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This is the second in a series of talks by Dr Malika discussion with Dr Malik on his extensive experience in treating fifteen hundred Avi AMS is internationally known for his expertise in this area
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this is part two
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This is the second part on the discussion Gosh Malik was internationally known and is treatment of cerebral Ab EMS about what I learned in treating fifteen hundred ABS part two
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Aren't dramatic is the John R Davis Endowed Chair and Executive Vice Chair of the Department of neurological surgery at Henry Ford health into a choice
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along with Dr Malika is Eric Nussbaum who is the chair of the National Brain aneurysm and Tumor Center and Director of Complex Korean or surgery as a Woodman midwest brain and spine center in
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Minneapolis and St Paul Minnesota he is also an associate editor in Chief of Asinine in a board member of SCI Digital
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he's published these books an aneurism and a vascular malformation surgery which are available as you can see a lot of the pictures
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as multiple scientific publications on pubmed in Sinai
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also as a commentator is James Johnson the CEO of SCI National Digital Editor in Chief of Sai Digital and former Professor of Neurosurgery at the University of Minnesota Michigan Illinois and U C L A
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former chairman of neurosurgery at Henry Ford hospitals and at you I See in Chicago
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now these are not malformations
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why do we do about him
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next we Philly I reported this
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experience so
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we wanted to reported earlier on and buy from one of the people who was in already a lot of pictures and so forth they had completed the study ah so next
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so we had a total of sixty five patients from nineteen eighty to two thousand through thirty three females thirty one meals presentation was Eddie's fifty percent see his fifty percent and hamlet in
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forty one percent so this just tells you that even in these large lesions patients do present with average
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retriever forty two of them with surgical resection with embolization I think as a as a pill dude but that didn't quite go on to treatment and embolization and the
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AH and then stereotactic radiosurgery
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there was kind of a desperate move the patient actually added emirate and then the handwritten and night we started out of these Ah E eight letter clearly not suitable and then patients will offer
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them treatment but they declined next November and just this giant malformations you're talking about right perhaps but these are more than five to six centimeters not curricula any thoughts about
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this from from Your Perspective
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I mean We've operated on a number of these actually quite a few you know sometimes you'll find one that's frontal it's really most of the right frontal lobe or the left frontal lobe sparing language
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and speech and then I personally don't think they're that difficult to treat when you're not in truly eloquent brain when they're more central you have a problem and then we've also had some that are
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occipital and the patients willing to accept the field deficit you can take those out I think they're not that difficult surgically in my experience the real problems get into when they involve the
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Thalamus and the deeper structures or motor sensory motor Cortex I think very hard to treat some of these in preferably Yeah from my perspective
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when I went to Illinois we we had a film who is internationally known which is Gerard de Brun Origin was Superb Intervention English and we would see a lot of these we would see it A number of these
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are large malformations that were very difficult and he always believed in neither symbolization it was a superb Technician I actually find human being and he was able to reduce them in size I he
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would bring him back for multiple opposition and regret a month between them and and he would be able to reduce them in size so that they were either surgical candidates CE surgery or radio surgical
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candidates and so at that point we had some some doubts about this Bachelor marty grading system because it actually didn't fit what we were doing because he would take on the these large
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malformations as they say you shouldn't treat and and and and actually do fairly well with that do you do you have you have any similar experience or are comments about at
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all well we have used her embolization as as an adjunct to treating these legions Ah but you know I don't really know if you remember ah when we were in New Delhi on the World Federation with him in
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Nineteen Eighty Nine
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Ah there was a presentation from France on
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patients being treated with multiple embolization in a serious way
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and they had about two hundred and fifty I'm not exactly sure whether it was through forty to sixty around two hundred and fifty patients that they were treating bringing them back cheating blunt
