0:01
SNI Digital, Innovations in Learning,
0:07
in association with SNI, Surgical Neurology International,
0:14
are pleased to present another in the SNI Digital Interviews with Clinical Neuroscience Leaders
0:26
This interview is with Eric Nussbaum,
0:29
and he'll be talking in a two-part lecture series on my experience using ECIC bypass for cerebral ischemia, cerebral aneurysm, and skull-based surgery.
0:45
Dr. Nussbaum is the chair of the National Brain Aneurysm and Tumor Center and the director of Complex cranial neurosurgery
0:55
Midwest Spine and Brain in Minneapolis and St. Paul, Minnesota, and he's the associate editor-in-chief of SNI and a board member of SNI Digital.
1:13
Dr. Nussbaum has written numerous publications, there are three books listed, a video at list of
1:23
intracranial aneurysm surgery available on Amazon.
1:28
A book which is a subject of these two lectures on cerebral vascularization, microsurgical and endovascular
1:35
techniques from theme publishers, and
1:51
a publication basically targeted patients and families on brain aneurysms and vascular malformations He has multiple scientific publications that can be found on PubMed or in an idea. This is Eric
2:01
Nussbaum giving part two of his talk on several vascular disease. I'm glad we have it because we don't have much on the website at this moment on it
2:12
So why don't you go ahead, he said of the
2:18
National Brain Aneurysm and Tumor Center in Minneapolis, St. Paul, Twin Cities, Minnesota has had a large experience with several thousand uh aneurysms and uh and also bypass experience we just
2:32
heard in part one. So tell us what your experience is here. So you know a lot of the aneurysms that are sent to me are very difficulting aneurysms um and over the years they've become increasingly
2:45
more difficult with the rise of endovascular therapy um they can treat more and more and so some of the cases I'll show here today uh are from 15 or 20 years ago and today would probably be managed
2:57
with a stent or some type of flow diverter but um if you look at my experience um of roughly let's say 2, 700 aneurysms over my career um somewhere in the neighborhood of 7 to 8 percent have been
3:14
cases where I did not feel we could clip the aneurysm or readily coil the aneurysm or treat it endovascularly with the technology that was available at the time And so we were looking at. some form
3:27
of parent artery occlusion and revascularization. And that's really what this talk is about. Roughly 130 cases of patients who underwent either STAMCA bypass radial artery graft, which I don't know
3:46
this for sure, but my understanding is that, Jim, you may have been the first one to describe a radial artery graft as a revass technique. Safness vein graft, or some type of insight you bypass
3:60
where we
4:03
connect up, for example, the pica
4:06
to deal with an aneurysm. I've also used some short jump grafts where going from one cortical branch to another branch using a short bit of interposition, middle cerebral artery,
4:20
or saphenous vein. So that's really what I want us to talk about here today.
4:27
Did you do the first radial artery graft? I don't remember if we did the first, but I know we did an early one, but, and I know talking to the cardiovascular surgeons, we did this in Minnesota,
4:40
because
4:44
I was very worried about taking a radial artery. It's a little bigger vessel, and I know there's a lot of interest in that lately, but it's a bigger vessel, and I was very worried about
4:55
compromising the blood flow to the wrist. And so they had had a lot of experience with it, and then so we checked in to make sure there was a good vascular tree in the wrist, and we didn't do it a
5:08
lot, because I was very concerned about that. You get a little bigger vessel that you can use. People say, because the veins are dilated, they're hard to do with. You can do that, but anyway,
5:22
that's what we did.
5:26
So these are generally giant or fusiform lesions, they're not clippable, we have an integral part of our team as the endovascular group, so all cases are run by them. We're not a situation where
5:38
I'm looking at cases in a vacuum and operating on everyone.
5:44
But those were really the indications and one interesting thing, I'm gonna show you a case where I've used bypass to allow for prolonged temporary occlusion in patients where I wasn't sure whether or
5:55
not I'd be able to clip an aneurysm to use it as a safety net. If you don't wanna go to doing a hypothermic circulatory arrest, which we almost never do anymore. I'll show some examples. This was
6:07
a 68 year old woman with this large middle cerebral aneurysm and then she had this
6:14
middle cerebral branch emerging from the neck area of the aneurysm and she'd been seen by
6:22
another group And they wanted to just coil off the aneurysm and it. except the fact that they would lose that branch. But what we did was a slightly different approach with that patient, which was,
6:36
we took the superficial temporal artery and actually hooked it up to that branch over there. And then had our team come back and coil off the aneurysm the next day. And so, as you can see, it's
6:50
not an inconsequential branch that would have been sacrificed It would be very difficult to predict whether she would have tolerated sacrifice of that. But I think personally, it's a more elegant
7:02
example. And it's a good example. I put it in there because it's not just the open surgery or endovascular, we work together as a team. And she did while she had no deficit and was very happy with
7:15
the results. Very smart. Yeah. And simple and easy. You just have to, the only challenge was finding that, finding the vessel to bypass to the right. Vaseline, she becomes part of a series
7:27
that we wrote up here. This was when we had 126 patients using cerebral revascularization for aneurysms. I'll show you some other cases and some
7:39
of them are great, some of them are humbling. This was a young man, a professional musician some years ago. He had this middle cerebral aneurysm he presented with headaches and he was surgically
7:50
explored by a
7:54
couple of other surgeons in the Twin Cities and they felt it was unclippable and they sent him to me and I looked at it and I thought, boy, you know, I wonder I'll bet I could clip that aneurysm.
