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

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- Well thank you, Aaron, for including me on this distinguished panel. And if I may say somewhat older panel. Sorry about that, Robert. I'm gonna show this case first.

- [Robert] How quickly you have lost the only friend you've ever had.

- This is my first case. It's a 50-year-old woman who presents with this lesion indenting into the cerebral peduncle on the left side. So she presented with hemiparesis. You can see that this is an example of one of these thrombotic aneurysms. And it was previously treated endovascularly with coils. And this is a nice example of how that kind of a treatment strategy for a thrombotic giant aneurysm is doomed to failure. You can see recurrence here. You can very nicely see the outline of the aneurysm by the coil and its recurrence intraluminally. But if you study the films very carefully, what you'll notice is that she's got a very nice PCOM that fills the PCA. And it looks like there's a little bit of a nubbin of that P1 origin that might be useful for trapping. So this is one of those aneurysms that we'll just have to go in and explore and see what we get. So if I could go to the video, please. So what we're viewing here is a left orbitozygomatic craniotomy. And as most of these vascular approaches that you've been looking at, they're centered on the third nerve here. And this is the internal carotid artery here. This is the PCOM going back, and a posterior clinoid is back here with membrane of liliequist in the back. This region here is all of our thrombotic wall of the aneurysm. And you can see if you look back here, extrusion, as these coils often do, into the subarachnoid space, beyond the wall of the aneurysm. So this is the PCOM, which we're tracing proximately. And as we do, we can see the SCA origin here, the vascular trunk is here, and this is that little nubbin of the P1 segment. You can see it very nicely filling into the aneurysm. This is a dolichoectatic lesion. And so what it's given us is that little bit of the proximal P1 for the trapping. This is that proximal P1 segment again. Now we're gonna have to work on the other side distally to look for that trap. This is just extruded coils once again. Here's the PCOM going back to the P1 through junction right here. And this is our P2 segment going back. You can see it nicely opens up that space between the aneurysm and the P2 segment, and we're gonna need to close the junction or the distal outflow beyond there. Now this is the vascular bifurcation, here's the ipsilateral P1, contralateral P1 here. And we're gonna place that first clip on the inflow to the aneurysm here. And if you'll look real carefully, there's a little perforator that becomes very important right there. Because there's so much thrombus in the aneurysm, what it tends to do is push on the clip and keep that clip from seating exactly where we want it to seat. This is the distal clip now, it's going on the outflow of the aneurysm, just under that P1 and P2 segment. We're gonna just advance it a little bit further to get those tips completely across the outflow. And now we've completely trapped the aneurysm. Now, as Bill Couldwell just showed us, this is the same kind of a trick where we can go inside the aneurysm now, open it up and do a thrombectomy to soften things up. The idea here is you wanna take that solid tumor mass, and you wanna convert that into a soft workable sac. So this is inside the aneurysm. We can open this a little further now that we know that things are well controlled. And with the coosa and with just gently maneuvering and manipulating that organized thrombus free, you can break apart this intraluminal clot and soften this aneurysm up. Now, this is nice because I'm doing a dolichoectatic aneurysm without any kind of illumine that remains it's nice and soft and bloodless. It allows us to work comfortably here. There's no temporary occlusion on the vascular trunk or anything, that's just on our aneurysm segment. But now we need to go back to that perforator, and now that the aneurysm is softened, we can apply a second clip on top of the first, here, this really is acting as just a tentative clip. That first clip acts as sort of a scaffold for the second clip, and we can then remove this initial clip. So that was a tentative clip, this is our permanent clip. And if you look right there, you'll see that that perforator there was suboptimally included in that first clip is not completely free. And I do electrophysiological monitoring, and in fact, towards the progression of the case, there was some detriment of that signal due to that perforator occlusion. Now, again, because this sack is so soft, now that we've taken the thrombus out, we can do the same trick in the back side. We can stack a clip underneath that initial tentative clip. We can slide that right under the P1-2 junction. This was pretty good, but there was a little bit of a kink there. So this allows me that, second clip allows me to take off the first clip. And I'm much happier now with the contour of that PCA, as it goes all the way from carotid and back. So now this aneurysm is nice to excluded. You can see the perforators that actually go through the coils. It's a reminder that we should not try and remove the coils because you can result or you can cause some perforator injury in trying to remove those coils. That's the view inside the aneurysm, which is completely dead. This is a view of the vascular bifurcation. These are the perforators on the contralateral side, and again, important to really inspect those, make sure everything is healthy, everything is flowing and that all of your neuro-physiologic signals are preserved.

