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The Shanghai Surgical Neurology International and Internet Journal edited by Nancy Epstein
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is an AI digital innovations in learning a new video journal all video interactive with discussion edited by James I Osman in association with Sub Saharan Africa Neurosurgeons are pleased to present
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the thirteenth as a monthly series of Sub Saharan Africa International Grand rounds in neurosurgery held on the first Sunday of each month
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These meetings are held to provide global solutions to clinical challenges in neurosurgery seen worldwide
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moderator and organizer this meeting as a strata Bernard
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assisted via James haussmann and given to an international audience in attendance
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The first presentation is an anterior communicating artery aneurysms are harnessed steamy perspective given by Johann Showcase Alaska is always a member of the Peruvian Science and Technology
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Foundation
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and is also an expert in cerebral vascular and skull base neurosurgery interventional neuroradiology stereotactic radiosurgery all formerly associated with a department of neurosurgery and Helsinki as
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a university hospital there where he obtained his PHD
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is also the associate and co -author of many books and papers written with Doctor Ernest naming and is now head of the neurosurgical unit in a hospital regional del Cusco School of Medicine at the
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University Andina Cusco in Cusco Peru
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a diagram on the bottom of the page shows you the location of Peru and where Cusco is somewhat distant from Lima let's get started welcome everyone this is what we've been doing this for over a year
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and I'm so Glad to see the interest continues I'm sure more people will join in as we as we move into the aisle but we're we're going to have a number of presentations to date DR Johan show Velasquez
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is from Peru is is our guest speaker he'll be talking about microsurgical management of Anterior communicating artery aneurysm and then Professor Theo from Dhaka I them go will be giving a case
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presentation to complement the guest speakers talk and then and then we'll have a case presentation about the cerebral plasmacytoid that from from the the the group in Kenya Doctor or Mauro or Kim in
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Okuma I think Dr Kamala is a pathologist boat but Welcome everyone Jim would you like to to introduce our guest speaker
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Johar Misha is from Peru he went to medical school in Peru I ticket to the San Marcos Medical School and then went on to do a fellowship you tell Me if I'm wrong you know how many what Fellowship with
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Doctor Herman see Me up in Finland I got his phd up there and has God I'm just on a huge number of papers he's written up there and he has been attacked to Ernest Amy's right hand person for a very
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important assistant for for many many years and traveled when he was doing surgery around the world and so are really lucky to have somebody his major interest is in vascular although he's he's done
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work in other areas he's written books and and the the real valerie the reason that we wanted to have him is is because he is an accomplished person buddy comes from a part of the world which is very
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similar to to the Earth what other African colleagues are arguing in that it's a growing area of neurosurgery and in his perspective an aneurysm is very practical which has been doctored harness name
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is in that around the world people are doing a lot of interventional work and so forth we can talk about that later but DR ernest name he was the one who is promoted The the direct surgical approach
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to aneurysms and actually has done had done such a superb job he was able to do the surgery in very short periods of time at low cost with excellent results which is exactly the challenge that you
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have now so ah he'll be back with us a number of times in the future AH and we thought his experience would be very valuable so I hope dessert did I leave anything out your home is a red herring is
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fine saw thank you for again for your words Yes I was combining professor as naming off he said in all the last years and here for sure we have learned many things from this giant man and yet I am
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here to share with you some of his key points in the end a philosophy fall asleep in both a challenge and I know reasons so if I can is that if you let me start I kind of stay Please Thank you welcome
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again thank you so much for participating with US and agreeing to be our guest speaker you're recording your recording this right is being recorded great okay Yeah saw a Yeah I was thinking that I
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could cover when our time so by the time I prepared that far that time but I think I can manage the time until you were going to speak basically about the tricks and the deeps of the site and the
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reason why because his name is Perfect perspectives because at for sure he was one of the men who cooperated most recent maybe in the world them and although M CA aneurysms are more frequent in the in
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Finland where the second most frequent reasons there are that a km artery on the recent sub
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and this lecture is based on this publication they have a publication a mate in two thousand and eight and they were looking for that then operative technique and operative techniques of this for the
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management of these honorees and so on to all critical information also you can find in these two books they are freely available now you know the the the thinking microsurgery basics and tricks
