. To me, the big issue is some of the statistics you were talking about. And
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you talked about the microsurgical clipping and versus coiling, and that the re-bleeding rate, after clipping is lower than coiling. Yes. Yes, I got some questions about that to you, okay? Yeah.
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Yeah, so. The problem, first of all, I have a problem. I'm Eric, I want you to jump in here. I have a problem comparing clipping, which we've done for decades with coiling, which we started
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in, not 'cause we did it started in the '90s So it's about 25 years or 30 years maybe. And people haven't done the kinds of follow-ups angiographically that we did clipping or that we were forced to
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do. For example, the mortality rates or the complication rates, they define as the first 24 hours. In surgery, we define it as the first seven or 30 days so you can't compare apples to oranges.
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And they say, well, look, my reblading rate or complication rate in
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24 hours was 01 or something, very low figure. Well, I was in a conference where they did that in three days later, the patient ruptured and that was coiled. Yes. So the question is, you
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excited the reblading rates, which were lower with clipping, then they were with coiling. Are those reliable or are they actually worse and because of the data I mentioned? Well, so the reblading
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rates, so at this point, basically we have 30 years of experience with endovascular techniques. You know, the technique was the coils and then the pipeline was introduced and then most recently
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the web, there are many others But basically we have data on
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The 10-year follow-up, 10-year follow-up for coils, pipeline, and web, and
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there is no question that the reebly rate is higher in coiling, for instance, and we know that from primarily the brass trial at a barrel where, you know, outstanding microsurgeons and outstanding
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and the vascular treatment, you know, neurosurgeons treated the aneurysms and
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the bleeding rates were higher. The problem with the bleeding rate is that, as you point out, it takes a long time to acquire that information with the ISAT trial, the GDC trial, by the time they
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published their
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10-year results, three times the number of aneurysms had bled in the endovascular group as opposed to the microsurgical group. So looking at bleeding rates is not good because it takes a long time
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for that to happen and the follow up has been different. So what is the best way to assess the techniques at this point is looking at the retreatment rates because for someone to treat an aneurysm
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either surgically or endovascularly and then have to go back and tell the patient, listen, I'm so uncomfortable with what's going on that I think we need to to retreat it. It takes a lot for that
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to happen. And if you look at the retreatment rates, then we start to compare
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the two We can have a similar,
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you know, similar data for -
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for the different techniques. And then, and when you look at that, if you look at
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ISAT and BRAT for GDCs, you'll see that
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at two years, the retreatment rate for GDCs in ISAT
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was 17. And then at 10 years, BRAT had a retreatment rate of 20
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And the comparable rate for microsurgery for those,
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you know, in those studies is about 3.
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And then, but then people said, well, you know, the coils are a thing over the past. We now have the pipeline. But then with the pipeline, we have solid two year data
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And the, and the retreatment rate for pipeline is 8. And then at 10 years, the retreatment rate for pipeline
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is about 18. And, and web is, is not doing well, you know, basically at three years, the retreatment rate was 11. And the five year rate is 18. So, you know, knowing that it's, it's clear
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that the endovascular techniques seem to have a biological barrier. And, and I think that it may be because,
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because without really having thought this, you know, with, with clipping, we bring the normal edges of the intima together and then it can heal. But with the endovascular techniques, those
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remain open.
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At this point, if things continue at this rate, we see that the endovascular techniques have had a retreatment rate of 18 to 20 at 10 years. And
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if we, I have worked out a model with a correction and I estimate that at 20 years, the retreatment rate for endovascular angers is going to be about 26 and at 30 years, it's going to be about 30.
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No, let's stop for a minute. Those are astounding figures. Do you have police protection after this talk? Because I'm sure the
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instrument companies are not going to come after you. Eric, do you have any thoughts about this? I always thought that this was a very underestimated figure. What's your experience? What's your
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thinking? Well, I mean, you know, By the way, let me just say to the audience, you're not going to say that Eric is a head of the National Brain and Aneurysm Center and Discovery Center in
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Minneapolis, St. Paul. He's done over 2, 800, almost 33, 000 aneurysms and bypasses and so forth. There's been a lot of experience. Anyway, so what's your thinking about this? Is this fit
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what your experience is? You know, I think it probably is a good fit. You know, I'll preface it by saying that our team, we were early adopters of a multidisciplinary model, which included a
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group of interventional neuroadiologists to endovascularly treat aneurysms. And we think it's an indispensable aspect of treating some aneurysms. The problem that I've had for many years with the
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endovascular community, let's say, is that there, and I think that Dr. Tamargo was kind of alluding to this a little bit, there's a little bit of a moving target.
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that initially we had bare platinum coils and you know when you started to raise concerns about the recurrence rates and their or reblead rates you know so then the idea was well now we have coated
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coils and then when we started to talk about the fact that the coated coils were failing well then they initially had before flow diverting stents they had you know other types of stents so they would
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do stent assisted coiling and the idea was that that was going to cure all of these problems because now the stent would eventually prevent recantilization and then when we started to get good data on
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we started using the stent assisted coiling at our center probably in the early 2000s and by the time we were getting good data and starting to see problems then flow diverting stents were introduced
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you know in the 2010-2012 range and then When we started to see problems with that, we hear about the web. And so there is a moving target aspect to this. And the technology is advancing so quickly
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that by the time we're getting good long-term data on straight coiling of aneurysms or stent assisted coiling, that if you present that to an endovascular group, they'll say, well, that doesn't
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really apply to us anymore because now we have this other technique. And I think that's problematic in terms of being able to present patients with good, legitimate data upon which to base a
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decision as to what to do. I find it very difficult. I think that you can in the short-term, secure and aneurysm with a web device oftentimes, but work really comparing very much apples and
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oranges. And so I mean, I'm lucky to work with endovascular folks who are pretty open and honest and it's allowed us to have a balanced practice. I am concerned about many centers where
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endovascular is completely supplanted microsurgery and patients aren't even given the option of microsurgery. And I think the consequence, I'm interested to hear Rafael's take on this in an academic
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center where you're training residents, but it's becoming very problematic for younger neurosurgeons to achieve the kind of volumes to become truly proficient in microsurgery. And I worry about a
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self-fulfilling prophecy where at the end of vascular work,
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supplants microsurgery simply because of the fact that
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without good data, because of what I was mentioning, because of the rapidly evolving technology, there simply isn't enough volume to train young microsurgeons to become proficient And then if the
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results are bad, the technology or the techniques become lost. So, I'm curious to hear your thoughts on that.
