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SNI, Surgical Neurology International, a 2D Internet Journal, and SNI Digital Innovations and Learning, a 3D video journal,
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is pleased to present in association with the Sub-Saharan African Neurosurgeons, another in the series of Sub-Saharan Africa International Neurosurgery Grand Rounds held in the first Sunday of each
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month
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The general title of the Grand Rounds is global solutions to clinical challenges in neurosurgery.
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The moderators are Estrada Bernard and James Ellsman.
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The title of this presentation is Management of Intercerebral Hemorrhage, Past, Present and Future, A Lecture in Discussion
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Written by Kargol Elene
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Jr, who is the former professor and chairman, residency program director in the Department of Neurosurgery at the Medical College of Georgia, is trained at the University of Yale University School
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of Medicine, to his neurosurgery training at Emory University in Atlanta and was also in the staff of the University of Rochester and Rochester, New York It's now associated with key band physicians.
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neurosurgery in Atlanta.
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Yeah, sure. So Dr. Elene was
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professor and chairman of the department of the medical college of Georgia. He's currently in private practice. I think he was chairman there for about 10 years and he can correct me. He
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did his neurosurgery residency training at Emory University and was on a faculty at the University of Rochester in New York before he went on to the faculty at the Medical College of Georgia where he
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was chairman. He has expertise in cervical vascular disease trained in both endovascular and open vascular treatment. And we're glad that he's agreed to be our guest speaker and he's going to be
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talking about management of intraceural hemorrhage Dr. Alene, thank you again. Welcome. Thanks again. and Dr. Oslin for inviting me. Can you guys see my slides? No, not yet. Okay, hang on a
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second.
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I
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thought it was up, but.
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Did the previous speaker stop sharing? Yes. Okay. I think I may have done it while his was still up.
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Let me start
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It looks like it's coming on. Yes, there we go. Yes, we can see it now. Perfect. All right. Well, thanks again. So today, I'm just going to give a brief overview of the management of
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spontaneous intracranial hemorrhage. First, I'll say I have no disclosures, although I won't mention a couple of medications and two devices, company related devices, to which I have no
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affiliation or financial
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contact with. So I'll start with a brief introduction and then go on to management of hypertensive intracranial hemorrhage, and very briefly finish up with two other causes of spontaneous ICH,
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aviums and cavernous malformations.
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So again, most of you already know these stats, but in the US, there's one in every six deaths from cardiovascular disease, due to stroke that's based on the AHA 2018 from data
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It, one person has a stroke every 40 seconds and every four minutes someone dies of a stroke. Another way looking at it is almost 800, 000 persons per year in the US. will have a stroke.
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'Cause you know, most strokes are actually of the ischemic variety, 85 of all. Oh, I'm sorry. Carca, let me interrupt you for a minute. We're seeing a screen as a flow chart. Is that what we
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should be seeing right now? No, you should be seeing. Oh, hang on a second. You should be seeing my slides advancing. No, no, we're not seeing that.
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Second. I
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think I know what the problem might be. Well, I think it's like.
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How about now? Yeah, now we're seeing, yes. If you could start from the beginning, yes. Now we see it, thank you. Great, terrific So as I mentioned, no disclosures Um, And I'll just start
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with a brief introduction, hypertensive, and then AVMs and cab mouths. I think I mentioned that. I mentioned the stat, so I won't go over that again. So yeah, 85 of strokes are ischemic when
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there's a blockage of a small arterial in the brain. And 15 is hemorrhagic when there's aperture of a rupture of a small vessel. And there are two types of hemorrhagic strokes as you know,
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subarachnoid intercerebral. So I'll confine my discussion to the intercerebral hemorrhages. So again, these are twice as common as subarachnoid hemorrhage and has a 40 risk
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of death.
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I'll briefly go over some of the recent 2022 guidelines for the management of patients with spontaneous ICH. So this is a pretty dense document. I'm obviously not gonna go through all the detail and
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trivia in there, but just as a way of getting a handle on it, they basically reviewed the literature. and came up with classes or
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strengths of recommendation for each of their recommendations, and also the level or quality of evidence. So for instance, in terms of the strength of recommendation, it can range from a class one,
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where the benefit clearly outweighs the risk of treatment. All the way down to a class three, a moderate class three shows that there's no benefit of that intervention or a strong class three where
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there's actually harm So the risk is very much greater than any benefit that might be gleaned. And then on the level of evidence side, a level A is high quality evidence from at least one randomized
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controlled trial, all the way down to a level C, which is basically some limited data, meta-analysis, or even just consensus of expert opinion.
