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SNI, Surgical Neurology International, an international,
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and SNI Digital, a new interactive digital medical education system.
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In association with the Sub-Saharan African neurosurgeons are happy to present another in its monthly Sub-Saharan international African grand rounds in neurosurgery held the first Sunday of each month.
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In this 19 Sub-Saharan African international grants under our surgery grand rounds, the general topic is global solutions to clinical challenges in neurosurgery. The moderators are Strada Bernard
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and James Osman presented to an international audience on Sunday February 1st, 2026.
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And the topic in this meeting is mechanical thrombectomy for cerebral venous thrombosis in pregnancy. Case report and review of the literature by Caliph
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Abdefata in the Kenyatta University Hospital in Nairobi,
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Kenya. Caliph Abdefata is an interventional neurosurgeon, a hybrid neurosurgeon
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Okay, fine. Dr. Caliph is one of our colleagues. He works at the Kenyatta University Teaching Hospital and he's a neurosurgeon there with a team of two other neurosurgeons. They have three
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neurosurgeons in that hospital and he's going to present a case which they did as a team. And it's an interesting case. Now, he
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runs an endovascular program there in that hospital.
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Probably it's the only one at the moment in the public hospitals, or because our hospital is still a public hospital. In the private hospitals, there are some programs which run, but in the public
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hospital, because of the expenses involved, this is the only one, but this is the host of where he works, he works in the campus hospital. It's a very, very well equipped hospital for training
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and for managing, for managing cases in the
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private hospital So Dr. Halif, our firefighter, he can also explain as he joins and tell us about his hospital and his unit and all that, because I think it would be something interesting for the
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audience. Thank you.
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Thank you. That's very interesting, yeah.
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Thank you very much. Thank you, Father. Thank you, please proceed. Welcome. Thank you very much. Thank you for that kind introduction. Thank you for the opportunity to present. My name is
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Akhale Babatak. I'm one of the newest agents in one of the referral hospitals in Ayurabi, Kinyata University Digital Referral Hospital. It's a relatively new center with interest in tertiary care.
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Basically, all sub-specialties are available, and our focus was mainly on
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neuro-vascular. So I just wanted to discuss one subset of
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the overall topic that we were supposed to discuss, which is stroke. And that is cerebrovenastrombosis, which
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we see quite often, but is not as common as the ischemic strokes.
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So CVST is a rare disease that involves the formation of a clot within the venocinuses.
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And the venocinuses are the structures drain the blood from the brain. This is our common knowledge. It is not as common as ischemic stroke or hemorrhagic stroke. It accounts for around 05 of all
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stroke. So it's not a relatively common scenario.
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The risk factors are female gender, especially reproductive age female gender, smoking, pregnancy, and the use of oral contraceptive pills. The challenge with this disease is that it's symptoms
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or the presentation is non-specific These patients usually present with headache and seizures. And the diagnosis is almost always delayed because of the nonspecificity of the presenting symptoms. In
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one study, all the patients who presented with CVST or all the patients who had a diagnosis of CVST had some sort of interest level hemorrhage.
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Even though it's rare in its incidence, it has a 5 mortality, which is not very low.
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and 136 of patients have bad outcome, not necessarily mortality, but a more score above three.
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The goal of treatment is to prevent thrombus propagation and also to establish venous drainage. Excellent. What is the problem actually? Excellent slide, terrific. Yeah, thank you. So the main
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problem usually is the thrombosis If I just allow me to,
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sorry, just to see if I can get the whole slide in. All right, good, you can see here. So the problem is there's a thrombosis or formation of a thrombus within the venous sinus
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and then that will lead to venous hypertension, which will lead to
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sluggish drainage of of venous blood, breakage
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of the blood, brain barrier, edema, and then venous infecting - that venous infecting transforms to a hemorrhagic core. And then this also impacts the CSF reabsorption, which leads to
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intracranial hypertension and herniation. So that's usually the orthophysiology of CVST And that's where the problem lies. It's basically a plumbing problem.
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So if you look at this on the - can you see the cursor?
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Yes. Yeah. So if you look at the image on the right, right on the side of the screen, that is a huge cloth at the sphere, so it will sign us. And that now forces the black to look for other ways
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to drain out of the brain.
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So how do we make the diagnosis?
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The symptoms are very nonspecific. The only option that we have is to get
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imaging. So what type of imaging to use is the next question. And the best is to get an MRI MRV, which will show you where the clock is, the bottom of the clock And if there's any hemorrhagic
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transformation.
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So what do we look for in imaging?
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Usually we usually start with CT scan to find out if there's any bleed or anything. The main
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giveaway or the main thing to look for in CVST is a stroke that doesn't go with an arterial territory So, we all know.
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what an arterial stroke looks like. If there's an artery that is blocked, it's a specific territory that gets infected. So they image on the left, you'll see that that patient has an MCA stroke.
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No brainer, the area that was supposed to be supplied by the MCA probably at the M1 level occlusion and that area is infected. But if you look at it, if you look at this one on the right side,
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there is an MFAC there So it would look like a watershed ischemic in fact, but actually there is no, you know, artery that has this sort of distribution. So this is a giveaway. So this is what
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you look for in a CT scan an MFAC
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that doesn't represent an arterial territory.
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So the goal standard, we say this MRA, MRV,
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which will show you the clot distribution, the clock button. the infected area, whether they
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are hemorrhagic transformation. Is there a
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specific classification for superior cytosine thrombosis,
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which is usually adopted? Why do you worry about the superior cytosine thrombosis? Because it's the most lethal form of
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CVST. If you have a one-side block, usually you'll be able to drain on the other side if the blockates at the level of the transverse or sigmoid sinus. But if you have occlusion or a clogged
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occlusion at the posterior side of the spherous cytosine, these patients tend to present with a terrible neurology. So type A, if there's a partial occlusion, type B, is if there's complete
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occlusion. And type C is if there's only a cortical vein that is occluded and type D we put it one days. The sinus is uploaded. and there's clot also in the cortical veins.
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Are you doing a classification based on MRV or on catheter angiography? No, this is usually on MRV.
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Okay. Yeah.
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So there's a pepper that proposed that for patients who have a refractive CVST
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and that there is a role for intervention.
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This was a pepper done a while back. It had 185 patients of which
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one of them had
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intracilis of thrombosis
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with medical treatment, 84 of them had a good outcome and 5 had no reconolization.
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And of those 5 now, they, for some of the patients, they had to
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do a mechanical thrombectomy, and that's what we want to discuss today.
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So endovascular thrombectomy for severe cerebral venous sinus thrombosis, and in
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these people also, which was done in 2024, quite recent.
