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SNI Digital, Innovations in Learning,
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in association with SNI, Surgical Neurology International,
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are pleased to present another in the SNI Digital Interviews with Clinical Neuroscience Leaders
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This interview is with Eric Nussbaum,
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and he'll be talking in a two-part lecture series on my experience using ECIC bypass for cerebral ischemia, cerebral aneurysm, and skull-based surgery.
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Dr. Nussbaum is the chair of the National Brain Aneurysm and Tumor Center and the director of Complex cranial neurosurgery
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Midwest Spine and Brain in Minneapolis and St. Paul, Minnesota, and he's the associate editor-in-chief of SNI and a board member of SNI Digital.
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Dr. Nussbaum has written numerous publications, there are three books listed, a video at list of
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intracranial aneurysm surgery available on Amazon.
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A book which is a subject of these two lectures on cerebral vascularization, microsurgical and endovascular techniques from theme publishers, and a publication basically targeted patients and
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families on brain aneurysms and vascular malformations He has multiple scientific publications that can be found on PubMed, or in addition part one of the discussion with Dr. Nusbaum will be on his
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experience using ECIC bypass for surgery in cerebral ischemia Today's guest
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is Eric Nusbaum, Eric, and I've known each other for a long time. He
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went to Johns Hopkins and then the University of Maryland. Medical school went to Minnesota for his residency. I happened to go there also. And after that went and spent some time with Charlie
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Drake. He's been interested in vascular disease basically since he's been in neurosurgery. He's written a ton of papers on a whole variety of subjects, mostly vascular, but in some other
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interesting areas. He has some patents on things that are going on He's located in the Twin Cities, for those in other countries, that's Minneapolis and St. Paul. He's a chair of the National
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Brain Aneurysm and Tumor Center in the Twin Cities, and is known really not only nationally, but worldwide for his work and several vascular diseases. He's had a large series of aneurysms. How
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many is it now? 1800, the last count that I saw. Right, that was the, the Unruptured Interisms around 2000. And then ruptured? In another 700. So it's pretty, it's almost 3000 cases, which
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is a large series and a large experience. And in bypasses, how many of you've done that? About 500. 500 and AVMs and stuff. Oh, probably 400 or so. So, so I think the audience has a
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perspective And he was at the University of Minnesota and the faculty and went into his practicing. And so he comes with a widespread experience from practice. And also he's been involved in
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international neurosurgery, taking complex cases from countries around the world and managing them. And I can say 'cause I've read the papers on them extremely well and creatively. So Eric, why
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don't you start, I think you can share screen. Okay, so thank you so much, Jim. Today we're going to talk about surgical revascularization of the brain. I appreciate the kind introduction. And
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the goals of the presentation are going to be to review the indications for revascularization and to talk about our personal experience. Obviously I'm sitting here with one of the world's experts on
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revascularization
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So
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all insights, criticisms, comments are welcome. Our center was established back in 2002. I think as you alluded to, the focus has been super-vascular disease and skull-based tumors. And it's not
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just me, it's a large group of individuals from a variety of disciplines.
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It's getting to the topic of extracreneal intracranial bypass really first introduced in the 1960s.
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There are some interesting references, maybe earlier, of failed attempts, but a lot of the credit is given to Yasergil, who had, I guess, been working with Donahie, and
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reported a successful STAMCA bypass in the late '60s. It rapidly became an accepted technique to augment cerebral blood flow in patients with inclusive disease until the cooperative study in 1985
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called into question the efficacy and we'll talk a little bit more about that. And then the number of bypasses really declined sharply. The potential indications I wanted to cover today included
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ischemic disease, aneurysms, skull-based tumors, and the rare unfortunate necessity to use revask as a salvage maneuver
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See here is that although bypasses pretty well accepted when you have to sacrifice a vessel. There's still disagreement when it's necessary and certainly when it comes to ischemic disease,
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tremendous controversy as to when, if ever, it should be utilized. The other challenge has to do with the learning curve, which is the fact that it's a technically demanding operation because it's
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one of the finest microsurgical operations, as you know, requires continual practice. But when you're not doing it very often or when it's not being done much anymore, it's difficult to remain
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proficient with a revascularization.
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So I'm gonna start, jump into the area of occlusive disease, ischemic disease. And some of this applies to, just talk about the general technique in terms of revascularization.
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We have specialized jewelers type instruments. This is our revascularization tray for superficial bypass. We have other instruments, longer instruments for deeper bypasses. Just wanted to show an
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example of
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what it looks like under the microscope. Here you have the Particle Middle Cerebral Branch trapped between low tension, aneurysm, clips and opened and the superficial temporal artery prepared with
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a fish mouth opening. The anastomosis in this case performed with interrupted teno suture, which is generally my preference for this anastomosis, although sometimes I'll use a running stitch and
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then the completed anastomosis. This is what you ideally, I like it to look like. Just for the audience that's watching this, you can get into expensive instruments for this, but actually he's
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showing some jeweler's forceps there and you can see them on the right side of the tray here and he's got an arrow on it. And those actually are forceps and jeweler's use.
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And if you're having trouble, you go to a jeweler in your community or area or country, and they can get them for inexpensively if you buy them from instrument companies, the price is multiple
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times that. So it's just if you want to go and learn about it and practice in the laboratory, we use it on patients, those are instruments you can get, the prices are can be very low. And you
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want to add anything to that? Well, I would just say these actually are
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medical grade instruments and they're not expensive. They're about100 per force of, I mean, maybe that would be considered very expensive and some, but I mean, relatively speaking, pretty
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reasonable, yeah. Yeah, I think I used to get them for 10 or 20 bucks So, and I don't know what it is now, but just to know with that, you should look around No mysticism to, I mean, just want
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what you're really trying to do is get the very fine tips. Right. Okay. So the next one you had, and I guess, and the only other thing that I would add is I've seen some people doing superficial
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temporal artery to middle cerebral artery, anastomosis with very long instruments, which doesn't make any sense to me. Ergonomics are very important when you do this operation. These are shorter
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instruments you're working right on the cortical surface, and I think it actually makes it much easier. This might be the time to do this, but if you want to improve your microsurgical skills, I
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grew up at a time when the people in our department weren't actually heading used in microscope weren't used to it. And so I went down to the laboratory where they had a microscope. You either could
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have some animals you're going to anesthetize to use, or you can go down they're using a glove or a sponge or something like that. I'd get the special sutures that you use, which are a tenor, you
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can go into that. And if I didn't have any to begin with, the ophthalmologists have it, you can see if you can get some from them or if they put them there and didn't use them, you can use them.
