0:01
as a digital innovations are learning
0:06
a new video journal which is interactive with discussion
0:11
and offers this program and others on podcasts on Apple Amazon and spotify in association with US and I surgical neurology International an internet journal with Nancy have seen as editor -in -chief
0:30
are pleased to present another in the SNL Digital Series of interviews with clinical neuroscience leaders
0:39
this two part interview is a discussion with gausman like who is well known and his experience with cerebral avium it's about what I learned treating fifteen hundred cerebral Ab AMPs this is part one
1:03
Dr Malik is John R Davis Endowed Chair and Executive Vice Chair of the Department of neurological surgery at Henry Ford health and a choice
1:14
along with Dr Malika is Eric Nussbaum who is the chair of the National Brain aneurysm and Tumor Center and Director of Complex Korean or surgery as a Widmann midwest brain and spine center in
1:28
Minneapolis and St Paul Minnesota he also an associate editor in chief for this and I and a board member of SCI digital
1:40
he's published these books an aneurism and a vascular malformation surgery which are available as you can see a lot of the pictures
1:53
as multiple scientific publications on pubmed in satellite
1:60
also as a commentator is James Johnson the CEO of SCI National Digital Editor in Chief of SCI Digital and former Professor of Neurosurgery at the University of Minnesota Michigan Illinois and U C L A
2:18
former chairman of neurosurgery at Henry Ford Hospitals and U I C and Chicago
2:26
Okay now it says I'm recording I'm going to go to Screenshare I'm Putting Up Your PowerPoint which is there should go to A and I believe the condition warrior he goes to Richard gorgeous slideshow
2:44
right correct and play from start for the Nerd as I hoped I hope we're doing it young I can see it now okay Cry So
2:60
I'm I'M just going to start right away and I hope this records and allowed to do it again and anywhere
3:10
we have the privilege this morning of having two very extremely well known and experienced vascular neurosurgeons on this program how one is Gao smile like oh and both of them I've known for over
3:28
forty fifty years our house is degenerate Davis endowed Chair or Executive Vice Chair of the Department of Neurosurgery at Henry Ford Health We met each other when I went went up there from Minnesota
3:43
and Eric was also trained in Minnesota Eric Nussbaum is the second person Eric's head of the National Brain injury Brain aneurysm and AH Tour center in the twin cities St Paul and Minneapolis he been
3:59
had that booth at a private practice for years his wife's also in the involved in radio surgery and is a stereotactic and functional neurosurgeon he's had from a lot of experience also with the topic
4:16
that Gaza is going to talk about today and cerebral vascular malformations so I think Osama and I have to change the slides when you're going to have to just tell me change slides okay
4:30
Hey So you know obviously I have no conflict of interest disclosures and We a Very I need VM Database supported by the fawns from John R Davis Cheer phones
4:48
now natural history obviously for any disease for us to create and look at the long term outcomes of our treatment should be what we need to understand the natural history so I AM just giving you a
5:07
gist of what I have learned over the last fifty years dealing with vest for malformations ah since most of the treatment decisions on natural history Ah is it's very critical to understand his
5:25
influence first of all it is that the bleeding from Arteriovenous malformations is the most critical risk and it happens to our lifetime in Nineteen sixties it was suggested that as we grow older
5:45
certainly beyond the age of sixty the incidence of hemorrhage decreases this has not been proven and actually it has been ruined wrong with further experience we also noticed that in our experience
6:04
the highest presentation with bleeding is in the areas under twenty and over sixty in the middle you see the
6:15
seniors headaches neurological deficit and like and now with the increasing number of diagnostic studies we also notice incidental vascular malformations so we're Gonna interrupt you during the talk
6:33
you're so there there's A and I just wrote a paper or couldn't be more than one few weeks ago I think I sent two guys What it's a common conception that that first off they haven't ruptured don't
6:46
worry about them that they'll never bother you in life or it is it's a percentage is small and and as we particularly you don't have to worry about them as you get older because there's not going to
6:58
be a problem what you're saying in your experience that's not true that's absolutely not true okay
7:08
saw the natural history standpoint the two most significant studies one came from Mayo Clinic which was back in the late eighties
7:22
it indicated that the most serious nature of these liens as well as ongoing risk throughout lifetime so this was from the Mayo clinic and from Finland and Finland is more important because they they
7:40
have had most of the country's major neurological issues were only handled at one institution so they had a long -term fodder there is a two to three percent annual bleeding risk this is very well
7:55
established with associated mortality and morbidity and there is increased risk of bleeding for one year after initial haemorrhage
8:08
the
8:11
