Grand Rounds-Management of Complex Aneurysms: Clip Reconstruction and Bypass Techniques

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- Hello ladies and gentlemen and welcome. The following talk is a discussion regarding management of complex intercranial aneurysms using clip reconstruction and bypass techniques. Dr. Laligam Sekhar, from University of Washington in Seattle will be our discusser. Thank you for joining us. We're really looking forward to this talk and your expert opinions, please go ahead.

- All right, ladies and gentlemen, thank you for being here. Today, we're gonna speak about the treatment of complex Large and giant aneurysms and particular we're gonna focus on clip reconstruction and bypasses. So there are a number of both endovascular and microsurgical options for treating large and giant aneurysms. And some of them are outlined in the slide, but I'm gonna focus mainly on the microsurgical aspects. First of all, we have to define what's a complex aneurysm. Of course, aneurysms are complex sometimes because it's size, very large size or giant size. They may be complex because of the shape of the neck or due to the fact that they have a lot of thrombus inside and or the origin of branches, of course, previous treatment and recurrence also make some quite complex. So there are different treatment options for ruptured and unruptured aneurysms. Now in terms of stent placement, we don't like that for ruptured aneurysms because the patient needs to be on dual antiplatelet therapy for about three months. And it becomes very difficult to manage the patient in the ICU in terms of placing a shunt or even placing a central line, et cetera. So that's out, of course for unruptured aneurysms, you can place stance, either flow diversion stance or high porosity stance. For certain ruptured aneurysms Balloon Assisted Coiling can be employed. And in some patients that can be a temporizing treatment that is you can use this treatment to hold a patient from having a Q3 bleed and then later on, think about some other endovascular therapy. And then you move on to microsurgical treatments and basically you have two options, namely Clip Reconstruction and Bypasses. Now when we talk about unruptured aneurysms, obviously you have more options. The bigger option for some complex aneurysms is the placement of a stent with coils or a flow diversion stent, namely the pipeline embolization device. Again clip reconstruction and bypasses are also options, for unruptured aneurysms. Now when you're talking about the treatment of unruptured aneurysms, you have to think about a natural history. The best study about natural history is the "International study of unruptured intracranial aneurysms". There were some flaws in the study that patients being followed, where patients essentially, who are rejected for treatment by other neurosurgeons and they were being followed for the streets. Nevertheless, it gave us a lot of valuable information. And what it did tell us was that the relative rupture, depended on two things, the location being the most critical areas, the internal carotid artery, PCom area and the posterior circulation. Now there's been a further study, which has not yet been fully published, which is a Japanese Unruptured Cerebral Aneurysm Study. This study showed that Acom aneurysms also have a high propensity rupture, and this is something that we already know. So when you are thinking about treatment of unruptured aneurysms, you have to consider the aneurysm features such as the size of the aneurysm and location. But also the patient's condition have to be considered. What is the physiological age of the patient? What's the expected longevity and what are the goals of treatment? And lastly, you need to think about the experience and expertise of the treating center. Ideally, a center which is treating complex aneurysms should have experience with a large number of cases being every year and must have both endovascular and microsurgery expertise. In our own institution we have here, a rough idea, a number of aneurysms being treated. But if you look at the figures, you can see with the ruptured aneurysms, we have split almost evenly, 50/50 with endovascular and microsurgical treatment, but as for the unruptured aneurysms. Again, it is almost down the line, but much larger percentage of unruptured aneurysms being treated both with Bypasses and our stent-assisted coiling techniques. And in future there will also be a large reflection of the floor diversion devices such as pipeline, which we already deployed about 20 of them. But we are doing, treating a number of aneurysms this way as well. Now moving on to microsurgical clip reconstruction, there are pros and cons. This technique definitely requires temporary occlusion and frequently temporary trapping. You may need to open the aneurysm and empty the clot, and you will have to reconstruct the aneurysm neck by either means of clips or by using suturing technique, et cetera. You may have significant atherosclerotic changes involving both the sack of the aneurysm under the neck. And you may need to do an atherectomy then come back to me. And some complex aneurysms it's very hard to predict how it's going to go so I will make all preparations for bypass, including perhaps the exposure of the radial artery, saphenous vein. And the final decision is made only at the time of surgery. And it's very critical of course, in all of these cases to have ICG angiography and Doppler probes and of course, some cases you might even use Intraoperative angiography. And we also use neurophysiological monitoring in making an assistance in making decisions. And other very important statement would be, when in doubt, if the vessel is going to be open or not, then do a Bypass procedure and I've learned as to some bad experiences. Now, how was that Clip Reconstruction done? Basically there is temporary proximal occlusion, frequently, temporary trapping may be utilized, all of the branches must be dissected. And again, as I mentioned, the aneurysm sack may need to be open especially if there's a thrombus atheroma, and there are different techniques of tripping, all of which employ more than one clip. So one technique is called fragmentation, that is basically you divide the aneurysm neck into two or three different parts and each part is clipped with a different clip, you have tandem clipping, that is your one clip. And then another clip on top of it, stacking them so that the closing force becomes more serially enhanced. You've circling clips, you may also use booster clips and nub clips, et cetera. And then, in some patients, you have to leave behind portions of the aneurysm neck in order to preserve a branch or a parent vessel. In spite of all of these things, in some patients, delayed thrombosis of arteries may occur. And in most of our patients, when we are planning a complex clip reconstruction, we give them aspirin preoperatively, at least on the morning of surgery. What are some of the pros and cons of Clip Reconstruction. On the pro side, you have a shorter time of temporary occlusion, and it's certainly less complicated than Bypass, On the con side, We have cases where the aneurysm recurs, making the second operation more complex, a branch may clot off in a delayed fashion or you may also get stenosis of a branch, resulting in ischemia. Alternatively, you may have pieces of the aneurysm left behind. So the post-operative angiogram may not be a really pretty. Now I'm going to show you a few patients to illustrate points. This is a 63 year old woman with an unruptured Acom aneurysm. One of the things that was evident during surgery was that the neck was very atherosclerotic. What you can see here is that this is a left carotid injection. There is a single, A1 segment There is no A1 coming from the other side and this of course predisposes the patient to the development of aneurysms. And this is a diagram of the view during surgery. What we've done here is a left sided approach because this is the left ACA which has dominant left sided approach from a small paratemporal craniotomy, combined with an autonomy and opening the Sylvian fissure. So we'll now bring on the video. So now we open the seventh fisher and here we are dissecting the aneurysm, a small amount of gyrus rectus dissection has been done, and you can see a very sporadic neck and I'm trying the first clip, as first clip is being placed. This is not an encircling clip but the clip is being placed in a way that the ipsilateral A2, which is right here is there. Now I'm using the endoscope and the endoscope clearly shows that the vessel perforating vessel is caught in the blades of the clip. So what I'm doing then is re-adjusting the clip, and I will re-check with the endoscope. And what we can see now is there is a perforator, which is clear off the clip. And then after that, I'm going to place an additional clip to catch a piece of the neck, which was not completely occluded. I'm using the micro DAPA probe to verify flow through the vessel. And again checking with the endoscope at the end of the procedure. So this operation illustrates a couple of points. One is that we use the endoscope to assist in the clip placement. Secondly, how you deal with a complex neck, you should not really cinch down on the neck. You have to leave a little bit of a neck open because the inside lumen is gonna be completely occluded externally. It looks good it won't be glued inside.

