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Microsurgical Anatomy Applied to Cerebrovascular Lesions

Pablo Rubino

December 21, 2020


- Hello, ladies and gentlemen and thank you for joining us for another session of the Virtual Operating Room from the Neurosurgical Atlas. My name is Aaron Cohen. Today's guest is Dr. Pablo Rubino from Argentina, from Hospital El Cruce. He's a Vice Chairman of Neurosurgery there. He's also Director of Cerebrovascular Neurosurgery. He is a very accomplished microsurgeon. A student of Dr. Rhoton and Dr. De Olivero. Pablo, you've been a dear friend along the years. I truly admire you for the work you have done in both microsurgical anatomy and surgery. So, I'm very much looking forward to learning from you today, please go ahead.

- Okay, thank you very much, dear Dr. Aaron for the invitation, it is for me a real honor to be part of this Neurosurgical Atlas. I think that the contribution you made with this Neurosurgical Atlas for the world is tremendous contribution on... Thank you very much for the invitation to talk. Today, I'd like to propose for you and the rest of the audience, to talk about some points regarding microsurgical anatomy applied to cerebrovascular lesion. I'd like to do like a journey from the anatomy, and how we can use this microsurgical anatomy in some topics, and we can use for some cases. So, how we can use, take advantages of the microsurgical anatomy. For instance, I always try to start, when we're talking about anatomy, with some cases, just to emphasize what is important of a microsurgical anatomy. This is a typical vascular lesion, that at least for me is a challenge lesion. Which is a giant ophthalmic aneurysm. So, if we want to treat this aneurysm, we need to know the microsurgical anatomy, not only the anatomy, how to reach this area, but also how to expose, not only the carotid artery, the optic nerve, then this complex structure. We also need to know the anatomy to perform the right approach to expose this lesion. As you can see here, this is a giant ophthalmic aneurysm. so, we need to get an approach, opening the cervical tissue. And then, we need to remove anterior clinoid process, as you can see here, in order to expose the clinoid segment often internal carotid artery, to have a proximal control. And finally, you can be ready, not only to clip this aneurysm, but also to decompress the optic nerve. So, this is the important of anatomy. I like to do like a journey from following rotten classification from the beginning to the end, from proximal to distant. So, we need to know the carotid artery in all its segment. For instance, the cervical artery of internal carotid artery. So, we need to know that this carotid artery, we can find medial and deepest, and deep to the sternocleidomastoid muscle. So, we have a dissection for anterior one. You can see that the surgical segment, it starts at this level, at the level of the fourth cervical vertebra. And the artery at this level is following by the internal jugular vein, laterally and posteriorly, as you can see here, at the vascular nerve. So, this is the anatomy, we need to know because we need this anatomy to apply in different aspects. This is a very common surgery for vascular surgery, with this, the carotid endarterectomy. So, we need to expose the internal carotid artery, the carotid bifurcation, and then, we can expose the plaque and remove it. And finally, we can use microsurgical sutures to resolve this problem. This is the anatomy we need. For instance, in carotid endarterectomy, but not only for carotid endarterectomy, but also, in some cases, you have to deal with tumor, like this one. This is carotid body tumor. I operated on with my colleague, my head and neck surgeon, we make a team. So, by using our anatomy, we can remove this giant tumor and preserve the normal carotid artery. Only because we know microsurgical anatomy and microsurgical technique. This is the very important junction of knowledge, okay. And of course, in some cases like this one, this is a patient that was a young patient. The patient was operated on another country from a macroadenoma. And unfortunately, they have a problem with the carotid artery, make a traumatic aneurysm. So, they sent to our hospital. We see that the best solution for the patient was trapping and bypass. So, we do the, first, the suture at the level of the MCA, because we need to replace the flow. It is important not only to know how to apply this anatomy, but also, I think is very important to say that I am doing the surgery now, but, the second part of the surgery was completed by my current Chief of Resident, Dr. Richardo. And then, we moved to the neck. My Chief of Resident completed the second part of the surgery. We did the first suture at the level of the brain, and then we move to the internal carotid artery We did a fish mount and then we cut the cervical carotid artery. And then, we start with the stitches. One stitch. And then, this other one. And then, the second one. So, I am emphasizing not only the microsurgery that they need, but also how you can use the anatomy of the cervical carotid artery to resolve. Athology, it's very important for neurosurgery. Okay? So we complete now the suture, on the neck. Okay. And this is maybe one of the last stitches. So, we are working now in the cervical carotid artery, and we need a wide exposure. we need to know where is the intrajugular vein, the vagus nerve, the carotid bifurcation, the different branches that we can find here. And this is, maybe at the end of the surgery. We just want to emphasize the anatomy of a cervical carotid artery, not only the microsurgery techniques of the bypass. Okay? This is the final view after completing the bypass. So, this is the importance