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Welcome to SNI Digital Innovations in Learning in association with UCLA Neurosurgery. Linda Liao, chairwoman and its faculty are pleased to bring you the UCLA Department of Neurosurgery 101
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lecture series on neurosurgery and clinical and basic neuroscience.
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This series of lectures are provided free to bring the advances in clinical and basic neuroscience to physicians and patients everywhere. One out of every five people in the world suffer from a
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neurologically related disease. The lecture and discussion will be on skull base and cerebral vasoid. surgery, behold the inseparable twins.
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The speaker is Jock J. Marcos, Professor and Coach Herman, Department of Neurosurgery, University of Miami, Florida, United States of America, Director of Cerebral Bascular Surgery, Director
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of Scobase Surgery, and Director of the Fellowship Program.
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Good morning.
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Well, it's a distinct pleasure. Really an honor to introduce one of the, you know, world renowned, several vascular skull based surgeons, and fortunate enough to call a friend Although last
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night we that was questionable. Apparently that dinner, but Professor Marcos has an amazing life story. He was born and raised in Lebanon, through very turbulent times, went to medical school in
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Lebanon and
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had to escape The, the reality there that was and actually went to the UK to become a registrar. Similar to. Milan story yet. You have to still have to make it to that to that level. And there in
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London, he
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noted that the upward mobility in London was very limited or in the UK to go where he wanted to go. You had to wait till the professor died if you wanted a position. And he was fortunate enough to
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meet Roberto Heros, who offered him a residency spot at the University of Michigan, Minnesota, where he then re-began his residency training and trained under Dr. Heros. He then did two
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fellowships, two several vascular fellowships, one with Art Day at Gainesville and then went to De Barrow and trained under Dr. Spessler and then came to Miami and has been at Miami ever since for
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his very illustrious career. He is the co-chairman of the Department of Neurosurgery in Miami. And he also has a joint appointment in the ENT department. And he's the director of the skull-based
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cervical vascular surgery program there And it has been the past president of the North American Skull-based Society of the joint section of cervical vascular surgery, the Society of University of
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Neurosurgeons. And he has one of the most sought-after fellowships in the country and that we're so fortunate today to have him allow
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to speak to us And when I say that, when you hear him, not only will you love what he says, that you will love how he says it. So without further ado, Jacques, welcome.
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Well, this is terrific
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Thank you Marvin, and you are wrong, you are absolutely my friend
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Let's share a screen
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We're all good, but thank you. This is a tremendous pleasure to be
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here. You are some fantastic group yourselves. I appreciate all the glowing remarks. It's a journey of passion. It's not a journey for achievement. It's always been about the passion and that's
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what I hope the residents in this room are driven by.
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Your program led by Linda is a spectacular place, a spectacular group. I've put some asterisks, people who I actually know very closely and our two departments seem to be inseparable twins in the
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sense that there's been a great exchange. You can see the asterisks here. Your my current fellow, your former resident, Matt, so driven and so passionate apparently he insisted that this picture
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be taken again so he is in the center. Here he is, he took Linda's spot and I love having him with us, he is, as I was telling some of you, he has one of the rare qualities of what I love to see
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in residence or fellows, the power of very subtle and deep observation and that's how you learn, you don't learn really by passively observing somebody, the way he analyzes every case we do
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together, the little remarks, the little details he notices really remarkable and of course all his other qualities but it's been a joy to have him. So I thought I'll give you two talks today, one
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talking about inseparable twins, a skull base and cerebrovascular surgery, to me at least seem quite inseparable. It does does not mean that. you are failing if you only do one of them with
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something else. This is simply my model. It may become a very outdated dinosaur-ish model in the future, but perhaps some elements of that twin ship you will appreciate. So that's what I want to
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share with you in the first talk today. And thank you for everybody else who's joining on Zoom. I obviously don't know who it is, but I saw a very large number of names. I appreciate that, thank
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you.
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Disclosures are irrelevant.
