Grand Rounds-AANS Operative Nuances 3D Session During Miami Meeting: Part II

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- Talking. This is a little ICA aneurysm, you can see right here. It is actually more complex than it looks like here. And obviously with the ICA aneurysm, you've gotta get to the basal artery where ICA sits. So here we're looking through just a regular retro sigmoid approach. Lower cranial nerves are down here. Six cranial nerve is running right along here. This is a patient that had ruptured. Here you see part of ICA. Here we see part of ICA, that's the aneurysm, basil artery down underneath here. So the trick is to separate this aneurysm that had ruptured sufficiently from the basilar artery and from ICA, so that we can put a clip on it. So you see a loop ICA coming right here, you see a portion of it right there. And aneurysm here, brainstem sitting here, seven and eight, and so very carefully separating the dome of the aneurysm now from the brainstem, because we have to put a clip around it. And you could see that this is obviously another case that couldn't be done endovascularly, unless you would sacrifice ICA, which is obviously not acceptable. So using scissors to separate the arachnoid adhesions, we find, we create a channel between the cranial nerve, the brain stem and the vessels. So at this point, if it ruptured, we would be able to occlude the basilar artery here, but we have a heck of a time with the distal control. But as you can see, I mean, you have absolutely no reason to put a retractor in here because you've got plenty of room. Six cranial nerve begin setting off to the side. And then just continuing. It's unfortunately very adhese here, so it was a real challenge going around it. Plus a degree of anxiety about rupturing the aneurysm without having full control. You can see that branch ICA right here. The other branch coming out over here, which is where the aneurysm was. We see that right here. A few from afar and then placing the clip. So going through that opening that we've created here have to preserve portion because that's where the other branch of ICA comes out. And once that's taken care of, what we wanna do, is we wanna see whether these vessels fill appropriately right here and right there. And so we do an ICG and you can see very nicely that they're both filling. And that's really the incredible value of ICG. Be nice if we could have taken back, some of those patients we've heard in the past where we clearly preserved the vessel, but anatomically, but not on the inside of the lumen. This is just the right orbitozygomatic craniotomy for middle cerebral artery aneurysm. You can see the aneurysm over here. Obviously a previous surgery on the other side from a ruptured aneurysm. And here again just opening the Sylvian fissure. I like high magnification but the mouthpiece you're constantly moving back and forth it is not great for videos. But it sure is great to be watching what you're doing. And so here, obviously the key is to get the vessels off. This is the base of the aneurysm. And if you look around, you can see how tight it is adherent to this portion of the middle cerebral artery branch. So this middle cerebral artery branch, normally you can really just sharply dissect them. The neck is over here and this branch is obviously in the way of clipping it properly. You can see it right there. Aneurysm base is there. So actually I end up... There's a little bit of bleeding. I just can't separate it adequately. So what I'm doing is, I'm gonna shrink the aneurysm with bipolar and then just cut across the aneurysm directly to separate it from this major middle cerebral artery vessel that I wanna preserve. And you can see that here. And so now cutting really the dome of the aneurysm down to where the neck is. This is the vessel that I wanna preserve. Now we're down to the neck of the aneurysm right here. And then putting a small sugita curved clip at the base of the aneurysm. And it looks like we might have compromised the base, but in fact this is directly underneath, as you can see when you lift up even bigger. Again ICG, you look not just whether it's filling, but the rapidity of filling. You wanna make sure that the distal branch feels exactly the same as the branches that don't have the clip on them. And here you see the clipped middle cerebral artery aneurysm.

- Did you really need it? You think it was like a medical approach...

- Well, no, absolutely not, but it's such a routine and it's a very small opening. It gives you a little more of an angle. And what is important in my mind is that it becomes part of the routine for the resident. Because when you do it only for the occasional, and then it becomes a big case. You're absolutely right. There's really no reason why you need it for a middle cerebral artery aneurysm. But that's my rationale.

- Dr. Steinberg, do you use IV heparin for your bypass? And if you do, what's the dose and when do you give it?