to know the anatomy or the different segment. Then we can move to another segment, which is the petrous carotid artery. Remember that the petrous carotid artery described like a canal in the petrous portion of the temporal bone. We can find here a very short one, which is the vertical segment. And then a second segment, which is the largest one, which is the horizontal segment of the petrous carotid artery. Sometimes we need to deal with lesion. Maybe not a real vascular lesion, but, as you can see here, this is the tumor at the level of the petrous apex. This tumor was involving the internal carotid artery. So, in order to remove this tumor, we need to apply the anatomy of the middle fossa. We need to know how to perform a middle fossa peeling. We need to recognize the [Indistinct] as you can see here. And then, we use some firing glue to avoid bleeding. And then, we start the, complete the middle fossa peeling. You can see the huge tumor, which is involving, is surrounding the petrous portion of internal carotid artery. So, we start debulking of the tumor. It's not the vascular lesion, but we need to expose. As you can see here, the internal carotid artery at the level of pertrous portion. So, we use a drill just to expose and remove the tumor, which was maybe already affect the petrous apex and the interior of the carotid artery. You can see here this is internal carotid artery of the petrous portion. We complete the middle fossa peeling. Here you find B3, B2 and here the carotid artery, petrous apex. And then we drill interior and exterior, and middle and posterior, we remove most of the tumor and we preserve the internal carotid artery, only by using the microsurgical anatomy. This is, I think, the important thing to know on how to apply this anatomy. Anatomy alone sometimes is boring. Anatomy applied to the surgery, it is very important, like a tressure for everybody, okay. This is the final view, and you can see in the dissection, I did years ago, the petrous portion of the internal carotid artery, and here was the tumor, okay? And, here you find B3, B4, B2 and B1, okay? Then, we can move to this. Let's go in ascending direction. And, we'll find the carotid, the cavernous portion of the internal carotid artery. Remember that, after passing this ligament that we call petrolingual ligament, it start here. The cavernous portion of internal carotid artery. Because of the time, I just want to emphasize, at least for me, what is the most important segment, and we can only say the controversial segment of the carotid portion of internal carotid artery, which is the anterior ascending segment of the cavernous portion of internal carotid artery. This segment that we also call clinoid segment, of the internal carotid artery. I see this is a very important aspect because when we have to deal with paraclinoid aneurysm in this area, and not only paraclinoid, but also with tumor like malign, or something like that. We need to know these anatomy. From a strict anatomical point of view, we can consider the clinoid segment as a different portion of the internal carotid artery. We can not consider, from an anatomical point of view, this segment inside of the cavernous sinus. But, as you can see, we have some channel, venous channel, from the cavernous sinus inside of this segment. So, from a surgical point of view, anyone who was working around this area, can see that, after removing the interior clinoid process, we can see a very red bleeding coming from the cavernous sinus. So, from a surgical point of view, I think that this segment can be considered as part of the cavernous sinus, but, it's not in the cavernous sinus from an anatomical point of view, because we have this limit, the inferior or the proximal dural ring and the distal dural ring, okay? But I think that another important information regarding this area is not only the rings, the proximal and distal dural rings, but also the configuration and the structure that they find the anterior clinoid process. The anterior clinoid process is just the posterior and medial projection of the anterior clinoid process, as you can see here. And we can consider three attachments. One is the lesser explainer, which is here. The second attachment is the optic canal, which is superior and anterior. And finally, we have the optic strut here, which go posterior medially, and remember that all of this great attachment we need to remove in order to remove him. process unexposed the clinoid segment of internal carotid artery. I remember, which is very important. The optical strut, which is the inferior aspect of the canal. But also the superior and major limit of a superior orbital fissure. So above the previous that we find the optic nerve below, we find the oculomotor nerve and posteriorly we'll find the clinoid segment of internal carotid artery. So take into account all of this chapter when we are dealing with the product line of aneurism and you need to remove the interior clinoid process in order to expose here, as you can see the clinoid segment. Not only to open the restart on proximity learning, but also to have a proximal control in case you need to deal with the decision at this level. And here you can see an example, this is enlarge, and you can aneurism that we can say the true of timely clinoreism, which is a superior variant. So we need to apply anatomy that we learn in the lab. It means we need to perform a clidoinal approach. As you can see now, we try to identify the first triangularis which is the maximum opening, not to open the facility official in the lateral aspect. Then we should go medium or the front or side of the superficial Sylvian vein. I always like to use a very small cotton, a five millimeter cotton at the tip of the section to reduce the