- Sekhar, I appreciate. That's a great case, I saw that you put the clip essentially, from the back of the aneurysm forward between the two A2s, rather finished trading the ipsilateral A2 with a straight clip. Can you discuss what the advantage is between the two textings are?

- Absolutely, that's a very good point. The question is why didn't I use a fenestrated clip and why did I bring a clip sort of around the other aneurysm? Well, the fender skater clip definitely has a advantages, which is in the fenestration, you can preserve the ipsilateral vessel. There are some disadvantages however, the first one is that, the proximal aspect where the clip blades are closing, always, it has a lower closing pressure. So you have to always reinforce an additional clip proximally. The second thing in the case of an Acom aneurysm, and occasionally with basilar tip, there may not be enough space, to get the fenestrated clip in. You can imagine that you're already working through a tight space and you'll have to get the fenestrated clip and it has to open a fair amount. And as a standard clip, which has got a little bit of a curvature sometimes is easier to fit in there. That's why I used this kind of clip here, but certainly, one should consider the use of fenestrated clip. The other thing I didn't show in these videos, is I use something called a rubber dam inner position technique frequently. What I would do is, I would dissect the perforators, and I will interpose a small rubber piece what I call a rubber dam in between the aneurysm and the perforators. So when I put the clip on the backside, the clip will slide along the rubber dam, sparing the perforators. I use it very frequently with basilar tip aneurysms.

- Those are great points. Thank you so much, please go ahead.