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policies in the two thousand and eleven and also we have published tanks to surgical neurology international this video surgical Atlas where you can surely find manny Mania on their resumes and all
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those that they just that what Professor Harrington Jimmy was using for for treating those challenging cases stop we can see now the anatomy of this on their resumes wiki by this and antonio a lot of
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artery on their resumes in this five segments you know they won and from the bifurcation guaranteed bifurcation until the day come the actual date from the come until the general of the Gods Callosum
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the three goin through the den of the Corpus Callosum and the place where the petticoat that robbery colossal artery aneurysm are originated under a four and a five segments that already by that by
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the imaginary line in the coronary is shorter and about the prevalence as I was telling so MTH bifurcation bifurcation aneurysms are more prevalent in finland now basically it might be due to some
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kind of genetic differences in the population yet but in more serious a commodity and the resumes are the most frequent to globally came why is this challenging because of the complexity in the
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anatomy Yeah so there are a lot of whoa ama the Non and architecture InC and Interrogate time aspects running around is a commodity and also when you find the aneurysms in that place there are a lot
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of anatomical variations yeah and for sure that the location of this on their resumes make them challenging and all the bustle at bay for a dozen running on all done note of neurovascular elements
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that are around this area make make this and the surgery challenging game and usually this the origin of this acre interest appear in between the dominant a one segment and anterior communicating RT
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mill on the dome is often located between the two a two segments and to one of these I agree the God aspect in this and the reason is to recognize this a recurrent artery of Huebner and the other pair
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for eight years during the surgery and in more serious this is a very complicated there are no reason saw it carries a lot of morbidity and mortality especially if the notice audience that are treat
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in those cases are not so specialized and the one moreover these are discount offer structure brings up and is
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the diastolic dysfunction so through this before for actors or the damage in that four acres that are running around this aneurysm when we can get those neurological symptoms young and so for US
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already what we need is to have a very precise anatomical knowledge for the dissection and also we need or we must i avoid injuring the front aloft during the regression Yeah but all the suspects are
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very difficult to when you monitor large or complex aneurysms so that the aim of the surgery is basically to clip this I notice him but respecting the normal anatomy around this on resumes usually the
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sign
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on their resumes and that they'll come again in our theory they appear with sure at night to hemorrhage and they are usually richer richer with aneurysms and yet even in front of of what we know
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generally about the size of a or risk size of the recent flurry of June this and aneurysms even can break when they are very small so in the knowledge that we have about seven million Millimeters off
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and resumes in the anterior circulation for treating them maybe is not suitable for the case of this acre mine ever since Yeah because they the media the medium size of the of the only reasons treated
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in the cities for example is seven millimeters which means that even a smaller aneurysms where's your turret okay so this is also very important to take into account for the phenomenon in patients
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that are carrying this on their resumes even though they are not tons of turrets so I and other aspects in this case decided that that there can be associated with other reasons especially in the AMC
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a bifurcation and for that it needs a really highly and expat experience yet the neurosurgeons game
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it's publication was made based on the corp your data a scorpio least one is the first place where professor Harrison's need me was the origin though he has spent around maybe fifteen or twenty years
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there and today collected the Go database for public alpha for this publication until later when she moved to Helsinki then she collected data and he collected again the database of Helsinki but this
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first publication is based on this and three thousand more than two thousand and thirty cents or more than four thousand I noticed treated the name you know in the in coop game
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some you know that Japan and Finland were like the privilege to places for for aneurysms maybe also because the archive screening and a population and also because of course that genetic aspects and
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some
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aspects of the population like smoking or other risk factors that they were collecting and they made a place with a huge prevalence of other reasons now on to until that time there were over one
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thousand patients with aneurysms treated since the nineteen fifty one game so it was showing already that they they have they had a good experience in the minors enough of this aneurysms of course
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this a database also and show it not only share this near me said experience but also all the neurosurgeons experiences that were operating in groups
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where we've had this
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inland asea on the Ot sims where more than one thousand and from this more than one thousand around eighty percent of the A C on their way or where a command the only sims and or like a like a