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I agree. We were very early adopters on the technique at Hopkins. We were the
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only center that participated in ISA in North America. And very early on started seeing the problems And then as we were starting to see the image of the coils, then
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as you mentioned, the pipeline was introduced, and then the web was
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introduced. What is the web? So for those who don't know, what's a web? Yeah, so the web is a device. You want me to show you a picture of that or just Well, if you can do it, simply find if
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now where you can just describe it. Yeah, yeah. So the web is it's like a little sphere or cylinder that is made of interwoven fibers.
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And let me see if I if I if I can show you this picture.
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Dance for woven woven and a bridge. Yeah, it's a woven and a bridge. It's like a little, you know, it's like a little sack.
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And they put it inside the aneurysm and it pops open, you know, and it comes in two varieties, one that is mostly a sphere called and the other one that is that has shoulders. Don't worry about
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don't worry about the picture. You just described it to me. That's good enough. So, you know,
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what the pipeline has worked well for for sidewall aneurysms, but then people said, you know, we need something for why.
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bifurcation aneurysms and the web was supposed to be the solution for that, but it really hasn't worked that well. But, you know, we pushed at Hopkins, you know, again, I've had a great group
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of endovascular colleagues.
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And, you know, whenever they came over and said, you know, we can do this, we can do that, I said, well, let's try it. To the point that we went down to clipping only, you know, treating
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microsurgically, only 20 of the aneurysms. But then as we've seen the problems, we have stabilized now at a lot of 45 microsurgical and
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55 endovascular. And I didn't know exactly where we would fit with all the institutions My son made me that because of the referral pattern, we were doing more. But there was a paper that came out
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a couple of weeks ago. The topic is completely unrelated for that papers, too, is whether both transfusions are helpful after sober actinoid hemorrhage. But the interesting thing about that study
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is that it involved 23 centers at Canada, the United States and Australia. And if you look through it, it has the statistics of what percentage of aneurysms were treated endovascularly and
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microsurgical, and the period is, I believe, 2018 to 2023. And it's 40, 60. Again, 40 open
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and 60 endovascular. So I think the field is maybe stabilizing that, although like Dr. Nostam says, it's worrisome that some institutions have completely abandoned, you know, microsurgical
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techniques and that's a disservice to the patients because you know one of the things that I I tried to do in the paper was to sort out like which aneurysms are good for endovascular treatment and
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which ones are good for surgery. And
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it turns out that of 12 different types of aneurysms, five are good for surgery, five are good for endovascular and two can be treated either way Like, for instance, anti-communicating artery
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aneurysms, I don't think are good for endovascular, but they are great for surgery. And the best paper for that, the paper that I quote is up to the most found
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paper where he showed his series of anti-communicating artery aneurysms and 96 of his patients went back to doing what they were doing before And Dan, I think he had a 1 mortality and 3 maybe didn't
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have you know, a great outcomes. But you know, those are our numbers and the endovascular numbers for anterior communicating artery aneurysms have been much worse than that. So let me interrupt
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you for a minute here. So you've given some really blockbuster statements here. You didn't even put them in your paper. I think you wanted to shield yourself from abuse here So,
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but anyway, we've agreed that that it's very hard to compare clipping with coiling because
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there's not good follow-up and as Erica said,
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it's the landscape is constantly changing. That's number one, number two. It looks like without a question of a doubt, the reblading rate is higher. I mean, that's how you look at it, it's
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higher. Yes. And I'm not even sure that we know the truth because I'm not sure we're seeing all those. And the other thing you said is the papers are now validating that the pendulum is swinging
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more to the center in that there's more people now doing clipping than there used to be. I think it used to be 80, 20, you're right. And now it's come back to, let's say, 40, 60, or it's
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getting even better. And the problem is people don't know how to either not train to clip. I'll tell you what my concern is about the coiling And that is, initially, neurosurgeons would get an
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aneurysm. And they'd say, well, OK, let's send it over to coiling. Or let's send it over interventional. Well, first of all, if they're not part of your team, you'll never see that patient
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again.
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And if they do it, they'll say, oh, it was successful. And I don't think they bring these people back to every angiogram them. I know when Gerard de Brund and I were working with it initially
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with coiling. we brought them back to re-angiogram. Nobody had done that. In fact, it was very hard to find out what the rebreathing rate was after clipping 'cause people hadn't done that either.
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Right. And so there is, I think it's a very small percentage, but some aneurysms regrow. I think it's less than 8 or could be 4. Maybe you know. So - No, I, you know, I don't know. And again,
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the regrow is great. Then you get into this debate of whether it's significant or not You know, and that has been a big issue with the endovascular techniques that there's a remnant or there's a
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recurrence. And then the question is, well, you know, is it significant? And that's why, you know, that's why I personally have settled on the retreatment rate. Because when a patient gets
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retreated, it means that, you know, a lot of people looked at that and said, you know, we're gonna grow and take you back. To the endovascular suite or surgery and it means that that you know
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people were very worried about and then and when you look at the retreatment rates You know whether where it'd be? Coiling a web or or the The pipeline, you know, it's a team to 20 at 10 years Okay,
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so so I think you hear what you're telling us is exactly what we're talking about is that People have been brainwashed to believe that this is this is the Going to be the solution to all problems and
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the answer is no, it's not there is a Complication rate. There's a rebleeding rate. There's a regrowth rate and and I'm not sure all that's reported Whereas in the clipping I think we've been held
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to the we've really been held to the fire here to make sure that it's been reported to be careful about the data because we're looking at two sets of data. You agree with that, Eric? I do. I mean,
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I very much, that's what I was saying. I think you're comparing apples to oranges. I think that patients need to understand what they're getting with the differing treatments, and it's important
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to be able to give them a reasonable expectation of outcomes and whether they're going to need to be retreated. I think there's some kind of tangentially related but important conversations to have.