it also came to light in Finland when they followed their patients who had were followed face several years the risk of bleeding continued as if it happened initially AH now as we all know that a
8:33
special made a report that the small malformations as significantly higher risk of bleeding than the large ones that troy is that true in your experience that's not true and I expediency that in all
8:50
honestly elaborately drawn in the presentation is a hurricane is that true in your experience probably not I mean i think we've come to think that how is a small malformation going to be diagnosed I
9:05
mean other than bleeding said probably the numbers were skewed the larger malformations you know more likely to cause seizures or scale and so I think it's probably not a correct perception the the
9:17
other thing is the smaller malformations are more common at your home compared to the larger ones and therefore we're going to see many more of them in our experience plus is the larger ones excellent
9:34
points excellent point
9:39
is this the no skip One or is it none of this is fine so this is actually like I was mentioning to saw this was actually a fellow from Walter Reed who went to I think he and he evaluated sixty TI
9:56
patients have been treated great for idioms are a mean period of eleven years twenty three thirty seven percent experienced hemorrhage with an annual rate of three point three percent see him as is
10:12
generally accepted are all idioms and one year after the first MV twenty six percent had died and thirty nine percent had moderate disability odd experiences similar to know who said in Edge Study and
10:27
Earn My right about this in the Finland they referred all they wanted to know he drew hi your journey steamy all the Vascular cases were referred to a centre as arrest correct whatever that's great so
10:44
it's a very good and it being as close to a population study as you can get right that's true that's why I put a lot of weight on the information okay that makes sense to you Eric Yes Yeah they have
10:59
the best data some of the other studies that Mayo Clinic study there were a lot of flaws associated with it I if it's the study I'm thinking of the Andras study they had one patient who I think bled
11:09
eight times and really skewed the data
11:13
okay very very good thanks okay goes so Saudi efforts to predict risk of bleeding and asymptomatic LVMH cabin homeless do only the fistulas these continue but I think the data so far is fairly solid
11:32
in regards to their percentages now this would come up I have a lot of discussion at the trial which was Randomisation between conservative and treatment groups
11:48
as those unconcerned it yielded predictable or controversial results
11:56
because
11:59
it indicated that the treatment arm had more risks and were outcome losses non treatable ones but the follow up is only few years and any treatment is going to potentially cause risk and you say is an
12:23
issue of balancing the risk benefit ratio and when we follow these patients for many years the Anti barely bleed and they can die and they would err neurologic deficit so This sturdy actually muddied
12:41
the water quite a bit especially for those people neurologist and others who who see this and they tell patients you don't have to worry about it
12:56
which is not true AH RK any thoughts about her Earth
13:03
I think we're somewhat reminiscent of the N ruptured aneurysm trial probably showing us that although they may be a little bit more benign in some patients than we had maybe previously understood also
13:18
underestimating the long term consequences for some of these patients as Dr Malik is saying of simply following them and because they don't have enough follow up to I include and identify those
13:30
patients who bleed and have significant consequence to their
13:38
my while other my Mother always said figures don't lie but Lily Liar Configure Yeah and then so essentially What You're saying is this study has got it's flaws that's right the two started arguing
13:56
when the sake of the study was not right okay this is good start for gate hemorrhage risk is for Me is still debated through your next you know before I do this I want it I missed the first try I
14:15
Guess You're we're talking about fifty years of experience how many a VM save you are but there's a difference how many have you seen how many have you treated surgically Yeah I'M going to mention
14:27
this you know we have a database unfortunately it has not been updated in last almost and years because we ran into problems with the horror data system we were using 'em the analyze they went out of
14:47
business disordered somebody else so I hear somebody's voice updating that information but up until two thousand and fifteen think we had about fifteen hundred less from affirmations in our database
15:01
okay then do I think I have some some statistic to that effect later on in the presentation okay an error commonly i just want the audience to understand what the experiences are you've got fifty
15:16
years of experience what was how many idioms have you done Oh I don't have fifty years of experience but thank you I do a little more geneva than that and operated about four hundred and fifty a D AMs
15:28
are surgically we have treated for more than that you know with radio surgeon embolization that type of thing and but I I you know I don't have a detailed database I I will really track more closely
15:43
the treated avium some of the ones we follow
15:47