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medical printing another pedicle
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by that time they reported that they had achieved nineteen percent
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arbitration with nineteen percent of the patients the permissions were completely obliterated
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in two percent there has lost the patience to follow up two or three percent and the other seventy eight seventy nine percent were still under treatment
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they obviously had some complications from radiation which is understandable
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but the more interesting thing that was reported was that they hadn't lost nine patients
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to re bleeding
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they died
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so am I
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Observation Analysis was this that in order to achieve nineteen percent kill rate they lost nine patients
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and if you are to achieve hundred percent kill rate god knows how many patients you will lose
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because they were not subjected to further treatment like you were mentioning that those patients you can reduce them and then go ahead and remove them surgically or do radiosurgery and so forth
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I'll tell you my You know my Experience with what You're talking about Jim I think you know You're talking about a uniquely skilled endovascular technician that you worked with correct what I have
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seen well first of all I you know I'm not saying you can never cure an alien with embolization but I think it's pretty rare and I would wonder about the long -term follow up on some of those patients
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DR malik that you're talking about if you did a fight or follow the instagram how many of those nineteen per cent were actually cured because I we have an aggressive endovascular group in the twin
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cities who have you know employed that technique and quite a few of those patients end up coming to see me with a recurrent avion several years later but in addition after three or four sessions from
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my perspective the the The leading rate during these envelope repeated embolization starts to become an unacceptable risk
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because your block off most of your access vessels even even in the hands of good endovascular technicians most of them are are struggling I mean I'm seeing patient hemorrhages you know after three
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four rounds of embolization and again jim I think there's probably I'm not debating that Dr de Brun Maybe you know did it and did it well but I dunno how many people can do it well without starting to
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hurt a lot of patience and if you're doing it as an adjunct to treatment I have no problem with it if your stated goal is Cure I mean there is some interesting work now out on Trans Venus
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symbolization and I think if you can maybe analyze off The venous side in the night is without having a catastrophic haemorrhage you might cure the avium but in arterial embolization I think I Dunno
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Doctor Malik I'd love to hear your thoughts but I mean I think the rate of actual cure has got to be exceedingly small and I don't believe it's nineteen percent personal aide said this was after
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repeated embolization that's how it was reported you know I think it was an award from Texas I think from Houston who also promoted the idea of
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and vascular treatment out of his selected patients that he thought will be absolutely unable to complete have a treat him his success rate was thirteen percent in selected patients not our one so so
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I think for all practical purposes that's what I have believed over the years that embolization is not the preferred treatment is that using that as an adjunct is absolutely valuable and here again I
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think you have to be very selective and methodical
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I like them to
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analyze the
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deeper feeders if at all possible cause that's where we're most proud of it if as a middle signals supply superficial I can put a clip on it or rather just I can just
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weird ASs so this
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thing was lacking I think we're getting to one of the central messages of this program in that Is you can read a lot of papers or people would recommend a B C or D but but if you have a team of people
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you have an individual person you've got a search and you Gotta radio surgeon
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it depends upon your team as part of that's part I think you may be mentioned that at the very beginning house had to that's part of the factors you make and making a decision on what to do and
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obviously have a skilled neurosurgeon do you have a for a good and vascular person that tells you one thing if you have a skilled neurosurgeon you don't have a very skilled ashley and a vascular
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person that makes it a whole nother set of choices for you if you have john don't have radio surgery because they don't have a gamma knife or whatever it is that makes another factor so so what it
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does is it takes all the studies that are published and and it's and it's all cave and if you're going to do a study and have to large study I dunno what I get out of that Gerard never liked to use