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So in terms of blood pressure management, when a patient comes in, They make mention that the titration down to a relatively normal pressure should be smooth and controlled, so avoid any sudden
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swings in blood pressure from too high to too low. Initiating treatment within two hours of the ICH onset and reaching a target within one hour is ideal, and when someone presents with hypertension
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defined as anything over 150 to 220, getting it down to a range of about 130 to 150 is ideal, so aiming for about
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140. If it's lowered any lower than 130, that can be potentially harmful. A lot of these patients already have chronic hypertension, and so if you overcorrect them, you could be
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setting up for an ischemic problem when they've already presented with a hemorrhagic one, so be careful of lowering the blood pressure too rapidly or too drastically.
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I don't know about Africa, but a lot of patients in the US. come in with some type of anticoagulation because, as I mentioned before, heart disease is a concomitant to risk factors. So, this is
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a useful chart when someone presents with an ICH and they're on anticoagulation So, there are four main categories, if they come in with vitamin K antagonist, that Coumadin, depending on the INR
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level, you can give PCC, which is a prothermium complex concentrate, in two separate levels So, either 10 to 20 units per kilogram or 25 to 50 units per kilogram. If they present, having been on
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the bigger trend, which is a Pradaxa, or
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with a factor 18 inhibitor, one of the newer direct oral anticoagulation, then you can give them activated charcoal. if they're presented within two hours of taking that medication. But most
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patients present several hours after taking the med. So if that's the case, then you can give one of the antagonists. The specific antagonist for the Pradaxa is either a psilomab and
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the specific one for
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aliquists or a pixaban is
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adenexanet alpha If they're not available, then you give PCCs to correct the effect of the anticoagulation. And then obviously, if they're in heparins, you'd give protonine to counteract the
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effect of heparin. So what about surgery for these patients? Well,
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you know, historically, we've performed surgery for large ICH patients if they're a severe neurological deficit or deteriorating, and you know, surprisingly, there's not a lot of data to suggest
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that it actually convincingly improves functional outcome or mortality. So the level of data is weak, as you can see on the left, there are 2B. But the recommendation is for most patients with
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spontaneous ICH of moderate or greatest severity, a usefulness of craniotomy to improve functional outcomes or mortalities uncertain. And then for patients who are deteriorating, craniotomy for
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evacuation might be considered a life-saving measure. So that's generally the time when we present patients with this option is been therapeutically deteriorating and there's a chance that we can
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actually save their life.
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Well, patients that present with posterior fossa hemorrhage are a subcategory, which is a little bit as a little more clear. You can see the level of incidence is a, what a recommendation is, is
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a class one. which is pretty strong. So for patients with cerebellar hemorrhage, who are deteriorating neurologically, have brain symptoms, compression, andor hydrocephalus from ventricular
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obstruction, or have an ICH volume greater than 15, then immediate surgical removal of the hemorrhage with or without EVD is recommended. And this has clearly been shown to be superior to medical
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management and will reduce mortality. So that's a clear recommendation Now, so here's a patient of mine from a few months ago, 68-year-old woman presented severe hypertension and headache at this
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massive cerebral hemorrhage. There's really not
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a question or a discussion as to what should be done. The literature clearly supports taking her to surgery as we did emergently. You can see the coronal and sagittal images here showing severe
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compression of the local structures, including Bringsdom.
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She actually did quite well. So we did a
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sub-acceptyl craniectomy. Some people might do a bilateral. We did doing lateral because we can get from one side to the other. We're able to get a fairly good evacuation of the hematoma. So
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that's the, on the left is the immediate post-op on day one. And on the right is four weeks after surgery. And she made a remarkable recovery back to normal
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Well, in the last several years, we've made a brave attempt to use minimally invasive surgeries to try to affect the outcome of
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ICH disease. And again, this is a recommendation from 2022, but they reviewed the largest randomized controlled trial, which is the MISTI 3D trial. There've been several of them, the Stitch 1,
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Stitch 2. And they were all somewhat disappointing, just showing very lukewarm benefit in milk benefit at all. But in the largest trial, which was really a meta-analysis of trial comparing
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minimally invasive surgery with conventional craniotomy and standard medical care, they found that for patients with clots greater than 20 or 30 ml volume, a GCS score in the moderate range, then
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MIS evacuation with endoscopic or serotactic aspiration can be useful to reduce mortality compared to medical management alone They also found that it might be reasonable to select this over a
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conventional perniamine to improve functional outcomes and that
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the effectiveness is still uncertain. So up until now, the data was still somewhat soft on the utility of using MIS until this year. So for the first time, this is the Enrich trial, which was
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published this year in a new general medicine. And I was run out of a Grady hospital actually at Emory where I did some of my training. But what they did is looked at patients with a volume of 30 to
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80 ml, presenting within 24 hours of last known well. And they performed a small craniotomy and then use a minimal access port and image guidance. So they actually use the
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Niko device
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to evacuate intracranial hemorrhages. They also did some management that was common to both treatment under control group, aggressive resuscitation, blood pressure control, correction of any
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bleeding issues, and traditional surgical techniques like EVD or craniectomy for life threatening situations. But what they found is that the minimally invasive ICH evacuation compared to medical
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management resulted in better functional outcome at 180 days in low bar ICHs. The 30-day mortality was cut in half, so from 18 of the control group down to 93, and there was a low 313 risk of
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re-bleeding after the MIS surgery. So again, we've been sort of doing this half-heartedly for the last several years, but this is the first time that they've been definitive proof that it actually
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does result in a better outcome for the low bar hemorrhages So the effect for the deeper ICHs was not there at
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this stage, but this is encouraging data. So I just want to show you quickly. This is at our shop, we have the Artemis device, which is an endoscopic suction device. Yeah. Can you go back to
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that previous slide for a minute?