8:05
And so I took him to the operating room and there was, I basically used some some fenestrated clips here and had to leave a little bit of residual in order to make sure that there were some
8:19
lenticular strikes maintained. But I was very happy with this result and very encouraged. He was around 30. at the time. And of course, four years later, he calls me back and he says, My
8:31
headaches are back. And I said, Well, it's hard to believe that. And he said, It's the aneurysm back. I said, I don't think so. But this is his angiogram at that point. So, you know,
8:43
sometimes you can do a good job, but you can really see how the aneurysm is just completely overgrown, you know, that initial fenestrated clips. And there's another clip here that's been pushed
8:53
way out by this aneurysm. So, what do you do for that case? And this is a situation where what we've done is create a saphenous vingraft from the external prodded artery to one of the M2 branches.
9:10
And then, and I've seen this multiple times, as soon as we did that, the aneurysms from Bost. We didn't have to sacrifice the MCA. These are just the original clips that were there. that whole
9:26
segment's not filling. He has no deficit at this point. And we've followed him for 18 years with some follow-up integrams, and that's remained stable. Very good. Can you go back to the slide
9:40
before this? Sure.
9:44
I was operating at a,
9:47
it was a general hospital in Los Angeles
9:53
And they had microscope, and they had some things, but they weren't very used to doing bypasses or complicated kind of surgery. So we had this lady who came in with an aneurysm and looked just like
10:06
that. And she had a contralateral deficit. And we looked at the angiogram.
10:15
And there's, I'm sorry to take some time here And so we didn't have a lot of choices. And so I said, well, let's open it up and look at it and they explore it because I think if we put some
10:29
temporary clips on it We were prepared to to include the carotid Because I couldn't get medially to get the Middle part of the middle cerebral there. You see the medial Medial and so we could put
10:42
some temporary clips on it and this is a technique I used a lot you probably done it yourself a lot And that is I opened the aneurysm now, and then I essentially evacuated Evacuated all the contents
10:57
and it shrank down to a two walls against each other And then I had a series of long clips that they happen to have and I put them one right next to each other over the the mass Leaving the the middle
11:13
cerebral vessel at the bottom. I may have left some Extra but but essentially occluded the aneurysm the reason I say this is because if I'm in an area where I don't have what I need it doesn't mean I
11:26
give up because there are things you can do and that was an example of how you if you at least have some minimal equipment and some some experience you can go in and you can do that now she woke up
11:41
from surgery she had a deficit and seven days later she walked out of the hospital And so it's an example that we get kind of tied up in figuring that it's a big aneurysm I don't think I can do it.
11:56
And I'm going to get you to a principle I'm not sure you agree with this but to me I always thought rather than doing a substitute that if I could get the larger aneurysms if I could get them included
12:10
myself using temporary clipping and so forth and reducing the size of the aneurysm it was far better than me doing alternative kind of surgery or multiple inter cranial bypasses and so forth. So I
12:25
always tried to tend to find a way to do that. It doesn't, I think what you did here was fine. And that's one of the things that happened. And the second message that comes here, it is a very
12:38
important message is when you put a bypass in there, what you're getting is flow going, both is
12:47
going retrograde and enter a grade It's going both directions. And the flow that's coming toward the carotid is substantial. And it's substantial enough to essentially overcome whatever flow you
13:01
have coming up the carotid. And then it creates an area where there's stasis in a thrombosis. I've done patients with
13:11
bypasses that didn't have an aneurysm that may have had a stenosis or something like that, and woke up with a deficit and it got better. because what you get is this, you're changing the dynamics
13:23
of the circulation and you get retrograde thrombosis because there's
13:30
opposing flows. Eventually, they recover, they do pretty well. But I think that's what you saw and it only tells you that we've got to be humble because we don't understand everything and it's
13:41
going on here. We definitely don't understand. And the other thing, I'll talk about this towards the end I think every surgeon needs to find, you know, their niche, their niche, their comfort
13:53
level, you know, in terms of what works well for them.
13:58
I, when I was a resident, I watched a lot, I saw a lot of aneurysms temporarily trapped and opened and for me, that was a very uncomfortable situation Because you basically. gone to a point of no
14:18
return. The aneurysms wide open. And I saw some very atherosminous or calcified vessels where it was challenging to get those, to get the thing closed again. Whereas if you do a bypass first and
14:34
then try to open the vessel, what I found is it becomes a very relaxed situation because worst case scenario, you just have to temporarily trap the segment if you can't reconstruct it well If you
14:46
can't reconstruct it, you have your bypass in place and you don't have that clock ticking and you're worried, I'm at seven minutes, I'm at nine, I'm at 12 minutes, have I exceeded the tolerance?
14:57
You know what I'm saying? But it's a personal, I mean, I think it's just different from one surgeon to the next. Well, I couldn't disagree with what you said. I think it's reasonable. If you
15:07
can do all that, if what I'm saying is, hey, if you're in a very, let's say I'm in the middle of Africa.
15:16
And I've got this lady with this problem and I can't do a bypass. They don't have the instruments, they don't have a smooth sutures, microscope is a little old. I can use it. But
15:29
I've had no, if I send them off, the patients can probably wind up being dead, a high percentage. So in there are some sets of circumstances where you might do that. Oh, absolutely. And if you
15:41
can clip an aneurysm, I don't think there's any doubt that if you could clip an aneurysm without hurting the patient, then it's the best treatment. I mean, it's better than, you know, it's
15:54
really, I don't want to, I mean, I don't want to say anything to upset my endovascular colleagues. But I think they generally would agree that if you have a well-clipped aneurysm, it's the best
16:05
outcome. The problem is always if you can do it successfully without hurting the patient. So I couldn't agree with you more Yeah, I think all right Terrific.
16:18
Also emphasizes why you need to do follow-up angiography. Right, absolutely. It's a perfect case to demo, and that's including the people who do interventional procedures. Right, absolutely.
