Dealing with Intraoperative Misadventures

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- Welcome colleagues and friends. Thank you for joining us for another session of neurovascular surgery series from the Congress of Neurological Surgeons. This is the last session on complication management in neurosurgery, and more specifically intra-operative complications. My name is Aaron Cohen from the Neurosurgical Atlas. We also have Dr. Dan Barrow, chairman of neurosurgery from Emory University. Dan, thank you for joining us.

- Good morning, Aaron. Great to be here. Thanks.

- Same here, thank you. So, we have no specific disclosures related to this talk either from Dr. Barrow or myself. Intraoperative complications are the most important variables that define the best of us. How we deal with our complication define how good we are and how much more we need to progress to get better in our career. Dan, there are certain variables that personally, I feel most importantly associated with improving the effects of the complications. Dr. Thaw Sant, God bless his soul, used to say that the only way to avoid complication is not to operate. So we all know that all of us have many complications unfortunately. The most important thing is to make them least affecting the patient. The series of things in the order that I think are most important is how the surgeon keeps his or her composure during surgery at the moment when the complication occurs. That's so important of, so dependent upon the surgical intelligence and the temperament of the surgeon. If one loses his or her composure and, or very much responding with their emotions, knee jerk response, that's unanimously leading to more complications and that leads to more emotional response. And obviously that's a cascade that leads to a major intra-operative disaster. So I think the surgeons' temperament, the way they react to the first complication or the first event of the complication in that surgery is most important. I think when a major hemorrhage happens, a vascular injury occurs, the surgeon often thinks of one solution and they'll go for it. My philosophy has always been the first solution you think about is most likely not your best solution. So take a deep breath, keep yourself together and think about the consequences of every decision you make rather than about the decision itself. If you have major bleeding doing AVM surgery, coagulating that major artery or putting a clip on it, is that the best thing to do? What could be the effect of that movement or maneuver? The second most important with this, which is really is part of the first one is patience. If there is severe hemorrhage, it's just blood. Obviously there's a fair amount of it left in the patient, and we wanna make sure we make a good decision, although the time is very limited. So just making a decision on an emotional foundation is a very wrong one. Temperament, we talked about. There is no time in surgery that the temperament is more important when the severe complication occurs from the resident or the surgeon himself or herself. The surgeon is the captain of the operating room, and therefore he or she has to be the model leader for the rest of the team. Becoming angry, blaming others and creating an environment that is threatening to other team members is unacceptable and only increases the risk of complications. Experience is obviously very important. As you can see, I put skill further down the line because there are other things more important than skill to manage a complication. And I want everybody to remember that. Skill is very important, but it's not the most important one. An extremely skillful surgeon could have a lot of complications if they don't have that proper temperament, composure and the way they use their skills to manage a complication. So it's just not what you have, it's how you use it. Obviously, how the complication affects you and how you react to it is also an important factor for future cases and the tolerance of the surgeon to taking risks, the surgeon himself, the institution where he or she works. There institutions or surgeons who are very risk averse, and a complication can be devastating to them, and in fact, would affect the way they manage a single case in the future. That reaction is not uncommon in neurosurgery because we're all so driven for perfection. However, I think that could be an enemy. In fact, if one complication can significantly affect the rest of your career or the way you arrange a case, that can really place other patients at risk because complication is part of what we do. But however we handle it is even more important in affecting the outcome of the patient. So we all have complication, what's most important is how we handle it. And we cannot let risk averse behaviors place the treatment of future patients at risk. If one has a complication in one case, and then he or she says, okay, from now on, I'm never gonna manage it that way, no matter what, that could deprive future patients of a good care that they were deprived because the surgeon had a bad outcome in one single instance. Your colleagues are so important in how you manage your complications. And I often have a low threshold. I recommend to many others that if you're in a big complication in surgery to call your colleagues in, it's important to have your people that you rely upon because when you have that person with you, they're not as stressed as you are, no matter how good you are. You are stressed in that situation. They can come in and having a pair of eyes, looking at things in a very unemotional manner and giving you feedback is so extremely important. It also provides you with a subconscious level of less guilt because you know you did everything you can, you have somebody else, was there as a witness and helped you out. And it can give you a perspective to others why this happened. And if it's an absolutely major complication, you have others who can provide a perspective. I think those are extremely important to provide a reinforcement for the surgeon about what happened, how could have been done differently. And as I said again, you can't just let one complication shape how you manage that specific case in the future. We have to remember what happened. We never forget how patients suffer from the mistakes we make. We should always remember, but we keep our eyes on the road. In other words, we'll continue to push forward. We'll continue to do what is best for the patient in the future, and do not make that unfortunate event and the significant suffering to be a role model in handling all our cases in the future. Dan, would you please comment on these thoughts?