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Yes. Go back one side. Yes. It says the 30-day mortality in the surgical group just go back to the slide. 30 day mortality in the surgical group. was much higher than it
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was in the control group, right? Was it, did I get that right? 93 percent,
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okay. 18. I misread that. So it's lower in the surgical group. Okay, I'm sorry. Exactly. Yeah, so it's basically cut in half compared to the control group. And this is actually the first time
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this has been shown. So I just wanna go through one, just a technique of, and again, I'm not endorsing any particular device. There's several out there. This is one that we use called the
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Artemis Penumbra device. But I'll show a very quick
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video here to outline how it's done. So it's important to get,
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it's important to get an image guided CAT scan before the procedure. The Artemis is a endoscopic suction device And so the patient's taken three hours. room, intubated, placed in pins for the ease
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of using the image guidance. And the key is to use the long axis of the clot to plan the trajectory. And then if you extrapolate out, that basically gives you the entry point where the where the
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burble should be made. So once that's done with image guidance, the peel away sheet just peeled down to the level of the scalp. And then the endoscope through which the Artemis is placed is then
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advanced through the peel away sheet down to about somewhere between 23 to 34
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of the length of axis of the clot. Devices turned on. It's a simple suction device with irrigation that can then evacuate the clot with great efficiency and the endoscopic port enables you to see
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the margins of the
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complete removal or near complete removal, you can actually move that scope back and forth To view the anatomy as you're pulling out. So here's a patient of mine that I did Probably a few months ago
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now came in with this left side in deep ICH
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When we projected the entry point it actually ended up being very close to the front of the forehead and obviously It's pretty hard to do a craniotomy there. So we actually did an Eyebrow incision
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directly over the the eyebrow Did a very small craniotomy as you can see on that second image and then advanced the endoscope down to evacuate the clock So that third cat scan is post-update one and
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then the one on the right is actually the six week follow-up And he made a good recovery The hope the suggestion is that by getting the cloud out sooner you reduce the secondary injury that can be
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done occur after the hematoma breaks down and also get the patient's home faster. So the length of state tends to be shorter for these patients compared to just medical management alone. So very
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quickly moving on to ADMs, they occur in about 1 of the population, patient can present with bleeding, obviously also seizures, headache and stroke. As we all know, it's a direct connection of
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one more arteries to one more veins without an intervening capillary bed The three main components are the feeders, the nytus and the venous outflow. So the treatment options here are varied.
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Obviously, there's surgery. There is neuroendovascular treatment or, you know, embolization, which is not generally used to cure an EDM, but can be used to make the surgery safer there. I can
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remember maybe two AVMs in my entire career where we actually cured the AVM simply because it was very small. and there was a single feeding artery which we could shut down. But most commonly we use
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combined treatment and there's several patients who have large whole hemispheric AVMs for which we know that the risk of treatment is much higher than the natural history, so we just leave those
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alone. So this is a patient that comes in with a 56-year-old man with headache and dysphagia and CAT scan shows this bleed, which obviously could be hypertensive, but given the fact that he did not
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have a hystrahypertension was relatively young, we suspected an AVM. So the MRI and then eventually the angiogram show this, and I'll show the sequences here. This is a lateral view of a left
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internal carotid injection, so that's the ICA going up, and there's an ACA branch early of arterial, mid arterial, showing the mitus. And then as the venous phase evolves, and see several
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multiple. Ectatic vessels. I don't know if you can see my pointer, but this is the largest one, but there are also some venous aneurysms as well And almost certainly he bled from one of these
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Ectatic vessels probably the larger one There's another view and then the late venous phase draining both into
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the Dripenolovian and and Trolard and This is just the AP view again showing both anterior and middle stream of artery feeders and dominant draining veins Into those sinuses that I mentioned so
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In order to treat this we started out by doing a two-stage Embolization procedure where we used onyx glue you can see that glue embolosate there
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and Here so we did ACF feeders and then came back and then MCA feeders which You know, cut down on a flow to the AVM, because I mentioned this is not a cure. This just simply helps to make surgery
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a bit safer. And then, um, this is the, uh, post-EMBO AP view again, saying seeing the NIDUS again, partial immunization is not quite as dense as the pre-EMBO image. And then we take the
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patient to surgery. So this is the post-EMBO MRI scan. We use image guidance, uh, to help localize the NIDUS as we're operating And I'll just briefly show, uh, a schematic of, uh, the
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technique of how, um, how I resect, uh, these AVM. So it's important to keep the head, uh, the AVM uppermost when you're positioning, um, again, using image guidance and, uh, you want to
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do a wide, uh, skin incision. You want to encompass the entire NIDUS and any draining veins that you might encounter, uh, retract the scalp flap. do a generous craniotomy, and then you reflect
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the dura generally towards the main sinus, in this case, the satchel sinus. Again, taking here to identify any draining veins that might be present. So for instance, if there's a draining vein
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that's attached to the dura, you don't want to rip that. It'll be a very quick case if that happens. So you can leave the dura attachment to that draining vein while reflecting the rest of the dura.