suction. And then you must to identify not only the veins, but also the arteries. It's very common that you have the bridging veins. Sometimes you can sacrifice. I tried to sacrifice most of them, but sometimes I can't. And then you need to identify the arteries that they never close from one side to a side. I mean that frontal artery go to the frontal side temporaral artery go to the temporary side. Sometimes you have some loops, but you have to define very well because you can avoid injure this structure. Then you have to do delicate movement, try to avoid bleeding because bleeding means that you cannot see very well what you're doing, where you're going. So then you have to complete the opening of the CR Fisher. Here. We find another vein. I tried to dissect from superior inferior. Then I continued with the section. I am reaching out to . I am working around the spine. Then I move above the optic nerve am opening now So you can see the optic nerve having strong compression by the aneurism. Then I complete as much as I can. The opening of the serial feature. I always, especially in incidental cases, I try to avoid the retraction. I use microsisor and suction and I use a transitory protection with the suction. But after completing the opening, as you can see here, mca and carotid artery, I can use sort of structure to sustain different alone. Okay. I complete, now you can see here, the oculomotor there. I just put a retractor and you can see now this is large. I'm working now in the superior aspect of the sack. Just throw to the sack. I realize that it's impossible to clear this aneurism without removing antibiotic in the process. I decided to do an internural clanedectomy This is another discussion in all of my cases, maybe 80% of my cases I use intermural. I learned from professor. I think that in some cases you don't need, so if you can avoid you can you have to do so. The first thing I do is just to cut in this earlier. The most important thing for me is to identify the inferior aspect of the of the process here with the like sector. I try to follow a snapshot and then I started reading. I need to read two imaginary lines. One is above immediate to the optic nerve. And the second line is from the lateral aspect to the media or medial to the lateral, just to identify the inferior aspect of the anterior process. And finally, when you join both the medial and the lateral one, the last part is to remove the optical strap. So you can make a fractured sharp. Finally, you can complete atraumatic Proctor of me until you can use the process. I remove it. As you can see now in one piece, we dedicate the movement. You need to free that kind of the process from the production or ring. You can observe some bleeding from the clanging. Second, you can put some pirate in glue, and then you are ready to open and to cut the optic strap, to open the distal arch much as much as you can, then we are ready to do open the, you can see the distal part of the neck carotid artery here. So I am cutting the distal ring I am deceptive. I try to do as much as I can. Sometimes I tend to do 360 degree. Sometimes you don't need, I use now that I used to follow the direction of the artery, after clipping I always check the only aneurism and the carotid artery. And I realize there is some remain of the neck here and here. So my, the section should be more acute. You can see here part of the suck so I removed, the arteries. I need to expose an open much better the distillery in order to have a better exposure of the suck, maybe these maneuver, we lead me to play the clip safer and easier. Okay? Now I am completing the opening of the fetal artery. You can see here some material in the segment. So now I have enough room to put here. Okay? So this is, I think the important thing too, to know the anatomy, to apply this anatomy in the real surgical field to extrapolate anatomy, you learn in the lab today, or after clipping, we can decompress the optic nerve. The patient has some visual deficit before the surgery, fortunately, after a surgery recovery very well. And I'll turn to her research deficit, biracial clinical condition, okay? Now am opening the clip. Now you can see that if you've been nice, much better, We can go deeper with a clip. And then we check with Doppler, no flow in the sub. We preserve the flow and then we correlate, puncture the suck in order to check the correct clipping to decompress the optic nerve. This is the advantages of surgical anatomy. Okay. We always use the tripolar to shrink the sack to avoid the compression of it. Compression of the optic nerve. Maybe this is the final view on this is Okay. Sometimes we can use the same anatomy. In other case, this is superior, but in this case, we can use a different strategy, but the same philosophy and the same anatomy, okay. Left side. So, but in this case, we choose remotion or removal of interior clanoid process. So we start the approach and then we did a drilling of the lateral wall. As you can see here of the orbit, in order to expose chapter We removed part of the, we complete the opening with the sizer of the, and then we start like... just to go and expose the most lateral aspect of the anterior carotid process. So we are doing the same surgery, but now by using the extra learn corridor. So the anatomy is the same. We are doing another different, strategy, because sometimes we can say that many people say that it's the removal of the, until Grande or the process is safer. They prefer to do. We try to do both, depending on the case. I usually, for the tumor I prefer a federal, But in this case, we choose just to compare, but there is the same. So we need to expose the three attachments of interior client or the process. And then we started reading the listeners