- Yeah, I agree with all of your points exactly. I would add maybe a couple of thoughts. I think of complication management in two phases, the best way to manage a complication is to avoid it. And so complication avoidance, I think, is part of the subject. What do we do? How do we plan? How do we recommend and advise patients about whether or not to have surgery in order to avoid complications. And then, of course, the fact that all of those are going to have them and we have to manage them, which I think is another aspect. I also agree on your last line about keeping your eyes on the road. I think there is a thin line between being absolutely devastated by a complication to the point that you can't get up and go back to work the next day. And at the other extreme being cavalier about it. There is a point along that spectrum that is appropriate when we have complications, we should be devastated to some degree, but we've got to get back on the horse and go back, and work and learn from those errors we made, but we should never become callous, and not take it personally when we have a complication. And I think that brings up the final point I'd like to make is what I would add to your list of personal reflections. And you touched upon it, but I would add the word honesty. I think being honest about our complications is very important. Shortly after I joined the faculty at Emory is probably about 1986, I heard a talk. It was one of the most influential I've heard in my career. One of my now mentors, and people I admire, Roberto Heros gave a talk. I will never forget, it was at a relatively small meeting. And he was talking about AVM complications and I'll never forget his opening line was, "AVM surgery is like doing the Cuban cha-cha. You take two steps forward and one step back." And he proceeded to show case after case, after case where this case, everything went great, and this one looks exactly the same, but things went terribly wrong and he spent time pointing out the differences, the subtle differences in the AVMs and why he made a mistake. And it was one of the most honest talks I've heard. And it really influenced my career in being able to focus on learning from my mistakes, sharing them with others so that we all get better. So I think you're right on with your points.

- I appreciate that. I think that is so well said. I should have emphasized that more. I think those people like Roberto Heros, and in fact, I talked to him this last Monday about this. I compare Roberto Heros to one other person who has been so good about that, and that's Charlie Drake. I think Charlie Drake, Roberto Heros, and you yourself, Dan I think you have been extremely honest about it and surgeons, unfortunately, don't do enough of it. I think we all are guilty that we don't expose our complications. And part of that is because our other colleagues are very critical of that. In fact, I presented my basilar aneurysm clip series three years ago, and published in journal of neurosurgery. We're extremely honest. We had an independent nurse review every patient outcome after surgery at six months and one year. And we published it very honestly on outcomes were more, more than other series published. And we felt pretty honest and good about it. And in fact, we got one very difficult editorial from another surgeon who was trying to teach us how to do microsurgery. And I think that's the reason why people are often, avoid being very honest because of that, because they worry about those kind of reactions. And I think as a community, we have to be more tolerant of describing complications because that's when our pennant patients benefit the most. And on another note, there has been studies in the past that have shown that surgeons or clinicians who evaluate their own results can have to have up to 30 to 40% error rate of minimizing their complications. So it is very important for surgeons to have independent nurses, not part of their team, not working under them or other people, not necessarily nurses to evaluate their outcomes, not their fellow, not their medical students or residents, because I think there is a hierarchy and their hierarchy can confound how we describe our outcomes. So with that in mind, let me discuss three cases. Dan, if you don't mind, and I'll ask you to comment that have been significant complications for me and what I learned from them. I can tell you that the first case when I had a severe complication was when I was doing an ophthalmic artery aneurysm over 15 years ago, where I was drilling the clinoid, and unfortunately avulsed an cathe-aneurysm. I have had only one other intra-operative complication when aneurysm hemorrhage had occurred at that point. And I'll tell you it's, you can grow fast when things happen, but the key part was remaining calm and keeping your composure. Let's go ahead and should this case that my fellow was doing, in fact, but it has a great learning case again related during an Extradural Clinoidectomy. I don't wanna point out some of the things that in this visual demonstrate, the blindfold that the surgeon has during, doing procedures that can lead to complications. This is a left sided approach to a middle spinner women . We're doing an extradural clinoidectomy on the left side. And as you can see, the drill is being used by my fellow. And he's so focused on the anatomy superficially on optic nerve, and the dura that he misses the point. In other words, he has a blind sort of fold on in terms of what else is important within the anatomy. And that narrowed attention span is one of the most common reasons for complications. If you're too focused, if everything is so analytical for you, that you're thinking about every moment of the surgery, you're gonna miss that big picture of what could be there. And that's for early learners, they're spending so much of their attention span on some details of step two step of the operation that they miss the big picture and they get into trouble. So in this video he's been drilling and we'll see here, he's very much focused on the optic nerve, but the carotid artery, which is at the depth of the dissection was ignored. Again, so much energy is being used on an attention span for certain things and not the other ones. I propered her, help was summoned in that point, as you expect, I came in and then I looked at this and as you can see, there's no way to be able to repair this vessel primarily. It's within the skull base. So I used a piece of cotton to be able to tamponade it, and then to keep the cotton in place, I went ahead and tucked the dura and sutured it to the precranium, to tamponade that space and exclude it from the intercranial space as it is, and keep the pressure. This is relatively a simple complication. There's no much to manage. So the ENT cotton was left in place, was not removed. The dura was reflected backwards and the patient didn't have any undue complications or pseudo aneurysm after surgery. Very simple, small tamponade in a small location, but what it shows is that the operator, which all of us are guilty about has a very narrow attention span, we all do. And it's about how you parse out, how you separate your attention capital to be able to realize there are other structures at tricks that we missed. So this was the way the hemorrhage was controlled with tamponading on the dura and the rest of the operation in this case went fine, and the patient didn't have any undue side effects from this. Dan, do you have any thoughts in managing this specific complication?