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similarly like seventy or eighty percent of those patients were of direct cases and the median dia diameter of this on Edison whereas you are seeing here is seven millimeters
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and a giant aneurysm swear quite a few just fifteen and forty four mannerisms in this a calm area were also very rare only three of navy subs came
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i guess you can see that from or ruptured aneurysm in Finland around thirty percent are from the are coming from the akon the segment to you but you can recognize as I was telling the beginning that
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in Finland the most prevalent than the reasons are coming from the MCL by Vocation Yeah and the second one is this a come on ever since
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the correlation with intracerebral hematoma on the interim into Galera hematoma is this one
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because of that close proximity that they have with the pentacles usually around twenty percent of the cases have intraventricular hemorrhage and another fifteen are having the same intracerebral
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hemorrhage
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and regarding the associated aneurysms most commonly associated aneurysms are these middle cerebral artery bifurcation the MC A bifurcation however also there may be multiple aneurysms in the owner a
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calm complex young like two persons or two percent of the population happen two or more aneurysms on the same or a comb complex and even a couple emissions cut at three on the resumes in that in that
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area
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so Yeah this is certainly the bitter about anatomy when I share with your those lights you can where you can revise this segment and this anatomical considerations especially about the the the
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position and the placement of this a one segment came also about these
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Awan anomalies we can have frequently this hypoplasia or replace your duplication offended Thracian author of even the in infra of the course of this a one segment okay so you have also been the
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literature recover a lot of revisions about about this em anomalies in day one segments segments and of course this is a clinically important because we need to care than normal anatomy even though or
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more even more if em we have like a glassy of this a one a one segment so we need to preserve carefully all the best as they are running around the analysis game importantly this mythical integral
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state the arteries or you know this medal ah arteries spurt for a toss -up year from the A one segment differently from the lateral better for a door that appeared other are getting from them in one
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segment and to all this go of course to the to the deeper structures in the brain and the diameter damascene of are pair for a dorsal may produce severe neurological deficits came close where you can
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revise about how the claws and how they enter and in the interior are better for a theme so stance which kind of is structures that are irrigating obviously all the optic systems aren't part of the
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from the law Yup
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and again the preserve the preservation of these arteriosus is is very important when you are operating under the communicating artery aneurysm regarding these recurrent the Arctic have given their
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business a big branch come in usually from the eighth to segment also can come directly from them and they were communicating artery or even it can come from it can appear from them a one segment and
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is very crucial to preserve this this this artery and usually this a Catholic and different course running around regarding the a one segment or like come in around sixty percent of the cases most of
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the cases and the Sarah Huebner That it's a superior course regarding the A one trunk and also a trust an anterior course and the posterior course at least frequently okay so
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during the dissection of the of the LDS hymns of a one segment going through the lateral or going going through the cherry on the approach or inter hemispheric approaches we should preserve this very
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important destructor of his size of a censure for the old and the road to avoid the neurological damage in the brain Cape St regarding that they are communicating our theory of Corso we know very well
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that these are structural joints of the anterior part of the Willis Circle and and we should recognize very well the normal configuration of this are a commodity since due to variations of the AOA
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segments also this can have different positions and also we should recognize and how high it is and this structure from the skull base since this
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step is essential for choosing the correct approach for treating descended or completed receives training
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when some other anatomical aspects also you know that there are communicating artery are nearly since they have small beer for a thirsty are going to the ER to the the Angelica structure so we should
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preserve them and preserve the curtains near me also was she she commended on the importance of clipping those aneurysms in the perpendicular manner yes though then you can avoid to damage or avoid or
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you can avoid clipping but before it does the thought of running near to the to the aneurysm in this and it'll complicate the next segment game
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Well Yeah we should have the usual idea that as we were mentioning usually done the reasons appear from a in the direction coming from the dominant a one yet so new to the bus glaring flaw and that
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all these aspects of the aneurysm is coming and following the flow of this dominant a one segment and that we should recognize that in the imagine of the sir of this resumes
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and regarding the aid to sick mental roof of these two two other arteries this orbitofrontal and frontal polar arteries that are appearing near to the anterior communicating segment with already then