to know the roof of the, and finally, we complete a very similar process by making a removal of one, one piece of incubated, prostate by cutting on braking, optical strut. So here we are completed the drilling. We are removing part of entrepreneurial, the process that you can see this area here, you, you can, you can get the optic nerve. You're removing. Now the optimist, remember that just above we find optic nerve below, we have the oculomotor nerve, and then we complete the removal of it until with the process by road. after completing the removal, we check segment in case we need to approximate. And then we just opened the Luria in the deepest part of our approach as you can see here, we opening the duda, like a T-shaped infusion, very the lower part of the in the middle, in the deepest, the Fisher. And then we make two more cuts to the frontal side another cut to the temporary side. We just put it shooter. In this case, we don't need the opening of a Syrian Fisher bar. We only go there, click to the deepest part of the section. We open the carotid sister, we release CSF, and we just see the part of the aneurism here. And then we can see here. This is part of the. We need to open the in order to put a clip. We also need to identify that it's no relation with the proximal artery part of the neck. So with proximal control, we exposed the proximal part of the neck. Then we did a sector. We complete the opening of the retailer in order to place the clip and avoid the rumen of the neck. We can avoid that. Sometimes the dancing does not close very well. If you open in the distance and you can see now I'm finally ready to cook. So you in this game, maybe you just only can see the deepest part of rain. There is no dissection Fisher and go directly to the deepest part. We use these sector. Now we are ready to okay. Slight curve. Yeah, we can resolve. Then we Doppler. We preserve the flow in the internal carotid artery. This is the same anatomy, a different corridor and different strategy so the anatomy, I'm the philosophy, the stain proximal control clear, very clear, no blood in the surgical field pressure, always structure as much as you can. You can see this very small opening of the Buddha. Okay? Okay. Let's go. Now, they're moving now from the to the super Kleiner, they are in the super corner. The segment, we can identify three different portion. The most Brooke is the Dalbec portion until we reach, we identify here, the Tiecon, this is the second segment communicating second. And finally, the collagen segment. We can also find here to terminal segment, ACA MCA. This is an inferior view. Most of the time at this level, often circles, Willie, we will find here many of the brain, only the diesel part, you will find, we can also find aneurism, or you can also find ABMS, or you can see here in this section, this is like a white opening of a Syrian Fisher in approach. So most of the time we did tell you another approach. You can expose this, not only the superclass segment with this three division, but also the MCA and one, an intro segment, the application then ACA a complex all of these you can explore by using the 10 Syrian road of material approach. So let's see one more Accenture call. You can use your anatomy to expose on this unreached tradition at this level, this is a lady who suffered from aneurism. She had a bleeding, ACA was treated by Cody twice, and she also had another regimen here in the proximal MCA. We were worried about this distortion of MCA and the blossoming of the carotid artery. So as you can see in the CT, the patient also cups on lesion at the level of the less until the colon or the process. We did it tell you another approach we complete a white exposure as you can see here, because of the previous bleeding, the Arab nausea was sticky, but we can also identify the normal anatomy or we'll try to use the normal anatomy. We'll learn in the lab here, this vein, we preserve the vein. You can see here, AMCA deliver another approach. In my last book, we find the first aneurism from the proximal MCA. So then we move just media to the internal carotid bifurcation and move unexposed, ACA Aiko complex. We opening the sister system so we can create like a tunnel from the right side to the left side, going just above the optic nerve. As you can see here, and we can expose this tumor, would you say, okay, this is point to mark with the cursor here. You can see here compressing the optic nerve on the carotid artery. So by using this anatomy, we create like a tunnel from the left side to the right or from the right side to the lip side, in order to remove the tumor, just using the normal anatomy that the brain for us in the peninsula and corridor, okay. So we can complete the removal of the tumor, do more myself, of course, per serving the different instructor. And then after completed the removal of a tumor using the anatomy we move to the lateral aspect between the optic nerve and the carotid artery here, we are removing part of the tumor. Then we move, to the right side we are working in the left side. Now you see this dynamic that we create here. We complete the removal of a tumor. Then we move and we go between the optic nerve. And this corridor took us to the basilar artery. You can also see the SCA and you can also see here sign of coy. So now we can be sick. The proximal part of a neck, then the distal part of the neck using this corridor between the optic nerve optic nerve and carotid artery. And you see one of the corridor with a youth to reach road after expulsion, we can put in a sector, we need to check before and after clipping that there is not perforating branches in ballroom the clip, Chicky, it's not perforating grandkids. We have a room now to put on a straight lead, you