- So the next case we're gonna talk about is very interesting. This is a 57 year old man who collapsed and had a seizure and he had and has grade four fisher grade three/four subarachnoid hemorrhage. And of course was not in very good condition when he presented. So these picture show here that the aneurysm is calcified, quite large, at least partially thrombosed. And then here you can see, the extent of the subarachnoid hemorrhage. He had done a CT angiogram. And what you can see here is that the right A1 is markedly dominant. And you have a sense already that the neck is very broad and here's one A2 coming out here. Some calcium on the A2 are pulling behind the aneurysm. The left A1 is a rather small. So this was a giant aneurysm. The question is, what do you do with this patient? The first thing to note is that, the aneurysm is projecting right into, the lateral ventricle on the left side. So if you were to put in a ventriculostomy, it is better to do it in the operating room with the stereotactic navigation, because placing a ventric classmate, just in the emergency room, we all know where metrics can hand up. So just a little bit more and you'll end up right in the aneurysm. So we gotta be very careful about that. So what happened here is the angiogram on the patient. It shows something that we already know the right A1 is macular dominant. The neck is very broad and the etudes are around. What you don't see here, is the thrombosed parts of the aneurysm which all of this is thrombosed. The left A1 is just barely present, but as you will see during surgery, there was in fact, a little bit of flow from the left A1. So what we did with this patient is, we took the patient to surgery the next day, he had a right occipital ventriculostomy, using neuronavigation, and we elected to treat this patient, by a bilateral frontal approach, so bifrontal approach combined with biorbital osteotomy, why bifrontal approach, this is the approach which gives you, better control of the distal vessels, where a while you still have control of the proximal vessel. So it's always better for these very complex aneurysms to have an interim aesthetic approach. So this patient then had... This patient then had a temporary trapping and we performed an endo aneurysmectomy, and the section of the aneurysm wall we've sutured the aneurysm neck, and we... reinforced it with a clip graft. So this is a schema of how the surgery was done. You can see a by bifrontal craniotomy and on orbital osteotomy, this is sort of the anatomical picture of where we were with the entire miss approach. And this is what you're gonna be seeing here, right A1, right Heubner, right frontopolar and then the two A2s, and then the left Heubner, left A1, the two rather here. And then this is the frontal polar on the left side. This is the left A1. We didn't think it was there but it was actually there. So we had to dissect it and put a temporary clip. And then I did a resection of the aneurysm wall and suturing, and then reinforced with a clip. So these are pictures, still pictures of what you're going to see in the video, essentially, in terms of sporadic approach, temporary clips here on A2s. And here is the aneurysm, which has got a pretty thick wall. Nevertheless, the parts of the aneurysm wall are pretty thin. That's where they do rupture. The aneurysm was opened, but then I found out is that there was still brisk bleeding, so I temporarily closed it, found the A1 on the left side and put a clip on that. And then I was able to fully open it and proceed with the surgery. So now you won't see the next video. So now what we've done is right frontal temporal and bifrontal craniotomy with orbital osteotomy, but really we didn't use a frontotemporal exposure. We are a separate approach and interhemispheric approach. So we are interhemispheric here. We have divided that the, the very proximal portion of the sinus. Now we've identified the right A2, here's the corpus callosum, and this is the left A2 will be seen here, Left frontal lobe right frontal lobe. Now we are down to the aneurysm. You can see the thrombosis portion. So we've got to go around the aneurysm and now I'm going around on the right side to find the right A1. Here you can see the optic nerve and chiasm here, so that's a right A1. So I'm going to place a temporary clip. Now, when we do a temporary clip here, we will raise the patient in burst suppression using propofol. And if the patient is completely occluded, then we may also raise the blood pressure a little bit. So both A2s are temporary occluded. I opened the aneurysm and you can see that the aneurysm is still bleeding briskly. So the wall here is sticking out, I just close it with a simple stitch. And I'm going to go back and look around on the left side. So I'm looking around the left side. Here's the left A1. It is small, but present, still giving some blood flow to the aneurysm. There is a left A1. You can see that there. So we will place a temporary clip on that. And there's a temporary clip going on the left A1. It is small, but big enough to contribute some flow to the aneurysm. Now I'm just aspirating, making sure there's no more bleeding. Now what I'm doing is completely opening up the wall and removing all of the thrombus and atheroma. So when you do an atherectomy, the key is that we have to clear all of the orifices. So you have two vessels coming in and two vessels going out. So we have to completely clear them of any atheroma or thrombus so that when you do the reconstruction, then the vessel orifices will be open. So now once I've done that, I'm going to excise a large portions of the aneurysm sack, just keeping enough. And there's still a little bit of back bleeding from one of the frontopolar vessels, which is some retrograde flow. So what I'm doing now is suturing the aneurysm sack pretty close to the neck using eight or nine on sutures. My assistant is very capable here providing a little bit of suction. Here I'm using interrupted sutures interrupted actually seven occluding sutures. The wall thick enough. Then right before I release completely close the aneurysm, I'm gonna release the temporary clips and flush through any blood or air or anything. I flush all of that out. I'm removing all the temporary clips. And what I'm going to do here is the last clip coming off. This is a suture portion, and I'm going to also flush it with some heparin saline. And we are checking with a micro-Doppler probe, make sure there's flow in both A2 vessels, and then place a last-ditch on the aneurysm. And then just to reinforce the wall, I'm going to place a clip on the portion of the neck that's been sutured. And here you will appreciate one perforating vessel, which is preserved carefully. And this is a frontopolar. Here's ICG angiography showing flow in the right frontopolar there. That's the right A1 that's the right Heubner, and then similarly, we'll visualize all the vessels on the left side. Here's the A2 and A2 over here. We're not showing the entire angiogram, but we carefully look at all the vessels to make sure that everything is flowing through. Now, the postoperative CTA looks very good. Here you can see the clip and here you see the various vessels. And this is the fusion MRI showing what he has. He does have a small stroke in the Heubner territory and whether or not it's due to our temporary occlusion or due to the initial subarachnoid hemorrhage. We don't know because it's the first time that we've got an MRI scan on him. And then the patient actually... This is an angiogram. The angiogram as expected shows some irregularity. Note this area here in the reconstructed segment, nevertheless overall it looks very good. Good flow in all the vessels, et cetera. This patient had unexpected hypertensive therapy for vasospasm. And then he had a ventriculoperitoneal Shunt. He recovered normal speech, cognition improved considerably, hemiparesis improved and resolved. And then at two months postoperatively, he was independent for all daily living activities. Now because of the fact that this is aneurysmorrhaphy, and some irregularity was noted. We brought the patient back three months later, three months after his discharged on a repeat angiogram. So I do this always, when you do an aneurysmorrhaphy, make sure there has not been a change. So here's four months later. So what did we see? This shows now there is a recurrent aneurysm, right in this area close to the aneurysmorrhaphy site. So the question at this point is how do we treat that? We do have treatment options. One thing you might consider is to place a stent from here across into the opposite A2, and then put some coils. But the stent obviously addresses it's almost consider a symptomatic treatment because it doesn't look at the entire site and the other option is surgical. So what would you do with surgery? The reason I believe that the patient has developed a recurrence is that there's a lot of stress on the site. Keep in mind that this is the main vessel that is coming up here. There's a big bifurcation. So there's a jet of back flow into that area. So what we need to do is to create an alternative site, or alternative place for the blood to flow through to the other side. So what we plan to do is to go back, first of all, look at this and perform A3 to A3 side to side bypass, essentially giving him an artificial Acom so that there's another place for the blood to flow across so the stress on the site is reduced. So these are just more views, 3D views showing the recurrence and you'll see exactly where is the recurrence in a minute. So we are going go back again by the same approach, much easier this time. And what I found during the surgery was that the