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So are they inseparable because they want to be or because they have to be inseparable? So I'm gonna conclude later on by saying that they have to be inseparable and they don't have the choice if
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they want to be good twins. These are examples of surgeons who are pure cerebrovascular on your left, pure on the right and in between. both hybrids, you will notice how I drew the box of
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endoscopy as overlapping the cerebrovascular field to some degree, meaning there are definitely endonesal endoscopic skull-based surgeons who do cerebrovascular. I don't, it's very rare to have an
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endovascular or cerebrovascular, I mean endovascular neurosurgeon also do skull-based, just the nature of the technology and the passion and the interest. So you've got all these variations, it is
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a complete symbiosis, it's not parasitism, if you think of all the fields attached to cerebrovascular and skull-based, I am obviously, I obviously live in zone two right here and that's what
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really the talk is about is why should many of us be in zone two, what are the advantages? Well, cerebrovascular helps skull-based, how I'm just And these are some examples, internal carotid
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artery, balloon test occlusion for tumors, pre-optumor embolization, intra-oprepair, or bypass of injured arteries and veins during tumor resection. The microvascular skills that you need to
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dissect a tumor or a vessel are absolutely identical. The way you respect tissue, you manipulate brain. And also, skull base helps cerebral vascular I put the picture of this remarkable guy who
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probably many of you don't actually never knew in person. He died in 2016, a truly a giant of just being a good doctor and of course, all his other contributions to neuroanatomy. So skull base
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helps you understand how much exposure you really need for a vascular lesion and all the toolbox that you can choose from that are commensurate with your level of. of comfort. Then you start
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thinking of, well, well, what makes up a good cerebrovascular or a good skull based surgeon? And really, the techniques are, the characteristics are very similar. Of course, the scales are
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based neuro anatomical knowledge, delicate microsurgery. You make a mistake. There are intense consequences. Similar dissection techniques for tumors and vascular. You need to be able to have
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mental focus for prolonged time in both stamina, creative, adaptable. So this is Chang and Ang, the famous twins who in modern time certainly could have been separated. They only had this skin
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connection at the chest, but they chose to stay together. So the rest of the talk is going through case examples of first-day house cerebrovascular. can be at the service of skull base and then the
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other way around. So first, the obvious one, handling arteries during skull base procedures. So I'm gonna show you an example of an ELTO extreme lateral trans odontoid approach to a basilar in the
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imagination where I had to transpose vertebral artery. By the way, everything written in yellow in the talk is a skull base component Everything written in red is a vascular component. So this case,
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I'm sure as probably Marvin does and
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I do, we usually do endo nasally. That's the obvious way to do this, to decompress ventrally. I've actually have a series of about 17 of basilar in imagination done endo nasally like that. But
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this case, the problem is the carotid arteries were too close in the nasal pharynx
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And Even when I sent him to my rhinologist who did the laryngoscopy, again, he felt that the two carotid arteries were tortuous, bulging into the nasopharynx and the midline and the nasal approach
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wouldn't have been very good. So I did a far, well, an ELTO, meaning this is a left far lateral approach. You can see V3 here
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This is sectioning of C2 nerve root, dorsorhemus. This is exposure of V3 proximal and distal segments.
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Expose the tip of the transverse process of C1. I like these Colorado needles. They're very precise. Drilling with the diamond, the transverse process of C1, C1 hemilaminectomy, unlocking
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transverse process.
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covering the vertebral artery, circumferential dissection of the vertebral artery. You transpose it medially. And now there's nothing else between you and the opposite C1. You can now keep
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drilling. I can expose occiput C1 and C1, C2 joint, and drill lateral mass of C1, drill the
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occipital condyle, drill the odontoid process I know these 2D images don't give you the sense of depth, but I'm sure you know what we're talking about. We're going ventrally towards the midline,
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cutting the contralateral transverse ligament, and you can see post-op, this achieved, I was all the way here and achieved a complete decompression, and then my spine colleague fused the patient
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during the same surgery So that's your ELTO. And this is what pre-op it was, post-op, very nice decompression. Patient got significantly better. So perfect example of merging
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artery dissection scales with obviously pure skull-based bony
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drilling. Another example, trans cavernous approach to a large cavernous hemangioma, and they tend to be very bloody I don't know how many of your faculty or you have seen in the cavernous sinus.