- No, never use IV heparin for intracranial bypass. STAM say you don't need it. I do use it. If I clamp the carotid in the neck, that's the only time I will use it Or if I do a Dallas maneuver in the neck, then I will give 3000 units of heparin before cross clamping there.

- Thank you. Robert, in what setting do you bipolar your aneurysm to shrink?

- You know very rarely, but whenever I find it useful to make it easier to clip the neck. I mean, I don't hesitate to bipolar. I don't like to do a lot of bipolaring because if you've watched an aneurysm you've bipolared long enough. You'll see it become large again. So counting on bipolaring to control the aneurysm is a big mistake. If it helps you with neck occlusion, then do it. But not as a primary way to control the aneurysm. In my opinion.

- Thank you And would you just add, how big is your retrosigmoid approaches, usually for that kind of aneurysm.

- It's about three centimeters.

- Three centimeters.Thank...

- Right above the eye. It spares the temporalis muscle. So you don't have any trouble with the temporalis muscle. And it does give you a couple of degrees more anterior. Remember that the angle that the middle cerebral artery runs. So those few degrees they can help. But they're clearly not essential. but I really want the team for that to be so routine that I don't want it to be the exception.

- Gotcha. Thank you. Michael do you have any ideas about using bipolar for aneurysmorrhaphy? Please?

- Yeah I don't routinely do it. If I need to shrink an aneurysm or see around a corner, I would rather temporarily occluded it, puncture and deflate and get my visualization that way.

- Bill do you have any thoughts, please?

- Yeah, the same thing. I don't like to bipolar aneuryms especially small ones, because I was worried about creating emboli. But I'll actually clamp everything off and cut it off the vessel and then clip the aneurysms.

- Jerry, do you bipolar aneurysms?

- I will occasionally bipolar portion that's not gonna be retained after clipping. I remember watching Yester years ago and he was treating some tiny blister aneurysm small aneurysm by bipolaring. And I said, what is he doing? Cause that weakens the vessel actually. And that would be his definitive therapy. So I never do that for an aneurysm that I can't clip. I'll wrap it with muslin, but I won't bipolar. It doesn't strengthen it.

- Yeah. I spent a year with the Esther Glen. I know he does that very routinely almost. If you have good temporary occlusion and the aneurysm is very deflated, do it. I recently, a couple of weeks so I did an aneurysm, which I did that approach the acom, very high riding acom aneurysm through interhemispheric approach I temporary occlude the aneurysm. Was not adequately decompressed. And I coagulated to create a neck because it was so wide and it led to significant interpretive rupture. The patient did okay. But again, coagulating the aneurysms, you have to have aneurysm very well decompressed and coagulation has to be very low. Bursting an aneurysm ball because your bipolar sign is not good for anyone. This is my last two D case, and I really wanna include it because it had so many teaching for myself. And I thought we have to give sort of time for our colleagues to have some tumor cases. Our panel is so rich in vascular knowledge and Dr. Cole who is gonna put in some great cases for tumors. But this is a 42-year-old male, very successful malpractice attorney actually, who presented with a generalized seizure and probably knows more by gliomas than I do for sure. And doing a transsylvian approach. And that this is the tumor, as you can see, it's a sizeable tumor. And it just makes one think about it. 42-year-old, very sort of large insular tumor. And I think the best approach is maximizing resection. Intraoperative MRI would be helpful. Fluorescence really doesn't help in these ones. Although they're a group has done great work with confocal microscopy in these and I personally like awake craniotomy. So if I may open the discussion. Bill, how would you say approach is please?

- I think we can just do a standard frontotemporal craniotomy and I come in transsylvian and just dissect out tumor. it's in the operculum as well. So you'd have to resect that easily and then just do a microsurgical dissection try to remove the tumor as well. We could use interoperative MRI on this case, and that was discussed this morning in the plenary session, which I think is a reasonable indication for this. But usually if it's, you know, you can usually tell the difference between normal and glioma here under the microscope and the texture as well.