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And you can begin to use this under the microscope in a laboratory, or you can take it, put it in the operating room after people are gone, and you can sit there with a microscope and you use these
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instruments, and you can really get a lot of, learn a lot of the tricks of working under a microscope. And I did that for a year. I went down twice a week, for a year, and learned a great deal
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how to use that. You learn how to use a sucker, and so forth and so on. I don't know if you want to comment about that, but I think you've got to really get some facility for it. You can't just
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go in and just do this. You have to really get, this is skill you have to develop No, absolutely, F, I had completed my residency. I was, had started as a, on the faculty here at Minnesota.
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And in fact, at that point is really when I went to the microsurgery laboratory and did exactly what you're talking about because this is an operation that is hard to prepare for working with
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TENOSUJER, for example, it's not something that we generally do for any other indication. And it's a lot harder than it looks at first. I mean, the first time you start using the TENOSUJER, you
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tend to break the suture off the needle repeatedly. And you just have to become accustomed to working. You know, anyone can do it. It can be done. You just have to put in the practice exactly
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what you're talking about. On that sheet there, on the sheet there, you're also showing some Castro VAHO
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needle holders. You want to explain those a little bit? So different types of needle holders, my reference, is these are actually needle holders as well. I like to use these or you can use the
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caster type needle holders. It's just a question of what you prefer. This is actually a lot, has the ability to lock. Most of the time we don't use locking needle holders for this very fine suture
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because under the microscope at that level of magnification, when you lock and unlock, it's a tremendous jolt actually. But it's just a question of finding what's most comfortable in your hands,
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in the individual's hands, and people will find that different things work well for the work differently in their hands. And those needle holders are again, generally available in plastic surgeons,
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use it, general surgeons can have them. And so if you're trying to start and you want to
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put some things together, you can get the instruments fairly cheaply. If you've got a microscope that's in the corner, People don't use very much, take it out at the end of the day or beginning,
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come early and go down and practice with it. Get a sponge and stick it on a piece of wood with some thumbtacks or something like that. And just begin to play into the microscope trying knots and
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using it. You learn a lot of skills. Absolutely. And along the lines of what you said, the plastic surgeons who are doing free flaps will often have some of these instruments, very fine
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instruments And you can utilize those if need be. And the next slide you had is, I'm gonna wanna just show anybody. And that is the temporary clip. Tell everybody what a temporary clip is, why
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it's different from a regular clip and why you use it. So these are very, first of all, we're under very high magnification here. So one has to appreciate these are extremely fine clips temporary
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clips generally indicated by the gold coloring. close at a lower tension, a lower force than regular aneurysm clips with the idea of being not to injure the vessel when they're applied and then
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taken off. So enough closing force to stop the flow, but not enough closing force hopefully to injure
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the vessel. That's the key to it. And again, let's say I'm in
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a place where I don't have that very easily.
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You have to get those clips. The problem with using a regular aneurysm clip is that it damages the intima of the blood vessel and it can provide
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a cytrous rhombosis. The Dunson histologic studies show that the endothelium becomes damaged. So that's the purpose of the low power clip or in the low force. So If you get them fine, if you come
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to a meeting and you can get a couple of them and so forth, you probably may have to get a needle holder, but that's just something to put in your head. So if it comes to that, they're a little,
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they're a different force than the regular aneurysm clip. Can you use an aneurysm clip? You can, but it's, the risk to it is what I said. Let's see if you're stuck and you don't have anything.
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There's one other trick that I think I'll probably get to later, which Charlie, Charlie used. And I learned it from modernist videos. And that's the using a angle forceps.
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Okay, yeah, that's - Clushing forceps, everybody's got a cushion forceps. And you can take a cushion forceps. It's actually like a clip, but you apply the pressure. The problem is you can't put
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it on permanently, but you can temporarily occlude a vessel. and work on it with a pushing forceps. And I found that very useful. And I learned that from Charlie.
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Very helpful, for example, after you take the clips off, if you've got a little bit of bleeding and you wanna just stop flow very transiently, you can use that, that's a great technique. Yeah,
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do that too, go ahead. Okay, so sorry, it's time to get to the beginning, but now people from other countries are gonna look at this and they're gonna say, gee, where's microscope, instruments,
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clips, I can't do this And the answer is yes, and you can teach yourself to do this operation. In fact, you're the only one who can do it. And if you've learned how to do this operation, it will
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make you a much better microsurgeon. Absolutely. Right, so the techniques here are not only important when you're doing actual bypass surgery.
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Absolutely right, okay. So I'm gonna go through a series of, of images, some of them illustrations and some of the actual operative photos just to talk about the technique. We start out for the
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STAMCA bypass with a doppler, mapping out the course of the superficial temporal artery and then dissecting it out, starting down low, almost at the level of zygoma, leaving typically a cuff of
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tissue or fascia around the artery to protect it
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And then in general, to find a suitable cortical middle cerebral recipient branch, we start out with an opening centered at the squamosal suture. So that's a trick that I've used my entire career.
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This is what it looks like once the artery has been dissected free. Some people prefer to actually divide the artery at this point before making the craniotomy. I prefer to leave it intact. I think
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leaving it intact as long as possible
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for the artery itself and more likely to achieve a patent bypass, but there are variations and then You can see the craniectomy or craniotomy. That's been performed here
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So you just some people aren't confused you're not doing it through the burr hole No, not doing it through the start with the burr hole and then that and then you end up doing a small craniotomy
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around the burr hole I've got a couple of centimeters In maximal diameter. I don't generally for this operation use a larger Grannyotomy than that. I don't think you need a lot more than that
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I agree This is this is a good example of one of the large sylvian veins and here you have
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a Very favorable recipient artery on the surface
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In illustration showing a piece of background material put behind the artery because as shown before and I'll show again Once you open, temporarily clip and open that artery, it becomes almost
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invisible. And so having some type of background material of a contrasting color can be very helpful.