- Well, I assume that you did a postoperative angiogram to be sure there wasn't a pseudo aneurysm or some yeah. Nothing I would add. It is for this reason that I don't do an extradural clinoid resection when I'm operating on an aneurysm, I certainly do for a tumor, which this was, but I think for an aneurysm of the clinoidal segment or this proximal carotid, removing the clinoid extradurally can avulse the dome of the aneurysm. And so I think an intradural removal is safer in that setting, but for a tumor it's certainly appropriate.

- Okay. Excellent, thank you so much. Next video is interoperative aneurysm rupture, and I think it has other good points that I have learned. This is very early on in my career. And the hemorrhage occurred before any major dissection. This is a patient who presented, very young patient. Left sided weakness, continued to worsen, and blew a pupil on the right side. You can see the hemorrhage mostly in the frontal lobe. And I'm gonna go and take a moment and see how your hemorrhage tracks down into the frontal lobe. You have to appreciate that to see how the complication was managed. So this is an example how expecting a complication is so important because when we started opening the dura, obviously this is very unstable aneurysm. The patient became hemiplegic and blew a pupil within half an hour. So it tells you that the lesion is extremely unstable. When we started the splitting the fissure, the brain starts swelling more and more, coming out of the head. And then as you can see, I have a retractor there. Splitting the fissure on the right side fair amount of subarachnoid hemorrhage. And just about the moment when I was trying to dissect, the brain was too tight. And so I thought I'll go sub frontal and release some CSF. Here's the retractor, subfrontal on the right side. And then that's when the torrential bleeding happens. So at that moment, the torrential bleeding is coming through the frontal lobe that's not close to the aneurysm within the Sylvian fissure. This is an MCA aneurysm, and you can see it's pretty dramatic how the hemorrhage explores the frontal lobe. This is the moment when the surgeon has to be patient, don't do a knee jerk reaction. Why do I have torrential bleeding from the frontal lobe? It's because the aneurysm hemorrhage was tracking through the frontal lobe. Here you can see that massive hemorrhage. The frontal lobe is essentially, sort of creative track out for the hemorrhage of the aneurysm. And a knee reaction would be to remove thread through the frontal lobe to see what's going on. But in fact, it's the aneurysm in the temporal side. So I came back quickly, even though there was massive hemorrhage occurring through the frontal lobe, grab the aneurysm. As you can see, you can see the point of where exactly the aneurysm is bleeding. I'm holding it with a bipolar. There's no further hemorrhage through the frontal lobe and then got control of the M1 to the best I can. And then at that point was able to control the bleeding. So one more time, the knee reaction of controlling hemorrhage through the frontal lobe would have been fatal for this patient. Thinking twice, where is the hemorrhage coming from? What's the strategy to go? I have to leave the massive hemorrhage through the frontal lobe and go through the Sylvian fissure. Here is holding the aneurysm with a bipolar, obviously a dramatic maneuver. We don't recommend under usual calm circumstances. The entire MC complex is actually clamped down on the bipolar forceps. I put a temporary clip on the entire MC complex. I'll go ahead and start dissecting. Again, things I've never done. I've never had that temporary clip on entire MC complex, but these situations require dramatic reactions, but those are reactions you may never have done before. That's why you have to think, be composed, be intelligent, be patient doing things you've never done before to minimize the risk of complications. In this case, I put a permanent clip after a temporary clip was placed on M1, and second clip was placed to occlude the entire aneurysm and an ICG was performed, which demonstrated complete exclusion of the aneurysm. And I always say it's better to be lucky than good. And there's a picture of this patient, actually two days after surgery, she was, this is operating with a blown pupil. This is what we had as a CT scan after three months after surgery. And I believe there was a picture of hers included with her consent that demonstrates how this actually did two days after surgery. So, it is all about how we do handle the complication rather than the complication itself. So there's much to learn about that case. Any thoughts regarding that to, Dan?

- I think you nicely illustrated your entire list of characteristics one must possess to deal with complications adequately in that one case. Well done. It is always difficult when the aneurysm bleeds prematurely before you've dissected it. Once you've dissected an aneurysm, if it bleeds, it's generally pretty straightforward to deal with, but the premature rupture before you've actually exposed it, it can be catastrophic and you have to be patient and, yeah, efficient, which you were.