- Okay. Robert, do you do awake this, this one awake or sleep or intraoperative MRI?

- Yes. I think the surgeon should be awake and sitting and the patient should be asleep and laying.

- Okay. Fair enough. Well, let's just take a moment. And I know this is too dear, my apologies for this. let's go to the video please, Chris. This patient was performed awake and I have a reason for it because I think an awake patient and the surgeon was semi-awake, but sort awake enough to do the procedure. I want to go through some of the details in awake craniotomy. Personally, I feel an awake craniotomy is the most secure way for a surgeon to know how the patient is doing. And this patient really needs. And this is with the permission of this attorney, by the way. This patient needs a maximum resection. The MRI has to be more than 95%. That's personal opinion. I think Dr. Berger would argue with that, but as clean as you can get it, I think it's better. And if an awake patient, you know you're gonna get so close to the putamen, white matter tracks. many people who do sleep with a motor mapping, which is a very fair way to do it in intra-operative MRI. This is awake craniotomy. One of the most important things is to have somebody communicate with the patient to make them comfortable. This is a challenging operation. This is starting the right temporal lobectomy. I wish my operatives speed was that high. This has been increased until we get the more pertinent part of the operation. You got four hours or five hours to do this. After that the patient is not gonna be very co-operative with you. So the temporal lobectomy has to be done all the way to the Sylvian fissure. And I use that fluorescein angiography here, not because it's an angiogram because fluorescent loves ischemic brain. So if you have caused any of compromise of the vessels, you will immediately get a feedback. And I think I like that in this case, because it gives us another dimension. Temporal lobectomy has been completed. You find a third nerve along the tentorium. These are very basic techniques. We don't have to cover any of that. So let's get to the more difficult part of the operation. Insular glioma as you can see sort of dissecting the vessels off of the bigger branches. You can see part of these have been already sacrificed and that's because it was going to the temporal lobe. And then you get into this sort of intimidating way of going between these arteries and removing this tumor that is obviously somewhat different from the white matter. One thing that you keep in mind is you have to almost follow these vessels into the white matter. And I just like to have the patient awake to be able to detect any deficits. unfortunately, that would put you in a more stressful situation and the pressure of time that you have to finish the surgery earlier. But if that's what it takes for me personally. Again, there's many ways to skin the cat. So you continue working and that's how you find the MCA in this most horrible looking sort of tree fashion that obviously I personally like to see the patient awake because that means this patient could have a compromise at any moment. Then just like Dr. Couldwell mentioned, we've gotta removal the operculum. I want to map the motor cortex. This is a patient's face being mapped. And then I use a deep wide amount of track, even though they're awake to see if they have any reaction. I do everything I can to monitor the patient. I find the face. Now that I found the face, which is right here. I know how much to lift up parietal banks or the operculum. and work between these arteries. Really just a very uncomfortable position. And I continue to just use the fuller yellow 560 to see if I put a temporary clip on a vessel, do I detect any evidence of a blood-brain barrier quickly? Because of that now you see the perforaters in the ophthalmo perforators, which is obviously again uncomfortable. And you start seeing that, not to make appearance of the putamen. This is really important to remember if you pass this, it would have significant consequences. Remember the perforators Here unfortunately, my suction injured one of the perforators. The last thing you wanna do is become aggressive with a bipolar. Irrigate with thrombus solution, gentle pressure. The patient is doing fine. Take your time. And here is really the final steps of the operation. And the MC branches have been completely skeletonized. Stop that video please for me a second. So this is the post-operative MRI. Can you go back to the PowerPoint, please? This is the post-operative MRI. Again, shows that we just went all the way across the basal ganglia. Which I personally consider a reasonable resection in this patient. I don't use intraoperative MRI because I believe the surgeon should be able to differentiate the tumor from the normal brain. And as you can see, we're able to get all the way up there. But this is I think what means to provide a survival advantage, not necessarily just a glorified biopsy because this patient is necessarily an attorney and could have consequences after developing a deficit. I'm gonna finish with this tumor and have Dr. Couldwell take the podium for a while. A 41-year-old male with incidental left sphenoid wing meningioma. You can see this is sort of sitting there. It's not causing any edema. The patient is young. Bill would proceed with a resection here? Would you observe this?