- Can you hold off on that.

- This is the next case, so stop that for a minute, please. Can we go to the PowerPoint? Right, the second case is a giant ophthalmic aneurysm, which I think is a nice example of a couple of tricks that are sometimes necessary

- [Man] Could you advance your slides, please, thank you.

- Great, oh, before we go on to that second case, this is the view postoperatively on the angiogram. So the aneurysms has been excluded. You can see a good reconstitution of PCOM to P2 and no further aneurysm filling. So here's that a ophathalmic aneurysm, young lady, about 35 presents with progressive visual decline. You can see the giant aneurysm there, and angiographically, here's the anatomy. Very difficult contour from inflow to outflow. You can see adhesion of the carotid on this undersurface of the aneurysm. And you can see that that's a difficult reconstruction here, but one that I think really works quite favorably when this is done open. So if we can now go to the video. This is gonna be done through just a standard pterional approach. And this is the right side, so the frontal lobe is here. I've edited out a lot of the craniotomy, but I did just wanna show a little view of this distal dural ring dissection. You can see a very nice view if you're looking right across the carotid and along that dural membrane of the drill ring, you can see that nice layer of the distal dural ring here. And it really requires making those extra snips down into the carotid cave immediately and really feeling or freeing that immediate wall of the carotid. So this is now the view of the aneurysm. You can see on this overview. This is the internal carotid artery and our optic nervous here. I have used a little cuff of the dura to leave that this is the ophthalmic artery, I preserved the arachnoid, and this is all aneurysm here. This is the distal portion of the neck. The distal subclavian carotid PCOM is over here. And you can see the pulsation in the aneurysm. It's so big, and so pulsatile that we're gonna need a little softening to manipulate this aneurysm and complete the job. So I did expose the neck on this one. I have a temporary included, and then that temporary clip that you saw go on was on the PCOM. So the inflow to the aneurysm has been turned off. The aneurysm is now much softer, and I'm gonna first place this large fenestrated clip as again, a tentative clip. It's not gonna be perfect when I first put it on and I don't intend it to be that way, but it's gonna close this aneurysm down so that I can open the aneurysm, soften it up and finish the job. So here's the fenestrated clip closing on the neck , Our thalic is up here, our super Kleiner carotid is here and our neck is here. Now the aneurysm becomes nice and soft, and you can see that we can do an additional amount of dissection. We can apply this fenestrated clip and just the right portion. And we can now close the fenestration with a straight clip here. So what that does is it closes the net completely. Now I can puncher this, this is essentially like a suction decompression technique, but without all the hassle and fuss of having to manipulate the catheters in the neck, all you need to do is puncture the aneurysm, drain it down, and now you see the aneurysm becomes completely soft, completely manipulable. And we can peel it off this parasellar arachnoid plane. We can take the dissection all the way forward and inspect the tips of the clip. Now, as we do that, the real critical spot to look is right at the tips. And 'cause that's usually where if there's any residual filling, it will be coming from. And as we work our way underneath the aneurysm and inspect things here, what you'll appreciate is that the tip is not quite across just that little there's maybe a millimeter of neck. That's still beyond the tip. So we're gonna adjust the clips. We're gonna advance that second fenestrated clip a little bit further forward. And because we've advanced it forward, we need to add an additional clip. So I'm gonna take off a straight clip. I'm gonna put a second fenestrated clip on there. The advantage of fenestrated clips is it jumps around all of that tissue in the near portion of the aneurysm neck. And it allows that closing force to remain strong in the distal aspect. And then we can put that straight clip on there to close things. Now this was that tentative clip that was our first clip. And now we know that that can come off. That was again, just a temporary clip that allows us to apply the real permanent clips. And we can tailor the rest of the neck as Bill said, dress it up a little bit to get rid of doggies and such with additional clips there. Now I'm going into the aneurysm. I wanna just deflate things, get the pressure off of the optic nerve. You're looking inside the aneurysm here. You've got a nice view into that space. There's no bleeding. We know we've completely closed the neck. I've already done my IC green, which is not part of this video, but I know that the flow in the internal carotid artery is nicely preserved. And you can see that things look quite favorable. This is the optic nerve, all that work was underneath, barely had to manipulate or touch the nerve. And again, using a little bit of that drill full to protect and leaving that arachnoid. You can stop this, that those little tricks allow you to protect the actual

- Would you hold on for the video, please. Go to PowerPoint. Again, it's very useful to use those protective layers and-

- [Michael] Hey Michael, we got a couple of questions here. Would you consider using temporary clips as tentative clips to avoid high closing force injury to the perforators?