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The conclusion was
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that endovascular treatment was associated with favorable outcome on the patients who underwent that procedure.
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What is the current management? The current management is heparin, as a first-line treatment, which provides rapid anticoagulation.
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But we all know that heparin is not always suitable for all patients. There are patients who will develop bleeding, patients who have thrombocytopenia, patients who are watching neurology despite.
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treatment. So it doesn't have our patients and we need to have a plan B for those patients who have who are not responding to medications.
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Other medications that we use are the DOAX,
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the reparaxoban or what we want to emphasize is that if you do the MRAMR-V and in the MRV you find that the patient doesn't complete occlusion of the superior cytosinus, those patients tend to do us
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compared to the rest.
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So in the vascular procedure is an option and this is catheter-based treatment and there are two things that we can do at that point. We can literally remove the clot using the standard ischemic
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thrombectomy devices or we can put a microcatheter in the sinus and then give anti-thrombolytic drugs such as alteplase into the sinus and that creates a channel for the for blood to go through.
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And in one study where they did 21 procedures, 20 of those patients had a good outcome. So these are case for patients who have severe CVST, especially superior sagittal sinus or serious thyroid
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occlusion and who are not doing well with medical management in those patients can
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benefit from the vascular treatment.
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So this is a schematic
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plan of which patients might benefit. If you find that the patient is not responding to a paren, then they may benefit from endovascular treatment. And after you do that, if everything else failed,
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then you may need to do a decompressive clinic after me.
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So we want to present a case from our center, which was a 28 year old female first thermostat.
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with was a neurology. The story was that two weeks before the presentation of symptoms of headache, she had a bout of GE, gas ventilitis in which she had the
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re-envomiting. And then she developed headache. And by the time she was coming to us, she was GCS-12. She had to be intubated the second day. We started on her body and then she developed PV
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bleeding. This was her first pregnancy So it was a difficult case because it's a young female, pregnant with history of dehydration. I'll show you the images. She had a terrible CVST. So we had a
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discussion, multidisciplinary discussion amongst ourselves in neurosagerie, in neurology, or up-skying, in mortality and in physiology. And we realized that we could not continue with the heparin
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treatment. She was getting worse very rapidly. And we discussed pregnancy termination in terms of exposure to radiation, contrast, general anesthesia. We discussed with the husband extended
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family and their decision was that they want to keep the at least the pregnancy for now But we proceed with the catheter based treatment So if you look at the screen here on the on the left side of
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the screen where my casa is pointing This was high MRV. Sorry This is how MRV is a standard how standard MRV should look like but here is high MRV and you see complete absence of the serious digital
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sinus and absence of the both transverse sinuses is some flow on the on the right side of the sigmoid and Chugula vein, but on the left is complete absence. So The issue we made was to proceed with
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catheter phase development question. This is not a part of the MRI
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study At here you find there's a thrombus in the superior side of sinus. There is a hemorrhagic
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In fact, there is a Venus, in fact, doesn't correspond to any, any arterial territory.
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Then this is also a lateral view and an AP view of the MRV. You see that she's completely from both the superior side of the sinus. The brain is actually draining through the scalp veins So this
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indicates a very high ICP, intercontinental pressure.
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So we proceeded, we took her to the cath lab. We had an entry from the right femoral artery. We did a standard DSA with a five-range catheter, six vessel angiography. And we found that she had a
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complete process of the draining sinuses And we determined that the left transverse sinus to be the dominant sinus. And this was. based on our MRI finding. So we decided to use the left side as our
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access,
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because from the MR study, we found that she was draining partially on the right side, but actually her main drainage should have been coming from the left side, which was completely occluded.
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So this is how the
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arterial gram look like This is the guide that I find French, and if you see at that point there,
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this is the capillary face, and if you go forward, this is the venous face of the arterial gram. And you see this complete absence of complete angiosidance of the superior sagittal sinus. She's
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draining through the cortical veins, and the cortical veins are draining through the cavernous sinus, and then the protrosos, and then coming down that way on the right side.
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She's not in good shape at this point.
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So this is our Venus axis, this catheter here. Can you see that? Can you see my castle? Yes, yes. Yeah, so this is the guide catheter on the left jugular venus.
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And this here is a micro catheter that goes through the sigmoid transfers and then going all the way up to the superior sagittal sinus. And then at that point, at that point we push contrast and you
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see as I push contrast, there is no contrast coming back to the sinus. Ideally what you need to see is contrast coming down along the catheter and coming through the draining sinus.
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But at this point you see that we push contrast And then the, the, the, this. vertical vein is actually draining the contrast going all the way down to the cavernous sinus and then coming down
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that way.
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So we proceeded with the thrombectomy. This is the catheter, it was with those
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28 French catheter,
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and with that we deployed a
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stent retrieval, the metronic stent retrieval, and
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the initial phase you see where
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the blood was draining through the cortical veins, at least now it's coming down along the sinus. This was after the first pass, and we have to do a multiple passes.
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This sinus was almost a centimeter wide, and the catheter that the stent retrieval is designed for an MCA,
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a rice here, and On the side, the maximum size you can get is a six millimeter. So with one pass, we will not be able to, we can analyze. So we have to do multiple passes. And if you look at it,
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at least from the initial passes, you can see that the contrast is now coming down
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the sign as I'm not going through the veins.
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Can I ask you a question?
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Please. Is justice a mechanical thrombectomy? Are you infusing any hemolytic agent or is this just mechanical? So we could not use because this patient had a PV bleeding, she had a parvaginal
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bleeding, she was pregnant. One of the reasons why we couldn't continue with the medical treatment was because of the risk of loss and bleeding. So we did not want to put any, any, any, um,
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leadic agent into the, into the sinus. We were limited by that So we're going to line on mechanical from the victim alone. So you're just trying to break up the clot with the catheter? We just,
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yes, not normally the catheter with a stentri-triva. So stentri-triva
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is used for, ischemic stroke
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for thrombectomy and ischemic stroke. So using the same device, you deploy a stentri-triva through the catheter and then you pull back with a stentri-triva on the catheter and then that takes up,
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that creates a channel for drainage for the venous system.
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Okay. Have I explained clearly? Yeah, it works, it works like a basket, correct? Exactly, exactly. Yeah, so that's how it works. So you pull through that, it's a mesh-like system and then
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as you pull through, you create a channel. Then, but you need a big stentri-triva for the venous system because this we measured, it was almost a centimeter wide. while the stand is the maximum
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vegetation of the stand to three by six millimeter.
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So we had a very good outcome. After 24 hours, we were able to extubate how? You didn't show an angiogram or it was open. Yeah, it was, it was proficy. This is the initial, this one here.