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Raj studies because he didn't think he and this was an Ego he didn't think he should he should he should put his experience in with everybody else's because he was a very very skilled technician
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really skilled person and so it makes it different and makes how you look at the literature different you've got to have people an honest look at their their skills or abilities and then define your
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treatment as to what you have do you Guys agree with that or not absolutely absolutely it's a team approach I think I swapped my conclusions will say at the end of the presentation
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or Q developed your own team or nut and the twin says I know OK So let Me Get Back I wanted To i didn't want to have a picture parallel let's get back to your powerpoint there you go so as a very key
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point and you want to go on to this one lets you are here so let's see the Speaker I think this is this is a challenge that we folks who treat these aliens are faced with this is a twenty year old
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male who was playing basketball with some friends fence sake went to the Washroom didn't return the event and saw him he was unconscious had a seizure and had a my right sided weakness
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this is his or his study of swimming go back and AH so you can see hemorrhaged and got some antibiotic on the dollar got something magical of blood and if you look at the Samurai next one
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saw his malformation is
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centrally located
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right in his sensory motor cortex and the dominant side
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and then look at his angiogram
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This is his angiogram
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The Question I had was why did he do to this wasn't a twenty year old
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overhead Miami passes and they started getting better
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he has already hemorrhaged
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and what are our choices
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so I entered a pretty lengthy discussion with him in exactly what I was saying before
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I told them that he's going to get to a significant deficit his eyesight of leaving soon may be completely paralyzed
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there's no way about it
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so if he accept it then we can make an effort sought after Cochran for discussions with him and his family they decided to go ahead and have it treated so we did a
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couple of theirself and have as flour treatment embolization
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I think the next probably will show some
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not so and then I took him to surgery
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and I took out his malformation as well as my Routine
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of Big Letter is an angiogram on him and he had this small deep residual
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coming from electrical astride which because of the flow better and we never saw on the initial Angiogram
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exactly so obviously I took him back
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and took it out because now there was no problem he saw his flap was into him we knew where it was and this was actually I think and interpret study
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so he woke up in the
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While Dysphagia and dense right every Purse amply
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he slowly started getting better his leg got really good he's on many millions through
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young man hunting in about three months he became very proficient using his left hand using a computer and went back to college
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and since then he was fed the spastic hemiparesis
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he is fully employed has gotten married
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and I'm sure that he is not happy with this deficit but he's very content
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now I don't know what would have happened to him whether he would have had repeated believes are he would have died from it or not but I think the dishes this is what we need
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to address in and complex problems of this nature and if the patient is willing to accept a certain amount of risk these things are treatable
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terrific point eric and his writing letters I'm just going to go back and show people what you started with their grouse
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the thing I was Gonna mention to you looking at as you wonder recharge all the time about does that impel formation really push the cortex outer waters away from what you think as A is an eloquent
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eloquent areas obviously and in this much like it has a a very defined definite vascular pattern you obviously see some coming off the middle cerebral here here's this article illustrate years are
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coming the interior shots that approach correct it's complex
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and that I forgot there was a terrific result actually and I say whenever you take the rest out and that's what you got and I think your point is is is that better than
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not doing anything radiating and what aM in the category of untreatable lesion I mean that's what you're asking natural history and what you're trying to say is there is a there is a middle ground but
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you've got to be everybody's got to understand what that is exactly yeah I mean this is what led me to getting into this this at issue is you know if you go back and look at the sixties and seventies