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And then the technique is simply circumscribing the AVM going from superficial to deep while identifying all the feeders starting superficially and then going deeper and then basically coagulating
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them. So you can use a small AVM clip, bipolar, and then sectioning. And then as you go deeper and deeper, the night us should collapse. You should start to see a change in the color from
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arterial red to more purple and then eventually Venus, and then at the very end. You want to, and of course, preserving any on-passant vessels that might appear to go to the nitis, but going past
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it. And at the very end, you identify the major draining vein, and that's the last thing that you take. So, obviously, you don't want to take that prematurely, because then you can end up with
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an exploding nitis, which is pretty hard to take care of. So, that's the general technique, and that's exactly what we did in this patient I'll show you the
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intraoperative image here for the resection, and this is the post-op archeric ram, lateral, and AP view showing complete resection. So, one noticed that, so we didn't actually address the venous
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varics. There's absolutely no reason to go plowing into that area if you remove the nitis, because the venous tatic
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anatomical result is from the AVM So they the night is the high flow NIDUS is attempting to drain into the normal venous system and dilating. So if you just take care
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of that NIDUS, the venous system will take care of itself. And that happens to be an eloquent tissue, so you certainly don't want to go into that
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area. And then lastly, very briefly, cavernous malformations are now the source of simultaneous hemorrhage. That's flujo on the right. She actually died of a cab mal in her sleep, probably from
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a hemorrhage or seizure. But these are well-subscribed lesions, closely packed cluster of blood vessels without intervening parenchyma, generally looking dark or purple, described as mulberry-like.
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There's usually evidence of humicitorin staining, and they can range from a few millimeters to several centimeters with a rupture rate of about 1 per year. And that staining can be the source of
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seizure activity. But they can bleed at, again, at the rate of 1 per year. This is a patient who with a slowly progressive hemigaresis, but came in with a relatively sudden headache and this
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pre-operative MRI scan, which shows this blood collection in the posterior fossa. Here's the actual view. You can see it's partly in brainstem, partly in the cerebral peed uncle and partly in the
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fourth ventricle, so it's exophilic and with some acute blood And this is the CAT scan again showing the acute blood. So this patient with his history and presentation obviously needs surgery.
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There's really no substantial evidence to suggest that any other treatment is
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as effective. There's some soft data on radio surgery for cat mouths, but it's not the generally accepted way to go. So this patient we took to surgery, he's positioned with a head down, the head
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is Towards the floor, the foot is towards the ceiling. So we've elevated the cerebral hemisphere. We're looking into the fourth ventricle. And here you can see the choroid plexus. Now there is
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the exophidic part of the cavernous malformation. I'm using image-guided, using monitoring, SSEPs. Obviously this critical area, you wanna use all
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the answering techniques. So we're coagulating the exophidic portion of the cat mouth And then once we open it with the 11 blade, you can see the acute blood that
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extrudes out spontaneously. And then once the acute blood is cleared, you have a slightly better view of the actual lesion, which is sitting in the brainstem. They're the floor to the floor
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ventricle. The opening is widened. And the key here is to identify normal, hemocentric stained brain or brainstem in this case. from the actual cavernous malformation. That's sometimes tricky to
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do, but with a little bit of patience in using a semi-sharp resection tool here, a one or two, you can actually tease the cat mouth from the surrounding eloquent tissue to facilitate resection.