know, just, you then have to reserve that. They're not to me offer us. Okay. Of course, after we check, that's only to have a correct clipping, but also that there is not perforating branches, as you can see here, the perforating benches are free. There is no Raimondo hooky. We cure the patient after two endovascular treatment, then we move to aneurism. The proximal MCA. We use the same message just straight overnight, which is normal. This is a large artery. We need to preserve a, we put a smaller trip that we have by the time 740strike click. use our aneurisming on the other one and remove it two more. You see just in, right? So you're on an approach to expose and remove the tumor and the multiple aneurism as you can see in this case, now we are checking that we reserve. There are three, no perforating branches affected by the clip. Do you see the final view of our dissection call? We can use to treat multiple aneurism in one patient. with just one approach. This is the final rule of control. There is no more aneurism, very good removal of many clinoid very many managers. They're not their last pick, but I think that this very good. So the patient she did very well another example very similar to the previous one to expose multiple wineries. Have we just want to approach these patients suffering Siah months ago and we treated in acute phase. And then we also discover three aneurism. The left side. You can see two giants in the current assignment. So we decide to treat the super clinoid aneurism. And then in a second time, we send the patient to the basket, maybe for three sinus area. So we need to use now and different at the same approach. But in this case, we choose an approach. We asked the same philosophy just, but the difference that the decision it's a smaller, but we choose this approach for incidental and the aneurism, and this is the approach. The incision is at least two centimeters until you're two. Then the classic one, I think that we follow the doctor natal from Mexico, Dr. Maria, from Chile and everybody from Brazil, they were at least in Latin America. The first surgeon that are starting with military do not approach. So in this case, you can compare the infusion for me, they do not approach. And you see the classic approach is this, the craniotomy. In this case, we prefer to use interpersonal a section because you have more room to expose the temporal aspect of the clanatomy This is the craniotomy here we are starting the opening Fisher. This is my premium chief of Richard and Dr. Rader, who is doing the first part of the approach, the opening and Fisher. I think it's very important to not only to their anatomy, but also it's important to teach anatomy to the resident or fellow here we are boxing now exposing MCA aneurism. Then we complete our white opening civil Fisher. We put a retractor just to sustain the frontal lobe. And now you can see here, the dynamic segment, communicating portion and coronial segment. And here we find the colloidal unwritten, the coronal artery of the level of the neck. We are disecting. Now, in this case, we can see the previous CT answer that the segment, the junction was like engage anteriorly. So we just move this segment, posteriorly, this is the Johnson aneurism is very small. So just going just below, we can expose the aneurism was around here. You can see this, the searcher they are around this area. So using your anatomy of a patient, then after me, we learn the lab. We just go the current exposed Pichu way. aneurism using the meaningful learning and approach. We put a clip. We move after. This is B2 aneurism, then we went to the choroid here and you can see, I finally, we move to the MCA and you can see here, this has a little bit of the MCA bifurcation, actually hearing the dissection. We just, the sick, we put a clip and it's like curve, clip, chest to avoid the stenosis of the main trunk. Now you can see after clipping, we were worried about some change in the doctor. We didn't have by that time ICG. So we put, we removed, we changed the position of the clip. Then we just put another clip in the particular aspect. we can resolve this case. Yes, bye we'll. Sin, the microsurgery and anatomy puncher there isn't here. We used to bipolar. So the concept is the same. Why open a silver Fisher clean surgical field. In this case, the craniotomy was smaller. You can see skinny, but by using the anatomy and by applying the same philosophy, we can reach the same result. This is the portion control. And then we send the patient to the endovascular team to complete the resolution of the sinus aneurysm, regardless, two different segments. This is the signal that we call a pre communicate segment. And this is the ACA out attorney. Okay. So most of the aneurism or the aneurism you will find in the proximal lasted, and maybe you can not. from in the segment, the segment and superannuation segment. Most of the time, you will find here for all of these structure, you will need to do interim Frederick approach. So you need to know the anatomy of the internet and Frederick approach, the relation with there and forks on the Corpus callosum. Another important thing that at least for me, it's important, not only perforating branches, which is the most important is the recurrent artery at the level of the junction, a one or two. Is there a position of the proxy? My last bit of HQ, as you can see this section, 50% of the cases, the less to the right atrial, 30% of the occasion here approach approximately there, the right is anterior to the finally in 20%, they are the same and the same Devin. What is important? I think that in some cases, when you have to deal with some AECOM mannerism, this position of these, a one eight choose approximately eight two segments. Very