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many of these patients were being told that there's no treatment for them and they were coming back and forth with multiple hemorrhages I Think we had one in patient
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during my residency training Ah who would come in and the wife would tell whoever the President was on call my husband had another image
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just admit him so the next you know it's a great kiss the actual visit this is what I added was talking about actually teaching curse okay so here is another young man I think he's on sol nineteen or
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so
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who presented with headaches and seizures and this is his mouth for me
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didn't was you know most of his PSA temporal lobe and getting up into pride Australian hospital of soul desert to just accept a explain to him that he is going to have a field effect
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but his malformation can be treated
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so
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you look at the Angiogram the next one
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so multiple multiple vessels are supplying it this is a posture servers line next
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as the middle server supply
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but is not deployed to the malformations so we did that I think about this as suffer
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and the globalization this is a bucks now and I took him to surgery took out his malformation he obviously as a mindless EMI Anoxia
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later his son is adjusted to it he had no other deficits and his living fine
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or financial encourage and any any comment on that tire Eric
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know I mean that's what I was referring to Annie It's Doable and I think the embolization cuts down a little bit on the bleeding when you're working on the deeper parts of the Malformation and storks
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made it even better over the years the onyx particularly when they get the penetration into the night as an exactly any of the patients willing to accept the deficit we can cure these malformations
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gets back to what you're saying about your bias you're you're admitted bias and that if you can operate on it and surgically remove that COS I AM paraphrasing what you're saying in your experience
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that's the best treatment
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the next excellent coaches know
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so you know this is somebody who had years headaches this is a dominant society actually added midline shift and we managed to
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This malformation allowed but he was actually left with Dysphagia
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and this was before the days of an extent so far so I think I'll have him already easier to reduce it in size
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next
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this is how it looked at thirty
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next
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so
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in children again I think our experience has been Ah I feel that one hamlet is much higher percentage in children under the age of nineteen they basically present with averages and the tolerance of
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other neurologic deficit recovery is quite good so I think that there's those patients definitely need to be looked at and treated aggressively and give them definitive treatment rather than a
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treatment that may or may not work Next
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I think that so this army and Rebecca will make an event Yeah Okay let's see if it da
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if you can now why the video i don't know if that would show up I don't i don't think we were maybe maybe well Gosh maybe while I didn't try this
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trying to play the video
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Ah
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but this is a young girl about eight or nine years old who had a cerebellar radium and had rupture limited to the emirate and it was
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suppliers too small to do any less for treatment and we managed to dig it out and she was perfectly fine I think they they tolerate surgical procedures by the Saudi side know what we are living we
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should do is every come back in the future if you got some videos we can make sure reassure them because videos of Sarah Heck a lot more than this Ah I Miss her and get out of this here UPs okay I
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Gotta Start over Her
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Oh
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Okay I think here we are close to that spot Yeah Southerland just to get your comment about their pregnancy and I think our experience has been that our pregnancy increases the risk of eating about
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two fallen and is most common in the third trimester and postpartum period I don't think I have seen anybody bleeding clearly but we're not expose them to natural delivery although many of the
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patients who come in with other idioms who have had two or three pregnancies enabler regular deliveries but in the postpartum period i guess because of the ER mobility of the vessels increase volume
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the average tendency to bleed and it's side transferred if they have a life threatening him it'll remove the image on treat the malformation electively and an Iris follow them in high -risk pregnancy