- Can you stop that video please? No, I wouldn't. In order to temporarily occlude the neck with a temporary clip, it's just not big enough or strong enough, you really need a big gathering clip that'll get around all that tissue and pull it together. And so I don't think temporary clips on the neck would have worked, the only other way to use temporary clips rather than permanent clips would have been to completely trap that segment on the super Cline, both proximally and distally, which you can do. But I often find is that there are other vessels that feed between where you've trapped that will allow the aneurysm to fill.

- [Michael] And one other question is, is there a reason why you don't use suction decompression when you put a balloon up in the carotid and destroy clip and decompress the aneurysm?

- Yeah, it's really a matter of ease, as you saw in the video this is so easy. You know, if once you get those initial clips on and close the neck, you can do your own section decompression in 10 seconds. And if there's active bleeding, you're right there to control it. I have complete control over what's going on in the field. If I relegate that to an endovascular colleague or to a resident, or whoever's assisting me, I lose control of that. And so it's a, I think a lot more easy for me personally, just to deal with that myself, have a little bit of potential bleeding in the field, but to have complete control.

- Thank you. I think Michael, the next one is actually yours also. You're gonna start the discussion on deep thalamic cavernous. So if you'd be so kind, and then it will be Dr. Spetzler Steinberg.

- Okay, this case is a nice example of how we can get to very deep regions of the brain without having to go through much brain tissue, which is obviously a good for our patients. In this case, you can see a lesion here in the thalamus extending all the way up into the third ventricle. I think options for approaching this are several, you could approach this from below and try and reach up. The problem is that seeing those upper portions of the cavernoma might be very difficult, if you try to go from below. I think a way as to really just come right straight down on it, and have everything in a direct line of sight that gives you complete and easy access. And I'm gonna show you the way to that with this video, which is really through the, we have to, it's been described as a kind of a contralateral transcallosal approach or in this case it's ipsilateral. But the idea is that you wanna turn the head so that the nose is over here, the back of the head is here and the midline plane is essentially horizontal. When you do that, the inner hemispheric fissure opens up really nicely as you can see, this is the frontal lobe here, and there's no retraction here other than gravity, just pulling down on the frontal lobes. These are your pericallossal vessels. You see this nice whitish plane of the corpus callosum. And again, this is a really nice subarachnoids dissection that allows you to completely separate the frontal lobe, separate the arteries, and get about four centimeters deep into the brain on your journey, down to the thalamus. This is the only portion of the brain that you're gonna need to go through, this portion of corpus callosum. So one of the points that I didn't show because of the video started late was the veins. You really have to work through these bridging veins to get this corridor, but once you're down, there's really nothing else you need to work through. This is the transcallosal opening. This is the ependymal all the last little bit of a ependymal opening here. And this gets you right into the lateral ventricle. You all recognize the choroid plexus. You recognize that ependymal, and here's the framing of Monroe. Here's your choroid plexus and your thalamus stride vein, your septal vein here. Now, the way to get even further down is to open up the collateral fissure. So you have to get alongside the tinea choroidea on the fornix side rather than the thalamus side and just follow the internal cerebral vein back. So I've cauterized the choroid just a little bit, I've isolated the veins and preserved them. And you're really just opening up this nice arachnoid plane that really enlarged as your frame of Monroe. So it takes you right down to this cabinet's malformation. You get a beautiful view now of your target lesion. And again, you can see there's no retractor in there other than what the instruments are doing for you. You get a nice view of the lesion itself, beautiful architecture of the pathology. And now it can begin taking this out. The way I like to take out the cabinets malformations is to use cautery to kind of shrink things down. You don't wanna touch the surrounding brain. You just want to work on the pathologic tissue and with a little bit of cautery and just a little bit of traction, things shrink and pull to the center of your working space. You can start to open up these planes around where the gliadins rim interfaces with the pathologic tissue. You can see those little blebs that pull nicely away from the normal tissue. And you can get all the way down to the bottom of the third ventricle there. This is the plane, which is at your most lateral point. And it's really not a problem in getting those little spots that are at the extent of your exposure. More cavernoma here, nice planes of dissection away from the adjacent thalamus on the opposite side. And again, using cautery and a little bit of traction, you can pull things towards you, pull things to the center and get this completely separated. So this is our lesion, you can see that working space through the frame of the Monroe that's been enlarged. And again, still no retraction to still allowing gravity to do its thing. So this is the view you get at the end. You all recognize that as the vascular bifurcation, it's a lateral P1, contralateral P1 here, this is the vascular trunk. You can see the perforators along their course there, nicely preserved, all working above that. And if you hit hard to go below through an orbitozygomatic approach, it really would have been a significant reach upward with not a great view. This is the view down the clivus, you're actually looking down the dura of the clivus. So you can get all the way down to the level of the ICAS through this really quite amazing window. This is again, P1 contralateral, Pi ipsilateral vascular trunk. There's your enlarged transcollateral fissure approach. This is just showing the PCOM running forward, spectacular anatomy, and really the only cost has been what we've had to remove in opening up the corpus callosum there.