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you shall read our record into artillery of heaven they're abusing the a to segment also on to this is a very important while recognizing those structures during the Microsoft management of this
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aneurysms
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game we have we can have this another miguel variations the norm and when we look at the two that are notices we we have the by the thought but we know that those animals Mascara running these
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different positions and we're recover this classification of that of that data complicating our theory on their resumes regarding the direction of the dorm know if the dumb is going downward or we can
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see it on the resume going towards thy skull base or if it
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is forward we have this for the protection of or if it is upward it goes between the two and a two segments or even it can go backward Okay INOX exhilaration sobbed and in cases of complex aneurysms
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Wicca half this at dirty bottom though of all this under a complicated Carolina segment game and we are a recurrent also with this aspect that the aneurysms is usually originated in in the enjoyment
24:03
of the dominant a one under the aide two segments McKay and rarely rarely it appears directly from the dinner complicated drunk okay so
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the the technical aspects for treating those aneurysms that will base it basically on this direction under the direction of the dome
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came what they use for or for evaluating those I notice homes where we know that the gold standard for the for the management of this sims is the digital subtraction angiography however in Finland the
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more Sanders they use the city A Cave scenes it said that the efficacy and the the sensitivity and specificity of this city a similar to the digital subtraction and geography for aneurysms more than
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the diagram larger than two millimeters games home and it has it adamant that just seeing some the stall is invasive and you can really also associate or you can organize your your strategy by waiting
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other structures like the like the skull base or like the brain or there saw you're going to analyze better your approach you'll see in this SE Da them despite of the of the digital obsession and
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geography that is of course the gold standard in the imagined game and the request for the reconstruction of this element is very important to recognize this the foreign vessels that are going on the
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four main busses that are going on all day commentary you know the two a was then the two a tooth and even you can recognize of course the perpetrators that the appearance of those structures can do
26:05
and what we do or what they do in case of this negative for the Essay I noticed him but the image in which you really suspect that there is an aneurysm you sure you can compress the one of the
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internal carotid artery and you can make the diagnosis been held with with the
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game
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yet another important aspect in the imagine is to recognize the sabbatical or anomalies especially these Spanish stations hypoplasia to be more careful during the during the during the approach
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we can see or saw this bonus structures or is for sure even more important for planning the management of this giant Dora Joseph for aneurysms came unto about the microsurgical strategy and bear we
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need to have a good prep rapid planning and to choose the correct surgical approach or otherwise we really fail trying even to approach carefully this aneurysm and yet we need to evaluate the risk of
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due to damage the pair for a so is important that I prepared these images and and yet the technical demands of course requires a specialist neurosurgeon and all the tools that you might need for thy
27:44
sit for a careful dissection microscope this session of the doctors
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and the outcomes will be related to the of manipulation yet how much you manipulate the normal structures will produce even the buses possum or will produce the neurological damage if you retract
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highly the front along
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the way we have talked about this and what to do in case of interested about her hematomas usually after you recognize the aneurysms and if the hematoma is small then you can go first and clip the
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aneurism if the hematoma is is large then you should go first to treat our two but quit at least partially them Tommaso it can reduce the intracranial pressure and it can also help you to do dissect
28:48
carefully while there an atomic structures that are inside and they were going to fall for a moquet in those Emma Thomas that are usually enough from the love we can make small cortical incisions a
29:03
boy then of course the eloquent areas and and yet we can remove partially those madams in the case of interventricular hematomas and usually also it is rare that they can erase rare at least in the
29:21
publication and the weather in finland to do in Iraq that it is rare that the collocation of these external drainage is external particular drainage sardines there usually are going by microsurgery
29:37
and our finest thread in all the assistance you to evacuate all the CSF and
29:46
lamine that the analysis to evacuate to to reduce these these hematomas know and and Yeah and although they were communicating artery aneurysms produce this interim juggler hematomas so the posterior
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circulation are more related with this game and then yet air as I was telling I usually prefer her last name he was going through the learning the analysis and the opening dilemma that the remnant is
30:22
entering the third ventricle emigrating part of the hematoma or da da Da hemorrhoids and also allow in to release more CSF from the interventricular space
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am I
30:45
in in also in the case of this acute hydrocephalus if if it is a if the patient isn't in a barry collector's edition of course you should go and tour or perform identical outer brightness immediately