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Now, the superficial temporal artery has been divided, and a fish mouth opening created, and we've irrigated it backwards with heparinized saline solution. It's temporarily clipped proximally,
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and then what we're going to do is put temporary clips again on the recipient vessel, open a proper length, and then perform the anastomosis. Here the back wall has been sutured, and once the back
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wall has been sutured, you can look in through the front wall to make sure that you haven't caught the front wall with any of your sutures. This is to me a very important part of the operation to be
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able to look inside.
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Here's a stent or not. I don't. I'm going to show you a quick video to illustrate this. Here's the cortical branch. Here's the superficial temporal artery, which has been brought down, and now
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we've put temporary clips open dead. And this is an illustration of using interrupted 100 sutures for essentially the front wall, and then looking into the back in it. Here's an example of using a
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running suture for the back wall.
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Obviously it's a highly edited video, but the clips are removed.
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And that's what it looks like. And then you can use ICG if you have that capability on your microscope to demonstrate the potency of the anastomosis and of all the ear veins that are shown.
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Let me see.
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Okay. Go ahead. Okay. I'm going to talk about some of those things later. Okay.
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So going back to the historical background, after bypass was introduced in the 1960s, there were very large series that were amassed. I think, Jim, you had a large series of revascular, very
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large series, one of the biggest, that were amassed prior to the cooperative study, and the experience was generally very favorable. People were reporting excellent results. I know your results
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were excellent. But then after the cooperative trial, most surgeons stopped doing bypass, certainly for ischemic disease.
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It was a randomized multi-center trial, and it failed to show that bypass could prevent further ischemic events in patients with internal carotid, or middle cerebro. artery disease, and there,
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you know, we could spend an entire talk about the issues with the cooperative trial, that's not my goal here, but some of the major points that were made about problems with the trial include the
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lack of assessment of collateral circulation and cerebrovascular reserve, there were a lot of patients operated outside of the trial. The subgroup analysis was limited, but despite these problems,
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the study was really used to condemn bypass, and then Medicare ultimately starts to deny coverage for the operation, and it really fell out of favor. Let me stop there.
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You said an awful lot here, and it's true, basically, and in short, the bypass study was a first randomized controlled study of a surgical procedure
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And it was promoted by the government at that time because there are a lot of buy people doing bypasses, and it was basically individual series. And
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this, what I'm gonna tell you comes from information I, since I was very close to this, got from a lot of different people.
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And this is going to turn out to be one number one, a corrupt study. It was totally invalid
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After they published the study, the conclusions they made for the study were totally inaccurate. Said bypass is of no value in the treatment of stroke. And they only did a bypass in the anterior
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circulation. They didn't do the posterior circulation. And they should have limited it to patients who were selected as they were selected for this series of patients. Instead of a broad ranging
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statement, There was a huge amount of criticism of it. The AAS under Thor Sunt got a group together to go to the major center, which was in London, Ontario, and asked them to come up with the
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data. They couldn't come up with
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two successive reproducible sets of data, and they went there three times. And so it was obvious that the investigators, there was something wrong with the study, there was something wrong with
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the reporting. Behind this, I talked to a very prominent neurologist at the time, 'cause the neurologist who was in this study was very powerful in the country, and influenced a lot of grants.
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And
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I also talked to Nick Servers, who was on the committee, going from the AANS to look at the study. And he said the study is totally inadequate, totally a corrupt, not only should the study not be
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accepted, but they should not be awarded any further grants. So what I'm telling you is politics got into medicine. This is the first indication of this and that now is almost
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30 years ago. And we're seeing that repeatedly now, particularly with COVID-19, many reports that are coming out influenced to achieve an aim And so what it did is unjustly stopped surgery and what
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he's got here in the last sentence is Medicare stopped paying for it. You have to realize at this time, Medicare was paying for coronary artery bypasses and they were very threatened by the fact
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that if it came for cerebral bypass surgery, they'd be overwhelmed with requests. So they wanted to do a corrupt study and the study, they wanted to do a study, randomized controlled study.
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A lot of people, we left the study because it was corrupt. Others did patients as Eric has said. Many patients, they thought, needed, they did outside the study, put the ones they didn't need
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in the study. So the study was corrupted. But it's influenced cerebral vascular surgery for 30 years in neurology. And what it did, because we got it, got very involved, a surgeons in this, is
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it took surgery out of the picture and treating stroke. Because at that time, it was a neurologic disease. They weren't doing anything for it, except give patients aspirin, and maybe percent or
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something like that. But there was nothing they were doing, and weren't doing angiograms. When the bypass surgery came in, you got more definitive angiography, you found out where the lesionoids,
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you could make the diagnosis, and you had a treatment for it. And in many individual studies, the treatment was very successful. And we had that in our own experience. We had a lady and we had to,
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we operated on, I think, one of the first people. And she writes me every year. And we did a test once where we temporarily stopped her superficial temporal auger, which was very large, and she
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developed a schema. So the study is not accurate. Unfortunately, it has an undue influence They've had some other studies they tried to do, which were also corrupt. And so this is a stain on
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science in neurosurgery. The neurosurgeons were very passive in responding to this. And that passivity has led to their total passivity in regard to other things in regard to neurosurgery and
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medicine. And also their, their willingness to become employees of corporations because they weren't willing to stand up for what was right. So anyway, those are some editorial comments. I don't
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know. The audience probably doesn't know. I don't know how much you know about that. But what you said here is correct. And sorry if I took too much time. No, not at all. I mean, the study was
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a little bit before my time, but reading the literature that came out, everything that you said is objectively true. And I don't think we can underestimate the impact of it on vascular neurosurgery.