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This is how it was started. You push cut contrast and this contrast is not flowing back It was draining through the cortical veins. And if you look at it, it was the initial pass.
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And that's the part of that recanalized. And we kept on digging until we got a good flow that was draining throughout. And when we did the arterial gram from the other side, there was significant
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flow into the sanitose highness. OK, so we were happy We were happy with
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the from-vector.
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We were happy because the outcome was good. We were able to expect after 24 hours. She had a severe left side weakness, which gradually resolved, not completely, but gradually resolved because,
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as you saw, the MRI she had a big impact. Her seizures were under control with oral medications, and her pregnancy is progressing well, and we're planning to do a fetal anomalies kind of 27 weeks.
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So there, again, ecology stuff following her. So that was our case We had a good outcome, and our message to the community is that for patients who are not doing well with the medications, who
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are not progressing well, who probably have a contraindication for medical management, such as our patients who could develop PD bleeding at that point, mechanical thrombectomy, that should be
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explored. Thank you. That's an excellent presentation Can we ask you some questions?
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I was trying to do you have some things you wanted to ask?
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Well, go ahead, Jim. But yeah, the first question I had - and thank you. That was very thorough and very interesting. A lot of questions got generated in my mind. But the first thing is, how
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do you define
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the failure of medical therapy, the
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hipran therapy? Is it just a matter of failure of progression? Because you wouldn't expect the hipran to lice the clot. So it's a matter of the hipran just not - the things are getting worse
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despite hipran, is that how do you define the failure? So it's a clinical definition. It's a patient who's getting wasneurologically with medical treatment. So those are the patients who are
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refractory Other group of patients you start to help are in. And then on the next day, the plaques are 50s, 40s. And now you risk bigger problems again. So those patients also, you are limited
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and you'll have to switch to other therapies. Yeah, so it sounds like it's a matter of the kelvin not preventing progression. It sounds like that's the key. And what about the degree of hemorrhage?
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How does that influence your decision to intervene, the degree of the hemorrhagic venous enforant? So it's usually not a contraindication for treatment with heparin. So we know the pathophysiology
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of that hemorrhagic stroke. It's because of
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the edema, the venous clogging,
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cytopoxic edema, the treatment is actually pre-vascularization. So even with patients who think of hemorrhagic transformation, they need to get heparin. No, yeah, no, no, I wasn't speaking so
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much about the heparin per se, but the mechanical thrombectomy, especially in someone that may have had a, that you re-kennelizing after they've had a complete occlusion I was wondering if there's
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any concern that you might make the hemorrhage worse.
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Usually not because once you reopen the venous system, the drainage is better. So there's only one way which is to produce that pressure, which is to reverse colonize. So if you do the mechanical
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thrombectomy, the hemorrhage usually does not get worse. It should be getting better But in the event that you use leading agents, such as alteplase into the sinus. then that can have consequences,
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yes.
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There's some people who have some questions in the chat. And Dr. Kamani says, A cashew nut sign. I'm not familiar with that. Also on CT scan as an indicator of cysts. So for Dr. Kamani, are
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you still there?
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I don't hear Ben Matuso
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how much of the he asked how much of the sinus do you aim to open up what percentage of flow do you aim for? Ben, are you there?
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Ben Matuso? Yes, yes, yes, I'm here. Ben, Ben, ask your question here. Your question is how much of the sinus did you do you try to open up what percentage of flow do you aim for? In other
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words, when do you stop or what's your point there?
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Yes, I was just trying to get from my colleague, Dr. Khalif is my colleague
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and a good friend and thank you for the presentation. I just wanted to find out how much of the sinus you aim to open up because I saw for this particular case you didn't go for 100 of
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recondylization. Is there a threshold where you say that this is enough?
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So, yeah, good question, too, so the
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micro-catheter is like two millimeter.
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You can easily take that to the superior sinus out to the anterior third. And then once you deploy the centredivore, the centredivore is six millimeter. And if that centredivore goes through the
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system, my belief is that you've already created a channel. And once you create that channel, there is enough pressure to propagate if the patient doesn't have the risk factors that caused
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initially, which in this case was dehydration. And patient has already been on hyperin at some point. My belief is even
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with one pass with a centredivore, you may have created a channel for the venous flow So it's not, from my reading, there's no. need to look for 100 opening. There
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is actually no need to also explore the other side. We did it on the left side. In our case, you've seen it. There is actually no need to go to the left side. Once you create in our channel, you
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wait and see.
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So one more question. Another question there. So since you're in a thrombogenic environment, after you've done the mechanical thrombectomy, is there a need
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to have some sort of anti-coagulation? I know of you, in this case, you were balancing her bleeding risk already, but
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I'm just wondering about whether you, there might be a concern for read thrombosis if you're not using any for the anti-thrombotic
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In ideal cases, I think the heparin treatment will continue in ideals from the dark case. we weren't unable to do that. So the patients should be well hydrated. They, you should treat the initial
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or whatever we think is the main risk factor. And if there is no contraindication, then heparin treatment should continue because they're usually sick, they're in the ICU. So you also run a risk
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of DBT, pulmonary embolism and all those things. So yes, they should be on medication for that
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There's another question from Dr. Oakley. Dr. Oakley, are you there?
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He said, Great presentation. The challenge is the clinical suspicionthat will warrant MRA and MRV. Should both protocols be used in most brain, MRA scans, questionable MRI scans? And another you
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did say, through an MRA and an MRV,
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how would you answer him?
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So Let me just see the question clearly.
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Yes,
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the imaging of choice is MRMRV and you need to get
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both together with time-of-flight sequence, EDC, DWI, a full-stop protocol so that you get all the information that you need. You need to get, you need to rule out a material cost or a stroke.
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You also need to see, once you do the MRV, you'll be able to know where the clot is located, that's number one. You'll also know the amount of clot that is there, which is the clot button.
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You'll also know if there is any area that's already infected, if there's hemorrhagic transformation. So it's a standard, the goal standard for making the diagnosis So I think, yes, we should get
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MRA MRA. is the MRV, an extended MRA. Yes, it is, it's just a face of the
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MRV after you give the contrast. Okay, so you follow the, you're following the flow through into the phase and then you have to, since it's much slower, you have to prolong your, your, your
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evaluation. So it shows it, right? Yes, yes.
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Okay. So you mentioned that there was, there was poor prognosis with, with a, with acute occlusion. What, what's it? Can we stop, can we stop screen sharing for a minute here,
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as well?
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Can we see everybody? There we go. Oh my. So the question, the question I have, the question I have for you is, what cases do you think the prognosis is so poor that it's not worth pursuing?