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It's less of an issue now with the flow diversion, but certainly I was involved in some controversial conversations when we were talking about coiling aneurysms. I'd be interested to hear what
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Rafael says, but you know where we saw some interventional folks taking unruptured aneurysms and coiling off 50 you know, what they would coil the dome, for example, and 50 of the aneurysm taking
25:25
giant aneurysms with clotting them with the thinking some coils into the clot. You're basically dooming the patient to either needing retreatment, or I would think having a false sense of security
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about what it means
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to have a partially treated, unruptured aneurysm Certainly, I wouldn't go into a surgery probably for an unruptured aneurysm if I knew that I was gonna clip off 40 of the aneurysm. I mean, I think
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there are rare exceptions, obviously. You might have a situation where you have a very eccentric daughter sack and in the operating room, you found that it was very thin walled in that part. It
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was very calcified elsewhere. You made a decision to partially clip that But in general, again, emphasizing the apples and oranges comparison. Um, there are, there have been traditionally some
26:22
endovascular practitioners who've been happy to call it 50 treated, unruptured A come aneurysm, a treated aneurysm. And they may not take that patient back. I mean, they may accept that and tell
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the patient that there's, I used to hear the argument while there's scarring within the aneurysm that's going to make it less likely to re-bleak. And I'm not sure there's much of any data for that I
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mean, I worry about a 40 or 50 quality aneurysm potentially, at least initially, being less stable. I mean, you may be redirecting the flow in a way that you don't want to redirect it. When I
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was at UCLA, and they had a good people, I'm not here to indict them. That's not the point. But they developed partial coiling, just what you said, you know, they had a ruptured aneurysm, they
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didn't have time to do it. It was the intervention was trying to do something So the tape before the surgeon got there and will partially coil it. I didn't like that at all because I had the same
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concerns you did, they reported well, they didn't replete. I'm not so, I just don't like that. Looking at aneurysms and treating them surgically, partially coiling them, that doesn't make me
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feel very comfortable. What do you think about that? You wrote a little bit in your paper about that. Oh, I agree, it's very concerning. I think you have to And again, at this point, we
27:50
have been talking about
27:53
the limitations of endovascular. But then, on the other hand, there are some aneurysms that, particularly with the pipeline, are being treated very well. Like, for example, clignoidal
28:05
aneurysms, or tharmic aneurysms, superior hypothyseals. I published a paper that, with clignoidal aneurysms, We had, in particular, where we had to drill the. or to remove the tine, or we had
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a 30
28:25
visual problem rate. You know, not necessarily applying this, but, you know, the patients were not the same. And then with endovascular techniques, those are responding well. But, again,
28:40
partially treated aneurysms are very worrisome. And like Eric was saying, you know, I mean,
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we don't go into surgery saying we're going to partially clip this aneurysm, you know, like, sometimes it may happen, but it's very rare and it's not a planned event. We'll get into this specific
29:00
aneurysms in a minute. I wanted to ask you one more general question. And it was in your paper, and that is, what is the what is the there are two things we all grew up with. One is always a
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rupture rate, and two is a study that came out of the Mayo Clinic, which said that aneurysms in rupture below 10 millimeters and they made seven millimeters and then that was wrong. So there are
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two questions. One is what is the rupture rate of an aneurysm? I know there are many factors in it. Long term. I got a 30-year-old in front of me. Is it 1 a year and what's the cumulative rate?
29:39
I've got a 50-year-old or 55-year-old, what's the cumulative rate? What would you give me? So everybody knows what the general.
29:49
The best statistics for that are, number one, that you will have paper
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because in Finland, Finland is a country of about 5 million people, 5-6 million people.
30:06
They're very happy there. They don't want to leave what people don't want to go live in Finland, well, to recently. But they had a captive audience. And at one point, you know, 40 years ago or
30:19
whatever, they made a decision that they were not going to treat on ruptured aneurysm. So they did a prospective observational study for the rest of the world. And their rate was essentially 1 per
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year. And then there was a Japanese study, the Jukas,
30:37
Japanese or ruptured shaval aneurysm study. And that study was not prospective, but it's a huge study. And they came out with the same number So basically, the rate is 1 per year for ruptured.
30:51
And then - For un ruptured. Yeah, for un
30:56
ruptured aneurysm. Okay. Yeah, 1 per year. And then to translate into a patient, roughly speaking, if you have someone sitting in front of you, you know, a 50-year-old, that person has,
31:13
assuming it's a male, it's about 30 years of life. 30 years of life. And, you know, it's not exactly right, but you can assume that it's going to be like 30. The number of years left to live.
31:30
Every year that the 1 gets a little lower, but it doesn't get much lower. So it's about, you know, it's about the amount of time that people have left to live, actually. And that is a risk of
31:45
rupture over their lifetime Now, let me, I'm sure you're going to agree with this and so Eric, but now the aneurysm is not small. It's 5 millimeters. It's multi-lobed.
31:58
And it doesn't look very good and so forth. That you can't compare that. That doesn't fall in the same category as the one you just described. That's right. That's right, because then that
32:12
paper from Mayo Clinic was wrong You know that basically they said 10 millimeters and then someone said seven millimeters. And everybody said, well, that cannot be right because the aneurysms that
32:22
we're treating are less than that.