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When you think about the fact that how many even dedicated vascular neurosurgeons today are truly proficient with bypass, very few, probably as a result of the study. And you alluded to the fact
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that there have been additional studies. This is the cost study which was during my time. Again, a very Flood study from Micron. personal perspective. I mean, just to share a personal insight
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because I've participated in this study, although none of the patients that we entered in this study randomized to surgery. So I never operated on any patients in this study. But during one of the
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planning meetings, there was a question about post-operative evaluation of the patients. And I felt very strongly that the patient should have some type of post-operative imaging to prove that the
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bypass was open. And that was turned down. So in theory, you weren't going to be able to know whether the patients who failed or did poorly after surgery actually had a patent bypass. And my point
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was, wouldn't you want to know if all the strokes in the post-surgical group were in patients who did not have an open bypass? But really, other than doing a Doppler, which is pretty, as you know,
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unreliable, there was no post-operative imaging. It wasn't the first, it wasn't, it was just, let's just say it was an additional on what I would consider flawed study that
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had negative results. One, just a short comment before you get into your experience here. And that is the original bypass study only required bilateral carotid angiography and not for Tebow-based
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angiography. And one of the things you need to know, is all the circulation to the brain. And so it's very, very important to do that. We did that for years. But the study excluded that. So you
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can't really make a conclusion about the circulation based on two vessels out of four. Absolutely. Critically important to know about information. Okay, sorry to interrupt, but go ahead. Yeah,
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it's never interrupting. I'm gonna talk about them. experience in some personal cases.
30:34
From my perspective, you can achieve excellent results with bypass for ischemic disease, but the difficulty lies in patient selection. And, you know, the types of things, and I'll talk about
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this a little bit more later, but the clinical symptoms. I mean, I, I'm sent a lot of patients, for example, who have headache or dizziness, very nonspecific symptoms Those are patients that at
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this point, at least, we're not really considering for bypass patients who are basically asymptomatic in terms of their ischemic disease. We look at cross-sectional imaging and the angiographic
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findings, specifically what you're talking about. Some patients may have bilateral-crowded occlusion, but their leptomin and geo or direct collateralization through the poster communicating
31:18
arteries is robust. And they've already, they have their own internal bypass, much better than I could probably achieve surgically. And we've also come to rely more on ancillary blood flow testing.
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help us with patient selection.
31:34
There are two categories of patients that we've operated on. There's the acute category and then the subacute chronic category. When I first started in practice and doing regascularization, I
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focused much more on the second on the latter, on the subacute chronic patients with hypoperfusion and hemodynamic compromise. But over time, we've actually done a fair bit of work with this group
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and I'll show some examples This is actually the first patient that I personally ever did a bypass on. You can see this is a young woman. She was in her 30s. She had multiple strokes and was having
32:06
active TIAs. This is
32:09
her internal carotid artery injection. And you can see she has very poor feeling of the intracranial circulation. And then this is the superficial temporal artery and the degree of revascularization
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And she immediately after surgery stopped having TIAs and was a very dramatic case. And happily for me, this was the first patient that I operated on, and I developed a great interest in
32:36
revascularization after this. So I'll talk first about the more acute cases. I think they're very interesting cases. We have 75 plus patients who are having crescendo TIA's or what I would
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categorize as slowly progressive stroke or intractable hemodynamic events. We have patients whenever they would sit up, they would have neurologic deficit. You could lay them flat and raise their
33:01
blood pressure artificially and things would stop. But over the course of a week, when we're unable to start to get them up and to back off on the medical therapy, we've operated on some of those
33:12
patients. This is a young woman for many years ago. She's actually a professional actress. This is her angiogram showing her internal prodded artery, essentially stopping at the skull base. You
33:24
can see the external. vessels filling ahead of the internal vessels. This is her superficial temporal artery. She's having crescendo TIA as much as one might see with a critical carotid stenosis.
33:38
She's on heparin and then she had a really difficult TIA and we brought her to the operating room actually in the middle of the night
33:47
and kept the heparin running through the procedure until the bypass was established And this is her
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post-operative image. You can see the internal carotid artery here again stopping right above the ophthalmic and then the external carotid with this nice revascularization and she woke up and did
34:11
well after that. You look at the film there and you see that the anterior cerebral circulation is not filling. And I don't know if you did, you're doing vertebral bass, learn geography and these
34:23
people. So the, yes, everybody had four vessels. So her anterior cerebral is filling from the other side. Correct, yep. That's where it is and she probably could have some coming up from the
34:34
posterior circulation, which is how she, how she survived, but if she sits up or blood pressure goes down, she hits her ischemic cortex or ischemic
34:48
hemisphere, which doesn't have direct supply and so she has to depend upon collaterals. So I think, I mean, that's what, so it is an indication for surgery.
35:01
And then we actually wrote this up in Journal of Neurosurgery a few years ago, our experience with a treatment for patients in the acute stroke setting. And the type of patients, well, actually
35:12
I'll show you this case because I think it highlights some of the points. This is actually a teenager He was a
35:22
student at the university here. Visiting actually from out of the country and he presents with this carotid a section You can see this very beaded appearance very slow filling and the vessel really
35:33
never Never filling the intracranial circulation
35:40
Here you can see the opposite carotid injection so his anterior cerebles are filling, but he does not have Good collateral circulation through an a1 on the other side and you can see the vertebral
35:53
injection in the baser And he does not have what I would consider robust filling or he has very limited filling probably just leptomin and geol Collateral filling of that hemisphere that middle
36:04
cerebral territory What's notable here and so he's Presented with some numbness and mild weakness is admitted to the neurology service The next day he has more weakness and the next day he has more
36:17
weakness and what what we see here on his MRI diffusion sequences is the classic, maybe some watershed type of areas, a couple of other spots, but a large area of preserved territory. And in my
36:33
experience, this is what I'm looking for as a patient who's an excellent candidate potentially for bypass. A lot of deficit andor a lot of TIA's, a lot of symptoms with a lot of preserved territory
36:46
and predominantly a watershed type injury Obviously, if you get the patient who's got a large wedged out area of territory and they're not going to benefit significantly from bypass because they've
36:58
already completed their stroke. But this young man goes to the operating room, large superficial temporal artery. And this is the filling, you can see the filling all the way back down his middle
37:09
cerebral artery. And he basically, over the course of a week, completely recovered, excellent recovery and especially in a young patient like this.
37:22
It's obviously impossible to know how he would have done if we hadn't operated, but it's also hard for me to imagine that he would have done as well without the revascularization. Can you go back to
37:32
the slide before this? Sure. You were talking about something we talked about
37:39
once
37:41
it's 30, 50 years ago now doing the start in the 70s. And that is the area
37:50
that you've got the hyper density there. The rest of the brain, we would talk about it the time we said it's the penumbra. It's the hyper profuse brain. And none of the neurologists accepted that
38:02
concept.