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but a in most cases after securing the notice that you're surely the burn or the surgeon opens there let me know the minute is for removing this CSF
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well which approach to use you know that in in Finland to look at his near Me show it his lateral super orbital approach that the west uses for most of vascular on to to mars and located in the under
31:32
your skull base then however in some cases you must use the Internet Anterior hindering spherical approach on to in some other cases you can juice also that tell you another classic on that approach
31:47
or even the orbit the Seagull my comrades and all of those half are from Adamant that is I am but as I Am telling that the most common approach for are communicating aneurysms in Finland is the
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lateral super orbital approach which is a variant of the cherry on that approach but with the Les
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and opening of the temporal muscle and with a little bit more frontal location
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you can see also in internet we have parish this lateral super approach that is a B the other there is a link here to a place I I ask you kindly to go and check those videos similarly with the satyr
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in the hemispheric approach that I use it for high located the other complicated nanosystems game yes those are most of this approach is that cellular approach we can use for this don worth projecting
32:54
aneurysms yes since it allows a bear that a lateral axis but so far the letters were written approaches the preference to in most cases and to the hitter in spirit approach is is used when the eight
33:10
KM is very high and we call that a win at the a company is like thirteen to fifteen millimeters from the skull base game the arbiter of democracy romantic approach can also reduce the frontal of the
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direction but sometimes a beside the space that is that this approach offers is limited by the without content so rarely is yosef rarely this approach is used to watch your city in Finland and yet
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even though this orbital seek a second matic approaches is demanding it may also produce some kind of an erosion in years or even of Dermalogica in your Sim
33:58
Okay and yet in the case of the sandy Desert into Metallica Approach Yeah we just window and the reason is over thirty and over fifteen millimeters from the skull base and you can really minimize the
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brain retraction and and basically you go and follow the fox and the AH and the cingulate Gyrus to your identify first up Erica dorsal arteries and follow from from from the start the process in my
34:30
Life besides Donnelly Senior and I usually you you follow that to a two segments for finding that a commodity is little beater more on omar it takes a little bit more demanding it takes a bit more
34:49
time than the letter as a broader approach but it boys are really the retraction of that from the love of the wreck the director Sir Giles and to get you really don't need even to remove this a birth
35:06
of the front the love for accessing them the reason
35:13
The game is regarded in the CFS not just a case of ER en route to it it comes you go and open the allow me the dignity system and then the superintendent cistern and you release the CSF and sometimes
35:30
this is enough in case of Richard or even selected and you have to read the notices even you should open not only does he stand but also the alarming that that'd be nice for additional moving and in
35:44
the case of that one word projected aneurysms you may require to open in the liquid membrane Yeah sure you can remove more more CSF particular picture was a rarely perform at the
36:01
inter operatively for CSF Diamonds since this opening of the Lumia Therapy Analysis was enough for for reducing the internal pressure and fallout four allow in Utah to to go to a God complex
36:19
again regarding the general principles for the dissection of the aneurysm survey of course you should go onto the first step for all listeners going to release the CSF and there and you go through the
36:34
base of the front the loaf if you go through the lateral supra orbital all that tyrion and approaches and you can open all the dirty stairs for releasing the CSF on for allowing you to see clearly
36:49
that they are communicating a complex game and yet even if if that isn't the issue is insufficient for for in the CSF you should go on of an entirely Christian membrane Yeah through the of the Crayon
37:07
law and with that you can really smart yourself and really that is very beneficial and it takes maybe three to five minutes for releasing even all the tension that you have in the brain in the case of
37:24
refrigerated the aneurysms aren't already implemented the brains came and you should identify the ipsilateral and contralateral a one segments the two a two segments you should identify the recurrent
37:41
or artery of you from there and of course the a cop segment was your identify all these structures then you're Gonna start placing the the that leaps your temporary clips or pilot clips for finally
38:00
place in the definitive clip in the aneurysm
38:06
in some cases yet in some cases going through the lateral Supra orbital approach you must respect this
38:15
Gyrus rectus located and it will allow you to to check the A one segment the ipsilateral a one segment and the aid to segment game and that should be done in less than one hundred centimeter long your
38:34
Aunt betty few or many meters deep just to recognize those two stretchers came and usually you should preserve the bear Mother and direct nights on the hinder thing in the entire hemispheric site so
38:50
to also draw boy to rupture of the of the aneurysm yeah and and in rare cases you may expand the reception but already you may you may have a patient with some kind of of peripheral dollar syndrome so
39:09
it's important to recognize all the structures and to get tourists to respect his anatomical structure also only us as matter what you can eat for recognizing this arbuscular elements came and ye are
39:30
generally in Finland term one Sergeant operates the case and assistant is for some cases saw and are suited the tablet Doctor can help you when you when you are operating alone this beside the results
39:46
came on to your surely of course you can also detract with your with your aspirator or with your right bipolar but yet
39:56
most of the time you need to deserve the server Automatica and fix it a retraction for
40:04
cM very well all this elements in that that are communicating punks came soon and once you recognize all these elements you would the eclipse the eclipse may be and bought a one segments yeah and then
40:23