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And I needed to know how to control the cavernous ICA. How am I gonna do that if I'm not comfortable with both types of techniques?
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This is, will skip some of the history and things like that. He's 42 year old. For the residents who may not have seen such a lesion, They're very typical. Look at the CT scan.
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And look at the MRI, very nice borders, spilling into the cellar, high on T2 and homogeneously vividly enhancing. Yet you do an angiogram,
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nothing. If you're not familiar with the lesion, you think, Oh, this is easy. It's not bloody at all, angiogram is fine. Well, and look at the shift of the MCA upwards.
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And nothing to embolize, of course. So I'm doing
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a dolink, Hakuba, left trans cavernous approach. We're doing a clinoidectomy, extra diorly.
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And here is the beginning of the Hakuba dollink peeling. The biggest mistake is to actually get into the lesion now. As I know, maybe Anton is still remembers my voice from many years ago,
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surround your enemy. Really, this is what you want to do with these.
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And it's tedious because it's a big lesion, but you notice how I'm in the interdural plane
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Marching along slowly and being as nice on the temporal lobe as I can be. And sometimes you put cottonoid to shield it and so forth. Lombard rain is very helpful in these cases that large cavernous
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sinus lesion when you don't have access to CSF early. The point is here we are gradually surrounding it
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There is some oozing of course it's just a nature of the lesion but you'll accept it. at the beginning you can bipolar as need be
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and of course here are monitoring all the cranial nerve cavernous sinus this is V1 and at some point I will put a retractor and I need to figure out what triangle to use to enter
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and but I really want to know where is the cavernous carotid very early in the case I don't want to be debulking tumor it's gonna ooze as I'm debulking it and I won't see the carotid so that's what
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I'm doing a mixture of navigation and the doppler and I will find it and I mark it and obviously that's a no-fly zone as well as the the nerves but and I'm gonna find it here and I'm gonna use a
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doppler I can't remember if the doppler is edited in the video but I found it where I expected it and then we will continue the peeling.
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We're coagulating around the lesion,
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then we go interadurally
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and it will be a combined extra-dural, interadural look at the hyperimia of the dura which is bulging, look at the intra-dural carotid optic nerve.
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And when I've coagulated, see how hyperimic that dura is, yet it doesn't show up on angiogram. So you just coagulated notice the tumor is little by little becoming cyanotic.
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See, getting blue because all the tiny blood supply that it receives has been coagulated. Now this is manageable bleeding. Had I done this early on in the case, this would be a bloodbath. This is,
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they will always bleed to some degree. It's never, you know, clean because nature of the tumor, you just have to keep up, coagulate, interrupt the coagulation with sonopette or couza, and
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I'm not going to show you the whole case, but little by little becomes nice and clean.
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And this whole time, I know exactly where the cavernous carotid is
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A little tissue sealant to stop true venous cavernous bleeding.
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And at the end, you can see trige V1 hanging in midair. You can see V2 down here and V3 is down here. The patient woke up with
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a complete six and third palsy, both of which completely recovered one at four months and one at five months post-op.
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But it was a complete resection, carotid, here is a carotid,
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here is a post-op
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MRI.
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Another example, cavernous sinus exentoration of a
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WHO grade two, multiplary current meningioma you know, I'm sure you all have the same, you have patients who you specifically. they stick in your memory and you cannot forget them. This is such a
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patient because she actually died seven years after this surgery. I could not keep going with her, multiply her current, we've tried everything on her. Very sweet lady. But this is one of her
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many surgeries that I did was this one. And I'm gonna, it's an interesting concept. And if there are time for question for discussion, see what the rest of you would have done. This is a list of
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all the surgeries, radiation she's had, skull-based meningioma. It kept recurring. You will see her MRI
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in a second. This is in the pre-op area. You notice her third nerve palsy now for the first time on the right side, her pupil a little larger. And you will see why that is.