- At his age yes I would remove that.

- What's that?

- I would remove it.

- Remove it. The rest of the panel would agree with that. Okay. I'm gonna move on quickly to the video of this, please 3D. So this is the positioning. We try to bend the table a little bit sort of like not have the patients slip. I know these are very basic sort of methods. I'm sort of also showing up the new methods of doing 3D, using a handheld camera, which I think is important for us to appreciate how the position of the patient in the operating room works. Again this incision is very, very standard. I don't personally make it more frontal. I think staying just behind the hairline the scalp is soft and you can always retract it with fish hooks and again, making sure the head is elevated to be able to have a venous return. Again, I'm gonna move quickly in this part of the surgery with an increased speed. We like to do as much extra dural as possible. And then coagulating the dura to devascularize the tumor. Again, opening the Sylvian fissure. It's an art it's enjoyable. I will do it anytime I can have the chance to do it. You find the optic nerve very early on because now you know how much you can be aggressive laterally. If you don't know the optic nerve where it is initially, you always will be sort of intimidated about how far it is. So identify the important sub vascular structures as early as possible. Drain CSF, relaxed brain relaxed surgeon. Here is sort of getting back to the normal operative speed. And here is these MCA branches. This is the most difficult part of the operation. And I would like to take a moment and ask Robert if that's okay with you. What are the nuances here of dissecting these branches off of the medial sphenoid wing meningiom?

- Well, I you know, you're doing it. The big problem with these is always whether you have a meningioma that's actually invading the adventitia. In which case you are better off leaving some of the tumor behind on the blood vessel or whether it just sort of surrounds and you can separate them. I wouldn't sacrifice critical middle cerebral artery vessels. If it was invaded by tumor, I just let nature take care of it. And you can always add on little radiation.

- Thank you. And here is one of the nuances that I have learned in these cases is you sort of find the MCA as distally as approximately you can find, and then you go back to the skull base because it's fixed at the skull base. You know where it is compared to the optic nerve. And then when you find two points, you almost work along a straight line and divide the tumor in half. And this here is an optic nerve. And at the skull base am trying to find where the connection between the carotid artery is. And this is carotid artery, more closer to the skull base. And then work both sides and sort of divide the tumor in half. And it's sort of like an apple falls away. As you see again, come up to the distal part, find it proximally where it is at the skull base and then sort of divide the tumor in half. And you just hope that the carotid artery will be sitting waiting for you. And I think this is the most atraumatic way for you to be able to find it. And here it is. It's really a very pretty scene of the tumor just getting separated from the carotid artery. I think that's really the end of it after that is really easy to be able to take the tumor out. So with that, I would like to ask Dr. Couldwell to share some of his expert nuances with us, please.