even you can put him in if you can see really the AdA segment you can also put the clip in about a two segments and finally you're Gonna put a pilot clip that was caused by a bedrock zircon is near me
40:39
like the first clip but not ensuring all that are all not done not ensuring the cliff all aneurysm but it was enough at least to to reduce the volume of the aneurysm so you could put the pilot clip as
40:57
much as you can see it I notice him and then when you are doing that you can cooperate and step -by -step the dynamism to reduce the size there was you recover reduce the size you can recognize better
41:13
the neck of the aneurysm and you can would a second or you can take out that pilot clip and put to death any deep sleep yet you can do this kind of movement as much as you recognize very well the neck
41:29
of the aneurysm them since you are taking and place in the aneurysm or the clip in dynamism of course you should be very careful for not to to to damage in that neck of the aneurysm
41:45
but already you're you're you're have good control of the hemodynamics with the temporal eclipsing all the segments that cannot be more than three or five mi between three or five minutes you cannot
41:59
put temporary clips more than the time air and to avoid her of course that cetera vascular ischemia and to yea or if you are still there need more time for We're keeping the aneurysm you can remove
42:17
the temporary leaps add or improve the circulation and it again and again and go go back with the same temporary glimpse for the second or third stage and also it has been seen that when you put many
42:35
times this temporary eclipse you can produce a Hester notice of those a one segment so you must be very productive with your with your with your clip -in to yeah this cannot last long or to avoid all
42:51
the only sir damage in the brain came and yet the most critical part in in the clipping of this aneurysm is to avoid the aneurysm double the damage Done Edison Base since the reparation of this neck
43:13
is Beriberi Difficult okay so we should be very careful when we're when we're placing and take another taking out the law and the reason is that the eclipse it and yes for sure pre -operative you
43:29
should check that your clip which kind of clip the you reduce an term yet it should be like one point five the link of the link of the neck yeah that's them somehow the character clip the correct size
43:48
of the cliff of what you are going to juice it ensures a good closing and also in some clips we have seen that when you place the clip too deeply there isn't a low resistance or lower in pressure in
44:07
the proximal part of the leap saw this proximal part of the clip should go a bit Far from the from the NYC Yeah which means that the neck of the aneurysm should be at the middle part of the of the
44:26
clip
44:29
and
44:32
once you get finally the or the aneurysm clip it so you can reduce the size of dynamism with a with a with your bipolar okay and then if if the glyph doesn't allow you to to to clause old aneurysm you
44:55
can use a second clip you can use the technique of the double clip -in Yen as saw you put first darkly for US close to the next to the neck of the aneurysm and a second clip his place it under this
45:12
ugly pia ensuring a complete Illusion of the neck came in many cases also you can cut the dome of the aneurysm the sack of thy notice him and send it for research or for some anatomical studies
45:32
if you have use it to for a long time this temporary clipping or you have yosef many a times this temporary clipping you can apply Papa Berlin to preserve the muscle spasm and is a good test strategy
45:48
that was used during finland operating a small gotta nights can be applied over the air segments to avoid the species specific game and while there are of course also different sub somebody Asians in
46:07
the strategy according to the direction of the Dome You Know and then we will see We will see that a bit later so but also in
46:22
what to do when we are
46:26
going to clip donaldson but we have a sudden rupture of the interpretive structural dynamism Yeah we should try to make an initial console with one small cut or night and assumption under section two
46:42
or on on the on the place where it was broken okay and we can compress there with a Katana under suction tube and if if that is uncontrollable if the bleeding is uncontrollable we can use this I
46:58
didn't know seen it induces cardiac arrest it can darkness the geologist put her in those adenosine saw it gives you like one minute or between thirty seconds to one minute time for for a cardiac
47:14
arrest and in that time you can really improve your caribbean and you come a place properly the clip game
47:23
and also another strategy of course is to once you have seen the the unnoticed leak and you are with your got an idea and your urine suction tube but you should go and tried to to clip temporarily die
47:43
to a one segments game and finally you can use a pilot clip to a place and that for the initial placement of these clippings in the in the area where where the analysis is leaking game and also if if
48:05
the if the roof choice at the level of the neck Dennis little bit more challenging you should try to reconstruct debase their temporality Yeah and I could see that her in where when I was with
48:23
professor Hennis near Me he could try to reconstruct the even the naked or with eclipse so he put directly a small clips on the neck and then put a second clip like a double clip technique for trying
48:38
to close the borders of the of the rupture
48:43
or trapping is of course not recommended but if in any case you cannot close the the diane this leaking then maybe you should consider this a strategy for saving the life of the patient but or or you
49:00
should plan if you have a good center that can allow you to make a bypass surgery so then you should plan for for doing that Ma'AM And but usually in all these strategies work well when I notice him
49:18
because it's small small leaks Yeah it's more of rogers before you're finally there clip -in are all these reasons came also we have seen a very small aneurysms that Arab Juliet at this Ah desert
49:37
complex saw these very small aneurysms are two to three metres Sancha and sometimes even ara similar to this or blister like aneurysms and the treatment of these cases ice a little bit challenging you
49:53
know but for this is buried the double clipping technique is a very useful technique just firstly you put the the pilot clip in the segment what you recognize of dynamism otherwise you're once you
50:08
ensure that the clip is is it's there you should put a second clipper under this to ensure all the closing of the game are near near the end of your arm is it are we already on time
50:30
or how much more do you have to tug it okay is a couple of slides and then I finish
50:38
again so the verification of this clip -in we can see of course by this dabbler we can also adjust the geography and the death interrupted at the interpretive and yoga and yoga future the microscope
50:52