32:27
And then
32:29
David Weaver from Mayo said, well, the reason is that when the aneurysms rupture, they collapse and they seem smaller, but they were actually bigger But then
32:46
Brian Ho published a really fascinating paper where patients had had an aneurysm, they were waiting to have a procedure and then they ruptured. So they could compare the aneurysms before. And it
33:00
turns out that this thing that they were bigger and they collapse and are smaller is not true at all. If anything, they remain the same size or they get bigger. And we looked at that and over time,
33:14
the size of the ruptured aneurysms has decreased. And at this point, we published a paper that for us, the average size of a ruptured aneurysm is five millimeters, five millimeters. Well, Eric,
33:29
what's your experience? Yeah, I mean, you know, the Mayo Clinic study, it's a funny thing. I think that there were some positives that came out of that study because, you know, for example, I
33:39
remember when I was a resident, if you were found to have an aneurysm, it was treated. And, you know, there were some people in their 80s who were found to have un ruptured aneurysms and they
33:51
were treated and probably treated unnecessarily and some of those patients were probably hurt. And that was just, you know, the thinking back at the time. And I think it made us a little more
34:00
conservative, but I'll share with you a personal anecdote about that study. So University of Minnesota was a participating center. It was really previously under Roberto Herros, mostly, but, you
34:11
know, I after. He was there, Paul Camarado was there. I inherited that position. And so in the late '90s, when
34:22
the Unropechered Eners and Study came out, I went to one of the meetings, representing the University of Minnesota, where all the neurosurgeons from centers who participated were there. And Dave
34:31
Weber's was up at the front of the room. And members from the audience were allowed to ask questions. And so I actually was kind of young and a little bit brash And I stood up and I said, I'd like
34:43
to take a poll in the room for all the neurosurgeons here. If you yourself were found to have a 5-millimeter poster communicating artery aneurysm, would you have it treated or do you believe this
34:56
data? And literally every hand, basically, in the room went up that they would have it treated. Weber's was beside himself. And I don't think I was invited back to the next meeting I mean, I
35:10
mean, it's, you know, but I don't, I think. Sophisticated vascular neurosurgeons have not really accepted that, you know, that data. Probably the cavernous aneurysms, you know, they were
35:22
right, they're very, very benign, and if they do bleed, it's not particularly dangerous. But, yeah, I think it's, the other thing is, and I tell this to patients, you know, patients come
35:34
and see me, and they have, for example, a six millimeter aneurysm, and they'll tell me that they were counseled by another neurosurgeon that until it's seven millimeters, they don't have to worry
35:45
about it. Right. Biologically, I don't understand why anyone would think that a six millimeter aneurysm is fundamentally different from a seven millimeter aneurysm. If you're gonna tell
36:01
me a one millimeter aneurysm, I accept that, you know, or it could be a bump on the vessel, it could be in irregularity, or even a two or two and a half millimeter aneurysm, but you're gonna
36:10
really tell me that the, the, the, the, bodies know, you know, that there's a fundamental scientific difference between a six and a half millimeter or a 69 millimeter aneurysm and a 71
36:21
millimeter aneurysm. That just doesn't make sense. And I, you know, our experience, of course, is that the majority of aneurysms that present with rupture are under 10 millimeters and probably
36:33
seven millimeters are under, because they're the overwhelming majority of aneurysms. So to suggest to someone that it's safe, I mean, and they don't have to worry about it, I think it's a
36:44
disservice. I think let's say, so at this point, we'll go into the specific aneurysms in just a second here, but just summarizing, well, we still always agreed here, is that comparing clipping
36:57
and coiling is like comparing apples and oranges, you can't do that. But we know, I think, from all the evidence that you present it one way or the other, and that's in your paper, that That.
37:09
there is a higher rate of re-bleeding with coiling than there is with clipping. And whether it's acknowledged or not, at least in multiple studies, at least the lead you to say that. And
37:22
then the last statistics you just gave us for a fella is that it looks like we're shifting from
37:32
a period of,
37:35
can't do this, we're shifting from a period of going to dominant, dominant to coil, dominant and interventional, back to more of an equal share between the two. And then you, what you've just
37:51
talked about is what the rupture rate is just on an unwraptured aneurysm, turns out to be about 1 per year. And now if we get into an aneurysm, that's got multi-loved and it's a different shape and
38:05
so forth, and so on, and and size, and all those statistics become different. And there was a study, I think, in Finland, they did great studies, which I think Ernest Nimi was involved with,
38:20
where they tried to find out which aneurysms would rupture. And they went and they re-angigrammed people. And they found the ones that were growing was the ones that were gonna grow and then they
38:31
operated on those. And I cite that literature correctly. Yes, yes So, and I think the Japanese are now trying to use a molecular means of uptake of
38:44
various, it's a macrophage
38:49
substances that show up on imaging to show if the aneurysm is growing or if there's more macrophages, which means the vessel wall is
39:01
less muscle and so forth. But I'm not sure that's reached a level where they can use that as a determinant.