important. If you, if you have to decide the site of the approach, of course is not the only anatomical aspect that you have to take into account when you are dealing with the icon, Iris, because for the inferior one, you don't need to care about this, eh, configuration from the anterior one, maybe you, you don't, you can also choose the right side, according to the another aspect. But for me, the superior one is very important to know the relation between both a two. Maybe it's not the only aspect that we need to take into account, but it's very important because if you have for instance, an acorn arisen here and a superior one, if you choose the rice, I approach, you will have an open. I won't be here between both a two. So the clipping will be easier. And maybe you then need to remove. If you want to treat these Irishmen here from the contralateral side, maybe you need to remove part of the regular GI, but you need to displace the one segment of the left side. And finally, maybe you have to use a fenestrated glee to resolve the aneurism so here you have an example. This is a one here, contralateral, a one here, a calm and aneurism to build a one. And this is less, you hear it, right? So in this case I will choose and I choose the right side approach because for me, this is easier to clear from the right side, instead of going from the left side, when you have to retract a two, you have to remove part of the record, maybe you need to use, so it will be easier to use to choose the right side. I think it's very important, especially for a superior value icon. Now this the final result regarding, distal to the icon, this is a typical lesion that you can find, which is sand ABM. This ABN you see, there are deliberate of a paracentral low right side patient cause of bleeding. We have an agreement with my endovascular, eh, colleague with either endovascular treatment first, just to reduce the size of the neighbors. I asked him to work in the deepest part of the night and then using the anatomy, according to the lesion, we don't need to, we can, of course, I always ask for MRI, but just by looking there on Joda for, you know, where is this ABM? This is an MRI. You can see that the ABN is very close in relation with the motor strip area on the right side. So we do that approach approach. I always try to cross the midline on these two centimeter to have a more easier retraction. I start by resecting the interim feature here, and you can see here is something we need to deal with veins, not only the drainage vein that we take to find at the beginning, we need to recognize which is normal, which is the normal anatomy, which is the, the different anatomy. Okay. You can see some yellowish cortical surface because previous bleeding with the micro CCER only membranes. And then we just follow the beginning of the Venus drainage just to follow the venous drainage. We can identify not only the analogous, but also the feeders. We always try to preserve it very clean so she can feel, we start. We can identify here, son of a feeder of the ABM after it wide open, you know, Let's just see we preserve and the cortical rain by leaving the Gulf of medulla to avoid that much, the bang would not be very danger for the patient name. We are moving. We are splitting the Indian pretty Fisher. You can see here that we preserve water in order to avoid that much of the bane. If we can avoid retractor, we can avoid naming. We can identify the neighbors here. One of the feeders we use most of the time, micro clips to be safe. We say that we closed the feeder, we cut the feeders, and then we follow the us as close as we can. We are going to vote preserve the normal range. It's very important. I think that in ABM surgery, it's very important to know. And that to me, only to recognize where is the normal brain, but also where you hope to preserve the normal vascular structure to avoid a complication in the post-op here. We already saved either. Then we move and we will take on the 60 degree configuration. Next section of the navel, we are avoiding normal brain, the patient cogni giant Venus aneurism. Here, we remove it together with the rest of ABM. You know, it is very important about gleaning. Please, no need to suffer from bleeding from Navy. And sometimes it's impossible to avoid, but this will remove it. You can see the neighbors preserving the normal anatomy and just remove the ABM with Jack. It's not rest of the night. This is your final view. Remember the patient has an ABN and the level of the near to the motor strip, especially the left in the post-op. This was the patient. There is no, we go to total removal of ABN. This is a patient two days later, and this is one week later, you can check the here recover motor deficit that he suffered adjust at the beginning with a complete removal of the ABN, okay. Regarding the middle cerebral artery, remember that we can recognize four different segment. This is the first segment that we call in one. We can also divide the segment into two portion. This is the education portion and step both bifurcation portion. And this is important. What is the information we need to know in this area? And this is the segment that we can do, especially in the posterior aspect of anyone with many branches that they go straight arteries as well, to the internal caption. So all of these perforated branches, we can finding the posterior and superior aspect as much as 10, sometime we can find more than 10, but the most important thing is to know that where we can find this perforated branch in the posterior and superior aspect of the artery, and then, sorry, the artery makes a 90 degree curve, which is the second segment that we call the initial portion of the MCA. Finally, we have a particular person or finally