aneurysmorrhaphy site itself was just fine. There was actually an aneurysm that had formed here, presumably a weakened area of the neck. And there were two perforators. And what I did was I just place some additional clips, preserving the perforators. And then I went ahead and performed the actually here and A4 to A4 side-to-side anastomosis. All of that you will see in a minute. So now we have the video coming. So we repeated the bifrontal exposure. We just opened up the dural. We don't need to do a lot of work here because of the previous craniotomy was actually relatively easy to get through the interhemispheric space. We have interhemispheric approach here, just unilateral going down. And this looks more like you would see in a patient with an unruptured aneurysm at this point. Now, of course, the situation is not a rupture. The Corpus callosum here, A2, A2, I'm sorry, the A2 already turned around. So here is already A4, two A4 segments. So I'm going to go around the Corpus callosum. Here's the corpus callosum. I'm just preparing a site for possible a bypass. And here's the A3. These are the frontopolar branches and corpus callosum again. And I'm going to just go around it to the area of the aneurysm which is right about there. My first view of that. So we're just starting to see the aneurysm clip. This is the area of the previous repair. You can very nicely see the sutures. You can see the arachnoid bands that are formed there, and here you can see now the aneurysm that has formed, which is not at the prior repair site, but it said it's from the neck, which of course is weak in that area. And here's a perforator, one perforator actually, there were two perpetrators in this region, one and there's another one there. Here's the left A1. And then I'm just dissecting the brain on the right side a little bit. So I'm going to place an additional clip to catch the first one. Rather than just to close off the portion of the neck, which has not previously clipped. I'm still trying to leave enough here for some flow across at this point. And again, I'm adjusting the clip, making sure that there's some flow across the Acom. And then I'm gonna place an additional clip right over here, right in this area. So that part is done. Now, a lot of people would quit right at this stage, but what I'm going to do now is preventive as well as therapeutic. So I want to prevent this type of aneurysm from coming up again. So what we've done is we placed temporary clips on both a four vessels and I'm just marking the vessels. At this point, I give the patient heparin. We usually give them about 2,500 to 3000 units, and we will check the activated clotting time, make sure that it's more than 250, which is the therapeutic range. So I'm performing a linear arteriotomy. If you have a lot, you can also perform in a slightly oval opening. Either one is okay depending on the size of the vessel. And it's likely oblique, it's not exactly side to side. It's a superior and medial aspect. So the opening is usually about three millimeters in length. And what we're going to do is to place a stitch from the outside in, and then inside out and tie it. And then we're gonna come back on the inside of the wall. And we are going to suture it from the inside. So we're gonna suture the wall from the inside because we cannot evert the vessel. So we have to suture two walls on the inside so that's what we're doing here. And then we will emerge on the outside. So we're suturing, we are performing a running suture on the inside. That's what we're doing here off the back wall. You can see that posterior wall or the back wall being stitched. So this is a 9_O in this case, you can also use 10_O. And then what I'll do is I will tighten all the stitches and then I'll come out, and I'm going to tie a suture there so that now the back wall is closed. Then we will do a running stitch on the front wall. So it'll come back either from this way up or that way down. In the meantime, we will of course make sure we'll inject some hepanite saline make sure that the orifice is fully open. So now again stitching, starting a stitch on the front wall, so outside in, inside out. So now we've more or less completed the suturing of the front wall and then tying the last stitch and then closing a stitch on the other side as well. Now I wanna talk for a minute about continuous versus interrupted sutures. Interrupted sutures take longer time. And of course as you get near the edges, they become more difficult as you close more and more of the vessel however, they are more secure. So sometimes an option is to place a couple of interrupted stitches of the corners and then use continuous stitching. So here we remove the temporary clips. And so here, all the temporary chips are coming out and we will perform a Doppler flowmetry as well as I'm just checking the inflow jet. And here's the ICG angiogram, which shows a flow into the vessels and then also across, you can see that. And this is the frontopolar branch, and this is the frontopolar branch on the left side. And here you see where the two vessels are joined. So you will see in the postdoctoral angiogram that here is the connection point. So you can see that very clearly here in this slide, as well as in the slide and then of the aneurysm is closed. And this patient, since that time has had no deficits whatsoever, he didn't have any deficit as a result of this operation and he continues his recovery. The next case I like to show you is a basil of aneurysm with both posterior cerebral arteries arising from the neck. So note here that this is the three-dimensional angiogram, both the samples arising for the neck. Not only that the vessels are shaped like this, not like that. So it also makes it rather difficult to coil with a balloon. This is a patient who's at a ruptured aneurysm in a un ruptured case, one might think about a stand test as according but still it's pretty difficult because of the fact that the arteries are coming down like this. If they are like this it's somewhat easier to place a stent here and a wide stent configuration here and then coil. So this is one for surgery. So what is the information that you need for such a case? Where is the neck in relationship to the posterior clinoid? Here is the posterior clinoid, neck as well about, so that's not an issue. What is the status of the PCom vessels? So that's something that you need to see as well. Both PComs are actually minuscule in this patient. So this patient was operated by a frontotemporal and orbital osteotomy approach and a clip reconstruction. So what are some of the key steps? The first one, as I mentioned frontotemporal craniotomy, and we usually perform an orbital rather than an orbital zygomatic osteotomy. The zygomatic portion is frequently not needed. Then we have to do an extradural or intradural clinoidectomy and optic nerve decompression. Why do we need all that? Is we need that extra space to move the carotid and optic around because we may go on this side of the carotid or this side of the carotid. The next step is that frequently not in this case, we will remove the posterior clinoid. And how do we do that? We open the cavernous sinus and inject fibrin glue inside, and then we'll use the ultrasonic bone turret. The one that is available right now is a SONOPET, but there are other ones coming in the market later on. And we'll remove the posterior clinoid process. So when we're doing that, we'll protect the aneurysm with a small Cockrum Patti. Then we'll place the patient in burst suppression and apply a temporary clip. And nowadays what I'm also doing is adenosine induced transient cardiac arrest in some complex basilar tip aneurysms. In addition to the temporary clip, I'll use it for very short periods of time. It gives you very transcend arrest anywhere from 30 seconds to one minute. But of course you have to prepare the patient preoperatively. The anesthesiologist must be on board. The patient must be healthy, et cetera. Then what I do is I dissect the back of the aneurysm neck which is where the P1 perforators are. I will interpose a rubber dam there and then we will use a clipping technique. We'll clip the aneurysm and puncture it and empty it, and cauterize it and make sure everything is okay. So let's see here. This is the post-operative case and the video will come on board shortly. So here now we are working on the right side extradural clinoidectomy. And this is the extradural ophthalmic compression, I mean injecting a little fibrin glue in the cavernous sinus. This is a frontotemporal dural orbit. We will open the dural, opening the Sylvian fissure here. Sylvian fissure has been opened widely, and also laterally. You can see a very sclerotic carotid artery. You see that how sclerotic it is. And I've divided the PCom which is very minuscule in this patient. And this is the posterior clinoid process. So what I'm going to do here is actually inject a little fibrin glue and then remove it with the ultrasonic bone turret. Look how sclerotic the artery is. I generally don't like to put retractors on it. I just retracted intermittently with a suction. Here we see the basilar artery, which is very sclerotic also. And what I've done is temporary clip. And then I've actually clipped the aneurysm. We went fairly quickly through that. Multiple clips have been used. The aneurysm has been shrunken down and the temporary clip is now removed. So I didn't show you a lot of steps of how I dissected the aneurysm, et cetera. But I wanna give you an idea in this case how we proceeded. And you see the post operative scan, and this patient actually made an excellent recovery. He had a third mild weakness which resolved completely.