- Thank you Michael, it's really spectacular exposure and technical superiority that case of especially the cavernoma and how far you can reach. We don't have any questions for this part. And I think the next one was Dr. Spetzler. He had to step out in order to give another presentation and we'll wait for him to come back. We have Dr. Steinberg. Who's gonna teach us a slightly, a different way of doing a thalamic cavernoma and very thank you.

- So I've treated about, I just looked at the series 'cause I'm presenting it tomorrow 208 cavernous malformations in the brainstem thalamus are basal ganglia. And the approach to these that you take is very critical. So you really have to try to master multiple skull-based approaches. And this one I wanted to show you, I treated her a few months ago. This is a 45 year old female. She bled twice clinically within six months, had dysarthria right hand, and arm weakness and gait ataxia was located in the left down this extending down to the hypothalamus and to the upper mid-brain. And so I did this through a left parieto-occipital mesial paraphasiae approach. And so the patient is positioned to prone and I'm working from the top. I have the video. Yeah, this is it. Good, go back, that's the video. Can you start that? Great. So here's the left parietal occipital region. This is falx going into the tentorium. This is the pulmonal so working around the veins which are located over here, and there's a little bit of tissue of Polvena to go through. And what I found also is that there were some safe areas of brainstem and thalamus that you can operate in. I used to only operate on cab Mels when they came through a peel or a pentacle surface, there's some clot being taken out. So this is again, the left side, the basal vein of rosenthal is coming around here. You have to be careful of the veins. I opened a little bit of the tentorium and the incisura. So usually I'll take out cab Mels as one piece. Sometimes I will take them out in piecemeal. Here you're seeing, I'm gonna show you use of a laser in a second. I'm using mostly micro scissors and it's a small working space, but now there's the laser. This is the new OmniGuide CO2 Laser. And I found this very useful I've resected 48, cavernous mouth, deep cavernous malformations using it. And it allows you to go around the edge of the malformation without manipulating it as much. So this is a combination of scissors and CO2 laser to take this out. So I've taken out the upper thalamic portion and now working on the deeper thalamic portion. And I work on the edge of the malformation, in infer tutorial cab smells I don't take the hemosiderin. I do when it's super tentorial, here, you wanna preserve the hemosiderin stain, brainstem or thalamus. And then we're getting into the upper mid-brain for this.

- We gonna go ahead and show another aneurysm by Dr. Couldwell, who's gonna discuss how different it can be done. And then after that, we're gonna have a couple of microvascular compressions, which are really beautiful operations, my most favorite ones. Here's a question, Gary, any visual deficits going down could occur by going through the palvenar?

- [Gary] No, I've never seen any visual deficits going through the posterior aspect of the pulvenor, and we've done neuropsych testing and haven't picked up any cognitive issues either. So I think that is, is one of the safe Carters. I think it's a little high, I think it's too high to do through a super cerebellar approach, actually.

- [Aaron] Thank you.