if I were making a guess you would probably be two hundred something like that but anyway so the audiences got one hundred and fifty years of vascular experience on this call and and we go from two
16:00
hundred to fifteen hundred cases which which is a a large on fifteen hundred cases is a large number so I just wanted to establish that okay
16:14
through all
16:18
the therapeutic issues for eighty games I think revolve around these factors the location of the malformation the involvement of functional areas accessibility to the availability of resources
16:39
rapturous is non ruptured simple way pluses is some direct or incidental and risk of treatments versus matter history
16:51
I I I think of these as cardinal factors in deciding as to what to recommend to the patient next do so the
17:06
my own management principles have been establishing the diagnosis or in the case of Emily's get a city a obviously angiogram is the most critical
17:21
part of the study addressing Hematoma gently and not a VM that is only in cases when the immature mice very large and Tightens the person's life if he didn't have small no active intervention let day
17:41
enrich resolve
17:45
then treated more electively if the image was largely life threatening and carefully decompress approaching through the aquatic artemi avoiding the VM obviously if you run into bleeding you have to be
18:00
ready to control point the Uranium electorally four to six weeks later depending on the size of him it on the degree of mass effect and neurologic deficit I think I had only one patient who bled
18:18
exactly six weeks after the initial hemorrhage while we were getting ready to bring him back to consider her treatment and he showed back into the emergency room will the rich as the people have not
18:35
the embraced in the first six weeks or so a God I heard you do follow that up that's what I we all used to do that I know about when I went to U C L a that Neal Martin had done a devil had done and
18:51
operated on accurately and on life threatening relations what's your approach to that which I think generally I would agree with that you know usually we do an angiogram right away and if there are if
19:07
there is an identified problem like for example a large internal aneurysm as the source of the bleed we will try to secure that endovascular lie and if they can't secured endovascular lie then we
19:21
usually wait try to wait three weeks if possible and as opposed to civic six but I don't think there's a magic number
19:29
try not to operate on the patient acutely let that give the Hematoma a little bit of time to liquify and I think it does make it easier but I'm in and I think in general that's what you know really
19:41
has become the standard from my perspective and
19:47
the other factor to consider is that many times it and enrich the helium might get split into two segments and in an acute bleed you have been failing this is different than treating in after the
20:08
aneurysm because you then run into a swollen brain and it's better if it settled as one that's why I will generally do another angiogram before actually going advocate definitive treatment that tummy
20:28
it's Hella to me as very reasonable that's what I used to do we used to do together but I when I went to U C L a deal had an idea of it's population or whatever he had he had he and sam are sixty year
20:43
old boy a BMC came in with an acute blade and that he operated on them and he would do that he would make sure he had the angiogram and his huge results I had as a small number in their abundant
20:57
results or or or actually resemble more reasonable than I had expected because gauss is raised and eric has raised all the problem with acute surgery you may disrupt the vascular pattern I you you
21:13
don't may not know precisely where everything is cause it's move because of the hematoma usually it's easier to go in there when the hematomas are there you can decompress it and take out the the
21:25
bladder gives you more room to work on it and so so I think the majority of people would still follow what Gauss is outlined here but I just raised the issue that there there are some people who look
21:38
at it differently and have done it differently I dunno if the series Gosh are large enough to be comparable which is the problem right or sixty vs a fifteen hundred is not exactly an equal number may
21:52
not treated nobody's properly at an eight nine hundred or others in yards and fifteen hundred but the Ident one
22:04
point if I could me if the mathematician is small and the humic on my small then you have the person that he color from the neurological deficit
22:18
was treatment rather than y until the initial treatment and then being exposed to and at the surgical intervention or treatment It may be an argument that one could use AH if indeed the malformation
22:34
is very small superficial easily accessible that one could treat but overall I think some always seemed to see a fairly complex malformations in and for there is much more beneficial to wait on it are
22:57
reasonable clerk I mean I'm not suggesting at all that this was the case with need to know the series you're referencing from U C L a but I do think you have to be careful because sometimes the
23:07
patients will combine with a neurologic deficit and roberto heras used to make this point that if you can operate early and you can make that deficit permanent and it doesn't really look like you've
23:22
hurt the patient because they had a significant henry priestess and now they have a permanent heavy priest says but if you give them some time to recover sometimes they actually will get better and so