the cortical portion in this area, the distal part, we can also find aneurism here. Backwardation are ABN are more common here on the distal part. We can never find MBM, okay. In the proximal part, we can find MCA and aneurism core. We can apply this anatomy just by looking at this geography. This is AP projection. This is the lateral projection. Remember that we say in one segment of skier, that these, that we, we also say as final segment, and this is the second segment we call into and finally entry and finally enforcement, which is the cortical left. So you can see the geography and geographies like the skeleton of the rain. So if you know, I not to mean microsurgical anatomy by just looking at the agenda for, you know, where is the same year? This ABN is medial to the end segment. So if they be any media lit interesting, when they be any here, this ABN, he said the little bit of the . So if I know anatomy, I can understand where is this ADM? This ABN is here. Okay. So I can use a frontal temperant approach. I need to open this little feature, but in this case, I cannot go only to the anterior aspect of the CDN feature. I need to go to the posterior one because I need to expose not only the approach, but to have a proximal control money too. I need to also explore the fortitude to expose the natives, but also to expose the distal part of, into that. I need to preserve. I only need to remove the RT who just we, that we don't find in the medial aspect of the intra segment, which is here. This is the navel, or they need to preserve the segment because if I don't preserve, I can have a person with the neurological motor deficit. So this is the final view after removing , and I'm preserving, as you can see here, the end to segment, so we can use this, what can apply this anatomy because we can preserve the normal vascular anatomy, maybe because of the time. And we'll just keep these cases similar cases about, another ABN at the level of a temporal Novus. I just only want to say that this is in one segment. This is two. So in this case junction, so we can go back to them today. And the junction is in one and then two segments. So by looking at this anatomy, I know that where the stadium and I know what is the approach, let me finish with the basilar artery. Just remember that the basilar artery it started at the level of inferior. Clayville by the junction of both. Then the basilar artery goes in ascending aspect until the artery reach the dorsal cell. Where the artery is split into terminal branches that we call here, the right on the left side, before giving the posterior theoretically we can find the sea left and right ACA, and another important thing regarding the vassal artery is the relation with the phylum of perforating branches that all of them around, the posterior aspect of the V1 and go up to the posterior perforate system to reach the mesencephalon the thalamus. So all of this artery, we need to preserve when we are creating aneurism okay. So in order to reach and expose vascular and aneurism, we can choose a different approach. I prefer to do most of the time, the pretend put on approach, which is a concept similar to the clinical approach. But in this case, we need to have a more exposure, a bigger portion of the temporal elastic. And after completing the pretty important approach you can choose at least four corridors. One is between the carotid artery and the optic nerve. The second corridor is above the carotid bifurcation, which is this one then we can go lateral to the carotid, out to the media, to the oculomotor nerve. Finally, we can go Latin into the Oaklander motor. Now, without one more approach, one more corridor that we call pre temporal approach. When you need to move the temporal lobe in order to reach in the more lateral Antar lateral view of the vascular, the distal part of the artery we see is the typical a case in my hospital was patient, a young lady with the acute bleeding, maybe not working. Okay, very good neurological condition. In this case, you don't see this in normal configuration of the vascular aneurismably vascular bifurcation. We did the compared to the one. We did a pretend per approach. Then we be there and Fisher and then define them. And we started the opening even Fisher. Maybe you come fast forward look. Then we go between the optic nerve artery. We are using the different corridor. We have here room just to see the aneurysm, but we don't have in your room to have proximal control. You can see now part of the aneurism here, but we are not golfers. We are releasing CSF, but I consider a dangerous corridor. I was looking between the optic nerve artery, I am opening, the delinquencies membrane and here you can see here, this is not for me, enough place to work around the aneurism. So in this case, going to see here, this is the neck, some perforating branches BCA here left BCA. So we move to a printing, pretend for a corridor. We need to regulate district professors here, and then we need to dissect. We've got the vein and we dissect the medial aspect of the temporal low to retract it. Posteriorly we are working between oculomotor nerve. So we are free the temporary low. And you can see now after opening, we are releasing now the oculomotor nerve opening here. membrane. So we are ready. To watch now the aneurism much better than using the previous corridor here, you find PCA going above the oculomotor nerve. You can see the exposure we got. These temporary road is much better, at least in this state does the previous one. Okay. I don't know. I have enough room for proximal control. I kind of expose the algorithm 360 degree. So on ready here. Can you see the sack release all the perforating branches aspect, which is the most important thing so we can see from