- Thank you. Let's go ahead to the last video. Before we jump to the expert set of slides and comments by Dr. Barrow. This is a case, it's an transsphenoidal surgery. And this happened a while ago when I was actually using the microscope for the transsphenoidal operation, but still it's very relevant. And I wanna just comment on, this is a very aggressive pituitary adenoma. And you can see the carotid artery is within the tumor on the right side. So I want you to appreciate the location of the carotid artery. And this is why I feel it's so important to expect complications. Always think about every step. What is the imaging shows? What is the likely chance you're gonna have a major vascular injury. Which is the most common fatal or high-risk complication we have in neurosurgery, and how we should handle it. So this is an example of avoiding it, if we can, which is the best way to do it. Again, avoiding the complication is the best approach. Unfortunately, this case I did not appreciate the location. And this really was like walking into a house on fire. So I'm operating as you can see. But I did not as much expect the location at this. And, as you know, I'm coming from the left side. So it's pushing me toward the right side where the carotid is, such cross court approach through the nose. And then I did not expect that I'll have, I'll be cutting, literally cutting the wall of the carotid artery, as you will see in a moment. And I'm sorry, the video is a little bit, the operative field is a little bit out of the field of video. So I bring the micro-scissor and then I run into torrential bleeding. And in that case, I think the best approach, again, not to necessarily have a knee-jerk reaction. The knee jerk reaction is to pack this and potentially leave and hope what happens next, which is at times not unreasonable, but the packing wasn't really effective all the way in this case, because I didn't know where exactly the bleeding is coming from then. So, it wasn't really my career. I did get shocked. I've never seen any intraoperative hemorrhage through the nose ever in my training or fellowship. And as you can see, I'm packing just because I don't know what to do. There's fair amount of bleeding that's gonna eventually come out of the nose, on the drapes and on the floor because I have cut, sharp cut essentially across the wall of the carotid. So my heart rate is through the roof. I don't know what to do, but the worst mistake is to just do what you think is right, pack it, step back and think about what's right to do in this case. And I think I packed it, but you still can see, I think at some point I had my finger in the nose, but as you can see that there's blood coming on the floor. So, and the blood pressure was dropping a little bit. So got me very nervous. I packed it, I thought for a minute. And then I said, it's a sharp cut. I need to find where the cut is. We just don't have an option because packing is not helping me. I, in fact, removed the packing, as you can see in a moment. I found where the cut is and I covered it with cotton and wrapped it, exactly in that area. Because it's a sharp cut, which most often in transsphenoid surgery to small cut or tear, you be able to find it and put a pressure with a cut thrombin cotton right on the hemorrhage, hold the pressure. And all surgeons are really thankful to the circle of Willis and the coagulation cascade of their patients. And in this case, I was able to control the bleeding via putting a tamponade on the artery. Coming back transcranial on this tumor was difficult and this patient was losing vision. So I actually went ahead and remove more tumor. So I went ahead from a disparate surgeon who had his finger in the nose of the patient with no solution, to in fact, removing the tumor in the face of carotid injury. Obviously this is not necessarily a perfect answer of boards that if you have intraoperative carotid rupture to go ahead and remove tumor, but with a thoughtful process of what's the source of bleeding, how can I control it? I went ahead and tamponade the exact site, remove fair amount of the tumor that this patient had significant improvement in their vision after surgery. And obviously took the patient after resection into the angiogram suite to make sure there's no pseudo aneurysm. So this again, emphasizes the composure, lack of knee reaction response, improve attention span, a very thorough thought process of how to handle deletion and eventually providing the patient with a resection of a tumor and a good result in the face of a major intra-operative disaster. These are the points that I like to emphasize with this surgery. And it was very much a very novice surgeon at that year. Here, you can see this pseudo aneurysm that is on the carotid artery, it's very small. It was covered with a stent, a covered stent and this patient did excellent. And as you can see in a moment, interoperative, postoperative MRI demonstrated good resection. There's definitely a residual tumor, but there's definitely decompression and the vision was significantly improved. Obviously there are times that I probably would have lost and had so much bleeding that could have lost a patient on the table, but I give it my best shot. I kept my eye on the road. I didn't look back. And I said, oh, I have a major carotid injury. This is gonna be disaster. I said, I know it happened. How can I deal with it? How can I do what's right for the patient? So that's one way I dealt with it. Dan, what are your thoughts here?