- About the rubber band which I found very good. We use a little bit of maybe a cotton, should have taught cotton for the same purpose. What is your rubber band made out of? How thin it is? How can we learn to do it also in New York? Would you please tell us about that?

- Yeah, so this is actually that rubber bands, wasn't called rubber bands something that Peter Janetta was using when I was a resident in Pittsburgh, not for aneurysm surgery, he was always using it on top of patties. Cotton patties for retraction so the patties don't stick to the brain. We just take a glove. And of course, if you have nowadays Latex Free Glove, and you can cut it in various shapes for aneurysm surgery or for using it as a background. We just got a really thin piece, usually half a millimeter by let's say one. I'm sorry, half a centimeter by one centimeter in length. The most important thing is that you need to take it out. You need to remember to take it out afterwards. And I remember one case in Washington, DC, I did a very complex aneurysm. And I just couldn't remember if I took out the rubber band or not and I was so upset with myself. But then one of my fellows look through the entire video tape and he showed me exactly where I took it out. Of course, the nurses count them, you know. And it's a very nice way to avoid the clip from catching the porphyrias. Because you sort of dissect the porphyrias. You just put the rubber band there and then slide the clip between the aneurysm wall and the rubber band so the porphyrias won't be caught.

- Thank you.

- So this is next patient. I want to illustrate two points here, how we did the aneurysm repair with clips, but also want to show what happened here with aneurysmorrhaphy which was not good for the patient. So here's a patient, 59 years old. She had a very large MCA aneurysm. She had a small bleed. She was explored by other neurosurgeon, a very good one. And he found that the aneurysm was much more complex. Just put a lot of wrapping of muslin around and sent the patient to us for further treatment. And already the patient has a ischemia involved in the frontal lobe right here by MRI scan, and the 3D RA angiography shows that the patient has an aneurysm at the bifurcation of the middle cerebral artery. There's a large inferior branch, which is right here. And you can see that here as well and there's a smaller superior branch. Keep an eye on this because this becomes important later on. So what we did during surgery was the patient was operated by a carina approach. And we had temporary trapping and this branch and this branch were dissected. This one was one which was stuck more to the aneurysm neck. So I felt like I was able to get a good reconstruction and we had an ICG that showed good flow. However, here you see the pre-op, here you see the post-op. Post-operatively this vessel is clotted. And this is what I was talking about earlier, when in doubt, do a bypass. What could have been done here, maybe a side-to-side anastomosis, just to give an alternative route for the blood to flow through. This patient actually recovered. She is completely independent. Rest have some minimum memory deficits. I don't know whether they've been avoided by keeping that branch intact, but certainly that's what happened here. So we'll see the video now. Right side of approach. The right Sylvian fissure has been opened. And here is a temporary clip already on M1. one on the M2 and the other one on the other end too. This is going to be the superior branch, this is the inferior branch. I've actually shrunk on the aneurysm with a little bipolar cautery. And I'm opening up to see where the aneurysm clip has to be placed. I placed one clip, but with a Doppler I can see that the aneurysm is still filling. So I'm going to place an additional clip there. And here you see this branch here so I placed three clips. Look here, this branch is widely open and that's a rubber band being removed. Here's a branch, here's a branch. Everything looks hunky dory. Beautiful, but what happened to the patient? She developed a thrombosis off that branch, which was a little stenotic. I could see it during the surgery, but it was stenotic. So the lesson that I learned anyway, and I hope that you will learn from my experience as well, is that when you have a stenotic vessel, you may need to do something extra. So at this point, we're going to move on to brain bypasses for aneurysms. So brain bypasses maybe done in two basic situations. One is replacement of the parent artery and the other is replacement of a branch. Obviously the goal is to eliminate completely the aneurysm. And you also want to prevent the occurrence of a postoperative stroke. There are also certain long-term complications of a parent vessel occlusion. Let's say you have a carotid cavernous aneurysm in a young person. You may say, why not perform an endovascular occlusion? Now, you know that even all the endovascular people now have gotten away from that idea because we are seeing, especially in younger patients, we are seeing long-term complications. What are these? The first one is that there is an increase occurrence of aneurysms due to the increased cost flow. Secondly, imagine if the patient develops a carotid stenosis on the single carotid artery supplying both sides of the brain, that becomes a very complicated issue as Dr. Dowson showed us many, many years ago. So there are a lot of issues. So I think it is better to keep the arteries whenever possible. So this is what I talk about. When you take an artery should you perform a bypass, or can you just occlude it based on various tests? certainly your tests such as a bone occlusion tests, et cetera, give you some idea of the collateral circulation. But in my view, if you're gonna take an artery, especially a large artery, it is better to have some type of reconstruction. The same thing goes for unplanned arterial occlusion. Let's say you are in the middle of surgery. You think everything is going to be fine with an aneurysm. You get into it and then there's a big tear at the neck. You go on and try this and that, you eventually control it with a Sunkist clip or muslin gauze and some additional clips, whatever, you get an angiogram or you do a Doppler, the artery is not flowing. What do you do in this situation? The safest thing to do is to perform a bypass, why? Because you really don't know what is a tolerance to occlusion of that patient. Even if your monitoring is good, sometimes I've had experience, all the monitoring parameters are excellent at that time, postoperatively the patient has a little drop in the blood pressure and they have a stroke, big stroke. So I've seen that happen as well. So we talked about the reasons for bypasses. There are two types of bypasses. So one is local bypass and there are different techniques of local bypass. And I'm gonna show you some of that. Then you have extra intracranial bypass that is bringing blood flow on the outside. You may have low flow bypass such as STA-MCA bypass, OC-PICA, et cetera, or high flow such as a radial artery graft, or saphenous vein graft. So how do you decide what type of bypass is the best for a particular patient? Generally, I base it on which vessel needs to be replaced. If you have to replace a large vessel, it is better to use a high flow bypass. If you had to replace a smaller vessel, like the M2 or M3 three branch, you can generally get by with a local anastomosis. And of course, you also need to think about availability of donor vessels, such as radial artery, saphenous vein, et cetera. Now the anesthesia and neurophysiological monitoring and preparation is very important during bypass procedures. Now, we like to have a well developed and well versed anesthesia team for bypass procedures. We have a fairly standard protocol. So first of all, they employ balance total intravenous anesthesia because we wanna monitor both the sensory evoked potentials, but also motor evoked potentials and the electroencephalogram. During temporary occlusion for unruptured aneurysms we'll raise the blood pressure for ruptured aneurysms. We will keep it normal unless you have complete trapping, in which case you can raise the blood pressure more. We induce burst suppression with propofol. All of the patients are placed on aspirin, at least as of that morning. And then we continue the aspirin post-operatively. During the bypass I also like to give them heparin to maintain activated clotting time more than 250 seconds. And if there are changes in the MEP or SEP during occlusion, you can raise the blood pressure further. Or if you have... If it is possible, you can also release a temporary clip for short periods of time. So local bypasses, first, side to side of anastomosis. The good news is that we have already seen this a little bit in the previous case, but this reinforces it very nicely. What you need to do. So we make an opening like this. We start on the outside, go inside, come from inside out and tie the first stitch. And then we have to go back inside, the opposite side. If you're a right-handed person, you're gonna be suturing right to left and then you will suture from the inside. This is showing a lot of stitches. You normally don't need quite so many stitches as you've seen here. Probably only even had less than half this number. And then you finally emerge on the outside again, you tighten all of these stitches and then you tie it, and then you come on the outside. So this is a technique, a side-to-side anastomosis, very nice technique to learn and use. You can find a lot of use for it. Here's a young lady, 26-year-old. She had been previously operated endoscopically many times for fibrous dysplasia with very poor results. But she came to us with an acute subarachnoid hemorrhage in very bad condition. And lo and behold, the entire A2 is involved in the form of a large aneurysm, you can see that. Right away you know that this may not be able to be preserved because this looks almost like a pseudo aneurysm right here. So what we did here was we, I planned. Again, interhemispheric bifrontal approach. I performed the ATT bypass first, and then I explored the aneurysm just as I was dissecting a little bit of the neck, it ruptured so I was able to control it pretty quickly and play some clips, but I was not able to preserve the right A2, but no matter because the bypass is stilling nicely afterwards. This lady as expected, a complex postoperative course, but she made a very nice recovery afterwards and was able to return to her previous occupation as a college student. So the next technique we'll talk about is interposition graph technique. You may use a variety of vessels for this depending on what size of vessel you need. You can use the superficial temporal artery. I've used the superior thyroid or the lingual artery. You can use the radial artery. I normally don't like to use it because the radial artery is a fairly important artery, just to use a short segment it doesn't make sense. You can do saphenous vein, et cetera. The interpose gap should be slightly longer than the gap and you perform end to side anastomosis both sides. So here's one example. This is a 13 year old boy who presented with a right sided headaches for one month. And you could see this aneurysm of the M3 segment right here, there. And you can see right here M3, and this is the aneurysm and then branches coming out in four branches. So this boy was operated. And what I did was I resected this aneurysm and placed a short graft, actually in this patient radial artery graft and interposed it and it looked like everything was very good. And here's a postoperative angiogram right away. However, about four months later he developed again a severe headache. And so we brought him back into the angiogram. What we found was that he has a recurrence of aneurysm at the end of the graft. It is not at the graft, the brain lottery itself is okay, but just beyond the graft site. You'll see that in a minute. At surgery what I found, these are drawings from surgery. I don't have a video, but basically a very rapid graft was intact, but the remain of the artery in this area was not good. So I just