16:34
Interventional should be held to the same standard as an open surgery. They don't. They need to be at the same level. I wanted to show a radial artery case again. My understanding is that you
16:46
wrote up the first radial artery graft case, but here's a heavily calcified in a young man and a 35 year old man ruptured middle cerebral aneurysm. This is an intraoperative angiogram. That's the
17:00
name of the radiologist, not the patient's name. So don't worry about HIPAA. But you can see the graft to,
17:08
this would be, I guess, and it technically an M3 branch. And with a clip placed Proximal to the this we explored this. I did not feel I could reconstruct this with clips. It was so heavily
17:20
calcified I was just happy that we got around it and Sacrifice the M1 and the interpretive integram immediately showed that the aneurysm was about half the size as on the preoperative arteria gram and
17:35
then we watch this this went on to pretty nicely thrombose and what you get in a case like this is the
17:45
Bypass graft filling the middle cerebral artery down the M2 Keeping open just a little oops. I'm sorry keeping open just a little bit of aneurysm
17:54
and then filling out the other M2 and my point in part for showing this case is I've seen a lot of emphasis placed on completely trapping the aneurysm to exclude it from the circulation I have not
18:08
found that that's been necessary Obviously, there's a tiny risk that this could still bleed. But in general, it's almost a form of flow diversion. Instead of having the water hammer effect of the
18:20
M1 dead ending in this aneurysm, you basically, the only real need for flow is to come down the M2 and then back out the other M2. And there's no reason for that aneurysm to stay open. And in
18:33
general, it won't. And we've not had trouble with these aneurysms re-bleeding And if you think about it, if you were going to treat this with a complete exclusion of the aneurysm, you'd have to
18:44
either clip it or you'd have to do two bypasses. You might have to do two long vane graphs or radial autographs, or you might have to re-implant that other M2. And I think that sometimes or
18:57
oftentimes less is more. And this has been an elegant option in our experience. It's excellent.
19:06
Excellent This is a woman. I saw when she was 67 and she had this truly giant carotid proximal carotid aneurysm and some edema around it. And she was seen at another institution where they wanted to
19:23
do a hypothermic circulatory arrest. And I'll tell you, you know, Jim, you look at this patient, I just don't think she would have done well with that operation. Now I could be wrong. What she
19:35
did have was a very large superficial temporal artery. And so I said, I have a different option for you. We just did a superficial temporal artery bypass. And then you may remember the old
19:49
Silverstone clamp. This was back in the 90s. We found one in the basement at Minnesota, and we put a Silverstone clamp on her. And she did great. You know, she did wonderfully She thrombosed her
20:03
aneurysm. This is a post-operative angiogram and no deficit. And I followed her until she was in her 80s and she did beautifully with that. So again,
20:16
there's a lot of thought that you have to, if you're gonna replace the carotid, you have to have a long vein or a radial artery. Well, if you've got a generous super visual temporal artery, that
20:26
may well be more than enough, especially if you've got a little bit of flow across an A1 or from a PCOM, that may well be And it's a, think of how low risk that operation is compared to a
20:40
D-pypothermic circulatory arrest case, or even in a patient of that age, doing a long vein graft or a radial artery graft, in my hands, carries twice the risk of a simple S T A M C A bypass. I
20:55
totally agree with you. In fact, we didn't publish it, but we had early on after a minute, we did some bypasses and we did angiography immediately, the next within 24 hours of surgery.
21:09
And we were a little concerned because the artery was small, I think I'm trying to recall this accurately. So we did the bypass, it may not have been robust. And so actually we had a selverstone
21:22
clamp on the internal carotid artery. And what we did is we gradually occluded it. So if you get down to 80 of collusion, that's where you begin to get flow limitation. So we started there and
21:40
then we might gradually move the clamp down a little bit more in order to allow the bypass to enlarge.
21:50
And when we repeated the angiogram when the bypass, and it was within a week, got larger because of demand, we shut the clamp off. And so we did exactly what you
22:02
did And you have to have momentum happening at that point because you don't want to propagate the thrombus, We did that a number of times, but I never wrote it up. Yep, yep.
22:14
This is what it looks like at surgery. This was an example of a giant middle cerebral aneurysm. You can see the atheroma. And I just did not feel, and then there's actually a second aneurysm here.
22:27
This is the bifurcation. So here are two M2 branches. There's a second aneurysm here. No. I just didn't feel that we'd be able to get this thing clipped and reconstructed So what we did was,
22:38
here's the STA to one of the middle cerebrals. You can see a clip here on the second. We clipped this aneurysm. No. And then a clip on the
22:54
distal M1.
22:56
Yeah. So basically you've got the STAMCA bypass out here, right? And it's coming down and it irrigates one M2 back through the bifurcation out the other middle cerebral.
23:07
you know, again, a good result.
23:10
I think again, kind of a relatively simple, elegant option. Now, this aneurysm, if you explore the aneurysm and it's been walled and you can, you know, bring the walls together and you don't
23:26
have this. I hate this finding. The Atharoma calcification extending right down into the bifurcation makes me deeply nervous I saw several patients with large clips, attempted clipping of aneurysms
23:39
by other surgeons where when they brought the clip down, it just forced Atharoma into the vessel and then, you know, it's not filling and then you take the clips off and it's still not filling.
23:52
And you can get yourself into real trouble.