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Here we're using a small micro-grabber and putting some tension on it. Here we're using spreading of the forceps of the bipolar to help identify the plane And right there, you can see that lighter
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area, which is actually the brainstem. And then this can be resected in a piecemeal fashion.
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At the very end,
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we try to look for any small pockets of these little bubbles that can recur. But when you're in the brainstem, you've got to be a little bit more reticent to kind of go into the brainstem. You
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don't want to do that. You just want to try to stay in that plane that separates the normal brain stem from the lesion. And this is the post-op MRI scan. So I'll end with just one other piece of
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technology that we've been using for a few years now. At my shop, Pete Monogosta, we just got comprehensive stroke certification status from the DMV. And we've been using the VisI, which is an
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artificial intelligence app that basically reads the MRI scan even before the radiologists have a chance to do it. And it will alert you as to whether or not the patient has a large vessel occlusion
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in the case of ischemic stroke or an ICH. And we can scroll through the images. In the case of ICH, we can pull up the profusion studies if that was done. And we can also communicate back and
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forth between practitioners to facilitate management. And this has helped with the communication as well as with the management decision. so whether or not to intervene on patients with these
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diseases. So I'll stop there and ask if there are any questions.
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I would say any job, Kurt, go to this terrific job. Thank you.
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You want to stop sharing screen and I'd rather see who I'm sure people got thoughts or questions about this. Yes. Thank you, Cargill. That was excellent. A very comprehensive review and exquisite
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intraoperative pictures. Much appreciated. Mr. Nyeh.
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Any questions or comments? Well, I'll start, you know, I've had it when in my early part of my career, I had quite a bit of interest in intraceurobo hemorrhages and tried doing evacuations with
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the Archimedian screws, they had tactically, but didn't make much of a difference. I think the first surgical randomized clinical trial in all of surgery was by McKiss again, 1961 He did a
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clinical trial. on surgical evacuation of intracerebral hemorrhages and found that
31:02
for low bar hemorrhages, the study was for low bar hemorrhages, that they improved their mortality. So the more recent results are just for the confirmation, but also adding that you can improve
31:15
the functional outcomes. But importantly,
31:20
I think where we just can't make the difference is with those deep hemages of basal ganglia hemages and that is sort of like the spinal cord injury discussion we were having. But the neurologic
31:39
status on presentation and the size and the location seem to be the primary prognostic indicators. personally think there's going to be a combination of surgical and medical management. We've got to
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be able to, some of my early research at MCG was with curcumin, which is an ingredient in curry powder, and that actually does show an improvement in multiple types of stroke ischemic and the ICH
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and subarachnoid. So I think down the road, we'll be able to probably do a procedure, but also give a medication that can help reduce that those breakdown products of blood that then result in more
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edema and that kind of vicious cycle. So Professor, what's your approach to intra-ventricular hemorrhages? Are you aggressively irrigating? How do you manage those hematomas in which there is
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rupture into the ventricle? So good question. So up until now, we've basically been just putting DVDs in and as you know, They'll end up cutting off the nurse will call you it's caught it again.
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So what what I found to work is actually just injecting some TPA and just, you know, small volume, turning it off for about 10 minutes and then opening it And that actually will lice much of the
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clock certainly the one around the EVD catheter, and that would continue strange that would work. I know there are several centers that have tried continuous drainage But the
33:17
evidence that using the MIS works with ICH, I think some people are now trying to use, for instance, the Artemis with IVHs, because it's just a stone's throw from going into parentically to going
33:29
into the ventricle and evacuating the clock with the same port So, that's what I've started doing. We've only had one case that had a reasonable outcome, but I think that's one way of evacuating a
33:43
large volume of the clock right away to prevent.
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you know, hypercephalus or any impending urination? I've tried to, we got two questions. One from Sam, the other from Michael. Okay, sure. Dr. Kava, we'll go ahead.
34:03
All right, I'm going to stick to the issue of the intra-partum pandemic or yes. We have a series of over 200 cases that we started with ultrasound guided and then we move together with the
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navigation system. And we're using just regular endoscopy procedures.
34:27
We don't have the type of endoscopy that you exhibited, but we use the regular endoscopy. Now, my question is, when we do it, we don't aim at removing all the clots because of the fear of
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re-bleed. What is your experience with that? Two, at what time would you go into surgery?
34:46
And do you consider the volume and the Glasgow of the case? Because when we started with Glasgow of three, four, we don't. We had a lot of mortality. And now we don't go with that. But I must
34:57
confess that in the last
35:01
two cases, we had the Glasgow of four. And
35:05
they were nurses, postpartum, and they did so well. So we still have that challenge as to whether to go with four or not. Yeah
35:12
And then, yeah, so if you could address that.