- Thank you. I've actually included a few cases. Aaron wanted me to talk about some fairly common cases that we see. And so to that end, I've chosen cases that the average neurosurgeon would see quite frequently in their practice. And I've excluded any cases of bypass, et cetera. And so let's talk first about a spheno-orbital meningioma. And maybe we could go ahead and start the case, please. So this is a 50-year-old woman that presented with proptosis and visual loss in her left eye. And you'll see from the MRI that there's heavily calcified convexity here. And the orbit itself is very much involved with tumor. It's high prosodic bone, all through the lateral orbital wall and the middle fossa floor, et cetera. And so what we'll do is we'll just go through some of the basics. Here's her proptosis. She had several millimeters of proptosis plus this high prostatic lump on the side of her head. And so we'll do just bumping her in the lateral sort of frontal temporal incision. We'll use hair sparing if we could. And then,go ahead and use intra-operative monitoring. This is the incision. And then this is the hyperostatic bone here. So the flap has to include all of that. But the real key in this operation is to remove all the bone around the orbit because she's losing vision and all the hyperostatic bone is tumor in my mind. So we'll spend a lot of time actually drilling all the hyperstatic bone. Now you'll notice that there's tumor on both sides of the bone here. So what you're seeing is this is the orbit here. That's been exposed in the lateral orbit and the superior orbit. And we'll drill the optic canal here spent a lot of time completely removing all the bone around from the optic nerve. Here's the cranoid being removed. So we haven't removed any of the soft tissue tumor yet. We've just done bone work. And the major part of this operation is to completely expose. Here's V2 in the floor the middle fossa floor has been drilled. All the orbit and all the hyperostatic bone V2 optic nerve. Now, what we'll do is we'll take the soft tissue part of the tumor out with the dura. And so we'll plan our dural incision around the perimeter of the tumor. And then do a microdissection of the tumor off the brain. And I always emphasize to my fellows and residents that dissection of the tumor, is really a dissection of arachnoid planes. And you want to identify the adhesions of the tumor with the vessels and the cortex. And obviously as long as the arachnoid is preserved, it's a fairly simple matter. Unless in some cases, the arachnoid is not preserved. And you'll be able to tell that with T2 hyperintensity on the preoperative imaging. So we'll remove all the involved dura includes stripping up the lateral wall here of the cavernous sinus. You can see here's a V2, V1 and the lateral wall of the carvenous sinus has been removed, to remove all the tumor. Now, this is the important part, and I've become very aggressive at removing all the tumor involving the orbit. So the periorbit is involved and we'll remove all of the tumor off of the perio-orbita and completely decompressed the orbit. You really want the globe to reduce. And earlier in my career, I didn't reduce the orbit enough. I'm very aggressive here. This is a fairly young person. We'll do complete removal of the tumor off of the orbit. We used to reconstruct the orbit in these cases, and we're just publishing a series right now with our neuro-ophthalmologist and here you see me, I'm actually releasing the orbit, trying to get the globe to reduce because it's been so stretched and she had so much proptosis. So a closure here we'll seal off with a little piece of muscle and some fibrin glue, the opening we made into sphenoid sinus medial to the optic nerve. And then we'll go ahead and close. And I don't do any formal closure of the orbit in these cases because I really want the globe to reduce. And then in this case, we'll use a dural substitute for closure, and she lived a couple of states away. So what we'll do in this case she wanted us to do a one-stop here. So instead of a custom cranioplasty, we'll go ahead and on the spot methyl methacrylate cranioplasty for the bone that we've removed. And that completes the case and her proptosis improved significantly post-operatively. This is what the post-op scan looks like. You can see all the bone that's been removed, all the lateral orbital wall and the superior over a wall and the middle fossa floor as well. Bill, do you have any trouble with enophthalmous?

- No. I mean, it's interesting and I expected that question, Robert. So when you first.... if you could stop the video and not let the next one run, please. So when you first finished the case, you'll see the eye pulsating but the eye takes two or three months to reduce. And I found when I didn't do such an aggressive opening of the peri-orbita I still had proptosis because I think it scars.

- Yeah. And I've never had problems with enophthalmous in a case with pathology involving the peri-orbita. So I've completely abandoned trying to reconstruct the orbit with titanium or Medpor et cetera. And I left the orbit prior to reduce as much as possible. I just never have had pulsatiling enophthalmos with the case like that.