23:56
But so this finding intraoperatively worries me personally Reassemble. Reassemble
24:05
We've used bypass for some peripheral aneurysms. Here's a case where you can see a distal middle cerebral branch on the dominant side coming down into the aneurysm and then coming back up with a
24:16
fairly significant outflow and few options here. You could theoretically cut it off, cut it off into an end-to-end. We used an STA to the distal and then sacrificed it and opened it. Obviously we
24:29
explored it and it just, whenever I tried to clip this multiple times and however I tried to clip it, we lost the outflow of it. But,
24:43
and here's a case, I'm curious what you would do with this. This is a woman, I think she was 65. She actually entered a trial at the University of Minnesota. She was asymptomatic. She entered a
24:55
trial where they were gonna follow patients who were 65 for 20 years to see who developed dementia. and to attract their MRI scans. And so she had this really giant middle cerebral aneurysm. And we
25:12
had quite a discussion about what to do about it, whether to treat her at all. I'm curious whether you would have treated her. Here's her angiogram. So it's partially thrombost. And
25:22
this is another example of where we did an STAMCA and the thing immediately just thrombost, that whole segment thrombost. But would you treat her? It's a pretty large aneurysm I mean, the natural
25:34
history of these real giant aneurysms is not great, but she's asymptomatic. Well, the natural history - I'm not an older age wise, but the natural history is she's going to have a fairly
25:50
significant chance of rupturing, and that's not
25:55
going to be a good outcome. And I think the alternative you can offer her with the bypass, which I thought was very good,
26:04
The other thing is the angiogram doesn't show you the thrombose portion, which the which the MR does. And it's obviously extremely large over this. And so it's partially thrombose and maybe you
26:16
have some athromen and so forth. I think what you did is reasonable. The other thing it tells you is that it's very likely that she has no lenticular strikes that are functional in that portion. I
26:30
can't tell you for sure. You don't see them.
26:35
You see them off the anterior cerebral, see them off the small ones off the anterior. In this area it looks kind of barren. So, and more work needs to be done on lenticular strikes, or we've
26:46
talked about that. But I think you did a very good job. I think we would try to do something like that. Now people might want to put a stint in it. I'm not sure you can do that easily.
27:00
That's something I think probably deserves some real consideration and I think you did a good job.
27:08
And another example, tough case. This is actually a patient who had a basilar tip aneurysm clipped a few years earlier and then came back. The carotid was normal at the time that the basilar was
27:22
clipped about 10 years earlier and then comes back with this fusiform situation at the carotid bifurcation extending out to the anterior cerebral and then
27:34
at the middle cerebral and here's a here's a saphenous vane graft which you can see here on the intraoperative angigram and then I put a clip or two here on the distal internal carotid artery. So
27:51
basically you can see the immediate decrease in caliber of this in yourism at that point and.
27:59
the aneurysm extending out towards the ACOM. And
28:06
he's been followed for 10 years doing well with that. Young man, 22
28:20
years old, with this aneurysm, which ruptured, this peripheral PCA aneurysm Dr. Drake might have just taken the PCA at that point. In his experience, I think it was a 1 in 7 or 1 in 8, only
28:38
would have a deficit if you took it at this point.
28:44
I used the occipital artery and enastomosed it up to the cortical posterior cerebral artery on the surface. These are small vessels. This was a leaveno suture.
28:57
our Indo-Vascular colleagues went in and occluded the vessel right at the entrance to the aneurysm. And he's done well. But what do you think? What would you have done with this? Would you have
29:12
simply done an occlusion? Well, it would depend upon my age and the time of the date and the time. If Charlie Drake was looking at this, he might have said, well, okay, well, we'll put a clip
29:27
on one of the vertebrae, we'll lower the flow. I could also see if I was standing over his shoulder saying, Charlie, and why don't you do
29:40
a
29:44
series,
29:46
Eric's technique where he temporarily interrupt the circulation, go underneath the temporal lobe there, put temporary clips on it, evacuate the aneurysm and then put a clip across it and then open
29:53
it up I could see that as an option. I could see bypass as an option. I could see, and I think it gets back to what you said. I think it depends upon the individual. I always used to stay in the
30:05
circumstances. I always used to tell the residents, look, a lot of surgery is mumbo jumbo. Everybody says, I do it this way. I do it that way. You've got to have the pain engine for four days.
30:17
No, you've got to have it on for six days. It is all mumbo jumbo Nobody knows, never done randomized studies to find out. And I think you're on the edge or cusp here of those kinds of decisions.
30:31
So I couldn't criticize any approach to it. I think your approach is very reasonable. And what they've tried to do is randomize studies on everything so you didn't have those choices. But I just
30:44
told you about the bypass study, which was a total, a totally corrupt study has ruined neurosurgery, vascular neurosurgery for 30 years. So I'm not a I'm not a big fan of randomized studies I know
30:59
a lot of people do all my I've gone through the literature and COVID with randomized studies They had one with with nine million people in it and you'd think like that couldn't be Volacious well it
31:11
was fallacious the dose they were using comparing one drug to another was was in in a adequate So I don't want to I don't you know I don't want to I don't want to make any inappropriate statements,
31:23
but I'm going to tell you an object personal Observation of mine having been a math major at Hopkins in my undergraduate years And studying a little bit of chaos theory Early on it is my own personal
31:38
bias and I say this without definitive Evident you could ask people who are a lot smarter than me. I wonder very much about randomized controlled trials Whether if you repeated them, you wouldn't
31:52
get a different result. in the sense that I'm not convinced that we can control for enough variables in medicine, especially when you get to rare disease processes like these, or even less rare
32:07
disease processes, to be so confident that a randomized controlled trial really means that much. I'm just not convinced, but that's me and I, you know, that's a bias You
32:20
ought to write an editorial about that, or put that in an SI digital because I agree with you. And right now, it's heresy. You can't talk about it because you can't criticize randomized trials.
32:35
Well, we just gave you an example of one that was totally false, totally corrupt, and is ruined medicine and deprived patients of appropriate treatment Now, isn't that a worse outcome? I think
32:49
it's a terrible outcome. And is there anybody out there propose the randomized trial, who feels guilty about it? No.