- So I'm just gonna show a straight forward segment aneurysm. Could you roll the video, please? This is a young woman with a headache. She had a visual field cut. It was identified by the ophthalmologist, but she hadn't noticed. And just, just to explain sort of our philosophy about how we manage this. So you can see the aneurysm on the right side here. And what we'll do is we'll do, this I don't believe requires orbitozygomatic approach. We'll do a standard frontotemporal approach 'cause you're working right on the base of the skull as you come in and you've got beautiful view without having to remove the orbital rim. And so here's the right side optic nerve, and we'll identify the aneurysm immediately. It's a very simple approach and you need to get room to manipulate the clip, so here's the aneurysm. And so what we'll do early on is drill the crinoid completely on this case. And you've really got a couple of options for proximal control here. I like to remove the dural flap completely. So it doesn't catch in the drill, and we'll go ahead and drill the choroidal and drill the optic canal completely because it allows you a little mobility to move the optic nerve when you're placing your clip and move it away and more easily identify the ophthalmic artery. So we'll move crinoid here, which is partially eroded by the aneurysm. And then we're gonna identify the distal neck and the proximal neck. And we'll go ahead and completely open up the distal dural ring because you're gonna have to find, and release this aneurysm from the dural ring. So this is what I'm doing now, cut right on the aneurysm and get it all open because we're gonna have to place a fenestrated clip on this aneurysm, and you need to come around at circumferentially. So here, just like Mike showed in this video, we're gonna reduce the aneurysm and then move it away from this sphenoid ridge and the cavernous sinus.

- [Aaron] Assume you have a neck exposed.

- In this one, actually we do this one of two ways. We either do an open neck exposure, or sometimes I'll just come around some temporally and expose the carotid in the petrous bone and get proximal control that way. And so what we'll do is we'll place a fenestrated clip and you've really got to reconstruct the artery here. And so, this one we put in just an angle clip, we were able to change it to an angle clip, and I like to avoid fenestrated clips if I can. And then we have to clip off a little dog ear right there, and then we'll go ahead and do an ICG And make sure that the artery that you can see the artery there's the ophthalmic artery in view there. So that's filling nicely, and we'll make sure that we can see the artery and it's not crimped at this proximal end, which is sometimes more difficult to see. So the ICG is superb for assessing that. And then we'll go ahead and open up the aneurysm, make sure it's adequately clipped. And then again, seal off the sphenoid sinus that was wide open in this case when we drove the crinoid out. And that's it, thank you.

- Much appreciated. Can we please go back to the slides and we'll finish up shortly. I know it's been a long day for all of you guys, but I don't think any discussion of good cases really is great until you had some decompression, especially with 3D. Not that it's challenging, obviously the cases the experts showed is much more challenging than these, but it's just something that we do as neurosurgeons, even in private practice. And I think adding a little bit of flavor of the challenges we face would be helpful for all of us. So this is a 51 year old male with right-sided hemifacial spasms. And as you can see, there is a hint of a vessel on the right side, just right there. Again, you won't know until you get in, and it's important to know that hemifacial spasm typically starts around the eye and then goes to the face. So you have to differentiate it from other disorders. And be obviously I perform an MRI to rule out an epidermal, other lesion that could be present. Would you please take us to the 3D? So this is the exposure I use. I use a curvilinear incision because it turns the flap out of my way, and I use, this is the mastered groove. This is the superior nuclei. You see the flap is all the way away from you, then craniotomy is very small. You don't see the transfer sinus. You just sort of put a bear hole and get somewhat close to the floor of the poster fossa. And also you make sure you see the edge of the sigmoid sinus. The dural is open across the sigmoid sinus, especially curved along the floor of a poster fossa. You got to be careful in order to angle this is one of my residents. You've gonna be careful to angle your trajectory where the petrous turns into become the floor of the poster fossa. And that's where you need to be getting lost in this area could be dangerous. I perform a lumbar puncture before, right where the patient is in lateral position and view . And you can see it gives you a tremendous decompression. Nothing is worse than sort of being lost in posterior fossa with very sort of a swollen brain on a large patient, and then sort of vein going off and just turns a very beautiful surgery to a very difficult one. I think that lumbar puncture is critical and draining 30 or 40 CC of CSF, right when you are doing the washing your hands and people are draping. You see that beautiful vascular loop and did become the discoloration at the root exits on of the nerve. No retractors, you start, I just do not believe retractors are any necessary in this operation. It's just better for cerebellum, better for the patient. These patients go home the next day essentially, or did that after that. And I just think it's better microsurgical technique. I can show you any results, and here it is, we put a piece of rubber and piece of glove underneath the rubber glove. And when you remove that brain just looks almost intact when you see momentarily. So new retractors, it's a 45 minute operation and the patient does very well. And it makes up for some of those difficult vascular and skull-based cases. You just need these cases to keep your sanity in my opinion, and obviously wax in and out as Dr. Couldwell and Jeanetta have so beautifully mentioned on multiple occasions. And here's really the final result, is just a acute case to be able to get done before you go home after a long day. So can you stop that and go to PowerPoint, please? 62 year old female with left sided trigeminal neuralgia. It's been our preference to offer this surgery as old as 75 year old patients. It's just works very well as long as the patient has a very classic trigeminal neuralgia. So let's just look at it, there's not much happening, but that doesn't mean anything, especially on an MRI that is not very high resolution. Chris, would you mind put me through the video? The approach, the decision is very the same. Actually, I just switched this patient from Alaska. It's just to show you that this incision is very much the same. And then this time, as you can see the transfer Sigma sinus is very evidently present. Do you mind if I borrow your it's up there? You can see the transfer signal junction very clearly right there, tank you, Gary. You can see that right there, and the small craniotomy or craniotomy. And then you can see that I tend anteater petrous junction. You'll have to identify that to orient yourself where you're going. And after that, obviously open the arachnoid. I also do a lumbar puncture. I just like the brain to be relaxed and not compressed. It's just my first duty not to injure anything on the brain. I never take the superior petrosal vein. I do not use a retractor as you can see, there's no retractors here. You find the vessel, you elevate it, you preserve everything, that's the rule in microsurgery. You find both of these, you elevate them up, there's no retractors, when you open the raccoon membranes generously, you'll be able to do that. You'll also see a vein often at the bottom, and I believe it's reasonable to decompress both these. And I wanted to ask Bill, what is these veins? I mean, what's the role of this vein? You know, we found a big artery. What would you do? Do you decompress this? Or what are your thoughts?