- Could you run the next case please? So I think this next case, I'm not sure what this one is. So this is a hearing preservation operation in a acoustic tumor that's done by Clough Shelton myself. I have the luxury of working with a superb neurotologist, and this is a 59-year-old woman presents with tinnitus and right-sided hearing loss, serviceable hearing loss, and she has a CP angle tumor. And it's roughly, I think a two centimeter tumor just under two centimeters, about 1.8 centimeters. And we'll do a hearing preservation operation on this. You can see extending into the canal. it's cooler to bid for a middle fossa approach. So we'll do a retrosig hearing preservation. So lateral position, one thing that we like to do is pull the arm down out of the way to give you more room. You'll see how the Mayfield is mounted. I actually mounted from underneath, so I can kick it out more and get my retractors more room to place the C clamps. This is the incision that we'll use. And then the opening. And this is done in conjunction. Most of these cases, as you know, come through our otologist. So Clough likes to be involved even in the cases that we do the retro sigmoid. So he likes to drill out the IAC. And so the opening is the usual standard opening. Perhaps three centimeters, and then we'll open the dura and then come down on the tumor and here's Clough operating. And you see he's identifying the porus acousticus. And what he will do is he'll identify the vestibular complex and amputate the superior, inferior vestibular nerves, and then leave us with the facial and the cochlea intact. So we're using AVRs obviously during the case and facial nerve monitoring as well. So he'll start with drilling the canal here. He's trying to find the epicenter of the IAC. And so he'll drill to the end of the tumor. And if we get into air cells, so be it, we'll take care of that at the end of the case. And we'll wax those off. And what he's doing now, he's trying to find the plane between the cochlear and the vestibular nerve, and then he'll just amputate the vestibular nerves. So what you see here is the facial nerve is there and the vestibular nerve is just below it or to the right of that on the video. So here's now we'll come in and we'll start to do the tumor removal. And I just want to point out here, this is the ICA and the lower cranial nerves. And you'll see a small branch coming off right here. That's the labyrinthine artery. And we really wanna be careful with that. And so we'll dissect around the perimeter of the tumor. And then once we get the margins of the tumor isolated, we'll start to debulk the tumor. And just a standard ultrasonic debulking. And then now we'll get to the crux of the dissection, which is the dissection of the brainstem and of the nerves. And so what we'll do is you'll see I'm coming around the tumor and just getting down to the brain stem now and using these nice soft micro patties. And they really help to dissect. Here's the arachnoid, there's the eighth nerve right there. There's the cochlear nerve. And then seven you'll see me identify right here. There's seven. So we've identified eight and seven at both ends. And then the matter now is to just go ahead, you'll see, I'm putting papervine on the labyrinthine artery, because I'm worried about vasospasm. Manipulation induced vasospasm. Try and preserve that. It's a very long artery. It's often very small and can be very small and these larger tumors where you see it stretch. So here we go. Now, the plane of dissection, the direction of dissection is from medial to lateral. So we don't amputate the fibrose as they're going through the fine pores at the end of the IAC at the cochlear as it goes into the cochlear and we'll remove now. And this is where Clough amputated the vestibular nerves, and then we'll remove the left of the tumor. So what we'll do is we'll remove it. I just use very little dissection force and we'll get the tumor out completely. And then closure is simple. I think this is alloDerm, which is something that I've used for the last few years now. Works very well for closing the dura in the posterior fossa. And I've had no problems with CSF leaks. You want to wax in and wax out so we make sure that all the air cells are waxed off. And we'll cover it with either a MedPore in this case, or in a smaller case, alarger hole cover. And this patient came from a distance. So what we'll do is just do a sub-cuticular closure.

- Can we go back to the slides please, Chris? And would you like to take us through this and then we'll go with.