32:59
And what about the patients who suffered it didn't get it? So I agree with you. That just, that doesn't make sense to me.
33:09
Talk briefly about balloon test occlusion. You can't give this talk without mentioning it.
33:15
Here's a cavernous aneurysm today. We would treat that with a flow diverting stent
33:21
Here's a patient who has a pretty reasonable native collateral across the enter communicating artery.
33:29
We came up with this flow chart a few years ago because we still do occasionally balloon occlusion tests when we don't feel that we can salvage the vessel. And some patients will just fail outright
33:42
with the clinical part of the exam. Some will pass the clinical part of the exam but have some issues with the imaging, the nuclear med part of the imaging some will pass both. And, you know, I
33:54
think you can stratify these patients. If they fail everything, then we used to do a clip or high flow bypass today. We would do it a some type of stand probably, but we're not going to sack that
34:05
vessel without some type of revascularization. If you can get a higher flow bypass in this type of case, or a larger STA, that might be reasonable in this patient population. And in patients who
34:19
pass the balloon occlusion test fully, you know, sometimes you can just include the vessel without revascularization, but you do have to worry about sometimes these patients will have a
34:28
contralateral aneurysm. And, you know, Robert Spezler did some work looking at very long-term risk, increased risk of stroke with a carotid occlusion. And it's not necessarily something that most
34:42
people would want to have an occluded carotid. So we take that into consideration but we use this less today. because we don't include the carotid nearly as often with the advent of the better flow
34:58
diverting stance. No, I think that's true, okay. Let me show a few problem cases. This is a man, 63 years old, who actually was in a nursing home for dementia for a year before he had an
35:16
imaging study. And he's got this,
35:20
it ended up being about a seven centimeter, middle cerebral aneurysm, just crazy, you can see it here. And treated him with two radial art, early in my experience, two radial artery, two
35:35
saphenous vane graphs, one to either M2, the M2s were so far apart. And basically, the problem with this case was that, with this case was that. A day he woke up fine and then the next day he
35:51
occluded one of the vane graphs and had a stroke. And he had a very difficult course. He was left with a fair amount of disability. He survived and he's one of the patients that would come in and
36:01
thank me every year in my clinic and I would feel very guilty about his thanking me because he was
36:09
quite disabled before cognitively but afterwards he had a significant hemiparesis from that So some of these bypasses don't stay open and there can be consequences. This is a terrible case. You can
36:26
see this for tubular artery injection. You can see this really truly giant, mid-basilar aneurysm and then you can see the, you get into the distal basilar coming out with the PCAs here.
36:42
Well, now they would probably try to put a stint across that or something. if they, yeah, maybe if they could. If they could. I thought this looked kind of like a camel here, the camel's back
36:53
and then, and they had the super cerebellars there and the PCAs and what we did for this patient was, we endovascularly sacrificed the larger vert and that didn't help, it kept growing. And
37:14
this is a saphenous vane graft to the PCA here. So the carotid is filling, it's a common carotid injection, the external carotid saphenous vane graft coming up here to the PCA
37:32
and then sacrificed the distal basilar here. And then we were extremely happy with the
37:41
endographic result. You can see coils in the dominant vert here
37:46
And the problem is when he, this is the scan the next day, he went on to, and he thrombo, this is without contrast really, he thrombo's the basilar and that whole mid basilar and he lost
37:58
perforators to his brain stem. And
38:04
he survived for several months, but ultimately, ultimately didn't. So a case, I don't know, you know, I don't have a great answer for that aneurysm I don't know that trying to open that and
38:16
evacuate, I don't think it would have worked. You know, maybe endovascular today, but I guess my point is despite, despite best efforts, sometimes with these really tough cases, I mean, we
38:29
fail, I fail, but. Well, you do it because there may be a small chance you can make it because you know, if you don't do it, what's gonna happen? I mean, that's what you do. I'll just tell
38:42
you a brief story. Man, who came in with a basilar thrombosis, you could see an occlusion of the mid basilar artery.
38:57
It was before you could do a stents or anything like that. And so what we did is we had been working in the laboratory, we went down and talked to his wife. I said, there's nothing else we can do.
39:09
We have maybe one very rare possibility of saving him And that is if we go through the clavus and essentially open up the basilar
39:20
and see if I can take the atheroma out. Well, we did that, and the
39:27
man eventually died. But we did that, but there was an observation that made that was very interesting. When we put temporary clips in the basilar, opened the basilar and took the atheroma out,
39:35
we got backflow into the basilar artery.
39:43
And all the textbooks tell you that they're end arteries. That is not true.
39:50
So they have collateral, which also explains why people who come in with an embolus that's in, it includes the basilar and they're still survived. Right. And the answer is they're surviving
40:02
because they're pursuing collaterals in the brainstem. Right. So anyway, we did it in this man and he died after surgery We tried to do the very best we could to help him and we weren't able to.
40:15
That's what you've got. But I think the reason you're doing it is the same. I wanna see if I can help the patient. I mean, that's what you're doing. And this is a high risk operation. The family
40:26
knew who we knew. Here's a really giant protodoptomic aneurysm. And so this is an example of where I did a bypass first and that allowed me to temporarily. trap the segment for about 18 minutes.
40:50
And then that allowed us to clip the aneurysm.