35:17
I think most people would agree with that exact management. We were very hesitant to go after someone who is, you know, GCS 3, 4, 5. And in fact, the study was done with the moderate group. So
35:29
the exception, I think, would be if it's low bar, someone presents in a moderate grade. But then you actually see them actively deteriorate So if they deteriorate to GCS 4 or 3 before your eyes or
35:44
in the SCAT scanner. That would be my one exception when I would actually be relatively aggressive, especially if the patient's young. Because I do agree you can actually salvage a fair amount of
35:55
those. But I don't think the data is there yet to suggest that we can reverse someone who's, you know, had a blown people or both blown people's for a while. I mean, if there's underlying
36:06
brainstem, you know, durei hemorrhages, there's really no reason to take someone like that to the operating room. But if they're young, if it's relatively recent, if it's a relatively acute
36:17
deterioration, I think it does make sense. And in terms of the, what was your other question? I
36:26
forget. Yeah, I don't have to do with the level of resection or aspiration, because we use the regular in those scope and we don't aim at cleaning the entire blood because of your free bleed.
36:37
Especially if you're not able to control the D Right. That's right. And I think that that's probably the safest way to notice is when you got a patient with high creatinine, with high creatinine,
36:49
they tend to rebreathe a lot and we, we don't want to remove everything, leave something small there, I don't know your experience. Yeah, there's a philosophical difference between, you know,
36:58
the early, early users and the late users. I think the literature shows that the, if you operate ultra early, you're more likely to get a rebreathe and make this common sense And so, most people
37:09
don't take, rush someone to the operating room, if they're stable, right away, but wait up to a day. I mean, for the one, the case I show that was actually done two days after, because he was
37:21
stable, and it gave us time to get the image guided study The study I cited, they did it 24 hours, so I think it makes sense, unless someone's deteriorating, not to rush them as a level one
37:38
procedure.
37:40
actively deteriorating with the blown people and you know, they're in the process of herniating. Right, thank you. Dr. Magoha, you have your hand raised? Thank you, thank you. Dr. Kaba asked
37:53
half of my question. The first thing is, yes, locally, we might use the lotter system here, largely the little lotter system, which will allow us to suck, but pick large cloths you wouldn't be
38:04
able to. I had two questions. I saw the brow incision in the beautiful frontal burhole. We just used the standard burhole in the frontal and occipital burholes. Just a comment on that. What about
38:19
large, large bleeds? We tend to get massive bleeds extending all the way, typical hypertensive bleeds. Yeah. And we're very scared we're dealing with that. And locally, we have one other issue,
38:30
which is not really in the textbook, but it's quite strange. I want your comment. So if we have neurosurgeons who are in the peripheral facilities, and they attempt the cleaning out for me. and
38:40
it doesn't work. And then they referred to us in the referral facility. So we might attempt a coaxial approach where we'll go through the original craniotomy and then insert the endoscope and try
38:51
and use some hemostatic agents mostly in finding the bleeder and not just removing the clots, but that's just for selected patients every now and then. As you said, the ones you want to give a
39:01
chance young, they seem to respond, but have a re-bleed. What would you comment on both of those? And also, more importantly, though we do have neuro-navigation, it's not widely available. And
39:13
I know some of my residents are listening. So how would you tell them how to go about that? Thank you. Yeah. Well, again, I think there are many ways to skin a cat. The only reason why the
39:23
suggestion is made to kind of use a foreign incision or eyebrows, if the clots is longer in a
39:33
cringyocodal, if it's old-shaped,
39:36
from a logistical standpoint, you're more likely to see the edges of the cloud as you go in and out along the long axis. But there's nothing wrong with doing a typical cooker burhole and getting it
39:51
from that perspective, especially if you're going through the right frontal lobe, which is relatively
39:59
not eloquent. So again, many ways it's going to cat. So I don't think that's - it's not critical But I think as you
40:11
worry about
40:14
getting as much of the caught out as safely as possible, you're able to see the edges a little better than going in from the short axis and not being able to get that endoscope to swing all the way
40:27
anteriorly and posteriorly. So you're more likely to leave a larger residual just from a geometrical.
40:36
standpoint, if you go through the long axis as opposed to going through our short axis of of of deletion.
40:45
There's a there's a question in the chat from Dr. Consey regarding the pathology in Africa with respect to amyloid angiopathy, which used to be called Congolphilic angiopathy, but with so
41:02
the participants who are in Africa any any sense of how often the hemorrhages are attributable to amyloid angiopathy
41:13
or have they been pathology studies looking at that question.
41:22
It doesn't look like it.
41:25
Alvin, what do you do for industry, Brahamra, Junior, Sibra, Hematoma, and your country?