23:33
it's a little bit unfair it's a little bit comparing apples and oranges unless you're very careful about it because what you don't want to do from my perspective is take a patient who has a
23:41
recoverable deficit from the hematoma operate them early the brain is swollen end up giving them some type of permanent deficit that they could have otherwise avoided if you had operated on the avium
23:53
under more controlled circumstances all regional events resume accurately at EA Okay
24:02
Okay so
24:05
so as as we were talking before you know the risk of heat up care is vital role in the first several weeks spasm is extremely rare and unless there was an associated anarchism from which the bleed
24:24
happens so there is no need for nimodipine
24:29
as Sir Alec was indicating if feasible treat the entertain yellow green idol and resumes and have as clearly AH repeat the angiogram proud of definitive treatment as I mentioned before next
24:51
so what are treatment will vary more modalities this is one thing but just to mention that we could just observe the patient symptomatic treatment cheating see years addicts doing endovascular
25:11
treatment embolization is rarely definitive mostly as an adjunct
25:18
ah obviously microsurgery is the mainstay of treatment did your surgery definitely as Iran and multimodality treatment
25:30
combining different parts of the treatment depending upon the extent of the mathematician and rarities okay the next
25:42
so we we have had very significant improvement over the years in our surgical technique use of
25:58
different modalities were still at these are few areas where I feel the malformations still remain a challenge the smaller idioms that are deep especially the majority of Yams the bigger ones what to
26:18
do in elderly patients and much ado about incidentally found mediums and our Er I didn't comment on each one of them one by one
26:35
so smaller formations which are Great Wanna get too stressful modern grid ah basically are amenable to microsurgical dream
26:48
unless you are located in the brainstem or Telemachus
26:54
people who are medically unsuitable for surgical intervention
27:00
severe neurological deficit that actually precludes you from doing more intervention
27:10
failed other treatment modalities and the patient against surgical intervention because ultimately patient's decision what to do or what we can do is to educate them about the problems and x what
27:27
saw
27:29
the radio surgery best suited for Indians that are less than Ten CC and Mario
27:37
best resist a gluten and eighty five to ninety percent but more commonly sixty to seventy percent
27:46
obviously we have a little fear Three years with persistent risk of bleeding
27:53
events that are located deep and critical functional areas are best considered for radiosurgery
28:01
if the malformation is really small particularly in the perceive Fossa targeting that smaller Avian is a definite concern how how you localize it and whether you are targeting is OK and follow up
28:17
memorizing the new games are needed typical equation if the malformation is not completely occluded it is still prolonged to our Lady
28:30
I heard an entrance about that
28:34
you know I generally agree I you know I think our inclusion rates have been favorable with the Idioms we've chosen and the review stage radiosurgery I think we treat about one hundred and twenty a V
28:46
AMs with radio surgery Practice on
28:52
at the Edo it's really apples and oranges in terms of the treatment options older age and sometimes especially the deep AvI AMs the ones that are located in the language areas for example week from
29:05
often used radiosurgery and with the ones that we've chosen have gotten generally very good results but it's certainly not one hundred per cent inclusion and there certainly is a latent period and the
29:16
question that's been proposed whether there's any protection from the radio surgery causing some thickening or toughening of the vessels and I think the jury is out I don't think we know for sure
29:28
I think the questions are curious and maybe you're going to talk about this couch but really radiosurgery came in is very popular I agree with what you wrote that initially they thought the inclusion
29:44
rates for a high I think they did go declined but to Me I Wonder and Wonder what happens to these patients do they do what you suggested follow up ama rise and angiograms to till total inclusion and
30:00
I'm not sure that's happening Eric your wife is involved in radio surgery did she do repeated angiograms into the future to see what was happening oh Yeah we they have a regular schedule usually nine
30:16
months eighteen months and then keep going until it looks like it's secluded on M R imaging and then do a formal angiogram at that point to confirm it so those patients are followed very closely
30:26
unless they you know didn't show up for follow -up Gosh is that your experience with referrals I'm sure you'll get referrals of people entreated they've got it and they bled again have these people
30:39
been followed obviously not the people who have gone outside and have gotten radio surgery Ah I don't have a good handle on them or our own patients that we're treated and I Am very rigid about that
30:60
follow up because I've taken that upon myself to to follow those patients
31:10
and
31:12