40:54
So then the bypass goes on to, you don't see the bypass here, it's not an external injection, but I'm sure the bypass just occluded because she's got her good native flow. And we have an excellent
41:05
result on
41:09
the aneurysm. Now, I have to be, I mean, you know, I do need to be honest that this patient did have a complication, which was that she lost vision in that eye. And somehow, I know
41:24
the optic nerve was not in the clips, but I can tell you that the optic nerve was distorted by the clips and by the manipulation. And we irreparably damaged her optic nerve. But I do think - Did
41:37
you get her a system with a motor of salamic artery? Well here's the epsilon the cardery. Okay, so I'd say, then it's a, okay, all right. So that's the complication. But I think it's an
41:49
example of,
41:52
you know, an alternate use of bypass. Would she have tolerated 18 minutes of temporary inclusion or could I have done it in 12 or 13 maybe? But again, it converted it from a, what would have been
42:04
to me a very stressful situation when we punctured the aneurysm and we're trying to get clipped properly placed, you know, to not leave residual aneurysm. I mean, I think it's a great result. If
42:15
I hadn't told you that we injured her optic nerve, you know, you'd be super proud of the result. But, but I think it's a nice, it's a nice illustration of another use of, of revascularization,
42:28
you know, that hasn't been talked about much. I really, I've not seen that talked about, and I actually, at one point, I started to write it up. I have a few cases like that and I never
42:36
finished. But.
42:40
I think it's very good, I think you're right. I think it got down to the time of temporary occlusion. There were some studies again done by Lindsay Simon and asked up in England about how long can
42:53
the brain be ischemic? Because nobody really knew Suzuki, it
42:59
worked in Japan on this, using some protective agents among which was a barbiturate in Southampton, and they showed that it was effective But usually I tried to keep it under five minutes, but
43:11
sometimes you can't make it. And so it goes to 10 minutes and you wonder, Gee, am I gonna give 'em a deficit, and so forth. So what it also tells you is we don't understand the collateral
43:23
circulation of the brain, 'cause obviously the patient survived that occlusion time when you think that they wouldn't, and it was the only answer for it, this is collateral circulation and we're
43:36
supplying it. Look at all those lenticular strides, by the way, off the middle, cerebral.
43:42
Yes. Honorable. Yes. And nobody, everybody says those are end arteries. I don't believe it. Right. And so it doesn't make sense. So there's collateral so you don't think about it. I mean,
43:57
people don't pay attention to that, but
44:02
so what's your choice, leave it alone, not do it, or take some risks and you have to talk it over with the family and see what they want. So for aneurysms, you know, my conclusion, some of this
44:14
is personal to me. There are many options for revascularization, but in my experience, simpler is often better. STMCA is adequate much more often than people say. A lot of vascular neurosurgeons
44:30
think that if you're, to sacrifice the middle cerebro to the carotid. You must do a saphenous vein or a radial artery graft. That's not correct. I'm not saying that we never have a problem, but
44:43
with a lower flow situation. But if you've got a decent sized superficial temporal artery, it's a easier operation with lower risk and lower occlusion rates in my experience. We talked about in the
44:56
other section about stroke, the papency rates with STAMCA in my hands and my personal hands around 97. When you do a saphenous vein or a radial artery graft, it drops down to the high 80s. I have
45:08
about a 10 occlusion rate with
45:11
those grafts. And that could just
45:15
be me, but I think they're technically more difficult. You're taking a vein that has valves that have to be cut sometimes or you know, you don't reverse the flow or the radial artery graft.
45:27
Sometimes there's a little bit more tension on the radial artery. You don't have as much length as you'd like. Um, we find in my experience, simple proximal, uh, or should say simple perin
45:37
artery occlusion. It could be proximal or distal to the aneurysm. I didn't show any cases of that. I should have shown some cases. I have an experience that I wrote up a few years ago in
45:47
neurosurgery of you can sacrifice the vessel proximal to the aneurysm. You can also sacrifice a distal to the aneurysm and it works just as well. And it doesn't suddenly cause the aneurysm to
45:59
rupture But the point is that you rarely need to actually trap the segment. When you trap a segment, you also trap any perforators on that segment. And I think you're increasing the risk of a
46:08
problem. And I personally like to avoid situations where you don't have an exit option, like opening a giant aneurysm without a bypass in place. It just, it's uncomfortable for me personally. And
46:19
I find myself, I get nervous. Um, my physiologic tremor increases under those circumstances.
46:28
you know, worst case scenario, I just leave a clip on the vessel, I'm much happier personally. I would agree with all those. And I appreciate your honesty. I think to me after doing all these
46:42
things, the simpler, the better. And I had a, we talked about vingraft, my experience with vingraft was disastrous. And the reason was we would use put a vingraft in and invariably, and I
46:59
didn't do a lot, because we had people who hemorrhaged because of the tremendous flow that was going up and it could have been some ischemic brain or something. And I didn't like the vingraft idea,
47:11
but much at all. And then the radial artery, I didn't like that too much either because I was really worried about taking the arterial tree out of the arterial supply out of the arm And I often.
47:25
But I tried to keep it simpler and better. If I can do the aneurysm fine, if I can do it without a bypass fine, if I could do it in surgery fine, and it was a simpler bypass fine, all those
47:39
things I totally agree with. But you can get very elaborate on it, and we're treating the surgeon, not the patient.
47:48
Right. I mean, there's other options The insights you bypass as I think can be very elegant, I personally, there are some surgeons who are very big on doing intracranial, intracranial saphenous
47:59
vane
48:01
graphs, for example, running a vane graph from the middle cerebral to the PCA to allow for a PCA occlusion. I get really nervous because I think you're putting healthy normal vessels at risk. If
48:15
something goes wrong, you can be in a world of trouble. But there are surgeons who are very successful with it and do a nice job. I just don't do that operation much. I'd rather focus on the
48:26
diseased vessel and doing some form of distal revascularization to it, preferably without endangering what is a healthy vessel and may represent an important source of collateral if you absolutely,
48:41
if you really need it.