41:43
Thank you, so it is interesting, and I was following closely, but surprisingly, in Liberia, they have various issues
42:02
of which staying, managing, spontaneous intracerebral bleed. So near the telomeptane, since we do not have any allergy, we only have telomeptane. So most of the telomeptane is in charge It is
42:13
when
42:15
they only call neurosurgery for whether there is any need for surgical intervention. So ideally, most often we usually see them late. We are not exposed But most often there are some that we
42:30
usually do decompressive.
42:36
and after
42:41
the resumption of the brain swelling and then we planned for six months after to place back the bone flap. And that's why we usually use an extended EBD. But most of these patients are usually seen
42:56
by us late. Yeah, excellent point. Well, hello, Dr, so I had another question, Jim So Dr. Do, how do you store those craniactamine flaps? Oh, good. So, you know, Liberia, we do not have
43:13
a bone bank. So I usually place it within the abdominal wall. And yeah, that's what we usually do here. How I used to do that early in my career, I must tell you, I had quite a bit of issues
43:31
with infection So we resorted to.
43:34
is stirring all of them in the freezer, but has infection been an issue for you?
43:40
The seventh we have done, no. Locally.
43:46
How about bone resorption? One of my colleagues used to do it to the other institution and he abandoned it too just because he said he realized that a large percentage of the juice that he replaced
43:54
would just auto-resorb it, which is kind of shrink. And he couldn't figure it out. So I mean, I'm not sure why that would happen. Have you seen that happening in the ones that you placed in the
44:04
belly?
44:06
No, we have not had
44:10
condition of that kind. Yeah, but I guess, because most often I usually do that with the general surgeon, but he is often there and we try our best to reduce all rates of infection in the process.
44:30
Dr. Eileen, so some people many may not have access to the
44:36
endoscopy. Can you comment on whether there have been any comparisons of open versus endoscopic evacuation of intraceuroable images? Yeah, so the 2022 AHA data, they did compare MIS with open
44:55
craniotomy. And there's soft data that MIS might show an improvement.
45:05
Personally, I think that anything that you can do to reduce traversing normal brain is helpful, but it doesn't have to be an endoscope. For instance, we have, you can use any one of the
45:19
retractors that you can, the minimum invasive retractors that you can place, you know, trans-socal and you can actually do an open surgery through a minimally
45:30
a tubular port. And still, I think, reduced the risk of, you know, the damage that you can suffer, you know, plowing through normal brain. You know, if I remember the old days we would put in
45:42
the flat retractors and that would just tear through normal brain tissue to get at the cloud. And now, you know, it's pretty clear that if you use a tubular retractor and then you just expand,
45:53
you're just kind of compressing the normal brain, which then really expands, why don't you take that out. So I think that although an endoscope might be, you know, ideal, it's not necessarily
46:08
the only way to do a minimally invasive evacuation of an ICH. Yeah, I think that that's what that was going to make is the big advantage, of course, is putting the bone flap in the bellies that
46:19
you never lose it. I did a case just last week. And we were replacing a, replacing a bone flap. several months after evacuation for a large stroke, and we could not find a flap. And we're like,
46:33
where is this flap? We know it's in there. And luckily, we realized that the patient came in as a Jane Doe when she initially presented, and then later on they got a real name. So in a chart,
46:46
her real name is in there, but the moon flap is listed as a Jane Doe. So thankfully, I kept a little sticky up, and I still, I did this starring out when I was an intern, keeping a little sticky
46:57
of every patient that I ever, you know, perform a procedure on. So I have a little, I'm old-fashioned, a little ledger with all these stickies, under pictures name and medical record number. So
47:06
I looked back and I found out it was Jane Doe, so we averted a disaster. So. Yeah, Jane, how do you treat this problem? Yeah, I don't know if I can make it from it. Yeah, you have. Go ahead,
47:18
Dr. Carver. Yeah, so in our experience, the indoor scope, we just use it. We started using it. for the last six months, okay? But prior to that, we were using the ultrasound
47:34
and it had a very good effect. So it doesn't have to be only in the scope, but the ultrasound is as good as the in the scope. You can see life and you can actually do a lot. I'm glad to raise that,
47:48
Sam. If you are able to do, yes, it's a three centimeter
47:53
Jay Morgan, you've seen a lot of this in practice. What, how do you do this? With the deep ICHs, we leave them alone, typically, or put in a ventric and try to drain
48:08
them and we'll inject, like Cargill has said, if we have to try to break up clot and the ventricle, for the lower ones, we'll typically do an open procedure after a couple of days, unless they're
48:16
acutely deteriorating and then we'll go in right away and take it out. Nobody here is really using the in the scope We've tried some of those tubular retractors. Um, they, we haven't used them
48:28