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and delivered by C section at least that that has been a routine next
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in handily again I think they thought with treatments quite well and
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I think we reported Otra our experience
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with the patients who were in the older age group again the majority of them present with haemorrhage and saw your people England India it is presenting with emery so that that's why I think no one is
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immune from Eric Bleeding
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next online
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well the twenty eight patients
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or twenty four years and eighty seven percent treated a complete obliteration and overall mortality was two point six percent next
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month I think I'm
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okay
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now we have had this grow up and I dunno how much the addicks experience is either down island treated recently a few months ago a patient who have a proximal vessel occlusions
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that and a distant area so they have double jeopardy in an object people get Moya Moya are for any other reason vasculitis the Diablo se middle cerebral stenosis or Occlusion and two collaterals he
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got a destiny VM so they have dollar ischemia
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and savills those patients actually are very amenable to to be treated in denial we have aggressively treated them because that takes away another source of ischemia for them
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a burger point he
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suggested detailing their collaterals and so forth but most of the collaterals are the collateral so you can't analyze them so you just have to the most recent one actually was interesting it was
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typical Moyenne way I had ahead lot of supply from the external carotid branches primarily the manga so we used a mirror of millennial to do the embolization
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and it significantly reduced the size of the malformation which was quite big and ultimately we managed to dig it out without causing event any deficit was a
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bride a legal under on the dominant side her years of experience reserve combination of people with multiple vascular occlusions that Abraham's Yeah we have a few it's a fascinating group I mean at
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one point a river years ago we wondered about if you did some type of bypass what would happen to the avium and how is it related to the exclusion we never did it but we treated these patients I
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totally agree they're subject to the steal phenomenon in addition to their vascular occlusion and they need treatment I mean in most circumstances outside so interesting that you have this group
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because we have we have a very small group also but they're very interesting cases
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I think it's a really good example very good next
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and I'll for example this patient
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that he had left foot weakness initially was fed to be was very quietly young at that age ago they thought he had amis and so they followed him for a while and then he started having seizures and his
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see he is not so free that E n t E convulsions sleeping most of the time and had this Ah this confirmation you can see this is why typical of right -sided more and more a picture the supplies coming
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from the entire cerebral and even the the front of the fussiest terrible this left sided in Japan and on the rice cited in Japan very interesting phenomena he feels the middle cerebral IT feels down
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backward the left into your cerebral goes through the entire communicating and then feels the opposite side
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to that malformation and his ventricle was very large because his entrails river vein was white light there was draining it next
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I cookie the I don't take that picture is there so
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that he actually it was very easy to dig that out and obviously his left foot weakness and some of the leg weakness did not recover because it was long standing but his seizures got control and he had
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been doing cocaine and earn interest
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so we've also had a few patients who have spontaneously the mathematician has gotten obliterated
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so on the initial Angiogram had haemorrhage and then the malformation was seen that brought them back six weeks later to see what the current condition was expecting that malformation would be more
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prominent and was not seen
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and so for those people we have had an angiography or two to three times if necessary to be sure that it has not open up so mostly that happens with hamlet or if you have a smaller information and it
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has a single rainy rain so there is some possibility that it might spontaneously In none of those patients have presented back to Us with haemorrhage interesting you have an experience like that eric
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long I'm not sure I'd have to eat him I honestly don't remember a case that spontaneously occluded that way but you know you could understand especially with a single