38:05
And so they said, because actually if you accept it, then you have to accept the fact that bypass surgery works. If you believe it doesn't work, you can't accept the idea of a penumbra.
38:18
And so it gives you a fundamental, and now today, neurologists, and all these cerebral vascular neurologists talk about numbers, the numbers. And what it is, is it obviously makes sense. It was
38:32
a totally fallacious criticism 50 years ago to go along with the fallacious conclusions of the bypass study, is that you have several stages of neuronal dysfunction. Either you have normal
38:46
dysfunction, you have normal function,
38:49
you have some mild dysfunction, you can have, and these are studies that came out of England, Gen Zabs Astrup did those, where you can have a low level of blood supply to a neuron, and the neuron
39:03
stays alive, but it's not essentially a functioning neuron. And then you have a period where there's not enough circulation and it infarks.
39:15
And so we thought,
39:20
and the same way you did, that there's a large area of panumbra around there that you can see. And if you look at the ancient gram over here on the right side, you see a lot of some clues. You
39:32
look at the right, the left side you see, it's robust. What you see from the left anterior cerebral is filling both anterior cereals, and it's also filling a collateral over the hemisphere. The
39:46
angiogram doesn't go out further, and the dye isn't dense enough to show that it's filling the middle cerebral territory, but that's what it's doing. And if you look at the posterior, that's
39:57
exactly what's happening. Look at the posterior cerebral on the
40:02
left side here. And you can see there's one that comes out, but you see the dense number of collaterals that are developing.
40:15
to revascularize the temporal lobe, and that's also filling the metal cerebral. So the retrograde filling of the metal cerebral, you have to extend the angiogram to see that into the venous phase,
40:24
it exists, and it validates the panumbra, and it says why your patient improved. Because the patient didn't get a sudden infarction from a sudden vessel occlusion. The patient had a progressive
40:38
disease, he was young, and he had his own collateral circulation, obviously had it in the posterior circulation. And if you don't have a posterior communicating, you don't see it there, but he
40:50
establishes his own, his own collateral circulation off the posterior cerebral. So collateral circulation becomes very important, and people really didn't study that because they never did four
41:02
bessel angiograms. And they didn't begin to quantitate it until recently because it's hard to quantitate. And so anyway, that's what's behind the fact that there is a segment of people that you can
41:17
help because the neurons are still functioning. They're still alive, but they are not actively firing. And what you're doing is supplying the oxygen so essentially that cells can recover and so
41:32
forth and so on. This has been well described in the literature, but people ignored that also. That's what this is to us See that all the time.
41:43
Right, absolutely. And the fact that you get so much more robust filling and after the bypass, we did some studies about this. And if you go ahead and
41:56
this is refers to the study they did. If you go ahead and do a bypass to a brain that's basically normal, a bypass is not gonna flourish. It'll fill one or two vessels It may even occlude.
42:11
But if we went back and looked at the integrams of all the patients we had, correlated them with the number of vessels included, the more major vessels that occluded, the more robust the bypass
42:23
would be, which makes sense. Because you've eliminated the collateral circulation, and therefore you're forcing them to demand through the bypass, and look at the size of the super for September,
42:36
it's become a very large vessel
42:39
Right, and that actually, I mean, your point is excellent, it also comes up when you're doing bypass, for example, for aneurysms, which we're going to talk about, sometimes there's a question
42:49
of timing. You can do the bypass, and how long do you wait before you sacrifice the artery? If you wait too long, the bypass isn't needed, it can actually occlude, so you have to be very careful
43:02
with that And most of the time we do it at the same setting.
43:11
another, an interesting case from a few years ago, demonstrating the need for bypass, I think you'll find this fascinating. This is a 14 year old boy who was out hunting with his family and he was
43:23
shot in the eye with a pellet gun and he presented to an outside emergency room up in the Dakotas with his left eye swollen shot, but he had developed some speech trouble and right sided weakness.
43:34
And what's fascinating is on his head CT, there's this area of artifact, metal artifact sitting out here in the civilian fissure. And it took a second to figure out what had happened when they sent
43:48
us the imaging. But amazingly, he'd been shot in the back through the orbit. And the bullet had penetrated the carotid artery and it actually embolized within the carotid artery out his middle
44:01
cerebral artery. Wow. And so he was transferred down and this is his angiogram. So first clue here, he's got a karate cavernous fish shula. down behind the eye, down in the cavernous region.
44:15
And then you can see
44:19
this bullet, this BB bullet, whatever you'd call it, sitting out here, absolutely occluding the middle cerebral artery. Now he has a very large anterior temporal artery branch, which is
44:29
reconstituting some of the middle cerebral territory. But here we have a 14 year old who's weak and having speech difficulty, and he's got this So interesting case. What we did was our
44:46
interventional neurology colleagues, this was in the middle of the night. And so the first thing I asked them to include the fishula quickly, because I was wondering whether there couldn't be,
44:58
might be some steel going on because of the fishula. And then if we restored normal blood flow up here, I was interested to see what his collateral would do. But they included the fishula, it took
45:08
them a few minutes, it didn't make a difference in his symptoms. They actually took a device, one of their suction devices out to try to retrieve this, but they were unable to do that. When they,
45:19
it was wedged so, so heart, so firmly in the vessel that when they tried to pull it back, they could see the vessel start to intussescept. So they abandoned that. And you can see here some coils
45:34
here on the fish shore. And so what we did was we emergently took them to the operating room. And you can see his superficial temporal artery. You can see a bypass here now filling the middle
45:46
cerebral artery right back down to the bullet, to the fragment.
45:51
I think the other option, which I don't have nearly as much experience with would be the idea of opening down and actually doing some type of embollectomy, so to speak, opening the vessel. But I
46:02
thought this was a very elegant option. And we just did the bypass.
46:09
At one month follow-up, amazingly, he missed his globe. He missed the optic nerve. And so his vision was fine. He looks great, he's back in school. This is a follow-up arterial gram. It's a
46:21
common carotid injection. So you can see he fills the native internal carotid out the middle cerebral, up to the bullet. And when you're simultaneously injecting the superficial temporal artery,
46:31
the rest of the middle cerebral territory fills well. So you'd hardly know that there's anything there And he ends up with this small area of ischemia,
46:42
which is not consequential to him.