enough in order for us to buy the equipment, but we typically will, we'll do them open for the low bar, uh, lesions. Terrific. Well, Australia, we've had, uh, we've had a survey of how this
48:42
problem is treated and it's, and it really, it's, we don't find a standard approach anywhere And, uh, so I think it's almost close to 10 o'clock. I, we've still got everybody, just about
48:55
everybody here. Can I make a couple comments about interest rates for you by hematoma just from, uh, sure, please. And it's, uh, when I was editor of surgical neurology, we'd get a lot of
49:07
papers this 25 years ago. And I mean, just a couple of years older than J Morgan and, uh, and
49:16
You would have a few case reports of, uh, from Japan where they're technically oriented to do it and very technically sophisticated manner. There were the studies that you mentioned as Strata from
49:27
England, which showed maybe you shouldn't operate on them right away, you shouldn't be delayed. Buzz Hough from, who was at San Francisco that went to Michigan, studied what was biochemically
49:38
going on when you had a hematoma. And people tend to ignore this. Immediately after blood spews into the brain, there's a huge biochemical reaction to the brain tissue of primary, of secondary
49:52
injury And if you know that, it would seem that the most reasonable thing is to get it out of there as quickly as you can. Meanwhile, the whole thing to you, some of you know, did that in the
50:02
laboratory, where stereotypically, he placed a hematoma in the brain of some monkeys. And in one group, he evacuated them after 30 minutes, 60 minutes or a day, and found that the sooner you did
50:16
it, the more recovery there would be. I found no standard approach to intercranial hematoma the literature. We've had Dr. Mendelow talk about this and do randomized studies. It looks like the
50:27
studies are now going to earlier surgery. All the things that are being done go from craniotomy, which Jay just mentioned, to doing in China. What they do is they put a needle in the hematoma
50:40
after they see the CT and they aspirate it. I mean, there's so many people with this problem. It's probably almost the number one besides hydrocephalus neurosurgical problem in the world
50:51
And yet we still have and found a standard treatment for hydrocephalus besides shunting and intracellular hematoma. And I think, Cargill, you mentioned it a terrific way. We did that at UCLA, Dr.
51:05
Amart did that, which is the same approach going friendly and you go back through the clot with an endoscope. You've got a defined product where it was an endoscope and the light and the suction
51:16
were put together. So it looks like people all over the world, are doing it differently depending upon their circumstances.
51:25
And what's the right answer? And the right answer looks like it's the best that you can do in your circumstance. And I'm not sure I buy so much the randomized studies. And the reason for that,
51:36
they're usually take a long time, they're usually years behind, and they still haven't addressed the addition. This is over now 40 or 50 years about now becoming more acutely, which makes more
51:48
biochemical sense So that's my two cents worth. I think the AVM cargo you did, I was thrilled to see what a terrific job you did technically on that. We got a lot of comments that come into the
52:03
journal and video that just aren't that elegant and simple and straightforward. And in regard to Ernest Angiomas,
52:15
Isamawa is in the University of Chicago. I'm sure you know him and is working on genetic and biological reasons why The cavernous malformations bleed and ways to treat them. So this is an evolving
52:28
issue I'm sorry if I took too much time Astrata, but it was terrific. Oh, thank you presentation both Sam and your group and And cargo just great information. I learned a lot. Well, Jim. Thank
52:42
you You have a wealth of experience and serve a vascular disease. So appreciate you your your commentary Thank you Professor Ellene and and and thank you
52:55
From the to the group from Nigeria. This has been an excellent session But before we leave is dr kabula still on I know he wanted to To say something about the conference that's going on in in the
53:09
Congo Dr. Kabula are you are you still are you still connected?
53:16
Okay, it sounds like he isn't. Well, I think, as I said, I think it's been excellent. Again, I greatly appreciate the presentations and the comments and questions. I think we had a good
53:31
interaction. We'll continue next month, the first Sunday, and it will be at the usual time. With that, we'll close out. Unless Jim, do you have any closing statements before we end? No, Dr.
53:47
Magoo had his hand up. We'll see what he says, and then we'll close.
53:53
Dr. Magoo? Michael, do you want to say something?
53:59
No, no. The hand up was about the ultrasound. Do you know if there was a mini craniotomy or not, but it's fine, outside bar, the previous commenter? Okay. Sam had a very good, that was a very,
54:11
he made a presentation about this before, and that is ultrasound The use of ultrasound. Terrific adjunct, you don't have to rely on an awful lot of equipment. You got it around. And I think your
54:23
experience is just adds to what people can do to treat this problem.
54:29
All right. Thanks, everybody. And have a good rest of the day. And we'll see you at the beginning of next month. Thank you. Thank you. Thank you. Okay. Nice to see you.
54:42
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