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What are the contraindications based on clinical presentation? Many of
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the patients is very sick in terms of GCSEs, three, half comorbidities, probably the
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clotty button is too high,
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then whatever you do is probably is not going to help But if the patient has a fighting chance, young patient
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relatively with good resolve physiologically, no comorbidities, then the data shows that outcomes are good. The MRS score in six months is going to be below three
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Michael, Michael, Michael, Michael, you mentioned that you have to ensure when you're doing the MRV. that it's not time of flight. Can you explain that? It's all over. Thank you. Thank you
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for excellent presentation, Dr. Halif. I just wanted to say that when you request the MRI, MRI, MRV, depending on the protocol of your institution, if you don't have enough contrast, they can
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do time of flight MRV, which is just a gradient echo technique to visualize flow of blood And it doesn't give any real-time occlusion. So if you don't insist that it's not a time of flight, you
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could get an MRI, which would look like there's no occlusion. That's just one thing I wanted to note when requesting.
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Thank you. I don't understand that, explain it to me. Why is that different from waiting until the dye goes into the venous phase?
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No, I was just trying to explain. Locally, when we request for MRIs, if it's not a radiologist doing it in sister radiographer, sometimes they just use the gradient echo to show flow through
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the vessels. So in everyday practice, sometimes you get MRA MRVs, which are not congruent with the clinical presentation. So you have to make sure that you request, that you make sure to request
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a proper MRA MRV That's the point I wanted to highlight from the previous question before, yeah. Yeah, they have to extend it long enough so the dye gets into the venous face. Am I correct or am I
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wrong? You're correct, you're absolutely correct. Okay, okay, that's right, excellent. And let me see, we have another, Dr. Bowen, would you consider balloon embollectomy in view of the
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large diameter of the sinus? It's an interesting question.
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Caliph, what do you say to that? Yeah, so. from the literature to review, yes, there are people who do that then, but the,
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the discussion is
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the venous system is made of dural flops, they really triangular like that, sorry, they're like that triangular. So
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you'll want something that will conform with the edges of the dural sinuses Baloon is non-yielding. So most people are of the idea that you should use
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stentruth river as opposed to an embalectomy. There are people who are doing it, but in the event that the stent comes on the edge of the dural, it yields, it bends, it wobbles on itself, and it
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doesn't usually cause an injury. While a balloon under pressure, the sinus has to give way, not the balloon. So there are some people who use it, but from what I have. seeing its effort to use
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the central river. The only concern, and the main concern is the cost. It's probably 10 times more expensive than a balloon. That's safer.
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Can I ask you, there's some people who have joined us later. Can you make a just quick summary of the patient's presentation and what you saw in imaging what you did so that we can bring them. So
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they're up to date with what we're saying
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So in other words, this was a young woman who was pregnant who developed a stroke-like syndrome and your MR showed that she had a, it was a venus infarction-like, right? Yeah, so this was our MRI.
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So this is our MRI and as you can see,
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this is the lateral view, this is the EP view. It's complete occlusion of the superior sagittal sinus.
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and she's actually draining through the cortical veins and scalp veins.
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Now,
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it's interesting. Go back there, just a minute. We go back just a minute to that side. If you see the draining vein here on both sides, you see on the AP view. The scalp veins. Yeah. I'm sorry.
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Yeah, so. It's in the major veins here in the neck, see? Juggular veins Yes, this one is draining, this is partially hardly visible. These are supposed to be very large visible structures on
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the V. It's draining out through other, it's draining out, still trying to drain out through the juggular veins, but it's not enough, right? It's not enough, and it's draining through colletals.
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There is complete
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angiosylants of the spherocytal sinus. There
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is complete silence on the left's transverse and sigmoid Yeah, so she's she's draining through other means, but not through the usual.
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standard drainage system. And you're in the picture before, just go back a second, the picture before. Yeah, this is the MRI. Okay, no, before that, the one before that. I'm showing that.
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Yeah, so this is a normal MRI from the net, from online. This is how it looks like. So this is what you need to see the superior sagittal sinus. You need to see the draining veins draining into
39:29
the superior sagittal sinus. And you also need
39:34
to see the similar sinuses. And the image to the left is just shows that those things are absent, right? Yes, yes. Excellent. So in our case, this is completely absent. And here you're in the
39:47
you're in the venous phase because you don't see sinus but because they're already draining in the venous phase here, right? Yes, this is the venous phase So you said he just for summarizing for
39:59
everybody else you she was getting worse. I put you put her on hepar and she didn't respond to hepar and was still getting worse. She was pregnant and you decided to do a mechanical thrombectomy.
40:10
Isn't that the story? Yes, that's the story problem. One of the reasons why we couldn't go or continue with the heparin was that she developed a vaginal bleeding. Yes, okay. Which again, after
40:24
a while. No, I didn't understand the argument about she was pregnant. What was the, what was the, and you kept her, you went through and you kept the pregnancy. You were worried about
40:35
irradiation, right? Yeah, we were the multiple issues. We were worried about the contrast, the general anesthesia. For the team, yeah, this is what a Stent Retiva looks like. Can you see my
40:48
Casa? Oh yeah, see that. Yeah,
40:52
so this is what a Stent Retiva looks like. And you deploy it through a microcatheter. Okay. Yeah. But that was trying to get behind your thinking of why you decided to continue and not doing a
41:06
C-section or something like that. So - No, she was, it was early pregnancy probably. This was first time in Stapregna, few weeks.
41:15
It was a first trimester. Yes, first trimester, yes, yes, yes. Oh, okay.
41:21
And are you worried about the radiation effect from all the imaging or? From the, yeah, from the cath lab, there is a radiation exposure. We have to cover her all the way to the breast. So with
41:37
lentils and this is a standard practice worldwide. Oh, reasonable choice. I'm just trying to make sure everybody understands that. And then she recovered and you were able to get the clot out and
41:53
then she began to, you add flow, correct?
41:58
And this here, this here provides the venous phase of the, of the, of the four vessel and geography. So if you look at it, this is called the arterial phase, this is the first phase you
42:10
visualize the arteries, then this is the lateral phase. This is the start of the, this is the capillary phase where you can see the contrast at all And it's still the capillary phase and now this
42:24
is the end of the capillary phase. This is the venous phase now starting this is the venous phase. At this point, you're supposed to see that something like this. Yeah. Yeah. So, but in our
42:36
case, there was no flow. You can see the sign is here, but it's not through the image of flow. This is the right, right side The right side is draining a bit. But from our studies of the
42:52
MRI, the main flow was supposed to be on the left side.