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And she's explaining to me that she has now numbness. I did not include the older MRIs, but take my words. it see where this tumor is. This tumor now is four times bigger than it was six months
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before. And you can see previous surgeries. It's engulfing the carotid, it's intra cavernous. We've, I've of course, worked closely with my neuro oncologist, radiation oncologist, we've done
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gamma knife, we've done, we've tried a Vastin,
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and this is happening. So I mean, she was clearly going to die soon had I not tried something. So I told her, he's what we're going to do. I'm going to accentuate your cavernous sinus. But that
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means I'm going to take your anterior choroidal artery, because this tumor is all the way up to the carotid bifurcation. I am going to give you a stroke, an anterior choroidal infarct. That's the
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only way I know how to prolong your life Are you and your husband with me on it? And the answer is yes. So that's what this surgery is about, cavernous sinus accentuation, had passed her balloon
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test occlusion. I did not need to do a bypass.
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And just to show you the handling of the carotid artery during this cavernous sinus accentuation, we are going, I'm going to skip some
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Again, as before, it's a trans cavernous redo, multiple redo approach.
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Again, you surround it, you lay your borders, you go all the way. This is Mecklescave. Can you see trigeminal nerve in Mecklescave?
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Sonopetting the tumor,
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this is an optic nerve on the right side and defining where the ostalmic artery take-off is.
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And we're going to enter the cavernous, so we're going to find the horizontal petris carotid.
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Here is in the neck to control the cervical ICA, and of course we're monitoring to make sure Oh, by the way, this is this is an ICA bifurcation. You see what I mean is completely up to the this is
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A1. This is an
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M1, and you saw me put a clip just below ICA bifurcation. Here I'm measuring quantitatively the flow in the M1 with the occlusion of the cervical ICA to make sure that A1, there is good collateral
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via ACOM. And here I'm measuring again, I'm listening my monitoring and I'm measuring the flow to make sure it does not drop significantly so that there is good crossover from A1. Once I'm
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comfortable, this is true. Then I'm going to excise everything in between my clip and the the
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horizontal Peter scarot. You can see the clip on the oftalmic clip on the ICA and I'm not going to show you the resection in between
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cutting all of trigeminal and of course all the completely exaggerating the cavernous sinus. I'll show you in a second the handling. Oh, by the way, this is Gruber's ligament. This is where
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Dorellos canal passes. By the way, it's a board question. It is a petrosphenoid ligament It's not the
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petroclinoid or petroclival, so a favorite, at least anatomical question, of for alternatives to be that people. We know the limit cutting the off-tail make artery right here.
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and
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clipping of the carotid at the horizontal peteris segment, and at the end it will look like this. It's an empty space. You can see the basilar at the bottom. You can see, of course, the
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brainstem
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You can see the clips on the ICA, the horizontal ICA. I replaced them with wet clips to save money and
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measuring the flow one more time. See, this is not a familiar view to you where the carotid is missing. This is alloderm fat. And as I said, she lived seven years after this It recurred and she
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died couldn't identify operate on her anymore. I have no doubt she would have died that year. Had I had we left this tumor proceed. Oh, by the way, this is her stroke. Of course, the anterior
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coroidal infarct. I think it's included.
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This is fat graft. You can see the resection. Here is a stroke She was hemiplegic, then hemiparatic, and at four months, extremely subtle weakness. Completely functional. So we know anterior
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coroidal infarct. marks are of course more forgiving than obviously a large MCA in FARC. She and again, it's a judgment call, a quality of life issues, length of life, but excellent recovery.
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Now, the disasters Endonesal endoscopic approach for recurrent pituitaradenoma with a cavernous right
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ICA injury. We have had, I've been doing endonesal work since 2006 with my ENT colleagues, and I personally have three carotid artery injury This one was, as you will see, was not by me was was
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created by my wonderful rhinology colleague, and I'll show you what the mistake is in a second but the question is how do you handle this
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So this is recurrent pituitaria denoma.