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situation maybe I mean I would wonder so were these Avi Ems where you originally saw them on an angiogram yes yes yes do you think that they hemorrhage because there was a a significant venous outflow
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stenosis and then that's what caused it to obliterate these are basically small lesions they were not big malformations so and we we did the Angel revamps two or three times afterwards to make sure
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that it didn't open up
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and then kind of stresses my pointer prior to taking him to thirty six weeks later it is in order to get a repeat Angiogram
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hundred percent agree Jim I'm kind of up against the time he was going to ask you that I know you have his time thing or we can I think we're pretty much finishing okay if you have to go where we have
37:29
to go but anyway any comments or four you have to go you Wanna make about drug houses talk look great presentation amazing collective experience I think this is what can be done by a skilled surgeon
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with a dedicated interest at a big center and it should create a benchmark and I find it extremely impressive and you know I think nears are experienced probably with the difference being that I have
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less experience with some of the larger Deeper more dangerous malformations being taken on but electively but again I am very happy to see this experience and you should be congratulated for it
38:17
I'm a foreigner though I want to ask both you one of the things I think we're missing in the literature is is Gosh I Dunno if you have you you should have videos of you removing in a VM that is
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probably some of the things that we couldn't show because it was an on my computer not yours but would you mind if we had you come back and if you have somebody who got video on actually how do you
38:41
take the malformation out of it because I think it's enormously instructive to see somebody working their way through a malformation taking it out you see before you see after but actually there or
38:57
the whole the art of this surgery is in how you do it It was not no problem we can do that
39:05
you have some videos you could judge also era Eric I Think I do Yeah I mean they're not as pretty as the aneurysm videos because there's always inevitably some bleeding unfortunately I said OK we'll
39:19
take another life now but I think that's right people need to know how you deal with that and and join in a writer and have you come back and and do this both of you because I think that's enormously
39:35
instructive okay if you have to go go where have you considered I'm going to drop off you guys finish up thank you for including me are correct okay Thank you very much okay Gauss saw just a night of
39:49
ice fire from a technical standpoint you know having detailed selective selective angiography is very very critical position to maintain proper orientation you know rather than to estate and turning
40:06
the head I like to see it in a position that I know we're different structures are light grainy anatomy not minimally invasive stuff that is for upward of these days
40:22
would you repeat that I said lives could any ivory with widest warrior and not the minimally invasive stuff that is so popular today what's the problem with those approaches well you don't see out of
40:39
the structures and so you need to see is what I was seeing visualization of the feeding vessels and the draining veins you have to be able to see all of those obviously approaching the feeding vessels
40:56
utterly the energy to the draining veins as much as possible certainly leaving at least one of the larger ones in impact till the end differentiate between feeding vessels and emphasize vessels this
41:13
is also very important because some of the deficits come from just going around the malformation and taking everything out and some of those vessels are going through the malformation and actually
41:28
supplying distant part of the brain so taking a little extra time sometimes I don't use Glyphs is a post -op and your games you'll hardly ever see any cliffs but temporarily you could use temporary
41:47
clip and then scrutinize them the branch that is feeding at perpendicular level to the flow of the floor floor of the vessel and that way you can actually reserves the ampersand vessels and
42:06
recognizing those even while doing the envelope Asia because if you do embolization you're going to a clerk the distal vessels so that may be one of the things that one has to look at even during
42:21
embolization and be ready to deal with unexpected bleeding and swelling
42:31
you can run away from the operating room
42:35
or
42:37
nepal either LiAM's maintaining the peripheral line of dissection and these small feeders are the most difficult to control
42:47
they
42:50
they they've actually make you drag them back to the larger vessels because they don't have normally we can go to a tumor let's say dissect around it those other small vessels didn't cause any
43:07
problems but here they have gotten larger and his heart you can't globally the blood you have to regulate the soft tissue so you have to have a low power bipolar and expose a portion of the vessel and
43:25
slowly occlude them
43:29
this was the most frustrating part of it this one slide is as a world of information about a VM cited I think those are those are really key key points are minimally invasive that's what everybody's
43:49
doing now but do need to have a wide exposure another thing I think that you probably were going to say is is no microscope paralysis Taking out our JPM or a sizeable avium is like taking out a
44:02
vascular meningioma and you don't take it out through a little tiny Hole I mean that makes no sense and you and if you have to use lope she was little she is not an admission of of inability it's a
44:17
it's an admission that you read a wider perspective all the time until you can narrow it down to the point where you a microscope is beneficial when you get into microscope paralysis right exactly and
44:31
I mean you Gotta be adaptable here and the approach of feeding vested as early as absolutely right via visualize the feeding vessels in vain you can't do that with a minimally invasive approach avoid
44:44
injury to the draining veins cause if you include them you're going to back it up into the malformation it's going to be a disaster feeding on passage absolutely right