- So this is a 66-year-old gentleman with a giant thrombosed middle cerebral artery aneurysm. And he presented with headache. This is the CTA and we sensed that there's obviously there's calcium in the wall of the aneurysm. it's in the middle cerebral bifurcation. And we sensed that, It was probably bigger than that based on the configuration of the aneurysm and you'll see interoperatively. So here's the M1 then the M2s are coming out in a T-shaped fashion. So here's the Mayfield again, kicked out. So we can put our retractor mounts easier at the apex of the elbows of the Mayfield. And then we'll go ahead. And we just use a standard frontal temporal incision for this as middle cerebral as mentioned. And we'll preserve the STA on this case, because I was unsure as to whether I was going to get the aneurysm clipped and preserve both of the M2 branches. We'll avoid any local with epinephrine and we'll preserve the STA and leave the prattle branch intact. Go ahead and make our flap. Lift off the bone flap And you've gotta be careful here because the aneurysm is sitting just below your ridge. And so we'll drill that off. This is the aneurysm sitting right here. And we'll drill down to the meningo-orbital artery and then dissect the fissure. Obtain proximal control. open up the Sylvian fissure, and we'll get right down on the giant aneurysm. So there's the proximal carotid. Here's the aneurysm sitting right out here. This is the one of the lobes of the aneurysm right here. And you'll see that we'll preserve these crossing veins if we can. If it's not necessary to take, we won't take it. We have proximal control already. We'll dissect off the veins from around the aneurysm. It's pretty calcified. Now this one was interesting because we'll dissect it out completely, and then we'll decide what kind of a treatment plan we'll use. And we're prepared to do a bypass if necessary. And as I said that the aneurysm was very calcified and partially thrombosed. And I knew that going in and the whole posterior aspect of the aneurysm here was thrombosed off. this isn't working. Do you have another one of this, Aaron? So we'll preserve all the veins that we can during the procedure. Thank you very much. Yeah. Great. Great. Okay. So we'll go ahead and put a proximal clip on burst suppression 33 degrees, as Gary mentioned, and go ahead and try to clip. Now this part of the aneurysm is all thrombosed. So what I'm doing here is I'm gonna clip that off Beyond the thrombosis part, and you'll see why, because I couldn't put a clip across the base of the aneurysm, cause that lobe was completely thrombosed. So then we'll go ahead and do a thrombectomy now of that part of the aneurysm. So you can see everything's still open. So there's no rush here. We'll bring in the Coosa and perform a complete thrombectomy of this part of the aneurysm. Now it's important here. You'll see, I'm going to get bleeding and that's by design because I wanna make sure I flush the aneurysm completely. And you'll see there's some healthy bleeding, and then we'll go ahead and clip off this lobe of the aneurysm. And then we can go ahead and now place our definitive clip. So temporary clip across M1. Here's one of the M two branches the other one's on the other side. So we'll go ahead and place our clip across the neck of the aneurysm. Now this is a Charlie Drake trick. The first clip kept slipping down and occluding the M two takeoffs. And so I'll leave that clip on and it's so calcified, I'll use a fenestrated clip for the distal aspect of the aneurysm and then move it back. And you see now it's above the takeoff. It's clear of M two and now we can go ahead and clip it properly. And then we'll dress it up with the little dog ear with another small, tiny clip, and then go ahead and do an ICG. Now, one of the problems with ICG is obviously it's a beautiful technique, but this is all calcium in the wall and you'll see it. So it's filling well, both branches are filling, Here's M two on the other side M two on this side, but the calcium really obscures the visualization of the middle part there. So you have to remember that because you'll see these aneurysms, there'll be partially calcified and it can be a mosaic of color when you're doing the ICG. So in this case, it was so dysplastic. We felt that we put some Muslim around the base of it as well, and we finished. Great.

- Here there's a question from the audience is how do you prevent emboli from shooting distally?

- So that that's an important point. And so if I have the aneurysm clipped off, so M one proximal clip and we're manipulating the aneurysm. What I'll do is I'll plan to have the aneurysm open it up and flush it out, just like doing a carotid endarterectomy and we'll flush it out and then we'll clamp it off again. And then go ahead with our definitive clipping.

- Thank you so much. I'm gonna answer one other question that was raised previously is for that awake case. Why wouldn't you put the patient under general anesthesia for pinning and then wake him up. I think with regional scalp anesthesia, that means supraorbital, supertrochlear temporal and occipital blocks putting patients on in pins. In addition, obviously of infiltration of the scalp, where the pins are gonna go, as you can see that patient was very comfortable. Therefore, I don't think that sleep awake model is really necessary anymore with placing the blocks where they need to be as the patients are going to be Dr. Lawton has been very patiently waiting and I really appreciate his patience. He has great three amazing cases that he would like to share with us. Michael, thank you.

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