the still air that those numbers actually hold up or depending upon the size if it's only a centimeter or so all the prior to your readers definitely much higher than is about thirty four centimeter
31:29
thirty centimeters obviously once it gets larger there are not a quiet suitable radiosurgery
31:38
you know it was suggested to me be compartmentalized theory him and I do radio surgery on
31:47
some segments of it and I have no experience with it I have a couple of patients that I suggested we do that but it never happened
31:60
they will make an impression there were the least I am left with is that if they're done in the community and they're not followed rigidly like you sound like eric does the there is a chance that you
32:14
will miss a complete inclusion of the legion and that the patient will have this malformation and I worry about those patients being out there and what happens to them is there any study that you know
32:26
of that where they've done their
32:29
long term study with an inch or graphic follow up after radiosurgery
32:36
I know and I dunno they do hands reduce or do people Hana Database but I'm not quite sure if that has been addressed Yeah we can part of the police she was in again and ice spread out into the
32:51
community as you know very well and so things get treated
32:59
without a whole lot of far less scrutiny compared to being in gigging situations where patients get scrutinized alright
33:11
then it will appear eighty five percent of the world lives in the low to middle income countries and people in the in the in the developed countries and I know that's not a common term but in I income
33:22
countries don't understand that or you go back to Pakistan every year under and so there are dealing in a totally different environment and so following somebody up for a long time isn't easy or easy
33:36
or you have different treatment parameters you have to have because the circumstances are different is that correct absolutely absolutely distances they live by far away it don't want to go back to
33:50
the doctors there is a lot of cost issue you know your Anger I am our eyes they are not available in government institutions so they have to pay from their pocket and if they cannot pay for their
34:06
prescription our devoted to pay for repeated studies Oh Okay Bergen discussion all right cares the first patient or just a patient so here is a fifty six year old boy presented with a speech
34:24
impairment he had limited or expensive type is Asia and he had this hamlet
34:35
on the alot I didn't see any floyds on the left side of the next one he had initial angiogram which look In Norma
34:48
and in in these cases
34:54
we have always felt that these patients should have repeated angiograms to make sure that there's no AH vascular leg and I dislike Sebagai hemorrhage patients they are not animals were sober at night
35:08
and ridges but if the first angiogram is negative we will tend to repeat it and might bring the patient back to make sure that there was no source of bleeding similarly with HIV and if we're into
35:22
Super emergency location that is not typical of Hypertensive hemorrhage
35:30
I'll I'll bring those patients back and repeat the angel that was done in this case I'm sorry Gala and you can see that he has a small malformation without your Venus shining I was just going to ask
35:48
you that I'm Sorta serious and early draining vein on the image on the right side under that side Yeah so this is this is a follow up angiogram when the image on my God absorbed his mama information
36:02
showed up so long at that point I recommend it to him to have this removed this was superficial easily accessible but the patient and we discussed the option of doing radio surgery and he decided that
36:21
he would rather treated with radiosurgery
36:24
and was treated Andor Arab it got obliterated
36:32
quite appropriate I'll just make you know if I'll just pick one point on that last case you know I'm disappointed by the increasing our reluctance to use Diagnostic Catheter angiography in Super
36:47
vascular patients in general but this is a great example I've seen several patients like this where they never even had one diagnostic catheter angiogram let alone a follow up because people are
37:01
afraid of the invasive nature of catheter angiography in the community and patient comes back later with a repeat hemorrhage never having had an initial angiogram let alone a follow up and scram
37:15
delayed fashion and when you're dealing with cerebral vascular problems I don't believe the cross -sectional imaging is always enough sometimes it it does reveal the problem but often times like this
37:26
it doesn't and this is a great example of that absolutely absolutely uranium move on to this okay now this is this is a patient who was fifty two she presented with years and this was her malformation
37:49
and she was treated with radiosurgery
37:54
saw she presented to US with her increasingly sided weakness
38:05
and if we look at the I AM an AI
38:11
next one
38:14
she obviously had the effect of irradiation she got quite a bit of Fatima
38:21
and if you look at the middle picture that is here that is her arteriovenous malformation
38:31
if you look at the post contrast study
38:35
the target of radiosurgery was different then where the malformation was
38:47
Interesting or Curious okay so she got treated with steroids to reduce edema and once I saw repeated her anger them and you can see Somalia the earlier best way to get at is where is ready or
39:08