- [Bill] So yeah, I mean, my philosophy about this is I like to leave nothing around the root entry zone. So actually transpose the artery. If there's a vein there, I cauterize and cut it and I cut it, so it won't re-vascularize. And so that's my philosophy.

- So you do not put a Teflon patch?

- [Bill] No, I try to sling the artery. So I release the artery over a long period, over a long distance and then try to get enough redundancies so I can sling it away. And then I'll sling it to the peaches or the tentorium.

- So you would have quite Despair and cut?

- [Bill] Yes.

- Okay, Gary and Michael, any thoughts there please?

- [Gary] So I coagulate and cut all veins, I've never had a problem, even with the ones lying on the stem. We, you saying you put the arteries sling the artery Bill?

- [Bill] Yeah, we try to transpose the artery.

- [Gary] Yeah, I still use pledges like you do, I use T's pledges and I put in enough that they're not gonna move, you know, with CSF flow and it seems to work okay.

- Fair enough, I think that's reasonable. Michael, any thoughts there, please?

- [Michael] I'm more of like to transpose the vessel and get things off the nerve. So I wondered about you not taking the petrosal vein. 'Cause I take that if I have to routinely, if it's gonna tear or within the way, and I haven't seen problems with it. Bill was mentioning you had-

- [Bill] Yeah, I had one terrible complication with a woman with a petroclival tumor, but she had her cavernous sinus and the superior petrosal sinus was full of tumor at its most medial aspect. And I think I took a petrosal vein, she ended up with the venous infarct of the midbrain and the thalamus. And I couldn't think of anything else that caused that.

- [Michael] I suspect she had anomalous venous drainage, 'cause you know-

- [Bill] A routine case I've never seen a problem taking it.

- [Michael] Yeah, and I agree with you. I think it was an unusual case 'cause she had a lot of her venous collaterals that were reduced.

- Thank you, so I think when the venous anatomy is that you have to take the vein in that case belt. So there's, unfortunately that's an unfortunate patient that there's nothing to do about. I'm gonna just add, finished the discussion and we're gonna finish a little bit early on until Dr. Spetzler would show for his case. And this is a 22 year old female with a sudden headache and newer deficit. And this is an anterior sinus obviously you can see just around the area of the posterior portal medial region. What's important about this case is that I would like to know about my panel, how they would do this, and obviously try to minimize the retraction, you've heard enough of that for me today, but Gary, how would you remove this lesion? There is a hemorrhage there.

- [Gary] Yeah, I don't know, I usually don't operate immediately after hemorrhage. 'Cause I like to let the brain, I do and I like to let them regain autoregulation, I know there's some controversy. I would go through the clot actually through the posterior parietal region, likely rather than, I mean the other way to do it would be, yeah, I think you could go through the parietal cerebral region right through the clot.