and also Reagan years that he or Sam Okay I well I think all these are Yeah we just need to verify the complete occupation of vandalism and with that then we are sure and I could see or in some cases
51:12
that the
51:15
that there was a placement of one small or a theme that they're inside the third ventricle through that I'm not going to be analysed so it also ensures that does CSF can still go out and when you have
51:31
this acute hydrocephalus and when you have also intervened declaring hemorrhoids when all of this and it's lights are showing some details about this don were projected or forward projected or off
51:47
were predicted by cooperated on the resumes but basically in the main point on this aspects is to evaluate the best approach for looking at first the neck of the I notice him saw the position of the
52:02
head on to the should allow you to go directly to recognize this and join them in Within that a one and done they were communicating aren't even the dominant a one on the arisen and to the dominant a
52:18
one segment and anterior communicate in a segment game so and Yeah for complex on the reasons for the giant aneurysms or fusiform aneurysms you should also look very well the preoperative imagine and
52:37
you should be ready for also performing some kind of bypasses since this on their resumes are a bit challenging for for treating
52:48
and this is a picture with professor can understand me and his memory will cook anything much that will be all the code can stop sharing screen career she stopped sharing screen for a minute
53:06
I want you
53:09
to stop sharing screen let's go to the regular screen so he can see everybody
53:16
and yes
53:27
The near to that the strata trying to see if I can
53:34
help
53:36
Africa Okay alright Thank you Thank you see Everybody here We Are
53:44
I think that's Pretty Thorough Thank you for giving that comprehensive experience based on the experience of Professing Finland any any well I had one question for you it sounds like you
53:60
preferentially me put my video on you preferentially what We'd like a C t a for imaging the economy aneurysm zIP but in which cases might DSL Be preferable
54:16
maybe when you are having complex aneurysms you have complex medicine so then do you really need to recognize that dominance of thy wine or you'll need to really recognize all the muscular elements
54:31
properly so you can make a fashion of the desk which is that the essay Yeah so it's more functional it gives you more and time for for recognizing for for various small details in how the flow is
54:45
going through the arteries but honestly in most cases they're in the analysis more than two millimeters three millimeters city CETA works well but yet you don't recognize for example in the city a the
54:60
calcifications sometimes you that also use arbiter challenging you don't recognize very well the true size of the neck if you have a calcified aneurysm for example saw in those cases in the case of
55:14
complex Anderson's yet you would really do that the essay Want me to make a couple of comments here strata first of all this an outstanding presentation or as a incredible experience in detail that's
55:30
a really important night one of the chat comments was I who'd like to have the slides or a copy this is recorded ah it'll be recorded available on Sai digital for everybody you can download it to your
55:43
computer this is the kind of presentation you want to look over more than once and many times you can print it out if you want an s and a digital is and chance to do that too so you can have it for
55:56
your home computer which just prints out the complete audio and I think what we can do ah your hum in the future is there are twelve hundred harness niemi videos on Sai Digital NS and I and you can
56:12
text them out and then in the future meetings you can go through in a a calm aneurysm or other different aneurysm and you can show again what you said described in this introduction which essentially
56:25
will emphasize all the points and you may take a few cases to do that but I think that may or may help I I think we're just a couple of comments what would what he would professor whose name he is
56:38
doing assure you that you can do this in Africa it obviously takes a little time take some experience if you can go to the ot or if there's an autopsy or go to the morgue you can operated when they
56:52
take the skull off you can if this is done very often and and you can try some of these approaches to the aneurysm or you can use it if you over cadaver and work on that it gives you ways to do that
57:07
so there are other things you can do you can get a skull and and use various different approaches are many ways to do that and basically what Dr Ernest Nemea said there's two two things that cause
57:20
death from an aneurysm one is re rupture and the other spasm we didn't talk about spasm will do that in the future but reroute sure is is the key item and what Doctor Ernest niemi is is showing us
57:33
he's doing and what your home is doing is as you don't don't go directly to the dome of the aneurysm that is not the thing to do what you want to do is to anatomically show all the branches leading to
57:47
incoming from the aneurysm and as he was showing you go peripherally and you work centrally and then you get yourselves you can control the the vessels feeding the aneurysm and you can dissect it more
57:59
he puts a temporary clip or a pilot clip on the aneurysm and even to sex more so he can adjust the final club is that correct are Johan Yes yes this is best strategy and he uses his spinal drainage is
58:13
basically opening the limited terminology she endure and the approach a lot of people today are using are very and very interested in the minimally invasive approaches the problem is you have to be
58:30
experienced to understand that because minimally invasive approaches means you have minimum visualization and so we always use a larger craniotomy and and as time goes on and you get more experience
58:44
you can narrow it down and so forth but I always found that that's very helpful and and so forth so that stops them one of the major issues temporary cliffs you have to have those those are clips that
58:57
are less strong than the permanent cliffs if you go to a meeting I'm sure there's an Africa also you can find some temporary clips are usually applied with the same clip folder and A and and they just
59:12
damage the vessels less if you apply a temporary to get control so so those are some points I I am Edinburgh and Ilana no cheer but I don't want to take a Lotta time I think that's basically it but I
59:29
think we'll have your humpback many times in the future to talk about approaches to aneurysms I know you're all see Andrews is more frequently and he can help with that and you can present some more
59:43
cases and so forth or a shred I just wanted to make those comments and if other people have other questions please please ask the questions
59:54
any other questions or comments
59:58
DR theo will be giving his presentation momentarily but wanted to have the opportunity for for people to respond to the valid cause presentation
1:00:16