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you can see it here notice the injury will be on the right carotid you see where it is look where the right carotid is and of course we were aware of that pre-op but you'll see the mistake in a second
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so
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I have I work with very experienced trinologists there are three of them this is the first day that this device was being tried in at our place this is a sonopet apple design the apple I mean
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pineapple tip design it wasn't meant for this type of bone resection it's meant for coring thick bone clivers or something you see it it was actually you know I'm not blaming the device obviously it's
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it's it's a surgeon using it shouldn't have been using it for doing this you see the carotid obviously he didn't recognize it but the carotid is here so in a second you're not going to see it because
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it's such a powerful jet of blood that will immediately cover the lens.
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I can't, you can't even see the instant it happens. You'll see. I'll let it play. Boom. That's it. You see nothing. So, uh, to his, um, I was in the other room, to his, uh, to his credit,
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no panic. He puts a large bore sucker. You can immediately say this is not repairable. You kind of, you're not going to waste time doing bipolar and all this is massive injury. The point is,
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it's very easy to pack because it's a closed cavity. I'm not going to bore you with some of the carrying on bleeding, but he packs it.
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Uh, I, I, I come in here and we try to actually surround it to figure out, should we remove the tumor and then go to the angiosweet? But every time I would try to work some, it would bleed I
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said, that's it. We're going to the angiosweet. We'll come back later for the tumor.
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But here is where the team approach is key. And that's what I really want to show you. And of course, mixing, skull base, and vascular knowledge, I'm going to take you straight to the angiosweet,
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where two teams worked. Here is my excellent, at the time, colleague Ali Sultan doing the angiogram. Our packing was obviously occlusive. We were lucky. Look at the crossover So patient does not
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need his carotid. But what I want to show you is so you can see the endoscopic tower in the angiosweet on your left, the angio team on the right. And it's a symphony because the colleague has to
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pull the packing for Ali to advance the coils. So they were coordinating with each other
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And of course, the carotid was sacrificed with coils.
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and you can see the sucker here in the angiosweet as the angiogram's being done.
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And then we go back to the OR and I remove the tumor without difficulty. But we got lucky, you can imagine if there was no good cross-flow, it'll be a disaster. It'll be an emergency bypass unless
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there was a way of stenting this acutely. You can see the tail of the coil here
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And then removal of the tumor. Patient did it very well. So first, don't panic, just pack it, figure out if it's repairable or not.
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And that's a resection here.
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So let's go CV at the service of skull base, handling of veins during skull base procedures As you know, we are all in teaching a situation and less us all when we were residents, of course, we
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all made mistakes that we learned from, and sometimes we do mistakes on the way in during kind of silly little mistakes of tearing things on the way in. This is during acoustic neuroma surgery,
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simperitrosigmoid. I don't have on video the time of the injury, but the sigmoid sinus was injured and it was packed So I come in the first thing to do with venous injury. Do not please do not put
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powder gel foam or surgery flow in the sinus. You will embolize it to various places and you'll have massive venous strokes. You put tamponade, you keep your tamponade, elevate the head, but not
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to the point of creating air embolus and keep drilling. Extend your retro sigmoid to be on the sigmoid sinus, which is what I did here.
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And then if the injury is repair remember
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we switch or repair it before continuing, that's what I'm doing here. so-called the parachute technique of suturing. You put a running, you see, and then I tie it, and it closes the sinus. I
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mean, it closes the tear. The sinus was still patent. So again, if you don't know those techniques, the vascular techniques, while you're removing a skull-based tumor, it's stuff to do, or at
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least, obviously, you need a partner who knows how to do this
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Another example of a venous injury, we were doing this case. It was redoed, a jugular foramen schwannoma.
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And during the temporal craniotomy, the vein of labe was injured, and the temporal lobe bruised. So here you see it, the contusion of the left temporal lobe. Here is a vein of labe. So I mean,
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don't immediately say, ah, well, it's gone Let's co-agulate it. No. I mean, here I am trying to. figure out, can I resuscitate it? Can I do an end to end anestomosis? And yes, luckily I
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could because the cut was relatively sharp. The injury was relatively sharp. So,
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so that's what we're doing. It's a little under stretch. I'm bringing it back to life with the with a bold dissector to make sure it's not completely thrombosed all the way. And luckily it's
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working So I said, well, let's suture it. And hopefully, the venous impact will be less. And 9-0 suture,
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you know, venous anastomosis, of course, are a lot simpler than arterial ones because it doesn't really even need to be, you know, watertight. And actually, you don't want it that tight. A
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little ooze from it is good. You can wrap it with serge cells so it doesn't or include, if need be, just a few interrupted students.