resected the whole thing. There was still enough of a vessel here to perform a bypass, but now I use the lingual artery and a more distal to prior site. And this worked out just fine for this patient. And here you can see the postoperative. I think I'll show you after this. There we go. Here's the postoperative view after the lingual artery bypass, and this is the short lingual artery and he is actually being followed now four years, without neither curves. Now this was another patient with a large fusiform MCA M2 aneurysm. So what I did in this patient was I performed a clip repair, but I also wanted to use some floor diversion. And I was afraid that one of the clips was compromising the branches. So I placed a short interposition graft beyond that, just like this you see here, and this is the graft. And that kept the vessels actually nicely open. Now STA-MC a bypass. What about this? It is quite useful, but only for distal aneurysms. If you have a really large STA you can occasionally use it for the placement of the ICA, but it's generally not reliable. And this is well known experience, but even I relearned that in one or two patients. So it's not a good idea to rely on the STA. Although there are some surgeons that do like that. I don't like to rely on the STA replacement of the carotid artery. Here's a patient who presented with a severe headaches and seizures and subarachnoid hemorrhage, MP3 aneurysm, I'm sorry, M4 aneurysm. You could see that here. We thought it might be a mycotic aneurysm but it was not the case. It was actually just a fusiform developed aneurysm, so we did an STA-MC bypass and just did a resection of the aneurysm, here you see that. And this is the MRA after three months. There are also other low flow bypasses. And I like to show you one in particular, occipital PICA bypass. Here is an interesting patient, he's 21 years old, presented for evaluation of fusiform aneurysm of the vertebral blogger. Now when he was 12 years old, he had had a coil occlusion of a carotid artery. So what's wrong with this patient? He has a unilateral, more predominantly unilateral cutaneous and connective tissue disorder. You can see here the right arm is longer than the left, and this cutaneous abnormality is more on the right side. So he's got a connective tissue disease which is really more on one side. It's predominantly on the one side. So what has happened to this patient is first of all, focus on this MRA, left ICA is okay. Right ICA is occluded and here's one vertebrate, the other vertebrate has developed a very large, giant aneurysm, you can see that here. And the PICA is arising right in the middle of this aneurysm. This is PICA, and here is the aneurysm and the vertebral junctures right about here. And these are the old coils. So we did a test occlusion on this patient to see if he'll tolerate just simple occlusion. What we found during test occlusion, the PICA has very poor flow from the other side. So the PICA and needs to be replaced. So that's the first thing. So what do we do and how do we do that? You can do an occipital artery to PICA bypass, and then simple occlusion of this aneurysm. So that's kind of what was done. Occipital artery to PICA bypass. And then we did a occlusion of the aneurysm. Here I track the segment and the rest of the aneurysm just clouded off. So this patient now has a video, you'll see in a minute. And we have a right sided, far lateral approach, dissecting the occipital artery on the flap. Sometimes it's one of the most difficult and techniques which can tax a surgeons' patients. You have to start preferably distally, then come back down and then you have to take trace of right to the digastric group. And here I'm just checking the vessel, making sure that it's okay and marking the terminal ends. Now we've done a suboccipital craniotomy foramen magnum has been un ruled. We're moving a little bit of the con dial just to give us a little more exposure. That's a . And that we've also exposed the vertebral artery in the V3 segment, opening the dura mater. Here is the vertebral artery here, and here we see the interdural portion of the aneurysm. This is a PICA coming out. So I'm going to dissect the PICA here and then bringing the occipital artery down, creating a little space for the bypass right here. So here's the aneurysm. Remember there is bilobe. Here's one lobe, there's another little there. So I'm just getting a little more exposure to the vertebral artery. I'm going to put a clip extradurally and then I'm going to put a clip intradurally as well. Actually two clips extradurally and one intradurally. Now not only there's not much more of the aneurysm, but also PICA has very poor flow. So we need to revascularize the PICA. So what we're going to do is to connect the occipital artery to the PICA, so here's a PICA temporary clip. Well, the temporary, very temporary. It's at a bifurcation point essentially. Opening the vessel, and then marketing it with a marking pen. And then we'll flush through with aconite saline. The marketing just shows you nicely the wall. So you don't stitch the other wall. So here's now we are suturing with 10-0 nylon. So we suture the two ends of the graft, and then we'll suture one side and then the other side either using a continuous or interrupted. I'll probably use in this case continuous on one side and interrupt on the other side. So these are some intraoperative stitches. So making sure the stitches are in good shape, then releasing the clips. So now the bypass seems to be working just fine. We remove the temporary clip from the occipital artery, checking the Doppler flow. And then we do an indocyanine green angiogram. And see here, this is the occipital artery. That's PICA there. You can see very clearly the sign of the anastomosis. And then we closed the dura mater loosely around the graft, making sure that we don't compromise the glass. So what happened to this patient? So the PICA, occipital PICA, and I suppose is shown right here, but now the patient has two arteries instead of three. So a consideration is can we enhance a flow to the patient? If you look closely, he has already formed an early aneurysm on their PCA because the vertebral artery, which is now just one through the basilar, through the PCom is applying the carotid on the right side. But this has already formed an aneurysm. You can see that right here. So in an attempt to reduce a long term problem here, I went ahead also did a radial artery bypass graft. Of course, I chose the radial artery, a used radial artery from the normal hand not the abnormal hand. And it actually stayed open just fine. Here you can see that. And it looks very well and he had no problems whatsoever. So this leads us to the topic of high flow bypasses. We talked about so far, low flow. We're gonna talk about high flow bypasses. And these are operations where you need to think about a lot of steps and execute them correctly. Generally neurosurgery, we always say that neurosurgery is all about attention to detail. This is what we teach our residents. You have to pay attention to every aspect of the operation because you make one step wrong, just like when you're putting your pack-up sutures, you just put that into the brain, you might've done a beautiful operation but then you got into the brain and then you can have a subdural hematoma and a poor article. So attention to detail. So just like that high flow bypasses, attention to detail is very important. So do you use radial artery or saphenous vein? Now, if the radial artery is good caliber, I prefer to use that. Why, because it has a better size match to the intercranial vessels. In terms of patency there is no difference. We have not seen that, but if you do have a large saphenous vein, they do dilate and they don't look great. They are a little expanded and so on. And sometimes they'll run off as they come in. You have a larger reign going into a smaller vessel, that is not so great. Nevertheless, if you don't have radial artery, you can use saphenous vein. We normally, what we do is we make a duplex scanning and then we make an assessment. Which one is this? Oh, so here we see what's called a pressure distension technique, and then trimming the radial artery. You're going to see more of this again so just different shots. And then we suture the distal. And first, like you see here after having made an oval arteriotomy in the middle set of arteries, here's the radial artery graft. And then we will use continuous sutures usually, or sometimes interrupted and continuous sutures. And then once the distillate and osteomiosis is done, I will bring the graft back to the external or a donor vessel here, whatever that might be, and then sutured there. There are people who do it the other way around. But I think this is technically easier because you can flip the graft back and forth and so on. So here we see the radial artery being sutured to M2 segment of the middle cerebral artery. Then we put a temporary clip on the graft and then we pass it through a tunnel. In this case, a pre arterial tunnel, and then make an opening in the external and suture. 8_O nylon sutures are being used in this case to suture the... And here the graft, I mean the clips is being removed and we actually back bled the vessel and then we removed the temporary clips. And of course we will perform an ICG angiogram at the end of the procedure. I have a lodge experience with aneurysms, now aneurysm revascularization, less experience for tumors. Our bypass numbers for aneurysms are going down, why? Because the use of the pipeline embolization device. But still it's a very relevant technique. Now this shows the experience of bypasses over about a six-year period just to show you our complications, what sort of complications we encountered, and this kind of shows the location of the aneurysms, cavernous, MCA, ophthalmic, paraclinoid PCOM, bifurcation, MCA, ACA, posterior circulation, et cetera. Here, you see the size of the aneurysms, and here are the bypass details. Radial artery graft was used in 45 patients, saphenous vein in 12, STA-MCA in eight patients, occipital PICA and seven, and then intracranial grafts were used in these numbers of patients. And what's our complications? Not all of these complications are related to the bypass. Some of them are simply related to the fact that the patient had subarachnoids hemorrhage. It was in bad shape, but we've shown every single thing that happened to the patient so that there's transparency, six patients had strokes, four a hemisphere, and two to capsule. Three of these six patients made a complete recovery, four had hematomas and epidural, subdural, intraparenchymal, some infections. What sort of patency rate? 98% at the end. Some patients are quite salivary. That means that they may have a little stenosis, they need an endovascular or some patients had a little narrowing. We had to revisit that and then fix that and so on. Now there is a learning curve. Obviously as a learning curve improves and also has also improved. There were a total of five deaths in this group of patients. One was talked to be related to the bypass procedure. Three were late to the disease, namely subarachnoid hemorrhage, and one patient died of a myocardial infarction about three months after surgery. So I'm going to show you some illustrative cases. This is a very interesting patient that I operated along with Dr. Gora Brock in Croatia. This was a four-year-old girl presented with very severe headaches. An MRI scan showed a giant right MCA aneurysm. This was confirmed by angiography. She had no subarachnoid hemorrhage but she then was sent home. She came back again with very severe headache. And again, probably it was just due to aneurysmal expansion. So the question was, what do you do with this patient? And now you can see in the MRI scan, the young lady actually has two aneurysms. Here is one large one, and then there's another one. They are actually in line two M1 aneurysms. And the best angiograms we have are these, namely, here's a carotid artery. This is actually a fetal PCOM PCA. And here's the M1 segment. It goes into the aneurysm and you see very poor disorder