Sam Samuel eg Obama as a question in Chat Okay So now I have a question for now at when they gets to the end of the presentation know where my discussion but have it okay the the Doctor all in the
1:00:34
chat indicated that the the greatest presentation he wonders about or she wonders about types of clips preferable for a cut artery aneurysm Yeah Yeah in in in Finland in the beginning they were using
1:00:49
so that leaps also than that and of course yes as eclipse but actually the clips should be just basically on the size of an innocent on is more important to to to recognize very it was the length of
1:01:05
the clip and that of course also that according to your approach you would choose also the shape I believe even if you need some kind of angle it clips or the strike leaves or you know a song I think
1:01:19
it really needs are you really need the first check them that the anatomical variation than automaker accomplice of the Sir Aneurism and according to that you will select properly the deep don't
1:01:34
forget to to put one point five there longer or one point five and the size of the of the aneurysm of the neck of the aneurysm thus the clip should be one point five size than than the the size of the
1:01:52
neck of their of their noticing so that is at least that will ensure you not to
1:02:01
sleep the dark sleep later you
1:02:05
to that one assuming you're making a reference the place in the clip Perpendicular to a comment that parallel otherwise you would run the risk of compromising the contralateral vessel yes that is very
1:02:19
important also yeah that is very important so with that you avoid really the debate for eight of the therapeutic maybe that behind the neck of reason and of course with that nowadays with the
1:02:33
interpretive angiography you kind really see how are they going to buy substantive you are really ugly being sama sama important structure
1:02:44
his doctor has you had a comment please go ahead
1:02:50
Fenner Oh Summer Morning schumer
1:02:56
had a very muggy summer of Sam SR is A is is a both an intervention list and a in a certain surgeon is from Iraqis and Cincinnati and go Ahead and I don't get it thank you for this nice presentation
1:03:17
with a lot of experience setting up shared that is very helpful I think for all that involves a few comments here I first to that comment also from dictator or Oarsmen about the
1:03:34
dumb political clipping I think yeah for it depends on the setting based on my experience I have all the clips used multiple time especially with the temporary clip you can use it multiple times so
1:03:48
with the time it will it'll lose the the typical pressure required to whenever possible I will not use temporary clip in general unless it's a rupture cases because sometimes it cause injury to the R
1:04:02
three R I totally agree with that especially with the Pre operative imaging CETA showing some codification I will be a little bit cautious too that overuse of temporary clip I and another point is
1:04:17
that the exposure I think I to meant alternation died the I I think it's totally different and the setting can rupture a ruptured so for the rupture differently
1:04:31
I would go with the larger exposure opening with diversity stand available and would that would that I ended up chairs yeah sometimes I rupture with very regular shape and you resent that maybe ok
1:04:47
there's too many to do and I'll only do sound minimally invasive approaches does the thing that sometimes we do and Yeah I agree on that like larger exposure and overlays required for rupture angry or
1:05:03
large giant aneurysm and the last comment is that on defenestration
1:05:11
and after the home nation the dominant technology for the Fenestration importance just to mention that actually in the guidelines I I that the available guide nonetheless version is still they they
1:05:28
put them the guidelines that the administration of laminated them nowadays has no evidence
1:05:37
to be beneficial about actually I think they depend on all the friends that the central France has suggested specially done down the fenestration of what climbing terminology and the liquid membrane
1:05:50
for example has been used as very beneficial to prevent long -term hydrocephalus and especially that a sit and go from trying to notice him an idea thank you again for this nice lecture similar are
1:06:05
you doing endovascular approaches where you're into reasons I Yeah When or if you comment on for a comment your income artery aneurysm is the weather that might be lower likelihood than other sites
1:06:22
for for getting a complete inclusion
1:06:27
Yeah so at actually here in the states right now is that and device could at first that's that does not all so for not only that we think that we can get it and simple coiling especially with then
1:06:44
little with all the patient makes sense to start with cutting even that we know neil and we inform the patient that is that hi Heidi I am literally in a highly likelihood of recurrence maybe up to
1:06:56
twenty percent but it makes sense to start with and especially with those Arab check out all the Arab charter will start endovascular first still I think that the future undercut It does I think there
1:07:13
is no best auction and afford to call them Pizza Air isn't that simple aneurism Yeah you can argue that a well experienced open a cerebral vascular surgeon can do them easy deal with their M C A calm
1:07:28
and a well equipped endovascular at center also kind of direct read them safely but for the complex aneurysm I think here will be there or will offer team to decide I don't remember multiple cases
1:07:44
that I think it's is difficult to treat very complex ugly aneurysm involving one of the branches for example and then we end with the combined treatment which I think it will be definitely an
1:07:59
interesting concept to think of which is for example if you put the pipeline and the akon it's very risky because you may at jail one of the eight rules about if your time do a three to eighty three
1:08:17
so I decided that someone was brief before the application of pipeline that will change the whole equation so now you have that as a tray three and it's the most is like bypass distally and then it's
1:08:31
very safe to put the pipeline for any ugly looking aneurysm think this is a change to the equation usually those three phone to have multiple trial of clipping multiple trial offer or are pink or
1:08:46
endovascular to pen that's not typically three of them I Yeah I think combination of treatment is one of the good options right now available and the best option it is is to have a deep discussion
1:09:01
between worth and your bicycle outside and a surgical site and mainly dependent on the experience The more experience opened was going to available which is less and less right now the easier the
1:09:15
discussion I Am sure that your figures are good that's very good if there if there aren't any other burning questions though will switch to a presentation by professor then from the shake onto D of
1:09:32
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1:09:47
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