39:09
it hasn't, it hasn't, yeah. Okay, so we're still left with what we did before. So let's go, let's go into the individual aneurysm, so the location, but let's take, and I think you're right,
39:23
let's start with right up the carotid artery. Let's go to the
39:28
aneurysm, and you just mentioned it a few minutes ago, aneurysm right at the client eye, right at the origin of the ephthalmic artery In the past, we used to drill off the client eye and do things
39:40
like that. I remember Gerard de Brunde, who was a great interventionist, came up, and he could coil that far better than I could get through doing surgery on those, which is kind of what you just
39:53
said. How would you treat those? Yeah, I think cavernous, clainoidal, ophthalmic segments, should be a hypothesis segment aneurysms, are great for endovascular treatment, particularly in the
40:06
pipeline. and people may or may not throw a few coils in there, but they do very well with
40:15
pipeline. So, you know, cavernous, plainloidal, ophthalmic, and superior type of seals. You agree, Art? You know, for the most part, that's the direction that we've taken. I mean, I
40:27
always found removing the clinoic next to a large aneurysm to be a somewhat stressful experience. We did it, but I didn't love it I really embraced the use of the sonopet early on and found that
40:42
that made me a lot happier than having a drill rotating at 70, 000 RPMs next to
40:54
that aneurysm. You know, I think the exception, the rare exceptions are, we've had some patients with significant visual loss from larger aneurysms where I felt that, Previously, when they were
41:03
gonna be filling it with coils, even though there's some evidence that with a cranial nerve that the mass effect will subsides over time, there were times with significant visual loss where I've
41:16
been happier with the idea of actually being able to decompress the
41:20
aneurysm sac. And alternatively, almost paradoxically, very small, upthalmic aneurysms, which often have the upthalmic artery incorporated into the base I've continued sometimes to treat
41:32
surgically, where, especially for the un ruptured ones, where you can remove the clinoide. It's not particularly stressful. I don't find, you know, I'm not worried about, you know, rupturing
41:42
the aneurysm. And then you can kind of lift the optic nerve and pretty easily put a clip underneath and treat that kind of broad-based aneurysm. But I agree in general, that aneurysm is
41:53
well-treated endovascularly. Okay, let's go to the posterior communicating. So, yeah. Most of your communicating and your coriolis can go either way. I think they're, you know, they're
42:07
straightforward to clip, but also they're straightforward for them. Now, there are a couple of caveats. Again, as Eric was saying, if there's an artery that is coming out of the base of the
42:21
aneurysm, you know, that aneurysm is better for clipping. There's one situation where I think with post-circuplicating artery aneurysm that is clearly indicated to low surgery. And that is when
42:34
the patients be sent with a third nerve palsy. If the aneurysm is pressing on the third nerve, you get faster and more complete resolution of third nerve. If you decompress the
42:49
third nerve with clipping, clip and then rupture the, you know, drain the sac, then if you perpetuate the mass effect
42:59
with coils. And the aneurysms that
43:04
are easy to coil are easy to clip. And so that would be, you can say, go either way, I think it's clippable, you can see what you're doing and that could be done. Now let's go to the crowd of
43:18
bifurcation. So
43:21
corona bifurcation I think is better for surgery. That's the aneurysm
43:26
that the web was developed for, you know, for that ambassador.
43:32
But, you know, their results have not been great with that. And, and again, this is an aeurysm that is very, very well treated surgically. So I think, I think the corona termination is, is
43:45
better for surgery. All right, what do you think?
43:50
I like operating on corona bifurcation aneurysms I think that.
43:55
When they get large, it's hard. The perforators can be difficult. I think certainly endovascular has done a lot of those. They like the bifurcation aneurysms. I'm
44:07
happy to operate on them. I think it's, we have it a split, pretty split in our practice. For me, the most difficult thing about those aneurysms are the perforators off the back.
44:20
While the perforators are going to the lenticular stride vessels.
44:26
And so we used to have an approach here. We didn't look at it head on. We came down the middle cerebral artery. So you could look at the back and the front at the same time and put a cotton ball
44:37
and move those perforators out of the way. And then you can clip the aneurysm at least without having that as a problem. It's kind of like the basilar tip, but you can see better. And I agree with
44:49
you about that Middle cerebral, what would you do with that? I definitely surgery. I think those, those hydrants, they're actually very tricky. Often, broad-based and they have weird
45:04
configurations. And I think it's really advantageous to be able to look at them. And they can require pretty creative clip configurations, but I think they're better treated with surgery. How
45:21
about you, Eric? Yeah, absolutely I mean, I remember 20 years ago, maybe 15 years ago Roberto Harris giving a talk where he said we're all becoming expert middle cerebral artery aneurysm surgeons.
45:37
And I mean, there's no question that a larger percentage of my practice over the years has become middle cerebral artery aneurysms because they're so well treated surgically in general. I mean,
45:50
obviously there's rare exceptions, If it's easy to get proximal control for the most part, if you need it, you can open the middle, you can open the Sylvain Fisher to the degree that you need to
46:01
expose the aneurysm often circumferentially, get a good look at it from all vantage points. And I think, as was said, they often incorporate those M2 branches. They're often very irregular. And
46:18
it's reassuring to be able to reconstruct those with clips and a number of a relatively high percentage of the redo previously treated endovascular cases that I've done have been middle cerebral
46:32
aneurysms. They tend to fail in a more dramatic way endovascularly. And I think you can understand why based on the configuration. So I totally agree. Terrific discussion Okay, anterior
46:49
communicating, let's leave anyone out, but anterior communicating.
46:54
I think that's better for surgery also. You know, that's an interesting one because initially, you know, my endovascular colleagues started putting coils into them, but then the recurrence rate
47:10
was very, very high. And we went to a point where they were using the H construct which was, they would put coils into the anterior communicating aneurysm, then they would recur, they would put a
47:25
pipeline on one side and then a pipeline on the other. And that turned out to be a catastrophic treatment.
47:34
And I think they're very difficult to treat well endovascularly. I,
47:41
you know, a lot of the aneurysms that I've had to retreat after being previously coiled have been acom. So I favor a surgery for that. You're for your view, yeah, all right. You know, I like
47:57
surgery. I think that there are a kind of, you said it, you know, Dr. Aussman, you said it yourself. The aneurysms that are easy to treat surgically are often easy to treat endovascularly, the
48:07
aneurysms that are more difficult period can be difficult for either of, you know, discipline. But I think those aneurysms are often better treated surgically and I include a lot of the a kind of
48:19
aneurysms there I think the only thing you have to be careful about is that I do think you have to be a better surgeon to do a good job with the enter communicating aneurysms. Yeah, absolutely. And
48:34
so you, you know, it's true, but you know, you don't want to go out and just, you know, like have neuros, give neurosurgeons blanket, give all neurosurgeons blanket, whatever, to go clipping,
48:45
e-comm aneurysms are more tricky.