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and you see the temporal lobe contusion right there,
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and post-op, and we carried on removing the tumor, post-op the temporal lobe edema, I would submit to
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you, is probably much less than would have been had we actually sacrificed Labe, and this is fat graft at the tumor site
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Now, skull base at the service of cerebrovascular, I mean, there are many, many examples, but if I have time, I'll try to cover examples of these, aneurysms, duolavifistuli,
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and brainstem cavernomas,
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the obvious ones, aneurysms of the superior porphyseal artery aneurysm If you review Yasurgil's series, he said himself, Yasurgil doesn't give easily. credit to other people, but he said he had
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no idea how to clip those until Vinkodollin came and taught the rest of us, anatomy of the anterior clinoid and that paraclinoidal space. And so what I'm saying here is obviously you need to know
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how to drill the clinoid if you are going to clip these aneurysms. Now I fully realize endovascular has pretty much taken over in most centers the treatment of this aneurysm. I'm not necessarily
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saying it's wrong but there are times where you certainly need to drill the clinoid to deal with aneurysm of this region and this is such an example. It's a basic example but just to remind you that
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obviously you can't clip this without knowing how to drill an anterior clinoid
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For aneurysms, I drill clinoids, for tumors, I drill clinoids, or almost
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without exception. There are a few minor exceptions, but. So here's an aneurysm. The mistake would be to try to clip it without drilling the clinoid. You
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have zero control of the distal tips of your clip. And I am all for maximum exposure. Maximum needed exposure is what I like to do. I open the Dura in a U-shape and we're gonna drill with the
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diamond This is an older case, but I have nicer curved drills now with the shaft protected all the way. So you don't, or you can use the claw of the sonopet, although there were a few papers
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suggesting the ultrasound energy, perhaps injures the optic nerve. So I don't use the claw for clinoids. I use it for not for anterior clinoids.
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So we've drilled the clinoid. You've surrounded your enemy. Look at the weak murphy stitch on this aneurysm here. So I'm glad really it was taken care of. And now we have space for a temporary
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clip on the clinoidal segment of the carotid. And as you know, these aneurysms are usually treated with an angled, fenestrated clip. And I try different ones till I'm happy. And this one is good.
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And we obviously don't want to stay nose the carotid. And then as you see, there's a little dog here. And I think I'm gonna add a simple second clip right there. But again, without drilling the
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clinoid, you don't have the room to do this. And you will, you may do an imperfect job. Another example, transcavirus approach to clip a giant recurrent, coiled, stented. Baszler tip aneurysm.
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Really tough case. I really, I worried about this case. I'll show you why.
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This is when George Zenonos who is at UPMC was my fellow.
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The 60 year old. Let me show you the aneurysm. I haven't shown you the series of coiling and clippings. You can see the stent starting in the proximal bazzler and
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going into left P1 and then several sessions of coiling and and then stenting and it kept recanalysing. We did an all-cock test, showed very small pecums. Here is the aneurysm
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and the question is how to stop this aneurysm from growing. So the trans cavernous approach is the widest approach you can use for these aneurysms and
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perfect example of a skull-based technique at the service of cerebrovascular surgery.
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I am going to take us to some of the trans cavernous steps here, I'm getting CSF out. The initial portion of the video for some reason was dark, the later portion is better
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Here with me a second, sylvin fissure splitting, okay, so,
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maximum sylvin fissure dissection. You need all the room you can get. You can see heudner here parallel to A1. And now the trans cavernous portion of the case begins, meaning what does that really
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mean? Meaning this is the supraclinoid carotid, this is the anterior pitroclinoid ligament So you need to skeletonize the third nerve and the fourth nerve as they enter the oculomoly triangle. By
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cutting this Dura, as I'm doing right now, from interior to posterior, you notice as I do that, you get a better view of the posterior clinoid at the depth. Look at the coiled aneurysm right here.