- I think there are some very important teaching points you made most of them. The idea of taking a tear in an artery and packing it vigorously can actually be counterproductive. That vigorous packing, which is your natural reaction can actually tear the artery more. And I think identifying the site where the opening is, whether it's sharp or whether you've torn the neck of an aneurysm, whatever it may be, if you can isolate that and put something right over it and gently tamponade, it doesn't take a lot of pressure. Cotton, I like a lot because it's very absorbent. The two other adjuncts that I would just suggest in a situation like this is identifying the exact tear or cut in this case can be very difficult when you're looking at the inside of the carotid artery. So the use of adenosine can be lifesaving to give you that 30 seconds or so of cardiac arrest where you can actually see the hole and gently tamponade it. And the other adjunct that has been used in this situation is rather than packing desperately, is to put a Foley catheter up in the nose and let the balloon to the Foley catheter gently tamponade your gel foam, your cotton, whatever it is that your tamponading with, again, providing some gentle pressure just has to be the same as the mean arterial pressure and not overly zealous packing that can actually...

- I agree with you. That is so critical, well said. If you just do indiscriminate packing, some of the packings block the other packings from exactly tamponading the exact location. But if you just find it exactly, it's okay, let it bleed. It's just blood. Look at exactly where it's the bleeding point and just put the cotton right at that point, preserving everything else. It is so much more effective. And the hemostatic cascade of the humans in general, is so effective. If we just help that system with a surface to just create the wall of the platelets. And...

- I think it's definitely a situation where less is more.

- Well, no question about it. Most common when I see these people complaining that they had a major tear during a transsphenoidal surgery and the patient died on the table, was because they packed, they were very nervous. They were scared of removing the packing. The patient was bleeding down in their mouth, through the nasal pharynx and their blood pressure fell and went into cardiac arrest. Adenosine is critical. Just that 30 second for you to have the heart down, it's extremely safe, even without a pacing electrode on the heart, on the chest. And then you can just get your thought together. Where is the bleeding and the risk of any complications significantly decreases. So in all cases, the patients did well. It wasn't a complication that was an issue, reaction of the surgeon that in fact determined the result of the complication. So, Dan, I'm very excited for us to jump in your talk and hear your emerging pearls of technique. Let's go ahead.