48:45
When I was clipping,
48:47
we don't clip that many basilar tip aneurysms anymore, to be honest with you. And it was always a stressful operation. When I did it, Drake was fantastic and some of his students who I worked with
48:59
who had learned from him were great with it. But when I used to clip it, I used to really very much try to avoid sacrificing the PECOM, for example. The PECOM is an excellent source of collateral
49:10
flow. And
49:13
if you're clipping a basilar tip
49:18
end up with a problem with your PCA, and now you've lost your PCOM. It's an unhappy situation. I'm not saying I never took it. I did if I really needed the exposure, but I don't like messing with
49:31
healthy vessels in order to treat the abnormal ones. That's a personal thing. I agree with you. I think to me, with the basilar in yours, the problem I always had is I'd never saw the other side.
49:47
The thing that the complicating problem there are the perforators. If I'm putting a clip across it, how do I know I'm not getting a perforator in there? Well, you can maybe squeeze it down. You
49:55
can see it, a perforator is in
49:60
there. You try to readjust the clip and so forth. I didn't like that situation.
50:05
I tried temporary clips. We tried a temporary clip on the basilar to help with that. I didn't like that I think the interventionist can do a better job than we can, and so I just. It's not a macho
50:18
experience. It's what's best for the patient. Oh, absolutely, absolutely. One other thing I comment to throw all this. I used to use stents and vessels for bypass. You know, at least they make
50:32
a little PEP.
50:34
I put it in there. You don't need it. And you mentioned you didn't use
50:40
it, but I did it, what it did is it always assured me I was not getting the stitch on the opposite wall. 100. I used them. I didn't like it. You have to pull it out at some point, but it's
50:55
actually, but I know exactly what you're talking about. So it just, again, gets down to personal preference. I have what you do with three vascular. We should, we should, it should get you to
51:06
come back and do cranial-based tumors. I have about five minutes left. Do you want to do that five minutes? Okay. Yeah, this will be really quick I these are just to finish out the indications
51:16
other than ischemic disease. This will be really quick I was just going to show a one case We occasionally have a tumor where you have to sacrifice the internal carotid artery Here's a conjure
51:27
sarcoma With the carotid running through it and it was radiated and it kept growing and someone had subtotally resected it So we went and and so I went and did an sta MCA and then took the vessel took
51:39
the entire tumor out with the carotid the patient before surgery had lost, you know cranial nerve function and Then this is an eight-year follow-up. You can see the sta has grown up. You can see
51:52
how large it is filling the middle cerebral So occasionally we get this type of case and then one last idea This is an acoustic neuroma where we do all these cases together with our ENT surgeons and
52:05
the ENT surgeon was working on drilling the porous and they accidentally injured the AICA. And hard to know at that point how important it is, but basically you can see a little piece of gauze put
52:21
down as background and then putting the AICA back together end to end. I've had a couple of meningiomas where, especially I had two redo meningiomas where
52:33
I injured an anterior cerebral or something like that And I think the option is to hope for the collateral to be good or to do something like this. And I think it's another example of what I have
52:46
mentioned in our previous talk that learning revascularization makes you a better surgeon, a better microsurgeon and a better surgeon in general and gives you a certain comfort level, whereas a lot
53:02
of the surgeons I work with who are tumor surgeons, they would just that vessel is occluded and it might, they might get away with it most of the time, as opposed to saying like, well, we've got
53:11
two ends of the vessel, like why don't I just put it back together and have a better likelihood of a favorable outcome? I agree with that. So just to kind of finish up, these get into some biases.
53:25
I think this type of surgery should really be done at higher volume centers. And it would be nice at some point in neurosurgery to get away from ego and put patients first. And it's always a
53:38
struggle between the general neurosurgeon who wants to do everything and the macho idea. And then the idea that maybe it would be best to get patients with particular problems into the hands of
53:49
surgeons who do a lot of something. And that's my bias. So I think REVAST plays an important role in neurosurgery. There are giant aneurysms that we can help the occasional skull-based tumors, and
54:02
we talked about the occlusive. vascular disease, which, you know, remains an open area. But I think most people have a lot of experience with revascularization, do believe that there are
54:14
patients who are helped
54:18
with this surgery. Can you go back to the slide you had of the
54:23
Scobase tumor with
54:27
the carotid? I think you had a, right there. To me, first of all, I think a very challenging case, but to me, it tells me there's a lot of messages in this. And I look at Scobase surgery, I'm
54:40
sure people are gonna be, don't like this idea. Scobase surgery is a technique, it isn't a disease.
54:50
It is a technique to getting to a disease. It's a technique you use to getting disease. I don't call a craniotomy a disease category.
55:02
And so we got a whole bunch of people or scold-based surgeons, okay, I got that. Now here's a tumor that's wrapped around the carotid artery and you said it was what kind of tumor, sarcoma or some
55:13
kind? Contrary to sarcoma. Okay, terrible tumor.
55:19
If I look down to the future, what's gonna happen is we're gonna have a treatment that's gonna treat this tumor chemically
55:31
Either inject a tumor or put some needles in it or something, that tumor's gonna be disappearing with biochemical treatment by the end of this century.
55:43
And what it tells me is if we go another 100 years from now, we're now at 2,
55:51
200. People are gonna turn around, they're gonna look and they're gonna see what we're doing. They could even do it at 2, 120, 100 years from now. and say, Oh, those poor guys, why were they
56:03
using archaic ways of treating this tumor? Why can't they use these chemicalsthat shrink all these tumors, and so forth, and so on. And what that tells me is that don't try to be a hero. The goal
56:20
is to try to do the best you can for the patient with having the highest chance of success and the lowest outcome of complications That's the procedure you choose. Get him through that. Life is
56:34
complicated. I remember talking about, I had a patient who was had a glioblastoma. He was
56:43
a, he was a fight manager.