44:56
Unexpected bleeding and swelling I mean that's what your daily once you're dealing with dynamite and you Gotta know how to handle that for large relations yes that's why you have to maintain this this
45:10
this is almost a loop loop a loop loops a perspective because it allows you the the facility to go move around the edges of this large malformation you work in one area it's bleeding a little bitch
45:26
put some continuity center at stops that should do it you'd never dig yourself a hole because you can't see anything and you keep we keep gradually working around the rim of the thing and nearing the
45:39
base and when you come to the deep theaters at the bottom it is I've seen people try to coagulate those with a quiet elation high and you just burn right through the vessel they keep chasing it and
45:49
they burn through the vessel you can't do that and it's a that's where a microscope is helpful and you're right you got to bear out a longer segment of the vessel in your attic or coagulated at lower
46:02
powers so it doesn't burn the vessel that acquire it it it compresses it and catch it together just as tremendous judgment and tremendous experience sir but if you're in a hurry you don't know about
46:16
these things it doesn't come out will matter that what amidst
46:22
okay I think I was Superb Limitation surgery Limitations Okay you know everyone has their limitations and I think we need to learn from those experiences in order to I had to put access a log idioms
46:44
before the availability of interest for sport but I Embark on treating two patients with giants have written to a lithium and repeated repeated bleeds and the all died
47:02
the common denominator was extensive deep supply through the perforated
47:10
so if they were and similarly to patients in the Posterior Fossa where the supply was coming through the brainstem through perforating vessels it just impossible to control so understanding Ah now I
47:29
think we look at that little bit more carefully analyzing the Angiogram better and
47:40
they were probably better to be left alone even though they are hemorrhaging so we we did it out of the frustration but I found that as a as a limitation
47:57
Well I think it's annoying when when you can't do it and I remember I had a young woman I don't think she was into trade where she came she had a camera cavernous malformation in the in the in the
48:14
textural plate on the top of the Midbrain that it was extended into the into the into the ventricular system and bilaterally and and it was fairly large and she came and she wife came to me and
48:30
Ariston asked me about treatment or off your salaries mariner in and I said well why don't we go around and get other opinions while she went to the all the name brands and got opinions and many of
48:44
them said take it out and my feeling was you know
48:50
she had a mom she bled a number of times didn't have a deficit ah am i feeling I should you know something I think we should wait I think I am going to give you more of a deficit than your God which
49:04
is not much at all and the devastated I'm going to get the deficit I'm going to give you is devastating and I don't think we should do this or what she stuck with that and went through her life never
49:18
had to have it out and I had a bleed once I went through became a girl got a nursing degree and so forth raised a child now one case doesn't make a whole series but but but there are things which you
49:34
can get to like you were just talking about that when radiosurgery helped her know with embolization of alter know but so that the surgery or watching and there are some things where you just Gotta
49:47
say no I just don't think I I don't Think I can do this and that's what you're talking about in the slag Executive understanding you saw the problem and
50:02
annoying what the limitations are there are limitations king in our treatments whether it's for cancer of others for vascular disease or whatever it might be limitations additive and it's now unseren
50:18
ash okay so the are the malformations the deserting probably a repeat of it the malformation located in the Telemachus and brainstem supplied by the deep perforating vessels traversing the brain
50:35
tissue or at least in our in my hands not amenable to surgical resection AH As I said before as I counted three such cases was unsuccessful therefore it either you leave them alone or possibly treated
50:52
with radiosurgery if they are small enough to be amenable to it okay next
51:03
our approach absolutely collaborative multidisciplinary program between neurosurgery and west blow and radiosurgery each patient discussed individually treat the mathematician whenever feasible
51:21
and hard place microsurgery absolutely the preferred approach and Alaska support utilize fourteen idle aneurysms night and resumed our employee enough deep fetus radiosurgery in selected Deep
51:36
malformations patience is the Ultimate decision maker and confirmation of the completeness of treatment by angiography is critical
51:51
so this is a disorder was referring to if I didn't have the numbers at that time sun in our database the thought of patients evaluated between seventy one and two thousand fifteen or fifteen hundred
52:09
and seventy four total patients who definitive treatment was eight hundred and forty believe yams five hundred and seventy saturday alone or rhythm realization five hundred and thirty five eighteen
52:26
thirty twenty eight just as you are a bias template isn't alone in Salmon Kevin Loomis says you can see him in ninety one or Cranial Enduro Eerie Fistulas Ah multimodality approach and fourteen spinal
52:48
I'll combine fifty one Scalp another six and Vita send you one was earlier on we thought these were
52:57
bleeding but they are related to the covenant was buried so this this was an experience as a fifteen and I think we're updating it next
53:10
okay so mortality as possible treatment cerebral idioms fourteen patients two point zero five percent
53:23
one grid embolization and one hundred recognise hydrocephalus and rear center others basically enlarger used in incredible results and current ever Normas zero mortality urinary fistulas two pieces
53:43
one with thirty and other one was a trance penis a blue Jean saw embolization so that that that has been our experience obviously we don't have all the categorize people who have had some deficits
54:02
they often improve over a period of time but some people are left with deficit outstanding just outstanding results
54:15
okay this is somebody you can't treat
54:21
or I could see that right
54:25
or
54:28