46:47
Just terrific case, did you write that up? We did, we did, I'll show you here. We wrote it up in the pediatric journal neurosurgery. Very good. It's a great example of how, you know, what
46:57
would you do for this boy if you didn't have the ability to do re-vast unless you were comfortable going down and actually taking out the fragment? would be very difficult, I think. Well, we did
47:09
some, you know, we got patients with middle of cerebral stenosis or middle cerebral, the limb lie, who were in the hospital, and that's usually when you got them. And we did a number of
47:20
procedures where you go ahead and you open the middle of cerebral artery. The problem at the time, and this is before we, this is before we did bypasses, I guess, and was early on in a small
47:33
vessel surgery. We would put the people in some anticoagulants, but it didn't work, and my answer to that would be, is you need a patch, and I never got a chance to do that, and also to put them
47:47
on aspirin and percent, because it's a small vessel, when you saw it up, you can make it narrower, it can't occlude, but I think what you did is a simple, low-risk, effective, safe,
48:02
high-yield procedure to do that And it was an excellent choice.
48:09
I'll show you one more case here, which I think you'll enjoy. This is a patient who had chronic bilateral carotid occlusions in his 60s, and he had longstanding left leg weakness, but he was
48:30
having an occasional right body TIA.
48:35
So we performed a, and this is his head CT, you can see evidence of an old ischemic injury, probably here in the right hemisphere, so because his symptoms were in the right hemisphere.
48:52
I'm sorry, because his symptoms were right body, and it was a left hemispheric symptoms. We performed a left-sided bypass, and you can see that here. Here's the bypass, actually, on the left
49:06
side, the superficial temporal artery, you can see it filling the entire system, filling down to the carotid artery all the way back down and filling out the ophthalmic now. So you can really see
49:17
the amount of need that he had. But what's dramatic about this patient is that when he woke up in the recovery room, he told the nurse that he was able to move his left leg for the first time. And
49:32
the nurse called me about it and I said, well,
49:36
you probably, his left leg is moving And she said, yeah, his left leg is moving and he's so happy about it. And I came and checked him and he had been barely able to move his left leg and now he
49:46
was lifting his left leg off the bed. And so we did this post-operative arterogram and what you can see is that he actually feels not just the left ACA, but he feels the right ACA. And he had, in
49:58
addition to the fact that he was having TIAs in the left hemisphere, He probably had what we were talking about, some idling neurons or some hypo-perfused panumbra, where when we did the bypass on
50:11
the left, it actually filled that ACA. And now for the first time, those neurons are waking up. And it was an amazing case to me because of the fact that he hadn't really been able to use that
50:23
left leg for years. So he was able to sit that way for a long period of time. It was an extraordinarily dramatic case, I thought Nobody would believe that, if you told them that at the time you
50:34
were doing that, nobody would believe it. But what it does prove is what we just talked about. And that these neurons were at a very, very low functioning level, and you supplied them with oxygen
50:47
and all the nutrients they needed and that
50:50
was his recovery. You also think I see a slip of the anterior cerebral artery intercommunicating
50:60
A1 on the the other side there. Doesn't anybody see a little? It's very, right across the right there, right where you know we have here. He's already trying to go over to the other hemisphere,
51:09
which has a camaraderie occlusion. So he starved. He starved for vascular supply. Right, absolutely. I mean, you know, when you look at this is all from the superficial temporal artery just
51:23
from the, you know, it's really a dramatic, a dramatic case. Absolutely. Terrific So, I'll show you some talk about complications, problematic, sub-galial fluid collections because obviously
51:36
you're leaving the Dura open in a few patients, wound infection in a few.
51:42
We did have several patients with post-operative seizures, some of the acutely operated patients. I think sort of an analogy to when you would, we would do acute carotid endarctomy sometimes for
51:53
patients with crescendo TAs and they might wake up transiently worse
51:59
patient even using. fascinating case. Even using the low tension temporary aneurysm clips, I had one patient who a week after surgery came back to the hospital with a headache and he had a
52:12
hemorrhage into his non-dominant temporal lobe right underneath the area of the bypass from a pseudo aneurysm that had been created by the aneurysm clip. And actually had to take him back to the
52:25
operating room and repair that. And then one patient and one death. So there are complications associated with the operation, but they're limited. I mean, they're they and they are generally
52:38
manageable. Yes. Excellent results in a lot of patients.
52:44
Good results, meaning this was a group of patients who had a fair amount of residual disability from stroke. And then there are some poor cases, patients where we just were unable to establish a
52:57
patent bypass. Maybe some of them had some vasculitis.
53:02
patients who had progressive ischemia, despite our best efforts and the patient who passed away. What was your papency?
53:12
Well, the papency is excellent. The papency is around 97. Yeah, the papency is high that come. So what you're really saying, this is an operation where the papency is high. If they really need
53:27
it, they're going to immediately establish a demand I'm sure there's biochemical messages and going out to essentially dilate the blood vessel and make it accommodate to more flow and so forth. But
53:42
I think it's a procedure that has a high return in properly selected patients and low complications. One of the things we used to do because we were doing it early is we didn't replace the bone flap.
53:56
You know, the little thing that you put the side of the skull. And it was very interesting. We wrote a paper on that that people who had a deficit in their intracranial circulation, the number
54:09
wasn't a percentage, it wasn't high, but would revascularize through the burr hole and through the pedicle. And what it says is that nature wants to revascularize it. Everybody was criticizing it
54:21
at the time.