48:50
You know, see the full anatomy. You have to see the perfragers. You have to see the opposite A2. I've seen an unfortunate number of cases where someone's gone in and managed to clip off the. In
49:01
fact, I just operated a few weeks ago on a patient that years ago had been operated where the opposite A2 was sacrificed along with it. But I also agree, you can see the gymnastics that the
49:14
endovascular guides go to sometimes to treat an aneurysm You see that a lot with the A-com aneurysm. I remember a lot of times they would coil the aneurysm and they would coil back into the A-com and
49:27
sacrifice the A-com. And they would say, well, there's good A1s on both
49:32
sides. So what's the difference? I mean, you know, and I would sit there thinking, well, you know, we take it pretty seriously. We see some perforators off of the A-com itself, off the back,
49:41
I don't want to lose those, you know? So, you know,
49:46
There are cases, the ones that are pointing up and back, I think are harder for us surgically. If it's gonna be hidden by the A2s, it can be more challenging. But it's a good surgical aneurysm in
49:57
the hands of a good surgeon. Okay. So let's go to the posterior circulation.
50:05
We're well into three. Pica, pica aneurysm ruptured. Yeah Pica, I think is still better treated surgically, you know? It turns out that most pica origin aneurysms involve the pica.
50:25
And I think, again, if you do a good operation and that entails doing a far lateral, in my opinion, doing a far lateral transconular procedure, if you just do a craniectomy and don't remove the
50:37
frame and magnum or do anything else, you know, it's a reach But if you do this, I'll accept the training. So we remove the frame and magnum, and then remove the part of the one third of the
50:51
condyle, then it becomes a very good aneurysm to treat surgically. Eric, you worked with Charlie Drake for a while so you had some experience there. What's your approach to that aneurysm? I mean,
51:07
I do them exactly that way. Far lateral sub-oxipital approach is, I think, by far preferential I mean, the other aneurysm along the pica is the dissecting aneur. We see a lot of pica dissections.
51:21
I see a lot of them 'cause I wrote about that and talked about that a lot and I get those patients sent to me. That's a surgical lesion from my perspective. I've seen a lot of endovascular cases
51:34
where they've sacrificed the pica intentionally for that lesion and it bothers me. I think we have good options for that
51:42
And so I think Pike is a big part of the story. good surgical aneurysm,
51:48
you know, like all endovascular cases, if the patient's in really poor grade, if it's a really bad hemorrhage, and, you know, I don't have a problem with treating it endovascular, but we do a
51:57
good job with it. Of course, yes. Okay. Let's talk about the vertebral basilar junction
52:05
I think that those aneurysms tend to be fusiform often, or they have, I prefer to have them treated endovascularly, the vertebral basilar junction. Eric, what's your thought?
52:23
So I mean, by way of disclosure, Dr. Drake liked that aneurysm. I've only operated a few of them I find it a very stressful aneurysm to operate. I mean, ruptured. Unruptured, you can get there,
52:40
and it's not so bad.
52:44
You know, anecdotally, I had, um, I was operating on a ruptured VB junction aneurysm that was directed. They're often associated with the fenestration. I'm sure, you know, that you have to get
52:54
that anatomy. This one with the one I'm recalling was from a few years ago, I was it was directed back in towards the brain stem. Um, as soon as I started to suction away clot, the aneurysm
53:07
ruptured, I put a temporary clip on theipsilateral larger vertebral artery, which was exposed. It didn't slow it down I put a clip on the contralateral vertebral artery. It didn't slow it down,
53:18
at least it didn't feel like it. I somehow got a clip up on the basilar distal to the aneurysm, obviously it stopped it at that point. By that point, I started to, I thought I was, I was having
53:30
pain in my left arm. I was wondering if it was chest pain. I think it was because of the awkward angle in my neck, though I don't, I don't love that aneurysm just because I find working that far
53:43
past those lower cranial nerves, especially in a ruptured setting, gives me stress. But yeah, I like endovascularly is fine with me for that aneurysm. If they tell me they can't do it, I'll do
53:57
it. Okay, good. One last aneurysm, and that's a basilar tip. I mean, I'll be saying I'm leaving out the small minority, but they basilar tip.
54:09
Raphael, what's the story? So the basilar tip, you know, I mean, that's an operation that I love, but
54:20
I have gone to a endovascular treatment first for those aneurysms. And the reason for that is that, you know, whereas with other aneurysms, I noticed that the vast majority of my patients would go
54:36
back to doing what they were doing before, you know, they, I'm talking about on ruptured patients. with uninterrupted bachelors, I noticed that 15 to 20 of patients had some level of cognitive
54:50
dysfunction. And I was very distraught by that. And they didn't really have a stroke and they didn't have anything, but I think that it's somewhat surgery that it caused a problem. So, you know,
55:04
I called Duke Samsar and Juan Bager about it. And they said, no, we see the same thing that those patients are, you know, they have a high incidence of cognitive issues. So, I think that, I
55:23
don't feel as strongly, as for example, a
55:30
basilar trunk aneurysm treating endovascularly. I would say that, you know, for instance, if you have small, broad-based basilar aneurysm, that's good for surgery If you have a small.
55:43
uh small neck aneurysm if um I think it's reasonable to treat it endovascularly. Eric what's your time?
55:53
You know I mean it's that it's a tough aneurysm it's a you know I think probably the three of us have all operated on a fair number of upper basilar aneurysms. I certainly differentiate a superior
56:04
cerebellar aneurysm which I think is easily and well treated surgically with very low risk from a true basilar tip aneurysm Right. Where I mean you know in my experience I operated a fair number
56:17
early on in my career above 10 millimeters not that it's a magic number. I struggled more you know with the exposure of all the perforators. I did a lot I did them more through a subtemporal
56:34
approach you know as Dr Drake did and I liked that better. I was always uncomfortable with the with a taryonal or half half, you know, getting the half, I guess, gives you a little bit of both.