- Okay, Bill or Michael. That's very fair, I think that's most people probably do.

- Yeah, I would do that as well. It would do for the clot, but I'd come through. I'd wait to probably a couple of weeks, thank you. Can show us the angiogram real quick?

- Yeah, the angiogram.

- [Michael] Yeah, I think I'm going down the interhemispheric fissure is really attractive, but the problem is that getting that lateral corner here, traveling this distance laterally is a very tough stretch. So I would agree that a transcortical-

- [Gary] You know Mike, I used to do these deep and even kilometer AVMs, transcallosal or from a media and media and more posterior approach. And it was a struggle getting laterally.

- Right.

- [Gary] Yeah.

- Well this applies for any man in Jerome or anything like that. I did it not just like any of you guys mentioned, and again, that's become sort of my obsession with lack of retractor. So I think if you have to go that way, reaching here is almost impossible with significant retraction. So what we did here is we went to the good side and I use the transfarisne approach. And when all the way here without using the retraction in any moment during surgery, we're gonna go over that technique. And I want you guys know that again, you can see that all along my thought process is how can I decrease retraction of the brain and at the same time be able to protect normal structures. That's just one way to skin a cat, does not mean it's the only way, again for me to get here, this would require mobilizing this a lot. But again, if you remove the clot that probably would provide you what you need. If you don't mind, can we go through this video, Chris? Let's talk about the positioning of the patient. I love the lateral position because it's very physiologic. As you can see a very linear incision. I personally feel if there's a small hemorrhage and the patient is doing very well, this patient was absolutely intact neurologically going early on a small ABM ease, okay, this is the superior sagittal sinus, smaller incision, small craniotomy minimally-invasive, staying more on the left side rather than the right side. It's sort of the superior sagittal sinus. You can see the patient is right down. One key factor that works very well in retracting the sinus is putting a couple of stitches on the falx inferior to the sinus, and tacking that up laterally to a scalp flat. As you will see momentarily, this really increases the workspace through the interhemisphere corridor. This is just a great nuance that I saw one time during one of the sessions of WNS. And that's really one of the reasons I thought putting this session would be important because I learned so much and it's my responsibility to facilitate some of the transfer of information, including from our experts. So you see two stitches right on the falx and just mobilizing the sinus just a little bit laterally. It's not gonna be aggressive retraction. It's just gonna be enough for you to be able to see things and not necessarily use a retractor. As you can see, it just increases that space a little bit without necessarily occluding the sinus. I'm gonna check if we have any questions coming up from you guys. Why do you do surgery after the ABM bleeds? That's an excellent question. I think our panel mentioned that if the patient has any deficits or it's a large bleed and the brain looks angry, no need to take a risk with a patient. But if it's a small hemorrhage, a patient is doing very well. One reason to do that, if my opinion is to have a short, small deficit, rather than having them recover from the deficit and then come back, have the surgery and potentially have another deficit, like a double hit effect. I would rather just have them have one hit, recover from it and get on with their lives. But again, that decision has to be very individualized. It is the correct decision to wait on the ABM staff hemorrhage. And here is the cutting a piece of the falx. You can see that working after the falx has been sort of cut working across the falx and removing some of the clot within the area. Again, we moved the position by the way, that was from the back of the patient. I felt came from the head of the patient, just like Michael I'm left-handed. So anytime I can use the advantage of working with the left-hand is suction in the right hand and using the suction as a dynamic retractor, I do that. That's what we started from the other side. So this is actually the left side, now this is the right side where the AVM was, and here's the draining vein right on the callosal. And you're sort of on draping the arch and in this malformation. The same technique applies for many Juul for anything else. It's not the main AVM that is really important here. It's just, again, this is called the skull, so one of the feeders you wanna keep this vein that goes to the Atlantic system, very intact early on, and you've got to be very careful. We ultimately enter the corpus callosum and remove a more medial part of the tumor. Here is again, you see how far lateral I have gotten without any retractor. And this is really up to the ventricle and we're gonna see CSF soon. This is again, most of the ABM has been vascularized and the vein was sacrificed. And then we're gonna move anteriorly and ultimate to be able to see vein of Galen. It's just a very pretty, you know, seem to see the vein of Galen. It's very unusual again, that's the back of the head up there, and that was the drainage to the galenic system. This is a splenium of the corpus callosum, and this is sort of the examining the surrounding areas for any residual ultimate staff. Obviously you do not wanna Quigley the vein of Galen by mistake as a drainage system autominous malformation, studying the dark and your architecture of the AVM remains the ultimate goal of the surgeon. Again, sort of moving across, we thought there was a, we did an angiogram and we just saw a little bit early drainage of vein. It was difficult to see if it was luxury perfusion versus a small ABM, and so I just try to look around, make sure there's no residual ABM left. And I think actually I think this is the last piece coming out. This is not, I got ahead of myself. I think this is cutting the last draining vein anteriorly. So this is when the whole ABM comes out and add the next step, I tried to clean the field a little bit more, and this patient actually had a complete section with a little bit of luxury perfusion. You see a little bit of hyper vascularity, but actually there's no early draining vein. And this is the post-operative angiogram again, showing some luxury perfusion, but not necessarily an early draining vein. I think we have done really well. It's 4:40 and did we have another four or five cases to show, but I think it's best to say maybe taking off time a little bit as speed we ran through the cases was pretty high. Would you advise young surgeons to make such a small craniotomy? That's an excellent question. Working through small spaces comes with experience and I personally did not start that way. And I think if you start without using a generous craniotomy or not retractors, that can be a dangerous move. I a hundred percent agree with that. I think that comes with just becoming so comfortable that you just wanna push yourself to the next level because you feel that you can advance your microsurgical techniques. Believe me, if you can do it without a retractor, doing it with a retractor is much easier. I wanna thank all of you guys for such an amazing appearance. I want to thank, so actually, Robert, would you like to show your carvenoma. I'm sorry, I didn't see you walking in and I definitely wanna use the opportunity, shall we go back to Dr. Spetzler cavernoma, pontine cavernoma please.