now here, some collateral vessels. So someone might be tempted to say, she's the younger, why not just close off the artery? She's young and she'll tolerate it. Well, maybe she will, maybe she won't. The result of failure here is pretty bad. You'll have a young four year old girl who will have a massive stroke and carry that for the rest of her life. So the best thing to do here is to try to revascularize the patient. But the problem is she is four years old, very small. So this is one of the most difficult cases I've operated, by the way. This is the contralateral side, filling both ACAs. So you can see that here. And so what did we do here? We did a frontotemporal craniotomy and orbital osteotomy, I found two aneurysms, one giant, the terminal ICA was leading into the middle cerebral aneurysm, large one, and then a second one which led to two M2 branches. But I was able to resect the aneurysm and I was able to do a short interposition graft using radial artery. And the radial artery was removed so I took a piece of saphenous vein and reconstructed the radial artery so that she'll have a radial artery as well for the future. So this is a surgical schema. What you're going to see, here's a carotid artery, internal carotid, and this is the entry portal. This is fetal PCom. And this artery runs right into the aneurysm, the large one, large thrombus. There's a short segment of M1, there's a large aneurysm, and then there's a segment coming out here. So basically I just resected the aneurysm and placed the inner position graft. So we'll see now in the video. So right frontotemporal craniotomy has been done. And we are seeing here the dura opened and opening up the Sylvian fissure. You could see that the patient has not had any subarachnoid hemorrhage. Although the arachnoid membrane was rather thick in this case, raising a question of whether she might've had it much earlier. So here's a carotid artery and that's a fetal PCom, and we're gonna trace the M1 segment. That's the M1. And here's a giant aneurysm here all covered up and putting a temporary clip on the M1 just beyond the bifurcation. So then placed a distal temporary clip on one M2 then I have to dissect another M2, the aneurysm is still filling. So there is a short segment in between the two aneurysms. So I'm gonna put a clip on that. That's actually a short M1 segment in between the two aneurysms. So I'm gonna I emptied the first aneurism so then I dissect the aneurysm wall. We still have the second aneurysm which is right here. So that's the first aneurysm, just cutting out the aneurysm wall. And that is the artery as it runs into the aneurysm. That's the M1 vessel just beyond the terminal ICA. So that's what we have to deal with. So I'm just getting rid of that aneurysm and then we still have this one. So here is another M2, we'll find the other M2. So once that's done, I could dissect the aneurysm. The aneurysm is completely occluded, so we can get this out. And we have to have a good look around. You may ask me a question, what happened to the ventricular strides? I found the ventricular strides are arising really from the M2 segments. So whatever might've come out of the aneurysm presumably was clotted and never gave any problems to the patient. Here the aneurysm is by being dissected. You can see here where the M1 bifurcation was. This is coming out. So there's spilling from the anterior temporal artery, which I disconnected. And I accepted the occlusion of the anterior temporal branch, I isolated the radial artery graft. I see that and then we are just preparing it. We are taking the adventitious and a company veins away, and we are just extending it a little bit. and you will see me just using a little pressure to distend it, and then we'll transfer it intracranially and essentially enter in suture on both sides. So you could see it's a pretty tiny, dirty laundry graft. So here's proximal anastomosis. The key to remember here in a tight situations, I always tell people one thing to keep in mind and one thing only. Plan your operation exactly how you're going to do it. And then focus only on the next stitch. You gotta have absolute focus. Even sometimes I find my mind wondering here and there. It's like a meditation. Operation is the closest thing that neurosurgeons have to meditation. I call it operative meditation. We've gotta be totally focused on what we are doing, and then you're not likely to make mistakes. And it's very easy you will find the mind will wander when things are not going very well or things are going to easily. This is the two situations where you may have a problem with focus. But young people do need to a focus. So here now we just flipped the graft and we are doing the back wall. So perhaps I won't show you all the steps of this case. You will be able to see the video completely on the website. If you're interested obviously it will be on the website. But here you see the back wall being sutured. So here we used, I use the 9_O nylon sutures, not 10_O there because the vessel wall is a little thicker. Just taking our time. Everything is tiny in this patient. So if you interpret sutures and then if I can advance it a little bit, I'm gonna show you, now we are working on the distal segment. Here I put it right at a bifurcation point. So keep in mind, remember that there's a M2, M1 M2 bifurcation segments. So actually, I'm putting it right into the bifurcation so I've fish mouthed the graft such that I have a little bit wider opening to come into M. We use the same technique of suturing. I think that we can look at the end terminal portion. Here is the graft temporary clip being released and you could see the . And this patient actually has done very well. And just trying to make sure that we have no leaks. Sometimes you have one or two leaks that you may need to fix with a stitch. And here's the end. Here's a graft, that whole aneurysm is now gone and replaced with this graft. It looks a little stenotic in places right here. This is the ICP angiogram. And then we'll see the next... Well, let's see postoperative. And the patient made a complete recovery. She never had any problems. A couple more cases. A 68 year old woman with an incidentally found a giant MCA aneurysm. Same problem, vessels coming right out of the aneurysm. What to do in that case? So what we ended up doing here was bariatric bypass into one branch and into side an osteomiosis to connect the other branch and then closing off the aneurysm, which was very sclerotic, atherosclerotic. So now we'll see the video. Again, I'll go through the video a little bit fast in places you can see it in your leisure. He has a very sclerotic aneurysm, left Sylvian fissure which has been opened. So here we are suturing radial artery graft to one M2. You see that there. And then we are doing a side-to-side anastomosis here. And this is actually a very nice one to see in your leisure time. It shows you exactly how to do the side-to-side anastomosis in great detail. I'm going to advance it a little bit and show you here, now we're dissecting the aneurysm. We've done all the bypasses. It's a very sclerotic aneurysm. You can see the whole thing is sclerotic, but portions are thin enough that it can rupture. So I'm just gonna put temporary clips now on the two M2s. And the aneurysm is completely trapped, and there's a small branch that is bleeding. So we're going to excise the aneurysm, very sporadic. And here you can see the inlet and the outlet in a minute. And so that's the inlet still a little bit bleeding, despite the proximal temporary clip, meaning that it's not enough to close it down and I'm just closing it and ICG angiogram afterwards. Can see all the vessels spilling now. And this is a post-operative angiome, shows graft side-to-side anastomosis. You can see that very nicely here. Good recovery of the patient. All right, so here is another patient, perhaps the last one we're gonna see. This is a 62 year old woman who has had multiple callings of a giant basilar tip aneurysm. And she presented to us in a very poor condition, spastic quadriparesis, et cetera, not able to speak and so on. And you could see a very large brain cyst. And then she has this big tumor inside the brainstem, which is just a mass of coils. And when you look at her angiogram, we see that really, this is angiogram subtraction. And the whole thing is very complex, neck hole is a big ball here. and a PCA PComs are coming out of the ball essentially. You can see that here nicely and no P comps. So what do we do with this patient? The problem why this aneurysm keeps growing is because of the jetta flow going from the basilar artery into the aneurysm. So we need to take down the Jetta flow. Dr. Drake showed us years and years ago that you could do terminal basilar occlusion as a treatment for these cases. But in this patient if you did that, she will die. Why, she has no collateral flow. So we need to give her an artificial collateral. So how do we do that? So what we did here was we didn't have radial artery, So we had a saphenous vein. Actually, this lady first had endoscopic fenestration by my associate, Dr. Allen Morgan. And here's a catheter. The corals are actually migrated through the third ventricle into the catheter. We actually did fenestration of the system on a shunt. So those are the coils that you see. So that's the first thing that has been done with the patient. Then we perform the petrosal approach and saphenous vein graft bypass. Yes, so this is a left sided petrosal approach. So here is the sigmoid sinus, features bone, temporal lobe left side. And what I'm going to do is I'm going under the temporal lobe. Why we choose the left side? The left PCA was better. Normally, of course we prefer the right. The left PCA seemed to be bigger so we chose the left side. And then we divide the tentorium, and here's the terminal basil artery below SCA. And now we have isolated the left PCA, and here's a rubber band. This is a little large rubber band but we use a smaller version of it for aneurysms. And then we are going to make an oval opening here. And the patient has the same protocol that I talked about earlier. Here's a saphenous vein. I mentioned the radial artery were both very bad. So we using the saphenous vein and we are suturing it first on one side, and then you flip it and then suture the other side. And then we'll put a temporary clip on the graft itself and then removing the temporary clip on the PCAs. Then we're gonna pass the graft under the sigmoid sinus. Here's the vertebral artery in the V3 segment. I'm going to make a punch hole, use a vascular punch and usually a nice circular hole and then I'm gonna suture it to this vertebral artery. So that's being done. And then once this is completed, you can remove the temporary clips and then we will perform terminal basilar occlusion. So there we're gonna put our temporary clip. I'm sorry, permanent clip on the terminal basilar artery. That's right there. A pretty tight space, nevertheless, but the aneurysm is constricting everything, it's crowding the brainstem. So here's the graft flowing nicely, and you can see here's and there's the ICD angiogram showing very nice and flow through it. And how did the patient do? She made a remarkable recovery. She's improved quite a bit since that time. This is 18 months. Here you could see the bypass. She has two small aneurysmal neck residue, which is probably stable, and she's able to walk with help, et cetera, much improved. I think that we have come to the conclusion of this. So one can conclude that bypasses and vascular reconstruction a very important adjunct for the treatment of complex aneurysms. Definitely low diversion stamps are gonna be used more and more for complex unruptured aneurysms, but still we have problems when it comes to a number of cases, smaller vessels, ruptured aneurysms, et cetera, where you can already use stems. But also stems have their own set of problems, hemorrhage, crucial vessels, et cetera, et cetera. We just started learning about them. So in the meantime, I think vascular neurosurgeons need to focus on learning these things so that they can then use it on their patients.