56:46
But I felt better about getting the exposure of the peripheries with the subtemporal, but oftentimes seeing that opposite P1 feeling totally comfortable with it.
56:58
You know, at our center, the Baser tip aneurysms is an endovascular first aneurysm. And if they feel for some reason that they are not going to be able to treat it, and I do treat some of the
57:15
failures, the endovascular failures, but it's more often a bypass type of situation where we're going to do an upper basilar occlusion and bypass to the superecerebellar or the P1, well not P2, P3.
57:28
You
57:31
know, that type of thing is more surgical. I don't directly clip that many Baser tip in it. I mean, it is just the truth. I don't, we don't don't do that many anymore.
57:42
The really small narrow neck ones, you know, I think are pretty well treated, but there's a fair amount of variability in terms of the anatomy. And I mean, sometimes it's not always that easy to
57:53
predict. Sometimes you can look at the Dr. Drake's been a lot, you can look at where the bizzler apex is relative to the clinoids, but then, you know, you put in a lumbar drain and it can kind
58:02
of dip down, I find. And so sometimes if you get a really good look, it's fine. Sometimes it's really tight and really hard to see and it can be difficult to get a clip on the upper basilar if you
58:13
want a temporary clip. So I think it's a good endovascular aneurysm for the most part. The bigger ones are hard either way, really difficult to control that aneurysm. So for me, the most
58:27
challenging part of that aneurysm is the perforators. And we've all operated on them and you get some perforator in the clip and the patient has a deficit. You're devastated. The patient's
58:37
devastated.
58:40
you try to avoid doing that. And so I didn't like that very much. And I thought Endovascular had a better approach than I did. I remember what was Christmas Eve or something we were operating on,
58:51
a man who came in with a big giant basilar aneurysm. And we took him down to the operating arm and looked at the thing here. And I said, there's no way I'm gonna put a clip around this thing or
59:02
deflate it and put a clip around it and avoid the perforator. So I called Gerard, Gerard, and he came in the night. I said, Gerard, I want you to look at this because you're gonna have to coil
59:12
us 'cause I'm not gonna operate on this place and I'll kill him. And I think it depends upon, I've seen the people devastated by those perforators being taken and we've all been through that. But
59:25
so I'd agree with you Raphael and with Eric, I think it'd probably be an interventional first. So we've gone through this spectrum. Let me ask you a couple of other things because I think we've
59:37
done pretty well here.
59:41
The one of the problems we're looking at, I mean, you mentioned that earlier on, both you and Rafael did error. And that is we're getting surgeons who have less and less experience with this. And
59:54
if that's true, and we're now getting more and more aneurysms that should go to surgery, how are we gonna do this?
1:00:03
Well, I think that the, you know, the typical aneurysms for a while in the '60s and '70s was something that
1:00:17
was done in tertiary care centers, and then people came out and it become a
1:00:23
widely done technique. But I think now it's being re-concentrated into the centers. It turns out there are only 11 centers in the country that are approved for not crest cast.
1:00:40
fellowships for open surgery. So I think
1:00:46
it, you know, it may be of, you know, of benefit for them to be reconcentrated at high volume centers.
1:00:57
How many times do you want to enter, Rick? You know what? I mean, obviously preaching to the choir. I mean, my whole career, I've talked about this. I have a lot of issue with,
1:01:10
you know, with the idea of the, the old-fashioned idea of the generalist neurosurgeon who does everything. I understand it. I appreciate it. But
1:01:21
I think that it's a, you know, it's a tough operation and it should be done at centers set to higher volumes and by people who have the expertise. And I think that that's, that's what it's going
1:01:31
to take. I think the challenge is that because endovascular, I think it's easier to do endovascular. And I think that that's what we saw happen, at least in the upper Midwest over the years, was
1:01:44
that there was a period early in my career where nobody wanted to clip aneurysms and there weren't really coiling that many aneurysms or everything got sent in to our center. And then we reached a
1:01:55
point where many of the smaller hospitals and smaller towns had someone, often a neurologist, for example, who had been done a short Indo-Vascular Fellowship. And all of a sudden they have someone
1:02:07
coiling aneurysms and they might only coil three or four or five a year, but they wouldn't send them. And then what would be said, we would get the patient sent a few days after they'd been coiled
1:02:19
because they'd have one person working at this hospital and then they would be off for the weekend and the patient would need an intervention for vasospasm and that they would funnel the patient into
1:02:30
our center to have the treatment done. And then we would see the results of what they did. And sometimes it was good, but sometimes it wasn't good So I really. think that it's more than just
1:02:41
having open surgery concentrated in larger centers. I don't know how you do this, but
1:02:50
a multidisciplinary situation in order to
1:02:56
treat these cases. And so getting those patients in general, whether they're going to be treated endovascularly or with open surgery back to the big centers is I think what it's going to take. I
1:03:07
mean, somehow we've managed to local regionalized trauma into level one trauma centers, level, you know, level two, level three. I don't know why we don't do this for aneurysms. You say, yeah,
1:03:21
now you touched on one other subject and that is we've got a third of our viewers are from North America, USA, and the rest of them, the other two thirds are from around the world. And most of
1:03:36
those places, intervention is too costly. The coils are too costly. The equipment is too costly. And so as you had did, you're in a steamy one around the world talking about how you can do these
1:03:50
surgically, and you can do them skin to skin. I mean, you did, I don't know, thousands of them in an hour. And we have some videotapes showing that. And you and I talked to them, Eric, and,
1:04:03
and so for the, in the, in the, in the, in the part, come parts of the world where they don't have this, surgery still can be done. It can be done well. It can be done carefully. And, and
1:04:17
you have clips and so forth. It'll be a while before intervention comes there. And when it comes there, it probably won't be as highly received as it was here You guys have any thoughts about that,
1:04:28
Rafael? I think, I think that continuing to treat
1:04:34
aneurysms is very reasonable. And again, in people who want to concentrate on doing them,
1:04:44
again, here in the United States, we have the opportunity to select patients because we have
1:04:54
specialists near each other. But I think that
1:05:01
they're very good options for surgical options for most generations. Eric, your thoughts? Well, I mean, just, you know, I think that, you know, this is not meaning to be critical of any
1:05:15
different, you know, the way different people do it. But
1:05:20
I think that sometimes when people from outside of the United States, especially third world countries, where they don't have a lot of resources, they'll come and visit. And, you know, depending
1:05:30
on where they visit, can have a big impact on what they take away. There are centers, nothing wrong with this, that all the aneurysms have a lot of intensive neurophysiologic monitoring. And the
1:05:43
case, you know, an aneurysm can be a 12-hour case. I'm not critical, it takes as long as it takes, and if the results are good, the results are good. That's not just the way that I was trained,
1:05:54
you know. I think, you know, the average uninterrupted aneurysm takes. I'm not as quick as Dr. Hernandez-Yemi, but it takes about an hour and a half or two hours But, you know, if I'm going to
1:06:04
occlude a vessel intentionally, I mean, I'll use monitoring. I don't personally use electrophysiologic monitoring, otherwise, I don't think it has to be that complicated. And I think the point
1:06:13
you're raising is very important, which is that, you know, we've sent a lot of clips, older clips, you know, out to sub-Saharan Africa, that type of thing. They can do that operation very well.