here. So if you compare with the beginning, now we are ready. To expose much better. Not only the aneurism, but also the in case we need the proximal contract. It is enlarge review or PCA SCA. So we just put a barial clip if you can, fast forward a little, maybe more time. Okay. After clipping, I always try to check and then shrink the sack. Okay. This is important to use the anatomy. So we have a different corridor and then I choose the different maneuvers in order to, to treat these kind of aneurism I think maybe one of the more challenging ones, maybe this is your final view. Okay. This is a partial contract. The patient did very well. The CT, just to conclude something, we have to deal with this. This is a drawing made by one of my colleagues. Something we need to deal with these kinds of wineries. And this is that we call medulla because he's below the five millimeters below. And you can also see that the both PCA's are sending them direction like this. So in this case, you need to do a maneuver, which means a Trump stubbornness approach. In this case, this is a previous view. And this is after completing the trans governance approach, you have to remove interior cleaning or the process. Then you can go, you must go nearly to the oculomotor nerve at the level of the roof of the covenant, sinus unexposed, the Louvre or the on the plane or the process, and then remove it. Okay. This is the beginning. This is at the end, after removing process. So you can compare, this is the view you have before doing the transcribers approach. This is the view after completing the trans cameras approach, you can reach at least one centimeters below the dorsal center so, you have enough room to proximate continental, and you can the dissect the aneurism, this is one example. This is large vascular medulla in basila aneurism, we decide then surgical treatment. The patient was in a regular condition. So you can see we did, this is no lie here in the Northern Shaler. Here is the neck. Okay? You can see the direction of both PCA. So the same culture, we choose the different corridor. But in this case, we started by the transition road. Then we move and print the emperor, and then we can expose the other aneurism we moved to the approach. And this was your final view in the anatomical dissection. Or you can see here now this system, we didn't see at the beginning. So this is the patient you can see is worse, regular condition you can see this secular bleeding. So we started the opening, the ceiling Fisher. Maybe you can fast forward a little bit, please. So we complete the opening and the seed and Fisher. We choose a different corridor, but we are with and live in like our expulsion. So we move to the pre temporary approach. Even we cut part of it and Toria to see that data learning failure to the oculomotor nerve. We release CSF from the interpreter nuclear. We are not so happy with the exposure as if he was not knocking off. We remove release the ocular motor nerve from the oculomotor sister. So we are increasing our complexity of the surgery. We are using all the resources that we have. So in this case, we complete until you're clean or the process removal. As you see, before I removed the medulla clearly, then I complete the removal of the anticlidal process Told you before I always take to identify in to the border of process, and you can see here, I use fibrin glue to avoid bleeding from the covering of sinus. Then the following step was to remove until kind of the process I use chrism. Why I did this because I need to mobilize the carotid artery. So I removed then to kind of process one piece. And then I move medial to the oculomotor nerve because there is not any important chapter in between. So I can use the roof of the Cardinal sinus. And you can see here to open medulla. There is no bleeding because I already injected Am done with the micro CCER of medulla did really. You see Garrison, maybe you can fast forward a little, please. I complete after process. Now I have room for proximal control and expose the aneurism here. This is the anatomy we using it up. This is the anatomy we use in the real surgical field. So we would clip. So now I have enough room. Fortunately was very, what can I say? We think that the first bleed was very good. Didn't come flow anymore. And then we check with Doppler. We checked no perforating branches involved by the clip. So maybe you can fast forward a little please. Okay. This is the final view we gonna see here, please know, LaSalle and we side on the right side of score. This is the final view. I think that maybe more time than each, just finish here with this picture of my mentor, which is professor and this is professor rotten with, I also want to thank my friends that I have in my stage, my two stages in then I went there in 2004 and five, and then I came back to section seven. So this was my previous fellow friends from China, from South Korea and Dr. Abbey from Japan. And this is my friend and maybe one of the best surgeon especially in a scale race, which is, which is one of my best friends that I have a I have when I was seeing Dr. Rotten. I want to say thank you to everybody and especially to professor Darren coin to let me show part of my work here. Thank you very much.

- Great work. Thank you so much. Oh, we really appreciated Pablo. We appreciate all you're doing for neurosurgery for the sake of time. I'll just live it as really our great thanks for showing your work, sharing it with us and giving us an opportunity to learn from you. And again, thank you. And we look forward to being with you again in a few.

- What's the pressure for me to be part of neurosurgical levels. Okay. Well thank you.

- You're welcome.

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