or that's more of the same okay this right
54:36
Okay So my Conclusions you know I learned a great deal about these vascular malformations in the last fifty years and have tried to impart this knowledge to my residence and share with others and
54:56
medicine around the world and these vascular lesions requiring multidisciplinary approach with appropriate team that was for the best interest of the patient not our own bias we still need to learn
55:13
more about and find better and safer ways to deal with them and above all I think the most gratifying aspect has been knowing my patients supporting them and sharing their difficulties as well as
55:30
sales of their lights
55:33
outstanding
55:35
I would stay at a job let me stop sharing here a minute well it's just a terrific job and I think what we're Gonna do is this and I'll let us on this boat I think we're going to divided into this
55:50
whole thing about Abraham's into three parts okay part part but we're going to divide this is two hours we're Gonna Divide divided into two I'll divide I'll find a convenient time both about an hour
56:03
each way in part one and part two I think the issue with a VM since people need to see it they sheen and the maintenance amount from what you're showing them but the technical aspect of dealing with
56:18
this is extremely important and the next thing is I'd like to get you an Eric I actually I made videos but I don't have them I've saved some videos that are too old or too fuzzy but Ah I like to get
56:37
somebody and who's who knows what they're doing technically and this and this particular problem and every can you can you're going to have to get you're going to have to look at it on your of your
56:51
your computer with your screen because your computer can play your video Codec I can't sew so he probably already got thirty minutes of them will get thirty minutes with Eric and we're going to have
57:04
some discussion along the way and after that at and then we'll we'll have his three hour segment on Avi Yams and I think that's a you can't do better than that and I I think your your work is the
57:18
foundation of that here and so would you be willing to try to get together some examples of videos during surgery so I think I eat out you know this has been my major shortcoming is Not getting myself
57:37
trained into doing editing and doing videos ah many of them were recorded but that day they haven't been put into a proper presentation I have about I think four or five of them are richer rich richer
57:57
suffice
58:00
getting an assessment of how to go about the malformation so so I I think I can gather those but can we do that and none the next thirty days or something you're doing short shots and I'll ask Eric
58:16
and then even let's say even if it takes two hours then it's a the AMS parts one two three and four and the Reason I say that is is he you can give an hour talk to somebody and they're not that's
58:33
that's not how you're going to learn a subject
58:38
I mean you spent two hours talking about it there's there's a tremendous amount of judgment and wisdom in there or watching somebody operate is how you learn that takes us an hour or two hours adults
58:50
that's it if somebody wants to watch it and spend the time fine if they don't I can't help them but to me that's the only way you can learn about this subject
59:01
this is complicated it's challenging you have to see the resurgent skill is patience his judgement on what he does at each Sir I mean into this is rolled into this I I I've I've evolved to the point
59:15
where I look at the art of surgery
59:19
and because I had a resident where we had an Illinois cruiser booed we who you know he was from Michigan he was an aggressor is very very talented Surgeon we were operating one day and Chris came and
59:34
said you know Jim your there's nobody sees Caesars nobody will ever see or know what you've done here and I never forgot that unfortunately videos can help you and and US to do some other things up
59:49
but but but there is so much you gather from watching somebody do something you can't write it in a textbook there's just no way you can communicate that accept are watching her say I tell residents
1:00:05
that it was our routine we used to run to operate he loves back to off downloader we were not operating so little foot on the scarves and would go to the operating room and see somebody else operating
1:00:24
right okay and now even the residence is government case you are done with it and they disappear
1:00:35
they don't go into the next room to to see what's going on
1:00:42
because they think if they're not scrubbed in using their own as they are not learning
1:00:48
that's absolutely right that's why we had TV around the hospital than the average person and the officers so if the residents were near the operating room and there were seeing patients they could
1:00:59
step out for a few minutes and watch it on TV and a late pick up some key staff fender and so so that the amount of information that was transmitted became very huge if you really wanted to take
1:01:11
advantage of itself while okay Thank you very much for preparing and so forth I'll be back you will set up a time I'll get my Secretary who observed the same name As I Do I'll arrange US more these
1:01:24
are the key references and charged to Dr Malik's talks on cerebral Eve Yams it's best that you take screenshots for your records some of the references are given during the presentation so you should
1:01:40
should be prepared if you're interested to take screenshots of those images also
1:01:49
this is the essential references DR Malik recommended for your reading
1:01:57
take a screenshot of this for your Records
1:02:03
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1:04:54
This is the second in a series of talks by Dr Malika discussion with Dr Malik on his extensive experience in treating fifteen hundred Avi AMS is internationally known for his expertise in this area
1:05:10
this is part two
1:05:18
but
1:05:20
Sai Digital now offers all of it's programs on podcasts on Apple Amazon and spotify look for them under arrest and I digital
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and the Foundation supporting these programs also supports the medical news network which is dedicated to bringing truthful medical and science news to the world
1:05:41
the program is copyrighted in two thousand and twenty five of the James I and Caroline are Awesome and educational Foundation all rights are reserved contact entourage for more information
1:05:53
thank you very much for watching we hope You have enjoyed