1:06:28
And if they don't have the resources, if they don't have a biplane angiography suite, and they don't have the coils and the. technology, then, you know, they can treat those patients very
1:06:38
effectively with surgery.
1:06:41
I feel any thoughts? I agree. I agree completely that basically they, you know, if people want to concentrate on treating aneurysms surgically, you know, they're very good options for them in
1:06:51
most third world countries. Well, we could go on for a long time. There are
1:07:03
a lot of things to discuss what is practice going to evolve to in the next 25, 30 years. I don't think it's going to look anything like it did now and so forth. And, and, and, what, how you
1:07:18
should develop centers, what's that's going to do to the people in private practice. A lot of things to discuss. But I think we'll stop here. Raphael, you, you stimulated this discussion, which
1:07:29
I think is terrific. You see, we don't need the slides. What we need to
1:07:35
do is bring your brain and your experience and you can communicate that beautifully in your dead. Thank you. Eric, I thank you. Any thoughts any of you have last before we close up?
1:07:49
No, I just want to thank you, Jim, for the opportunity to participate in this. It's been great and I've loved spending time with you and Eric and discussing these issues Okay, Eric, any thoughts?
1:08:05
Look, my pleasure to wonderful people to spend an hour, hour and a half with. I guess, regarding the treatment of the aneurysms, I mean, I would again emphasize that, when you talk about
1:08:18
comparing results with open surgery and endovascular, I think it's important to get that data. This is really important data because there's not good, oftentimes not good data out there but I would,
1:08:32
I guess I always fall back. to my own personal position, which is that if it's done well, it's not a competition. And I know that, you know, I mean, that's basically what we're all saying, but
1:08:44
there are cases that are better done endovascularly and cases that are better done microsurgically. You know, if your name is Charlie Drake or, you know, then you're probably gonna, his results
1:08:56
with uninterrupted baselertip aneurysms be any endovascular practitioner alive today from my perspective. I mean, towards the later part of his career, he would have, he had a 1 complication rate
1:09:12
for his un ruptured baselertip hexaneurysms. I mean, it was astounding. Now, nobody, I mean, maybe someone will come along, but I don't think anyone will replicate that. But the point is that,
1:09:25
you know, we're all, nobody likes to think of the fact that we're not cogs in a wheel, we're not interchangeable, we're different. you know, Dr. Jim, you did some bypasses with the superior
1:09:39
cerebellar and the AICA that the AICA in particular, I can't do. I tried, I can, you know, and that's just the way it is. And I've done a lot of bypass work. So there's gonna be, you know,
1:09:54
there's gonna be situations where if you're the neurosurgeon or if Rafael's the neurosurgeon, you know, you may tip a little bit one way for a particular aneurysm or more towards endovascular for
1:10:06
another. And that's really the art, you know, this is an art and not a science. But it only works if you're in a multidisciplinary team where you have good surgery and good endovascular and honest
1:10:19
look at the results, people keeping each other honest. Where we get in trouble, I said this before, but I guess it's not too common to have a pure open microsurgery center but I really don't like
1:10:32
these, you know, all in dovascular centers where open surgery has been fallen by the wayside, I think it's a problem for the patient. Okay, very good. Lots of good wisdom today, and I really
1:10:46
appreciated you guys did great, and I think the audience is going to appreciate it. They're going to get a frank discussion of a common problem, and Rafael, you had to think about writing a paper
1:10:58
on what we started out with this What is the real problem, how do we compare these statistics, and what is the truth? Yeah, yeah. And it would be a wake-up paper, we'll publish it in SI, nobody
1:11:13
else will, but I'll tell you, because there's a lot of myth going out there, and not a lot of facts. Okay, yeah. That's a good, supportive idea. That's a good, supportive idea. Which wants
1:11:22
you to coil. Yeah. Yeah. All right, take care, and thank you both very much, okay? Thank you. Good night. Thank you so much.
1:11:33
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Surgical Neurology International is read in 239 countries and territories after 15 years of publication is the third largest readership. of neurosurgery journals in the world. And SNI Digital
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Innovations in Learning is viewed in 149 countries, and the 12 months since it's been published, the first video journal in the first video journal of neurosurgery. Foundation supporting these
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programs is devoted to helping people throughout the world.
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