- Thank you. Well, this segment, as Aaron has already introduced is managing difficult moments in cranial surgery. And as we've discussed, I think it's very important to openly talk about complications and inter-operative misadventures because that's how we learn and can avoid them and manage them when they occur. The subject of interoperative aneurysm rupture has been touched upon by Aaron, but it is one of the most dramatic interoperative misadventures that we deal with and can be dealt with very effectively if one keeps their composure and has the tools available to deal with it and the knowledge to do so. A number of articles have been written on this subject, and there are a number of techniques that have been advocated. The use of a large bore suction, a second section by the assistant, tamponading with cottonoids, proximal occlusion, carotid compression, et cetera. Most of these can be effective. I think induced hypotension is something we don't really generally use anymore. It doesn't really help and it can actually make things worse. We're gonna review some of these and how I've used them in my practice, the rupture of an aneurysm interoperatively after you've exposed, it is generally managed pretty well, and not as challenging. You need to stay calm obviously. You can tamponade the bleeding because it's exposed and the use of temporary clips can be extremely helpful in that situation. This is an example of an intraoperative rupture. You can see the Sylvian fissure has been opened. The aneurysm is exposed, and by simply and gently tamponading it, you can put a temporary clip, which allows the dissection of the branches that are inherent to the dome away sharply. And then a temporary clip can be placed over the dome of the aneurysm where the rupture is, allowing you to reperfuse the brain and minimize the temporary occlusion time, leaving enough aneurysm for the permanent clip, which will get rid of it on a permanent basis. So, the point being is that rupture after exposure generally matters pretty well. And shouldn't was that too much of a challenge. There is the reconstructed aneurysm. When an aneurysm ruptures before exposure, that's a very different situation, much more difficult. You showed one of those, Aaron. Very important to stay calm, follow the jet of blood with a large bore suction, gain exposure, gently tamponade the bleeding. If you over-pack, you can extend the rent in the dome. And again, the use of temporary clips can be very important. This is a patient that presented with this intercerebral hemorrhage. The CT angiogram shows this middle cerebral artery aneurysm. The patient was taken directly to surgery for a repair of that aneurysm without an angiogram. And you can see that upon opening before the Sylvian fissure was even open, there was torrential bleeding from an untimely interoperative rupture that couldn't really be controlled even with a large bore suction. So this is a perfect situation for the use of adenosine. Intravenous adenosine will provide about 20, 30, 40 seconds of a cardiac arrest and allow one to deal with a situation like this. This is that same case. Now, after the adenosine, you can see the heart has stopped and you can actually see the hole in the aneurysm. A temporary clip is placed, which stops that bleeding. And now the situation is under control. One that would have been extremely difficult without the use of the temporary cardiac arrest with adenosine. And now the aneurysm can be reconstructed in a more leisurely manner. Interoperative ICG shows that the aneurysms obliterated in the M2 branches film. Probably the worst of all situations with regard to an interoperative aneurysm rupture is when there was a tear at the neck because this often precludes clipping the rupture site without compromising the parent vessel. And this cartoon shows an example of that, of the tear on the parent artery, right at the neck, where if you move the clip down further, you're going to compromise the parent artery. Robert Spencer and I, several years ago, published a technical note on how you can deal with this by putting a piece of cotton over the tear and putting the clip exactly in the same place, the cotton, then being used to expand the surface area and tamponade the bleeding yet maintaining the patency of the parent artery. And this really works extraordinarily well. And I'll share with you just one example. This is a patient who has a posterior communicating artery aneurysm, here, as well as a large anterior choroidal. And you'll notice that as I'm dissecting this, I tear the neck of this large anterior choroidal artery, right at the origin of the anterior choroidal artery and the neck with the carotid artery. So this is potentially a disastrous problem. I tamponade this with some cotton and some gel foam, just to be able to see what's the bleeding is coming from. Notice, it's important not to over-pack this. Just gently tamponade it. I go ahead and clip the posterior communicating artery aneurysm, which is very simple just to get it out of the way. Now, try to deal with my potential disaster. This aneurysm is quite large, going behind the carotid bifurcation. And you see the tear very well right at the neck of the aneurysm. So in this case, I get to tamponade it with some cotton and some gel foam. I put a temporary clip on the internal carotid. You see the aneurysm now behind the bifurcation, and here's the anterior choroidal artery back here, which we wanna be absolutely certain we don't compromise. So this cotton is going to now be clipped right onto the neck of the aneurysm. And the cotton will acts as a bolster that will actually increase the surface area of the clip and compress that tear that I created, but yet maintain the patency of the carotid and the origin of the anterior choroidal artery. Now, the temporary clip is removed and fortunately things were all under control. So this is a nice technique to use in those rare situations where there is a tear in the neck itself. I now wanna move to a different topic. This is another interoperative misadventure where fortunately, some preparation ahead of time allowed me to deal with what would have been very difficult had I not been prepared. This is a large thrombotic, middle cerebral artery aneurysm, in a young physician that had been treated by endovascular therapy at another institution. You can see that there is a lot of residual aneurysm. There's this thrombotic mass and a lot of coils in the aneurysm. In the 3D, you can see the neck of this aneurysm is very difficult. And I was concerned that I might lose one or both M2 branches. And so to be prepared, I dissected out the superficial temporal artery. Initially here, you can see it. I descended that out and had it ready, but I really wasn't sure which branch I would potentially have trouble with, so I didn't do a bypass initially. At the time of surgery. Now this is on the left side to the Sylvian fissure. You can see this huge aneurysm. I'm putting a temporary clip on the M1 segment, and I'm gonna use a series of fenestrated clips to try to reconstruct that bifurcation using the fenestrations, to reconstruct the superior trunk of the M2. And after I get the aneurysm completely clipped, and you can see the M2 segment here that