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And I have, I am nowhere close to having proximal control yet,
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untreatable at this stage. Here is a third nerve,
41:14
right here. As you know, the third nerve has an oculomotor sleeve of CSF and Dura around it. So here I'm liberating the third nerve. Now I'm heading to the fourth nerve, the upper edge of
41:29
Parkinson triangle And that is fourth nerve. I can keep going backwards if I want all the way to mecklescave, but I don't need to. I've skeletonized three and four. I'm using every triangle I can
41:43
get. This is the drill that I like.
41:47
This is a posterior clinoidectomy. I could have used another, you know, the claw design, but I had room to use a clip. And now at last, I'm getting the hints of a proximal control of the basil.
42:02
But so this is after a complete skeletonization of three and four posterior clinoidectomy, opening what's left of lilyquist membrane Here is a small p-com that unfortunately is too small to be good
42:18
enough for collateral. I cut it to have more room. You can see right P1, we do ICG.
42:28
And
42:31
now obviously I'm here, I'm being an optimist. I said, well, maybe I can just clip it. Just like that, of course it didn't work The clip kept slipping, occluding the
42:42
basil at the top. I, of course, put old bros here. some older Sugita clips that have stronger closing force, didn't work. The coil mass is too big. It kept pushing the clips down. So I
42:59
obviously had to do what the next step should be is you put a temporary clip on the basilar, you trap temporarily, and you open the aneurysm. And with the hope, obviously, that by opening it,
43:11
you untether the coils and you push the coils a little off the neck So you have enough tissue to close with a clip. And that's what happened.
43:22
But just imagine having to do this without the trans - impossible, without trans-cabinence approach, without seeing what's going on. I have - I'm struggling as it is, let alone doing it through
43:35
so-called conventional approach, not doable.
43:41
And here now I've untethered enough I have some back bleeding, but you see. Now I'm able to put actually a permanent clip because of the detethering of the coil mass. Not removing, I'm not
43:56
removing the coils, I'm just uncoupling them from the top of the bazzler
44:03
under temporary trapping.
44:08
and I see G looked good, closure, post-op angiogram, tiny residual, you see the tiny residual at the left P1. I
44:19
would have lost the perforators had I had I done more
44:29
Some more obvious cases, a far lateral approach for a pica to pica bypass for what I judge was an unclippable VA pica aneurysm.
44:44
This is, it's an older case, but I always like to show it because it's really a nice picture at surgery when my former resident, Sammy El-Hamadi, who became my partner, who was with us, we did
44:59
this case together.
45:01
Here is, you'll see the aneurysm. It is bi-lobed, it's origin of left pica. You might look at this and say, Oh, that's easy to clip. But there is a second lobe on the other side, right there.
45:17
You will see at surgery, of course, I tried to clip it first But couldn't clip it, so then I did the pica to pica bypass. That's how I positioned my far lateral approach. I still do a hockey
45:28
stick incision. That's not the only way to do that approach, but
45:35
I'm gonna skip all the beginning of it.
45:42
C1 hemileminectomy, sulcus arteriosus here.
45:46
And far lateral obviously means making this craniotomy.
45:51
And then drilling the paracondular bone, not the condyle I don't know why people get confused about the nomenclature. Far lateral has nothing to do with drilling the occipital condyle, it's the
46:04
paracondular bone drilling. You don't need to drill the condyle itself unless you're chasing a tumor in the condyle. Here is a beautiful view of the synovial surface of the
46:17
condyle. It means I position the patient properly by opening that space with those four movements of the head to put it in. in this position. It gives you the flattest view you can of the cranial
46:32
vertebral junction. Here is a massive condular emissary vein, condular emissary vein canal. Luckily, sometimes this takes over from an atratic sigmoid sinus. Luckily, here it was not the case
46:47
because you can get a venous infarct if that's an only venous range route. But let me take you to the intra-dural view. So now we have V3. We finish the drilling. And you can see it will be a very
46:60
flat exposure. When I open the dura, I have nothing in my way. It's a nice flat view. So that's a good far lateral exposure. And I'm going, of course, straight to the aneurysm. Here is
47:17
proximal control, V4.