radiation effect was a mathematician looked exactly the same and so we took her to Saudi and and took it out and she did fine
39:22
and our initial deficit after steroids had resulted in said you did not cause her any particular problems
39:36
next
39:40
now in microsurgery obviously AH essentially all of those great one and two they are treated about with microsurgery Ah I think my biased opinion is that it provides immediate and best treatment in
39:58
multiple large cities including our own mortality is less than one percent significant morbidity is less than five percent and curated essentially hundred percent obviously to be proven with
40:13
postoperative angiography
40:16
which I routinely get done before the patient actually is discharged
40:26
Let's
40:28
resume the show must preserve the next one I think
40:33
he also this is a
40:37
this is your remember Felix was involved with the Tsar and this presentation of job application delight surgical removal of Arteriovenous malformations a basal Ganglia and our results are actually
40:54
very favorable
40:58
even though by a few of these smaller ones iron suitable for radiosurgery but if you can they moved and then you take away the later period and so forth next
41:15
saw it here is a young patient this is the old MRI scan
41:23
before regard The regular currency T scans so I sat left is left right is height looking from looking from the top so he was about eighteen at nineteen years old he presented with a sandwich with
41:41
extension into the in men to grow our system and this is his anger their next night
41:51
so he had
41:54
this pretty sizable malformation
41:58
he was related to one of our
42:02
colleagues a physician and they saw a lot of consultations and ultimately they ended up being in Pittsburgh sie in Boston
42:17
this is before the days of Gamma knife is ran out Wooden beam therapy was being used so he went through
42:30
Proton beam therapy
42:34
did not lead again but two years later
42:39
he repeated his angiogram and looked exactly the same
42:47
now do you might remember him
42:52
next
42:54
so
42:57
you know at that time we do not have embolization so we approached it transylvanian and occluded one of those large or electrical Australia vessel and then came
43:12
trask article and removed an affirmation he had to mild
43:20
dysphagia mostly initiating his speech and in two three months
43:28
they got better and he returned back to college and has been fine ever since the excellent excellent result goes
43:41
AH next to this is so this is young lady
43:46
actually I didn't came to US from a chile
43:52
with this hemorrhage and the malformation
43:58
next the angel
44:03
a similar location but little bit
44:08
more closer to the base then the other one and this was pretty easy to approach threw away our data abroad going from sub frontal location into the frontal lobe and said you got to get out next
44:32
and this is added to the post office gramin Shia had no issues with surgery I think this is just pushed to indicate that even though some of those legions might look very ominous and are complex but
44:53
if we actually analyze them and use rather abroad they are amenable to said you felt intervention
45:03
or reason to my desired
45:08
look they're very impressive cases I mean I think my experience personally supports that in the sense that I've operated on these types of cases in patients who have bled and who are in a life
45:22
threatening situation and have been pleasantly surprised with the long term outcome and I have less experience kind of tackling these electively or you know more some of along the lines of what you're
45:35
saying and and we've kind of gone probably more of the route of the you know the multimodality maybe ambilight part of it may be radio surgery see what happens then if there's a section that's left to
45:50
operate on that I mean what your but your cases are very elegant and I think it's people need to see this that you can tackle these and without you know devastating morbidity it's impressive
46:07
I think so it goes goes back your little bit reported on a study and other people can report on the study but the problem is that the study doesn't show I see the skill and the experience of the
46:24
person who is doing this and these are obviously from everybody is looking at these very challenging lesions and there is a factor here that leads girls to report successful results and he's an
46:41
excellent surgeon it gets excellent results and in the end I know at the time you were doing these people wouldn't do these cows were wrecked and and and so AH and this was an achievement at that time
46:57
itself an achievement now so it take somebody who is or was it was really highly skilled and reasonable to to do that so that would be my comment and that's a compliment to you for this thank you so a
47:12
lot
47:14
here are some of these approaches to these legions so you know going across Indian characterizing cycles branches and it's interesting that even the lenticular strides one or two branches will be the
47:31
ones that are actually
47:35
supplying the malformation and taking doors is a
47:43
feasible without any major deficit and all the armies that even in the west for treatment some of these are not wait a minute while to to humble eyes from those smaller vessels obviously now we have
48:00
better cricketers one dollar lot more experience and in doing so next
48:11
The
48:14
majority of the Deep malformations are also available to microsurgery and radiosurgery is a definite option especially for non -drug treatments are obviously we need to approach those we'll see if