- Thank you, Aaron. I think one thing about cavernous malformation. So I think they have taught us more about how to get the difficult portions of the brain. Did you did you take that away from me on purpose just because you're leaving Gary? Here you see cavernous malformation in the brainstem. So this, if you look at where the tentorium is and where the cavernous malformation is, you can see this would be a very ready, very reasonable to approach this through a super cerebellar infratentorial approach, is there. And so again, I think the super cerebellar infratentorial approach is something we do a weekly, maybe several times, and it gives you this incredible ability to go around the midbrain from one side to the other. So this is the beginning here is in 2D, just a small opening again, the sinuses appear cerebellum here, opening the arachnoid adhesions. And by being off the midline for these here, it gives you a lateral approach to the brainstem. And this will switch to a 3D here in a little bit, see the tentorium. So if the tentorium gets in the way we cut it obviously, depending on how high we need to go, down to the ambient cistern, opening the arachnoid, fourth nerve naturally is always nicely covered in the arachnoid. So when you're cutting tentorium, as long as you are keeping the arachnoid intact, you're protecting the fourth nerve. So with image guidance, we've made a decision of where we're gonna enter the mid brain and the lateral, and here we go into the 3D, the lateral approach in the midbrain is extremely well tolerated. You may get some temporary sensory symptoms, but it's just surprising how tolerant it is to get in there and then removing the hematoma. Now you can obviously it's on a very high magnification you're down in the deep hole and stretching the opening so that we have a better access. These are very small, sharp forceps. And then just working with the sucker, which is obviously a malleable sucker, so you can get the best angle to it. And then we go around and we take out the cavernous malformation piecemeal often, if there's a reasonable hemorrhage, like in this case and you get the clot out, it gives you a lot more room to work. This is where little forceps, very fine forceps with little teeth on the end are very helpful. When you picked up the little components of the cavernous malformation that remained in the cavity, and you can see it's sort of like delivering a baby, that's, and you just keep going. You could see the little teeth at the end, and I spent much more time today than I've ever done before going around the cavity and just picking up one, a white little thread after the other, until I'm as comfortable as can be that I've taken everything. Because you think about the walls of the cavernous malformation, one cell thick endothelial layer. When you've removed the blood out of the component of the cavernous malformation, then you have these little white strands that retract, but there's still a part cavernous malformation. And I think that's where you have a higher risk of recurrence. So it's worth spending a lot of time to get rid of that. And so this is also where the light instruments really come in very happily, but you see where the lateral entrances just incredibly well tolerated for this kind of lesion.

- Well, with that, thank you for being with us and enjoy your trip.

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