looks patent. On a Doppler, I find that there is no Doppler signal, and you can see ICG shows very, very minimal flow. So having had the STA dissected out, I rapidly do a bypass to a distal branch of that superior trunk. Normally for these I'll use an interrupted suture, but in this case you used a running suture so that I could revascularize this branch as quickly as possible. And ICG shows that I've got the bypass in place. And now I take the clips off and open the aneurysm to figure out what happened. You can see the coil mass inside. I'm actually ruining a pair of good scissors by cutting through that. And as I removed the clot, notice that what happened is when I put the clips on, I pushed this clot, you can see it down in the lumen, right there, occluding that M2 segment. And so the clips forced some of the thrombus down into the M2. Now I reconstruct it again. And the M2 branches now patent, and the aneurysm is completely obliterated, but that bypass was absolutely essential to perfuse the brain while I was dealing with that interoperative misadventure. If we look at the interoperative angiogram, you can see this is the initial angiogram showing the very slow filling through the superior trunk because of the thrombus that was there. This is the, you can see the external carotid injection shows the bypass spilling very well. And the final interoperative showing that both branches ended up being patent and the aneurysm completely obliterated. So a good word of caution about being prepared to try to prevent complications. I now wanna just mention a couple of complications and potential disasters in AVM surgery. One of the complications like with aneurysms is interoperative hemorrhage. And as Aaron you've spoken about, the last thing you wanna do is just pack off bleeding. You might end up with a hemorrhage occurring into the parenchyma and the packing, just simply doing nothing but obscuring it from your view. Here's a example of an AVM where I got into the nidus itself. You can see initially the ICG showing the surface anatomy of this AVM, not a terribly large AVM, but high flow. And I'm doing circumferential resection in the arachnoid to try to identify the margin. And I feel that I've found the superior margin as I'm working around it, but you'll notice that I get into some significant bleeding, which is because I'm in the nidus itself. I never, virtually never retract the brain during AVM surgery because it's already marginally perfused. But always have a retractor ready. And in this case, I'm using the retractor actually to tamponade the bleeding site, using it basically as the third hand, so that I can work more distally around the AVM, actually identify the edge of the nidus and then work back towards where I got into the bleeding. And now you see my area of bleeding and the actual edge of the AVM in the final resection cavity. So just the example of using your head and using in this case, a retractor blade as an extra arm to a tamponade bleeding, while it frees up my hands to do what I need to do in the AVM resected, as you can see here. One of the other problems that we've talked about in another one of our discussions is dealing with the deep diaphanous vessels, those little vessels that come through the white matter that are very, very difficult to coagulate. And here on this video, you can see that I'm deep into this AVM in the white matter near the wall of the ventricle. And it's very difficult to coagulate these little vessels that come through the white matter. They can retract into the white matter and chasing them can cause injury to normal brain. So it takes an enormous amount of patience, constant irrigation. non-stick bipolars to try to deal with these and with patience, you can usually get them coagulated as you see here, if they don't snap back into the white matter and bleed some more. The next video shows another way of dealing with these. Here's one of those little thin-walled vessels, and just notice how under constant irrigation with nonstick bipolars over and over again, the thing just fails to coagulate. You can still see that there's blood coming through it. And this is usually towards the end of the operation when you're oftentimes getting a little bit weary and would like to get finished, and it can be frustrating to deal with these. So I think one of the tools are these little spring clips that you can put on these vessels. You can see here, this is not an aneurysm clip, but actually a flat clip that is made for this purpose. And once you stop the blood flow, notice how easy it is to coagulate these and then divide them. So, I'm not a big clip user during aneurysm surgery, but I think for these particular vessels, these little spring clips can be extremely useful. One of the other problems that I've had to deal with is a occlusion of an artery en passage. Like most complications avoiding this is much better than dealing with it, but I will share with you a case I had where I actually did occlude an artery inadvertently and how I dealt with it. This is the AVM. You can see that the red arrows outline this artery en passage that gives branches to this AVM in the dominant hemisphere of this patient. At the time of surgery, my mistake was not that I didn't recognize the artery en passage, but that I coagulated too close to it. So here's the artery going on to normal brain. And there's the branch going to the AVM. I recognize that, but notice that my bipolar is way too close and too hot. And the manipulation and the bipolaring along that normal artery. Look how this is beginning to get thinner and thinner. And I have actually from thermal injury, actually occluded this artery en passage and the ICG demonstrates that. So this could be in the dominant hemisphere, this could be a potentially disastrous complication. So what I do is I actually open the artery, I forward bleed. And then I mechanically do essentially an angioplasty with a dissector to mechanically open the artery that I have have damaged. And eventually by dilating this with progressively larger dissectors, being careful not to tear it, I actually get back bleeding indicating that I've opened it up and then using a 10 O monofilament suture, I sew up my arteriotomy. Again, this is not the way to manage this. The best way to manage this is to avoid it. But it was a way that I got away with on this occasion of making a terrible technical error interoperatively. And after closing up that small arteriotomy, you can see the AVM is gone. I now do interoperative angiogram. This is the original interoperative angiogram showing occlusion of that vessel. And here's the one after I did that mechanical angioplasty, if you will, and you can see that I've reestablished flow. This is another terrible complication that I had many years ago. This was an AVM in the Sylvian fissure on the non-dominant side. And after resecting this lesion and thinking that everything was fine, the interoperative angiogram clearly demonstrates a hole in the artery. I mean, I'm sorry. In the middle cerebral distribution. Fortunately, I had saved the superficial temporal artery and immediately after this angiogram was done, did a bypass. You can see where I revascularized that artery. I'm not exactly sure how I inadvertently