48:30
corridors and feeders usually too small for endovascular region and embolization is very helpful if possible to take some of those deep feeders
48:46
next
48:49
for example gave this malformation
48:54
this is what seemed to be by deep although it is accessible tool and inter hemispheric approach one actor Jim and I described that he bought a braun I parasite one approach and the tissue go to the
49:18
Foxton to reveal junction a pioneer legions of legions in that area including the malformations that present and closer to the surface and next
49:31
here's another one again similar location but this is relatively superficial on the medial side of the hemisphere an amenable to treatment coming from the posterior cerebral you have access to it as
49:48
they perceive cerebral comes and all the thorium and the supplanting from the anterior cerebral is also accessible because it's coming on the medial side of it so this was feasible to to be removed
50:07
without causing neurologic is it next what approach did you use to get isolation seem the same way we went into his bag okay
50:21
this is this shows you that he caught a prone position and where the malformation is having the operative site down so it
50:32
relaxes the brain away from the fox and you don't have to do a whole lot of attraction
50:41
next
50:48
We I participated at one time as meg was coming magnetoencephalography from Scripps clinic or send some patients to do so since the localization obviously we can do water mapping and so forth and that
51:07
was very helpful because you could to they will tell you on the amirite where the sensory cortex was and in surgery we could do for years reversal or hand for example this next patient
51:28
you can see the malformation and it tells us about the fears he was at the sensory cortex was right in front of it where I'm pointing with the order and add a malformation came out It was very
51:46
superficial and I'm sure he might if we didn't have that little gladiator would have taken it out but it was very very alpha using functional MRI I think has also been quite helpful in at least
52:02
assessing the potential risk of all you're going to but you're going to face CE Radix to the next
52:18
any silver any of the ants again
52:23
obviously there was a significant problem from the standpoint of how deep they are aren't they just in the curriculum and obviously they're on the temporal side and none none none aside their sake if
52:42
they are on the fringe operculum you worry about the hand and the face now but our experience actually has been fairly reasonable
52:55
next
52:58
these were the kisses at that time that one of my colleagues reported next
53:06
and this is a very interesting patient at this this patient presented with severe headaches
53:14
actor brought her to the emergency room andor the water not easily control and if you can see this is going deeper to the insular next
53:30
this is Vera and Hugo and it had supplied obviously from the middle stable as you can see it also has supply from the anterior parietal
53:44
and we debated about this this was actually quite large retarded was probably larger for treating it with radiosurgery
53:55
were able to analyze the supply from the antioch rider you are able to actually get the Catacomb closer to the Malformation and then now next we do for instance I Am awry and actually has feet even
54:13
though this was on the left side as each was away from it saw and we had castle and experience the initial learn functional MRI that was done by the neurology department several of those were my
54:32
patients and we noticed that in the the idioms the speech actually had shifted to the opposite side that a fifth of patients were at the younger than seventy years there was a general tendency Irish
54:49
speech to shift away so that's where we operated on her and the
54:58
next
54:60
this is our postoperative angiogram and shelia actually did not have a speech problem or at least got better and as she has been doing quite well
55:18
excellent excellent
55:22
AH next
55:27
This is Sam desert the Pip I was mentioning Ah the study actually kind of gave me more courage to treat some of these patients a bit more aggressively next
55:42
thing the brain tissue or at least in our in my hands not amenable to surgical resection AH as I said before his attempt at three such cases was unsuccessful therefore it either you leave them alone
55:59
or possibly treat with radiosurgery if they are small enough to be amenable to it okay next
56:11
our approach absolutely collaborative multidisciplinary program between neurosurgery and vascular and radiosurgery efficient discussed individually
56:25
Great Mathematician whenever feasible
56:30
and hard place microsurgery absolutely the preferred approach and Alaska support utilize fourteen Idol and wisdoms night and resumed our Louisiana of the fetus radiosurgery and selected deep
56:45
malformations patience is the Ultimate decision maker and confirmation of the completeness of treatment weighed in geography history
56:60
so this is a disorder was referring to if I didn't have the numbers at that time sun in our database the thought of patients evaluated between seventy one and two thousand fifteen or fifteen hundred
57:18
and seventy four one daughter patients who definitive treatment was eight hundred and forty ble idioms five hundred and seventy saturday alone or with embolization five hundred and thirty five