43:02
And this is our catheter, this is the main catheter, the guided catheter at the skull-based level. This is the microcatheter. And without microcatheter, now we push contrast. And as we push
43:13
contrast, you are supposed to see contrast coming down the catheter through
43:20
the sinus going like this. But in this case, as you push contrast, the contrast is not coming down So all this area is full of clot, and then this here is a cortical vein, draining. So it's a
43:33
reverse drainage.
43:36
Okay, terrific. Yeah. So this is what we achieved, look at it here, the initial process, there's some reverse polarization at least, that this contrast coming down along the catheter.
43:53
Okay So on, and she did very well
43:58
with this treatment, were actually pleasantly surprised. So now she woke up after surgery or she was
44:08
obviously anesthetized, she woke up and she was, did she recover quickly or what happened? No, because of serious she was extubated a day before the procedure. She had a status of ellipticals,
44:21
so she was intubated. And the main reason why she was intubated was because we could not control our seizures. And
44:31
after the procedure, we, the seizures are controlled, at least with the medications, we manage to extubate after 24 hours. She left the issue around four, five days, after the procedure, but
44:44
she walked out of the hospital. Do you think the seizures were the seizures from, well, what do you think the reason for the seizures for the him, the infarction he had or general problem, What
44:55
do you think that was? I think the main issue was the hemorrhagic impact and the ICP crisis that you was having. Okay.
45:08
So I think it'll be useful to clarify for the audience, are you, so with the device that you use, are you removing cloud or physically, or is it more of a matter of establishing a channel to flow
45:26
through the cloud? I think I think it'll be good to clarify that. Yeah, so this here,
45:37
the device, the stencil quiver breaks
45:41
the clot,
45:43
okay? As you pull this through the sinus, the clot is broken into smaller pieces Without you also aspirate through the guide Kaffeta. the main catheter at the jugular level, your spirit with a 60
45:58
cc syringe? Yeah, excellent, excellent, excellent, excellent. So you get that through this. The point is not to entirely clear the chords in the sinus, it's to create a channel so that there's
46:13
venous drainage. Right, yeah. Excellent, yeah, I think it's good for people to understand that, thank you. Let me give you an extra, okay, let's say I don't have the benefit of
46:30
having somebody like you nearby or a hospital with people who are skilled like you and I'm further away. Maybe
46:40
a Dave's travel or something like that. But I can do, I have a CT and I can do the imaging which shows a clot. Is there, is it, should that person send the patient to you or can they essentially.
46:56
go ahead and make a burh hole over the sinus and try to open it and then suck the clot out. I'm just trying to, here I'm in a situation that's very frustrating and I'm trying to find a way I can do
47:07
this. What do you think?
47:11
So Corb, I think the good news with this is that these patients take time to get to us. It's not like an skimmick stroke where time is brain and that you only feel as to salvage the brain. In this
47:24
case, you treat the patient with medications. If the medications are helping, if the patient is not getting worse, then the standard of care is to fit them with that. But if with medication the
47:37
patient is getting worse, then the reasonable thing is to refer the patient. The problem that will happen if we advocate for a bar hall or for the sign-up is we will not know exactly where the clot
47:51
is even when you do when you do a CT scan.
47:56
And you think you may, you localize where it is, you probably need a navigation set to exactly localize with that. I don't, I'm not familiar with it, but from my reading event for this
48:09
presentation, I've not seen anybody doing surgical exploration for this sort of problem.
48:17
But I want to hear from the rest of the people, if anybody has
48:22
any literature or anything to add to that. Why do you think she had the clot in the first place? I'm going to come back to this. Why do you think she had the clot in the first place? So pregnancy
48:35
is how these are from the botogenic event. pregnancy is a risk factor, but she also had a bout of gastroenteritis. So a few days before the presentation, she developed vomiting and diarrhea.
48:49
Percio dehydrated. Dehydration, that was the trigger. There's a agenda, a couple other questions in the chat. So one question is, do you have a time limit for doing the clot retrieval?
49:06
So, in this case, time is not of the most essence, the most important here is the patient getting worse. And with the answer is yes, with medical treatment, then you go ahead. From my reading,
49:23
time here is not as important as it is in a stomach stroke, so that people were doing these 72 hours after making the diagnosis a week after presentation of the patient with the symptoms. So these
49:37
patients, the pressure builds up slowly. So initially, you drain through collaterals, you drain through
49:45
unconventional means, then eventually when the pressure is maximum, then these patients develop seizures, they in coma, that's when they need the treatment.
49:58
And I think that's my questions from my prof
50:05
Yeah, so
50:07
your hand was forced because she developed status epilepticus and she had to tear really considerably, all right? Yeah, and we could not continue with the medical management. Yeah, so there's
50:21
another question to chat. What is the long-term plan for the patient? This is from Dr. Boyne. When would you consider a follow-up DSA? And what are her risks of developing a Duro AV fistula?
50:38
Good question. Yeah, so in this specific patient, the follow-up is going to be with MR, MRV.
50:47
And the follow-up now is being done by the is being done by the gynecologist. So they're going to schedule half for
51:01
my fetal scan, fetal anomaly scan at
51:03
27 weeks at 27 weeks. and then we hope everything is going to be okay. The risk of developing Dural heavy fistula for such patients is high because these are patients who drained blood through
51:19
connections. We will see, but it's not a major concern for us right now.
51:27
Okay, very good. At the moment, she's doing very well
51:32
I still have a, I'm gonna ask a crazy question, Mr. Rata. I say, I'm really far away and I can't, there's a big storm and I can't move the person and so forth and so on. I still don't see why I
51:45
can't put a burrow hole over the sinus and it doesn't really matter where it is, I can put a catheter, I can almost, I think I'm not putting a fully catheter with a small fully or something with a
51:57
balloon at the end and the shoving in both ways is that a way why is that not a. I'm just trying to find a way to save this patient's life. What do you think about that? I know it's not what
52:10
everybody does, but here I've been well-trained. I see it, I recognize the problem, but I can't treat it. Well, I think first of all, Jim, you have to, you have to know where the occlusion is
52:25
and it needs to be a complete occlusion No, as you well know, entering,
52:35
repairing this, the sagittal sign is not an easy feat. Having entered the sign
52:43
is with meningiomas eroding through them and that could be fraud with difficulty. But I think the key issue and Dr. Abdi Fatah could address this, I think the key issue is Being able to localize
53:04
the extent of the occlusion, but because you need to have, you need to have, you're talking about being in a situation where you may not have access to the imaging, but that's going to be crucial
53:16
if you're going to make that kind of an intervention.
53:20
Dr. Frada, what are your thoughts? I actually see the sense in this argument, because in this patient, in our patient, if you did that, if you opened a bow hole over the sinus, there'll be no
53:34
bleeding initially. Initially, it's going to be completely, you make up a cut on the on the sinus and you'll find a cloth in this case, in our case. And if you put up fully catheter and push it
53:49
anteriorly and check out some cloths and get it from the other side, I actually see it might be able to work But I
53:60
haven't seen, from my reading, I haven't seen anybody doing that.