54:24
Why would you criticize nature? And some people go on and develop their own internal bypasses, either their ophthalmic artery enlarges or whatever it is. And so the logic of the argument against it
54:40
didn't make sense, because naturally the body, if it could, would establish those connections. Absolutely. And we've seen that. We've definitely seen that. I'm gonna show a couple of cases, a
54:51
more and more a type case in a second, where that's really dramatic. This was just early in our, Early in our experience, we were still using xenon CT. I don't even think it exists anymore. It
55:02
can be obtained, but we checked xenon pre and post up in 36 early cases and found some improvement. You can see here the pre-op where the darker blue and black is now much more dramatic post up in
55:18
terms of yellow and red for revascularization. What are the alternatives? Well, there's maximal medical therapy on the one hand, which we often try this for a lot of these patients. You can try
55:31
triple-H therapy like for aneurysms, anticoagulation, antiplate, the therapy, keeping people flat, limiting oral intake. This is something we used to see up in London, Ontario, sometimes, if
55:44
people would have a meal and they would then become symptomatic. And the other thing that a lot of internists forget You know, there's so much focus on lowering everyone's blood pressure because you
55:55
want it less than 140 over 90. You want a normal blood pressure, but these patients sometimes need better perfusion than that. You can be a little bit permissive in terms of having a slightly
56:05
higher blood pressure. That's right. That's right. They need more perfusion, not less. They need more. And then the other idea was intracranial antiplasty and stenting with the rise of
56:16
endovascular The problem was, the problem has been that we've had difficulty finding good quality stamps that stay open and don't reach the nose. So that there's a high failure rate in younger
56:32
patients with antursiculation disease and the
56:35
risks are significant in terms of procedural complications, stroke, dissection, vessel rupture, and even death. And there was a trial a few years ago, the SAMPRIS trial where they were adding
56:46
stenting to maximal medical therapy and they had to stop the
56:50
trial early. because of the high stroke rate in the patients who were receiving the stance. So that has not proved effective. Same problem is trying to work on small vessels. You had an angiogram
57:04
about 10 slides ago which showed an excellent, there was a boy with the
57:09
pellet embolus. His lenticular stride vessels in that film were seen very clearly. And you're talking about small vessel disease And
57:21
if you, it's very hard to operate on small vessels, it's hard to put a stint at it without getting included. That's why the failure rates high. That's why I thought about a patch. If you think
57:31
about it, the next time you're in an emergency situation, take a vane graft and put a patch in it and make it larger. And then make sure he's an aspirin and a percent or a heartburn or something.
57:43
Because your choices right at that moment are very limited if you can't do a bypass. Right, and this slide gets back to your point, which is that when the
57:52
brain is starved, it will grow blood supply in.
57:56
You know, there are other procedures, particularly that we've used for patients with more amoia, for example, where there's probably tremendous circulating growth factors. The
58:11
encephaloduro angiosin angiosus or the peal synangiosus procedures, where you just lay the artery down on the surface of the brain will often sew it down to the arachnoid.
58:22
For ACA revascularization, I've sometimes used just strip craniactamines where you do a small, you know, very narrow craniectomy over the ACA territory and leave it uncovered and leave the dura
58:32
open and they'll regrow blood supply. Multiple burholes can be used. I mentioned the embolactomy, which is rarely done. And then some of these muscle procedures, these muscle onlay procedures,
58:43
which I personally don't really like doing them, but they work The problem is I've seen patients. with really bad headaches and after the muscle procedures and then there's nothing you can
58:55
do because they do work and they've regrown supply. So I just wanted to show a quick example of Moya Moya in a young person and you can see the puff of smoke that's described in the poor intracranial
59:10
filling. And then I was just gonna show a quick video of what the Peel, St. Anjosis procedure and we can talk during this The dissection of the superficial temporal artery is really not different
59:21
from a traditional superficial temporal artery, middle cerebral anastomosis. But basically, here's the superficial temporal artery and we're coming down and taking some of the surrounding tissue,
59:36
leaving it intact. There's the artery being reflected forward. Now the temporalis-fashion muscle are being opened.
59:47
as described before, you can see probably
59:52
the squamosal suture along that line. And so there'll be a craniotomy performed underneath the artery. Obviously, in this case, you're gonna leave the artery and continuity and not divide it at
1:00:04
all. Here's the craniotomy that's been performed. The dura's opened. In this patient, I think we'll see there's not a good recipient vessel. You can just see some Sylvian veins and very tiny
1:00:18
cortical branches. And so the artery is laid down and then we
1:00:24
use 10-0 suture just to suture it down to the arachnoid. And that's what it looks like. And then amazingly, this patient, these patients will just grow new blood supply in, into the brain. Again,
1:00:39
demonstrating the phenomena that you talked about brain is starving for blood flow. And when you see this type of response, it's hard to think that some form of revascularization isn't beneficial to
1:00:52
this patient population.
1:00:56
That's very good. We had that same observation. So what are the indications for revascularizing the ischemic brain? We don't have firm scientific evidence because the trials have been done so
1:01:07
poorly
1:01:09
as you talked about, you know, from your personal experience and in my experience So all we have left is to rely on experience and expertise and then careful consideration of multiple factors. I
1:01:21
think it's important to remember that not everything that looks bad has to be treated. This was an 84 year old woman that I saw about 20 years ago and she came in with a TIA and she had this finding
1:01:33
her middle cerebral artery extending into both M2 branches. And the neurology team was very excited about the idea of having us do a bypass You know, I remember I saw her and she looked pretty frail.
1:01:48
She did not look like she was going to tolerate a craniotomy well. And, you know, I talked to them and I said, well, how about aspirin and Coumadin for her? And they said, well, we can try it.
1:02:01
But nobody believed with that narrowing that it was going to make a difference. But, you know, she lived into her early 90s and she stopped having spells and she was fine. So we don't do it just
1:02:10
because it's there It's a matter of judgment and I do like to see the patients, especially if they're a little older and I worry more about the risk
1:02:26
to them of failing or of not tolerating a craniotomy. We like to see them, you know, fail maximal medical therapy or not tolerate it. And then when you use very careful judgment, I do think that
1:02:34
the results are favorable
1:02:37
That's very interesting. I looked at that lesion and it was a strange lesion. It is a strange lesion, right? Yeah, and it troubles me because it doesn't look like the usual one. If you think
1:02:51
it's atherosclerosis, that has to be pretty extensive at the bifurcation there, going down to the horizontal, middle, cerebral, and it's just strange. I'm not sure I've seen anything like that.