56:46
And he had a very robust fighter that he was promoting. And he was worried he was gonna die from his glioblastoma and so forth. The young man with the glioblastoma, was killed in a car accident
56:59
weeks later.
57:02
And so you don't know. And so the answer is I do the best I can at that moment. I wanna get the patient out of the surgery with no complications, zero complications if I can, and minimal, get
57:16
them through with life. It's not my job to control somebody's life, maybe in five years or 10 years, something else is gonna come out that'll help it But I'm not big in being a hero and say I took
57:31
all this tumor out with some very invasive surgery and then wind up with the tumor recurring. I mean, that just makes no sense to me. So you gotta balance the fact with what's happening, what's
57:45
coming, there are many advances with what you can do. I'm probably by and people aren't gonna like this either the end of the century, surgery is going to be gone
57:57
You want to? We are on the same page.
58:01
I mean, I don't have a lot of cases like this with ReVAST for skull-based tumors. And the skull-based tumors that I operate are typically very large acoustic neuromas, very large petrioclyphum or
58:11
olfactory group meningiomas where the patients have deficit related to their mass effect because radio surgery has been incredible with this. And this particular patient, as I mentioned, he failed
58:23
other treatment, he was in excellent condition other than the fact that he had ophthalmopligia. And so he wasn't - he had non-functional cavernous sinus cracranial nerves. And so I thought it was
58:39
reasonable to do the operation. But you know what he gets back to? He gets back. He'd have to go back to medical school. And you remember the Hippocratic oath. And you remember premium no-no
58:50
cherry. And our goal is not to hurt people. Neurosurgeons are in a unique position to help, but we're also in a unique position to hurt people. And I spend a lot of time not operating on, you
59:03
know, evaluating and figuring out ways to not operate on patients, because I think that that's what's best for them. And I'm 100 with you. We have to be very open,
59:15
you know, as you well know, when Indo-Vascular was coming on the scene, there were a lot of neurosurgeons who viewed it as competitive rather than collaborative. We were early collaborators. And
59:28
I think it helped our patients a lot. And I've written papers, I've said this openly, I think the good results that we've had, in part, you know, at our center with open surgery, have been
59:40
related to the fact that we were able to push some of the patients that would have been high risk for open surgery towards Indo-Vascular early on. And some of that includes some of the basilar tip
59:49
aneurysms You know, that type of thing.
59:54
And I can recall, again, now we're just getting into philosophy and other things, but I can recall very vividly early on being sent a patient, a woman with a basilar tip aneurysm. And she was
1:00:09
from South Dakota from far away. And first that the films would get sent down. This was back before we had electronic imaging. So they'd send the films down and I looked at it and I was like,
1:00:20
that's a very good aneurysm for surgery. And then the patient comes to visit me in the office and she's a young mother and she's there with her husband and her three young children. And I'm sitting
1:00:33
there thinking about operating on her 12 centimeter basilar apex aneurysm. And I'm thinking about those perforators that you talked about. And thinking about Dr. Drake and
1:00:45
having talked to him about doing all these cases And then thinking about the fact that with a couple of why stents and some coils,
1:00:56
there was a high likelihood of contract and of course, we treated that endovascularly and I don't regret it for a minute. Although at the time, there was some ambivalence about, if this goes back,
1:01:07
whatever 15, 20 years. So I think you just have to step back and do what's right for the patient as pretty much always. Well, I totally agree I think you did a superb job and two excellent talks
1:01:24
and
1:01:26
I really appreciate it. And so just a terrific job. And I agree with your judgment and judgment comes with experience. All right, well, thank you, it's a pleasure. Okay, terrific. There's a
1:01:42
multi-edited book that came out a few years ago on revascularization and
1:01:48
if people have interest in seeing more. Dr. Nussbaum's references are listed as we shown previously. In the books he has written on a video at the severe cranial aneurysm surgery, cerebral
1:02:04
revascularization, and for the patient's brain adeurysms and vascular malformations. He has multiple scientific publications found on PubMed, or in
1:02:19
SNI, Surgical Neurology International.
1:02:25
We hope you enjoyed this presentation.
1:02:29
The material provided in this program is for informational purposes and is not intended for use as a diagnosis or treatment of a health problem or as a substitute for consulting, a licensed medical
1:02:44
professional.
1:02:48
At the end of the video, please fill out your evaluation of the program to help us improve future programs.
1:02:57
This recorded session is available free on SNIdigitalorg.
1:03:02
If you have questions, comments, or a request for CME, please write osmond at SNIdigitalorg. There are many ways to learn
1:03:13
The foundation supports these publications, SNI, Surgical Neurology International, a 2D Internet Journal with Nancy Epstein as its editor-in-chief. It is a web address
1:03:35
of SNIglobal, and the second is SNI Digital Innovations and Learning, a 3D live video journal, interactive with discussions.
1:03:46
And its web address is snidigitalorg.
1:03:50
Both publications are free on the internet 247, 365. SNI, Surgical Neurology International,
1:04:03
is read in 239 countries and territories in the 14 years of its publication It's the third most widely read 2D journal in neurosurgery.
1:04:16
SNI digital innovations in learning
1:04:21
is now viewed in 117 countries in seven months since its publication. It is a new 3D video journal.
1:04:34
The goal behind the publications and the foundation is to help people throughout the world In addition, the foundation has the medical news network. designed to bring truthful, medical, and
1:04:48
science news to the world. All the material in this program and these programs are copyrighted in 2024. For
1:04:59
the James I. and Carolyn Erosman Educational Foundation, all rights are reserved. We hope you enjoyed these presentations, and thank you very much for watching them.
View Transcript
Listen to Podcast