54:05
Sam, are you still there, Sam? Yes, I'm Sam,
54:12
you know me, I ask you a crazy question, but I can see somebody being in a situation where they do the CT, they say the whole sinus is closing. What's wrong with it? Why didn't I just stick
54:22
something in there, a sucker or something, trying to get the clot out and maybe put a catheter in? Am I crazy here? Sam?
54:32
I wouldn't be bold enough to do that. I guess if one was confronted with the proliferation of the sinus during surgery for some other thing, you have to deal with it because you can't abandon the
54:45
patient on the table, you have to try to conclude the breathing. But to go deliberately to do it, there's a lot of courage to do that. I wanted to ask him, what do you want to do? I think Jim,
54:57
he's saying politely that you are crazy for that idea
55:03
Okay, thank you very much. Okay, can I ask you what's got love do you use for your for your intervention? We have a Phillips. Yes, what's your cut love? Single plane Phillips. Okay, the
55:19
biplane. No, single plane, unfortunately. We have
55:24
a pipeline in the city, but yeah, in the hospital, we have a Phillips single plane. But there is a pipeline.
55:32
Okay. All right. Thank you. Sam, do you see these cases in Nigeria? Do you know what's your experience with it? No, we are experiencing my part of the country. We are really trying to have
55:47
to start a stroke intervention
55:51
service at Lagos. At the moment there is a Lagos, a recital battle at Abuja. But in
55:59
the eastern part of Nigeria we don't have. We're trying to, we're working on it very seriously. I want to set up a stroke center and be able to do these stroke interventions and to help the people
56:12
from a part of the country. So it is a project to write very much on the table now. So unfortunately, our speaker must have been a time prop or something didn't show
56:26
up, but. Yeah, I was hoping to interact with him I see how we can benefit from his experience. Now, if you're looking for that, we have an SI digital. If you look in there, you put in his name,
56:41
you'll see that there's his video presentation on how he set up a stroke center, okay? Yes, sorry, yes, thank you. We can also plan to. We'll see what happened logistically, and we can
56:55
reschedule him for another time in the future, 'Cause I think it'll be very good inter - interaction when discussing the challenges that people have and how his experiences might be applicable. I
57:08
agree, we need to work out from here. We'll do that, we'll do that. We have one of our senior colleagues here, Dr. Olocho Luna, maybe you could give us his comments on this case, Dr.
57:27
Olocho. Thank you, Prof. Malombic
57:30
I just want to say that for how you've actually discussed that case with me when he was doing it. And I think in terms of the next phase of people managing to do interventional radiology, as
57:44
neurosurgeons, this is excellent. And I think what also is quite useful is that, as he had mentioned that these kind of disease processes are slow in progressing. And one of the questions that
57:58
have been put through that if you are stuck. There is still medical management. And medical management as a paper that I showed earlier, 84 of people did well. So it does not mean that if you do
58:08
not have a whiz kid like Halif up Defata to do that for you, you are stuck, no. Start by the basics. You do the use of
58:19
anti-collagulation. And then if you're lucky enough to have that, something like Halif to assist, that's great. But in terms of the presentation, I think it is very clear, a lot of discussions I
58:29
think it has been a great, a great advance, and good to see that this is happening in the continent. Thank you. All right. I think there's a reason for this. There's another question in the - go
58:43
ahead, Jim. No, go ahead. I'm going to go ahead.
58:48
There's another question. Dr. Mohan, you wanted to ask - you want to make a point about the potential for decompressive craniectomy?
59:02
Dr. Mohan?
59:04
Dr. Mohan, can you tell us about the case you're talking about?
59:11
Yes, mine was just a comment about resource limited settings. It was a patient we had. So I was just giving you an example where we had, I think he was a patient in the 20s and developed this
59:24
after a motorcycle accident and it was a government hospital At that time we couldn't refer the patient and I think services in Arobi were limited. This is a peripheral. We are like about
59:42
350 kilometers from Arobi. So this patient deteriorated in ICU. So I think my point was just, I don't know, I don't know Dr. Khali for comment if, Would you opt for the compressive craniac to me?
59:58
You know, I've had only maybe a patient, so only two patients we've done this. We are not able to refer. Thank you.
1:00:09
Sorry. Any comments about that? So your point is, if you're not able to address the thrombosis, you'll address the increase intracranial pressure with the decompressive craniac to me and give them
1:00:23
time, correct? Yes. That's reasonable.
1:00:30
That's why I brought up my crazy case because
1:00:35
his situation was exactly what I'm talking about. They knew it, they knew it, the diagnosis is, but they couldn't do it. But the question is, can you, is there some way to do that? You guys
1:00:46
shot me down, so there's
1:00:49
no. Okay That is.
1:00:53
So a decompressive craniectomy, that's a reasonable choice, right? It may not be the answer, but what you're doing is obviously allowing time, and I assume with time what happened is the
1:01:08
thrombosis was laced.
1:01:11
Did you do a follow-up study at all? Dr. Mohan, to see over time what happened to it, is the sinus reconstructed?
1:01:21
Yes, Professor. So, he did reconstruct, but unfortunately the patient developed the in-fact progressed.
1:01:30
He still, I think, we saw him about a year ago, still quite a bit of disability,
1:01:37
but the thrombosis is still on
1:01:42
anticoagulants and on follow-up by the hematology
1:01:46
That's interesting. I developed a DBT in my legs. I had won some 10 years ago, but I don't develop one. Suddenly, it must have been three, four, five months ago, six months ago, and I had
1:01:59
some leg swelling. And they put me on anticoagulants. And obviously, I was worried about having an embolus and so forth this way. And they told me that long-term, I looked in the literature, I
1:02:13
couldn't see it, but that the body
1:02:18
can lice the clot on its own And so three months later, they did a repeat ultrasound and it was gone,
1:02:28
which
1:02:30
would probably, I'm assuming it was what happened with long-term. Do you have any experience with that, Dr. Khalif or Strata or anybody? If you wait long enough, does it lice? Oh, yeah, yeah.
1:02:44
I mean, your physiologic fibrinolytic processes will kick in, but in the acute, In your acute phase, you're having the issues with increased
1:02:57
pressure, and so if that's becoming, if you're developing expansion of the thrombotic process, then you're gonna be losing tissue and then having increased intracranial pressure, and that will
1:03:10
lead to decompensation and the patient's demise, but otherwise, if you're not having a process that continues to evolve, eventually the clot will get lysed. Okay,
1:03:30
Caliph, your background, what you trained as an interventionalist, is that, or did you learn this on your own?