occluded the artery, but it's a lesson to again, think ahead, save the superficial temporal artery, if you think there's any chance you might need it for an interoperative problem. And this brings up another issue when doing a bypass sometimes during surgery, when you don't necessarily anticipate having to do it, sometimes it's difficult to know which branch on the surface of the brain is the appropriate one to do a bypass to when you are sacrificing a vessel, either purposely or inadvertently. So this is a complex middle cerebral artery aneurysm that I really thought I might need to do a bypass on. I wasn't sure that I could clip this without compromising one or both of those middle cerebral branches. So the trick that I use in this situation is the aneurysm is exposed, as you can see here through the Sylvian fissure. I identify the middle cerebral artery branch that I think I might have difficulty with. In this case, it's the superior trunk. And I put a temporary clip on it as you can see here. Then I do an ICG run and look on the surface of the brain to see the branch that doesn't fill. And then when I take the temporary clip off, there's the branch filling beautifully. So we know that's the branch on the surface that corresponds to the one that I think I might lose. That allows me to go directly to the proper branch, do the bypass. In this case, a prophylactic bypass, in case I can't fix things, put the temporary clip back on, do an ICG. It documents that my bypass is patent. Now I can go about having my way with the aneurysm, putting a temporary clip on the M1, and we will then proceed to reconstruct this aneurysm. In this case, shrinking it down under constant irrigation, to try to reform the sac in a manner that makes it more acceptable with clipping using a series of fenestrated clips. This is the branch now that I bypassed, but it turns out with a group of fenestrated clips I was actually able to maintain the patency of that and get rid of the rest of the aneurysm. Now it's clipped and we puncture it to be sure it's completely deflated. And the final result, the ICG shows that that branch actually is patent, both M2's are patent. But a nice trick to be able to identify the vessel on the surface that you want to do the bypass to. Here's the interoperative angiogram showing that we did indeed spare both of those M2 branches. The last case that I wanna share is kind of an interesting story. It's a little bit embarrassing, but several years ago, one of my really good friends from high school that I grew up with, a farmer in Midwestern, Illinois, that I'd gone to school with back in high school, called me up one day and said, Dan, I had this horrible pain in my face. It's lancinating terrible pain. I saw a doctor and they did a scan and they said, I've got a blood vessel compressing a nerve. I said, Mick, I know exactly what the problem is. You're about 90 miles away from Washington University. One of my best friends is the chairman there. I'll arrange for him to see you. You need an operation. It's very straightforward. You'll have a good result. He said, no, no, no, no. I want you to do it, Dan. I'm gonna drive down to Atlanta. And so I told to come on down to Atlanta. And I put him on the schedule for the day after he was gonna arrive in his pickup truck. What I didn't do is I didn't see his MRI scan before he got there. He showed up and he said I forgot my MRI scan. And I said, oh my gosh, well, we got to get one. Well, I got an MRI scan all right. And what demonstrated was that he had a very dolichoectatic vertebrobasilar system. This wasn't a microvascular decompression that Mick needed. He needed a macrovascular decompression. And I didn't really have this information until literally hours before the operation. And that is not the way to take one of your good old friends from high school two months before your class reunion to the operating room. But this is what I ended up doing in that case. Here you can see on the left side, exposing the cerebella pontine angle, see the seventh and eighth nerve. And up here, the fifth nerve in this huge dolichoectatic vertebral artery compressing the seventh and eighth complex. And you can see the fifth nerve up here being compressed. Obviously putting a little pledget in is not going to solve this problem. So in this case, I dissected out the vertebrobasilar system, took a piece of Dura Repair in this case, cut it to the appropriate size and wrapped it around the vertebral artery. And then I took that Dura Repair and sewed it to the dura the lateral dura and the cerebella pontine angle, which you can see here now to create a sling, to pull the artery away from the fifth nerve. Here, you can see the mobilizing the fifth nerve, bringing that piece of Dura Repair up. Today, I've done this many times since and today I actually use a Gore-Tex and rather than sewing it to the dura, I actually now use a little screw, a little titanium screw, which is much faster, but I was kind of doing this, as I said, in a manner that was a little bit unexpected, and this is the way I dealt with it in this particular patient. Once that's tied down or screwed down, which is much more efficient, then you can take the other end of the Gore-Tex or Dura Repair or whatever you wanna use, and bring it up. And the swing will now pull the vertebral artery away from the brainstem and the cranial nerves. And you can just simply clip. This is a wet clipped. Most of the time today, I use an aneurysm clip. It just secures it better, but some kind of clip to clip the two edges together, trim the excess. And now the trigeminal nerve is completely decompressed. And I now put a little piece of pledget just to get some insurance. So we have a belt and suspenders. Turns out, Mick did great at our class reunion, about a month later, his face was not weak. His pain was gone, but as I said, that was not being very well-prepared and doing something on the fly. So those are some of the cases I wanted to share. And hope those have been useful in helping prepare people in the future.

- Excellent discussion. Excellent videos. Dan, that was a close call on your dear friend for the reunion, by the way. Great series of videos. I think it emphasizes the importance that so many of us do things when we're uncomfortable and have never done during intraoperative complications. So the real surgeon has to be able to innovate on the fly and really be confident under most difficult situations that decision he or she's making is a good one. And all of that I think comes down to the point that the best surgeons are differentiated by not when things go well, but by when things not go well. And I think that's always gonna be true. So with that in mind, I wanna again, thank you for working with me for this for lecture series on modern micro neurosurgery. Micro-neurosurgery is a dynamic field, it's exciting. It always evolves. We always find opportunities to help our patients and look forward to working with you in the near future, Dan.

- Me too, Aaron. Thank you so much for inviting me to do this. It's been a great pleasure. And always great to work with you. Take care and enjoy the rest of your day. Bye, bye.

- Same here. Thank you.

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