1:03:04
So I'm scratching my head is, what the heck is going on here? And
1:03:12
your judgment was just terrific, but I would have loved to see that later. And if not, if that was the true religion, she revascularized herself through collaterals. I mean, that's the only way
1:03:25
she could have gotten better. Right, right. So we look at, you know, the underlying process. I want to see symptoms referable to the territory again I'm not operating on somebody with a middle
1:03:39
cerebral stenosis who's got dizziness. you want to see poor collateral circulation, as you talked about, critical to see all the vessels, Moya Moya patients, patients who have poor blood flow
1:03:52
reserve on CT perfusion, MR perfusion is helpful, younger age is helpful, and then ideally patients who have symptoms that are refractory to medical therapy have been our general guidelines,
1:04:05
general indications. We also, like, so we did publish a lot of stuff in this, but
1:04:13
initially some of the people wanted early on, and there were people who did a lot of this before I did a dorm shader, and there were other people who did a lot of work in this, and so they would
1:04:28
always try to use a major mental surgery branch. And
1:04:34
we thought about that for a while. We did anatomical studies, And you can actually put the bypass into a. a major branch off the
1:04:45
middle cerebral, middle cerebral head, let's say M1 and M2 trunk, and rather than trying to temporarily include the major trunk, you can put the bypass into a vessel that comes off of the MCA,
1:04:57
one of those branches, usually at least a millimeter in size, and they were vascularized well, and you again lower your risk, so that's a thought we had. And the other question you brought up is,
1:05:15
we don't do it for dizziness. Well, I think that's reasonable. We did, as you know, a series of studies on posterior circulation disease, which unfortunately maybe a body is still doing it, but
1:05:31
I think that people have never really looked into this ischemia in the posterior circulation And it turns out there were some wonderful studies done in England. large studies, population studies.
1:05:45
And I don't remember, I don't think it was from Glasgow, it could have been Edinburgh and I'm not sure, published them, 88, 000 patients they followed. And these people, they followed them and
1:05:56
they looked at the people who eventually developed vertebral basilar disease. And they said, if you wait until the people develop all of their symptoms, it's too late. And they found these people,
1:06:08
particularly with the vertebral basilar disease, had symptoms a month or so earlier. And what were those symptoms? Deziness, vertigo, it was consistent. And so it's in the paper we wrote
1:06:24
summarizing all this. But
1:06:27
when you discard something like that, it always makes me feel a little bit bad because am I really missing something the brain is telling me about? And I've decided I'm just not going to listen to
1:06:40
that. So stick it in the back of your mind. Yes, they have dizziness. Yes, they have tinnitus. Yes, they may get some imbalance, but it's
1:06:53
in another set of patients. That becomes a very significant set of pre-sentence.
1:07:01
So let me clarify that. I 100 agree with you. And I didn't bring it in here, but we do have a series of patients where we have revascularized the poster circulation. My point was simply, if I see
1:07:16
a patient with a middle cerebral stenosis, and
1:07:21
the thing that brought them to medical attention was some dizziness, which as you know is a nonspecific complaint and may not be related, then I don't view that as an indication to do an STAMCA
1:07:31
bypass. But if we see a patient with dizziness and they have, for example, I have patients who have. one vertebral artery occluded and the second one is ending in pica, for example, or narrowed.
1:07:47
Those are patients that we do look at for some type of revascularization, but we don't have nearly the size or the experience with it. But you're right, it is probably an under-recognized and
1:08:01
under-treated population. I totally agree with you. I think it probably, I don't know if any studies will ever be done in this anymore, but I think when we can do appropriate studies, Fadi tried
1:08:15
to do that and actually did a very good job, but he was sabotaged by people who didn't want. It was, again, a neurology neurosurgery competition and a very good system of evaluating ischemia and
1:08:31
it was deep sex. It was
1:08:36
totally suppressed. but that's gonna happen. The other thing I'm gonna, you know, I think we have to be honest about is that the revascularization work for the posterior circulation, if you're
1:08:48
talking about working on the vertebral artery, it's very doable. Some of the bypasses that you described are very difficult bypasses. The bypass to the AICA is an exceedingly difficult because of
1:09:03
the depth and the narrow working angle Most neurosurgeon, I'm going to tell you, it's a very hard bypass for me. The STA, for example, to the supereserebellar or the PCA is a very challenging
1:09:17
bypass. And what I found with some of the ischemia patients, they have atherosclerotic vessels. So you can be work, you temporarily clip the supereserebellar
1:09:32
artery and the vessel has got some
1:09:36
calcification to it. That is a tough. It's a narrow working angle under the temporal lobe. And I think that that probably has contributed to the fact that there's less information about it because
1:09:48
even there aren't that many neurosurgeons who've been able to do that operation comfortably and reliably to be fair. Now, one of the things that we did is developed a longer instrument, longer
1:10:03
instrument that you use for a bypass so you could get into the deep areas and then you can, was a needle holder and longer forceps and so forth. And so
1:10:28
there were some other vets, some tricks anyway, but I think those are reasonable observations. All right. Okay, I think you're being modest. Okay, I mean, when I do that operation, the first
1:10:31
thing that happens is as soon as you put the temporary clips and open the vessel you bring your suture down there. you've got it like a suction down there. But as you put your long deep instrument,
1:10:43
blood or some fluid starts to run down the tip of your instrument and the whole field is submerged in liquid and you can't see anything and you're like, start to think, oh my goodness, how am I
1:10:52
even gonna do this in asthma? So it's not easy. It is a very difficult operation. Well, you have to have a dry field as much as you can and you have to be very a particular smart dad. I'm sure
1:11:01
you know that. Yeah And
1:11:05
yes, it can be complicated, but I think it can be done. And you need the instruments that are routinely available aren't long enough to do it. It's very difficult. Okay.
1:11:18
I think it's reasonable.
1:11:21
And ultimately we wrote a, there's a multi-edited book that came out a few years ago on revascularization. And you
1:11:29
know, if people, you know, have interest in seeing more. Dr. Nussbaum's references. are listed as we shown previously. In the books he has written on a video at the Sverna cranial aneurysm
1:11:44
surgery, cerebral revascularization, and for the patient's brain adeurysms and vascular malformations. He has multiple scientific publications found on PubMed, or in
1:12:01
SNI, surgical neurology international.
1:12:07
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The goal behind the publications and the foundation is to help people throughout the world In addition, the foundation has the medical news network designed to bring truthful medical and science news
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to the world. All the material in this program and these programs are copyrighted in 2024. For
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the James I. and Carolyn Erausman Educational Foundation, all rights are reserved. We hope you enjoyed these presentations, and thank you very much for watching them.
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