57:34
eighteen thirty twenty eight just as you are a bias template isn't alone in seven Kevin loomis says you can see him in ninety one or cranial Enduro Eerie fistulas a multi -modality approach and
57:52
fourteen spinal
57:57
I'll combine fifty one Scalp another six and Vita send you was earlier on we thought these were
58:06
bleeding but they are related with the governor was buried so this this was an experience as a fifteen and I think we're updating it next
58:19
okay so mortality as possible treatment similarly idioms fourteen patients two point zero five percent
58:31
one grid embolization and one hundred recognise hydrocephalus and rear center others basically enlarger have used and an incredible results and current an almost zero mortality and urinary fistulas
58:49
two pieces one with thirty and other one was a chance heinous explosion so embolization so that that that has been our experience obviously we don't have all the categorize people who have had some
59:09
deficits they often improve over a period of time but some people are left with deficit outstanding just outstanding results
59:24
okay this is somebody you can't treat
59:29
the eye could see that dried
59:34
or or that's more of the same okay this right
59:45
Okay So my Conclusions you know I learned a great deal about these vascular malformations in the last fifty years and have tried to impart this knowledge to my residence and share with others in
1:00:04
medicine around the world and these vascular lesions requiring multidisciplinary approach with appropriate team that was for the best interest of the patient not our own bias we still need to learn
1:00:21
more about and find better and safer ways to deal with them and above all I think the most gratifying aspect has been knowing my patients supporting them and sharing their difficulties as well as
1:00:38
sales of their lights
1:00:41
outstanding These are the key references and charged to Dr Malik's talks on cerebral Eve Yams it's best that you take screenshots for your records some of the references are given during the
1:00:58
presentation so you should be prepared if you're interested to take screenshots of those images also
1:01:08
this is the essential references DR Malik recommended for your reading
1:01:17
take a screenshot of this for your Records
1:01:22
we hope you enjoyed this presentation the views and opinions expressed in this program are those of the author or interviewee and do not necessarily reflect the official policy or position of SCI
1:01:37
digital or it's management
1:01:40
The Information contained on this program should not be considered to be medical advice patients should consult their own physicians for their opinions as to the specific medical needs
1:01:54
please fill out your evaluation of this video at the bottom of the rating scale which you can see below on photo is five stars on the home page one sars the lowest five is the highest to help Us
1:02:07
improve the information we bring you an SNL Digital
1:02:12
Foundation supporting these journals says anyway seller
1:02:18
S and I Surgical Neurology International as a web address of S and I Dot global it's an internet journal with Nancy Epstein as it's editor in Chief and Sai Digital innovations in Learning It's Address
1:02:34
is Asinine Digital Dot Org it's a new video journal which is interactive with discussion both are free available twenty four seven three sixty five on the Internet
1:02:49
Surgical Neurology International is read and two hundred and thirty nine countries and territories after fifteen years of publication it is the third largest readership in the world and our surgery
1:03:02
as an AI digital innovations and learning is now viewed in one hundred and fifty countries in fifteen months and it's the first video neurosurgery journal the goal of the foundation supporting these
1:03:15
programs is to help people throughout the world
1:03:19
this recorded session is available free on Sai digital's out or click on the blue icon at the bottom right of the home page if you have questions or comments or requests for seeing me cry invasions
1:03:31
and learning it's address is asinine digital Dot Org it's a new video journal which is interactive with discussion both are free available twenty four seven three sixty five on the Internet
1:03:48
Surgical Neurology International is read and two hundred and thirty nine countries and territories after fifteen years of publication it is the third largest readership in the world and our surgery
1:04:01
as an AI digital innovations and learning is now viewed in one hundred and fifty countries in fifteen months and it's the first video neurosurgery journal goes to the foundation supporting these
1:04:14
programs is to help people throughout the world
1:04:18
record a session is available free on Sai digital's out or click on the blue icon at the bottom right of the home page if you have questions or comments or requests for Cama Credit
1:04:31
as a digital now offers all of it's programs on podcasts on Apple Amazon and spotify look for them under arrest and I digital
1:04:41
and the Foundation supporting these programs also supports the medical news network which is dedicated to bringing truthful medical and science news to the world
1:04:53
the program is copyrighted in two thousand and twenty five of the James I and Caroline are Awesome and educational Foundation all rights are reserved contact entourage for more information
1:05:05
thank you very much for watching we hope You have enjoyed