1:03:37
No, I trained in a neurosurgeon, but I worked in a center where we do a lot of the vascular, did multiple courses in and out of the country Yeah. So, you do. We do cut that up as too, man.
1:03:52
Terrific teacher, very, very well presented. Very, very good job.
1:03:58
Anim, Anim, any thoughts, any further thoughts, Anim?
1:04:04
Not really, I mean, it's, we wanted to share this case because as you've seen, Dr. Alif is one of our younger neurosagion and he's doing very well and he's introduced this concept of managing
1:04:18
these cases and I hope we hope that we can be able to develop further. And as Dr. Lucio Luna also is, which is one of our senior
1:04:30
neurosagions of SAID, you know, it's really impressive that we're able to handle these cases at this level. There is another center also here in Nairobi where they do this and I hope I can get them
1:04:41
to give their presentation. They have, they have also almost set up a stroke center and managing these cases. And if I can get them to present, convincing people to present is not that easy, but
1:04:57
I think now Dr. Halif has come and we'll get more people from my, from aerobic presenting. We have some very good, no such, I don't see a neuro between the wonderful work. And I think we'd like
1:05:10
to share that experience. Thank you. Well, he's a good teacher, Nim. Say, Nim, I'm gonna take you back about five years when you were just a little bit younger We never saw these years ago,
1:05:22
right? Because we didn't have CTs, we didn't. How did we treat them?
1:05:28
First of all, how did we diagnose them? So that's not true. True, true, how did we diagnose them? How did we diagnose them? That is the problem. I mean, before the cities kind, most of these
1:05:38
cases would diagnose them through angiography, you know? So our patients would go angiography and if we see, so that we managed to make a diagnosis angiography. Then we just do thrombolysis. We
1:05:51
really, surgical management was really out of reach the AAAS. But now,
1:05:59
we have had a cardiac catheter for many a CAA in Arabic. But to sort of
1:06:08
start using this cardiac catheter for neurosurgery, this is really at the aliphase. They are about, I think, three hospitals, even where Dr. Mohan is working in, in, in Eldred, you know, I
1:06:22
think they should be able to set up this and, and to do that, because it's a level six hospital. So I think, I think,
1:06:31
here in Arabic, within the public hospitals, there are three hospitals, you know, the one where Dr. Aliph is and the Canadian National Hospital and Moi Hospital, which will be able to do that.
1:06:43
The private hospitals have very good facilities here in Arabic, just like you get to anywhere else in the world. and the private hospitals, like an Arabic hospital, like a Cannes hospital, he and
1:06:54
Nairobi, and even in Mombasa, there's a very good private hospital in Mombasa, in Notre-Archer, it's a public hospital, but it has a very good cardiac lab, and it's sometimes able to do these
1:07:07
types of cases. So in the early years, we were limited, lack of CT scan, lack of MRI, with micro diagnosis, and these cases we just managed them medically Hadly did we ever consider Sajal for
1:07:20
any of these and all of the such cool cases.
1:07:24
You brought up a good point. If you're a cardiologist, if you're a cardiologist, they're obviously more familiar with catheterization. If you took the case to a cardiologist, call it for
1:07:36
something, Would he be able to help with intervention? And that might help people in other hospitals that don't have the uneroyant eventualists.
1:07:47
Somebody wants to jump into that one. I think in my country, in my country, you're limited because you can only do it if it's within your specialty. I see, too. So the cardiologists wouldn't do
1:07:60
it, you know. So it's bureaucracy, right? Yeah, I got that. But you can say it everywhere. Yeah, but what you mentioned made a very good point because, you know, we can consider working with
1:08:12
the cardiologists to get that experience, you know, in the initial phase, because they do a lot of this work So, you know, you can work with the cardiologists to get some experience and apply
1:08:21
that experience, you know, as a neurosurgeon, you know, in the neurosurgical cases. I don't know why it's Dr. Olunya's, whether he's still around, Dr. Olunya's view about this, you know,
1:08:32
using the cardiologists, yes. Okay. Thank you. Thank you, Prof. Marambi. I think in terms of the principles of getting into this, those is the same. They tend to use firmer catheters. will
1:08:47
come in and let us know more. And the spaces into the brain are smaller. So although they think they can up to the proteins, they try and venture, but because of not only regulation, but also
1:09:02
insurance, you are going out of your fields, you have a disaster, you have got no leg to stand on. But what do you call it, if you can comment, thanks. Excellent, David, excellent analysis
1:09:15
But if the patient's life at stake, and do I let the bureaucracy stand in my way, or do I do something to try to save a life, 'cause if I don't do it, the patient dies.
1:09:30
Right, the difficulty is
1:09:33
it's all written down and nowadays with AI how they can manage to punch holes into your defense when you're on the dock five years later, when the patient does die when you've done what you've done,
1:09:44
you're finished.
1:09:47
Were you trained in the United States with a lot of lawyers? David?
1:09:53
No, not yet, but I have, with the interaction with a lot of lawyers in the US. but I mean Kenya is chasing us quite a lot in terms of what they are watching out, so I think the world has
1:10:05
collapsed and they hear everything, you have to be careful, thanks. In Kenya we have medical doctors who are lawyers and we have neurosagulans who are lawyers, I think two of my colleague
1:10:19
neurosagulans are lawyers, so you have to be very careful
1:10:26
It will be fishing for kisses to sustain their practice. I think
1:10:34
we don't have any problem like that in this our country. There's so many regulations I couldn't even keep track of them. So, but I'm just here, I'm desperate and here's a patient as a friend of
1:10:46
mine.
1:10:48
And they're dying right in front of me, I got to do something. I'm sure in a court they wouldn't convict me of going outside of my specialty But maybe you're right, I don't know,
1:10:59
regulations at some point, I'm worried about the patient's life. Sam, in
1:11:07
your hospital, Sam, you have some cardiologists, don't you? Yes, yes, we have a cadence of this in our hospitals. Could they help you out or is that the same problem that they have in Kenya?
1:11:13
Yeah.
1:11:25
They are interested, they are interested, as I said, who are trying to build up a cut lab. So, can a key internal service visit them? There was a similar service in the city where I live in,
1:11:39
but it didn't work. Unfortunately, this service virtually collapsed. So, it was a public hospital. We want to make that service available in the province sector now to be able to sustain it So,
1:11:55
that is what we're working on.
1:11:58
For many years, for many years, the first open heart surgery took place in
1:12:05
our city in 1974. But unfortunately, it wasn't sustained. Because the public hospitals do not - they don't have the Nigeria, and they've done sustained such services efficiently.