- Well, Sekhar, I really thank you for a very valuable that really expert discussion of very tough cases. Might have a very last question for you, is what are the top three pearls you have for young neurovascular nerve surgeons, both in terms of temperament and their approach to several vascular lesions as well as technical skills.

- Yes, so I believe that in future neurosurgical training is going to be different. How different? I think that neurosurgeons will first learn for four years basic neurosurgery. What does it mean? How do you take care of a neurosurgical patient? How do you examine them? How do you take care of an acutely ill patient? Be it head injury, subarachnoid hemorrhage, et cetera, whatever and do simple things. After the four-year period, the neurosurgeon has to decide about what they are going to learn and what they're going to do. I think in the future surgeons need to spend a minimum of four to five years learning both endovascular and microsurgical skills. Obviously there's gonna be some self-selection there. Somebody is going to say, well, I'm going to do more endovascular, but I'm gonna be more microsurgery. In my opinion surgeon should learn to do both. You need to learn the anatomy very, very, very well. This is the basis of everything we do. So you've got to learn all of Dr. Orton lectures, which are available on the AANS web, just backside up and upside down, everything you should now. You need to go to the cadaver laboratory and do a lot of the sessions. The next thing is the development of microsurgical skills. This has to start on day one when you enter neurosurgical training. There's no specific period when you start and there's no specific period when you end. When you end is when you stop neurosurgery. Next, learn from masters. Learn from masters in your own institution, the other institutions, look at videos, look at web based videos, et cetera. Don't learn only the basics, but also learn the problems and nuances, pick the brain of the people that have done them before and everything sometimes I make it look easy but it's not so easy. It comes with time and experience. The last point I would make is what I said earlier, the temperament is very important. Neurosurgeon needs to be at peace with himself, with a patient and with a family, and has to develop skills for just patient work. This is very important. You could be a flash in the pan and do great work one day and then we told me off the other day. That doesn't work for us. Our batting average has to be 1.0, not point anything. This is our problem.

- Well, Sekhar, I appreciate all you'll have dealt for neurosurgery. I appreciate all you have done for so many of your trainees and obviously most important for your patients, and thank you again for your very valuable time.

- Thank you very much, Aaron. It was really a great pleasure and I greatly appreciate the opportunity to be on the AANS video series that you put together so nicely.

- Thank you so much.

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