1:12:20
We're now trying to research, state it, and see what I can work with in the previous sector. I don't know the presentation, Nim, you were at the meeting of the first, we had, you fell as if
1:12:32
established a press editor, it was the first Latin American international military grand rounds, we had it a week ago, and we had a presentation on how you treat mental cerebral aneurysms, we had
1:12:46
a surgeon who presented his approach to it, and then they had an interventionalist who worked in
1:12:53
a community, it was a public hospital, isn't that right, Ristra? And he had a huge volume of cases, and that public hospital was able to pay for all the expenses associated with it because the
1:13:06
expenses of the coils in the private sector are probably too very high. Is that right? Serenity, did you get that? Yes, yes. Well, and I'm sure, I'm sure it causes an issue in Kenya too with
1:13:26
these endovascular procedures. I wanted to just comment a little bit about what you were saying about getting cardiologists involved. If you're knowing the US, some cardi has
1:13:41
neurointerventional specialty. So
1:13:44
specialty evolved. Some cardiologists got involved with it and they specialized and became neurointerventionalist But I think you're going to have difficulty with somebody who's not focusing on it as
1:13:60
a cardiologist because they may not be as familiar with the neurovascular anatomy and want to also make the argument about them not being able to handle the complications. But in Sam's case, where
1:14:14
you're working with a cardiologist and you might identify one or two people who might want to want to subspecialize and neuro them, that might be an avenue to agree. Lord.
1:14:28
That's the reason on David, your concerns, it sounds to me like the bad part of legal malpractice is spreading too rapidly around the world from America.
1:14:42
Yes. That is correct. We have, I'm told you,
1:14:49
you've got Netflix and YouTube and all these things. What do you call it? And Lincoln lawyers, all of these things are watched. So we have to be on our guard. Thanks.
1:15:01
Okay. Yeah. Yes. Thank you very much, Dr. Abdul Fattah. That was very nice person. You mentioned about the birth control and the complications that you see over there at your country. There
1:15:17
are types of birth control which cause more venous infarction.
1:15:26
and thrombosis, have you looked at the teeth, what type of weight it is causing that, because in the very past, when I was in France, every month we have one case of stroke because of the birth
1:15:35
control, pill they were using at that time. Although things have changed, now the new generation is much safer. Have you looked at that one or your gynecologist and look at that to see, they have
1:15:49
changed this, so to lower the chance of the thrombolysis in these patients. And the other point that you mentioned, it was about the hydration, but I know your country maybe is more exposed to the
1:16:04
high heat. Maybe you have to encourage and teach the people to have more hydration during the summertime to lower the chance of the
1:16:18
trommelambolosis. Thank you. Okay.
1:16:22
Any comments on that, Khaleb?
1:16:26
Yeah, thank you. So the both estrogen-based and progesterone-based oral contraceptive pills have been associated with risk of thrombosis.
1:16:38
The one that is faulted most is the P2, is
1:16:43
it called P2, one with a high level of progesterone, which is taken for emergency prevention of pregnancies opposed to a daily oral contraceptive pill. But in all cases, these medications are
1:16:58
non-risk factor
1:17:01
for venous
1:17:05
embolisms, in general, TBT, CVST, pulmonary embolisms.
1:17:14
So I think that as compared to what it used to be before, It's less because now the amount of. or more loaded in these pills are slightly lower. But the emergency pill is still, has got high risk.
1:17:30
There are things such as dehydration, things that can be prevented, yes. But in our case, this patient at two risk factors, one was the, was the dehydration, and the other one pregnancy.
1:17:41
Pregnancy is a thermogenic state. Thank you, Rem. Well, she was also dehydrated because of her gashrin, heritis All right, good point. Very well, yes, yes. Okay, I think we did pretty well
1:17:59
with that. Michael McGaugh, you're a spine surgeon, but do you have anything you want to say about this?
1:18:08
He's a spine surgeon, isn't he? And him isn't? No, he's also a couple of generalists. He's a neuroscientist. Thank you. Thank you. With this before you, done a great job on spine. Any
1:18:20
comments you have about this, Michael? No, it's an excellent case, excellent discussion, especially about the situation. We already came to the conclusion, but I just wanted to weigh in, since
1:18:32
we have some residents, given the situation that you proposed of going, of the behold, going through the sinus, I would advocate not to in a patient with thrombosis,
1:18:45
because if I look at it like meningiomas, a spiritual sinus, meningiomas, when we have those complex reconstructions, they still clot later on. So in a patient who's already clotting beforehand,
1:18:59
I think you'd violate virtuous triad and you might get a larger west cloth later on, that's what I would think. But I'm open to any comments from the field. I think it's been an excellent
1:19:13
discussion.
1:19:17
Dr. Hallif, and also thank you for the discussions for bringing different points first to think about. I think it's been a very useful session. Thank you. Right. We hope to see you in the future.
1:19:26
There's some work done in France by Dr. Mark Sindhu. I think you were talking about that. At the time,
1:19:34
Jim, when we were a little bit younger or five years or so,
1:19:39
people wouldn't operate on the sinus because of what Michael said, because it would thrombose and it got to be difficult. But he was working on sinus transplantation. I don't know if you remember
1:19:50
that, but she'll bear with no, but he's not here. But he was a French surgeon who did a very good job in that area. Max Sindhu has been to our units. I think even Dr. Magoha met him. Do you
1:20:06
remember Max Sindhu? Yes, yes, yes. Yeah, I remember him as been to our unit here. I think you organized with two other gentlemen at the time. Yeah, he was, you're quite right. I remember
1:20:18
that landmark paper and all the patients got re-thrombosed in those transplant cases, but also there's another study, I forget the name, which pretty much showed the same results in a battery
1:20:35
section of plots and tumors within the spear-sigital sinus. So I'm quite wary of opening it, but the trauma patients don't seem to have the same. It might be because they don't have the risk
1:20:48
factors for thrombosis, which would point towards virtual striate, which is what I would be thinking.
1:20:55
They, a nice thing I like to say, God is helping them doing the world round with regards to the trauma patients, but with the thrombosis patients, I'm wary.
1:21:05
Very, very interesting, interesting discussion there. Okay, Rastrada, I think
1:21:12
we - I think we've had a good discussion. We will contact our guest speaker and see if we can reschedule him. But thank you everyone for a very interesting and enlightening discussion.
1:21:29
We'll try to get that young man back. He does a very good job, Sam, and we'll put you in touch with him, okay? Thank you. Thank you for joining us. Thank you. All right, we'll see you next
1:21:42
month. Okay, thank you Thank you, okay. Thank you, everybody. All right, bye. Thank you. We hope you enjoyed this presentation.
1:21:51
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