47:24
And look how heavily calcified it is and of course I tried to clip it and I couldn't it kept occluding the pica see how the pica is coming from it right here.
47:35
So my craniotomy had crossed the midline on purpose see that's a view. So now I can do pica to pica bypass and trap the aneurysm I am not, I will probably show you some suturing in the second talk,
47:50
but here is a bypass completed.
47:54
And then I proceed to
47:58
trap the aneurysm
48:08
But you see the view that the far lateral gives you, it's tremendous. The general principle is you need more exposure for
48:20
vascular relations than you need for tumors, because tumors create their own space, aneurysms don't
48:31
And that's post-op and you see the pica side-to-side patent and the trapping.
48:43
I think I should just, I'm going to skip some cases. I want just to save time for questions The examples of dural fistuli requiring some extended exposure to clip the draining vein and skeletonize
48:60
the sigmoid sinus in spite of multiple embolization couldn't be cured
49:07
And another one, cannulating the spheno parietal sinus for interrupt embolization and maybe I'll just show, I had several examples of brain stem cavernomas requiring skull base approaches. I am
49:21
going to maybe show just one
49:31
Actually, no, this is far later. I already showed you for a letter. Let me show you the previous one Kawazi approach for cavernous. I mean, for a brain stem cavernoma.
49:45
Look at this lesion on your left that we were I was observing its familial cavernomas It
49:53
grew over time. See what's happening to it. And I'm waiting for it, of course, to reach the surface or near the surface to remove it. And she had minor bleeds in between, but I waited And now,
50:08
now it's like that. Now I have a so-called very confusing and misleading nomenclature, a safe entry zone, but we all use it. Here is DTI showing me I can come from enter or laterally That means an
50:24
interior petrocectomy, a Kawazi approach in my judgment. judgment was the best angle to get this. Here is how I like to do my question mark incisions for a temporary craniotomy and
50:40
a Kawazi approach and Lombard rain, very low craniotomy, extra-dural peeling, identifying greater superficial petrosan nerve, cutting a middleman in geolartery
50:58
and here is skeletonizing GSPN.
51:04
You see a very nice view of GSPN here. Geniculate ganglion will be here. These approaches always create some venous ooze.
51:14
Once you're at the petros ridge, you place your retractor, then you do the drilling
51:22
and you can drill all the way to the IAC and all the way to the petroclival junction.
51:33
And of course, the only two things you don't want to injure are the horizontal peter scarotid laterally, and
51:40
the basal turn of the cochlea. And those are otherwise everything is drillable. Then you open the
51:49
door at the tentorium. And all I want to show you is the brainstem view Here is Meckles cave. This is trigeminal nerve roots. I'm finishing cutting the tentorium. And this will open up the space.
52:05
And all I need is a right trajectory to enter the brainstem at the right spot. In the
52:15
peritrigeminal zone And of course cavernomeric section is easy, but it's just getting the best approach and angle to do it. And here I'm finishing drilling a little bit towards IAC the
52:31
And extra dually.
52:36
And, and here is a cavernoma. It's the angle and trajectory was just perfect for the case. And of course, we're monitoring, we have navigation. And that was it. And I'm not going to show you
52:49
its resection. Here is postop. So you can appreciate the trajectory. This is fat graft right there. That actually marks the angle of trajectory. You can see I saved hearing within sacrifice
53:03
semicircular canals. Here is a fat, cavernomer is sector. She did not turn her hair. Here she is immediately postop, moving everything, talking and here she is six weeks later. I think I will
53:19
stop here. Maybe I can put the concluding slides
53:25
to say I'm sorry, bear with me to say that.
53:32
These two twins, some twins are meant to be separated.
53:38
Some are meant to live in harmony. And I think CV and skull base are such twins.
53:52
That's a good question. Sure. So, you know, fantastic lecture and, you know, just amazing cases for our residents. Can you talk a little bit about, you know, if the residents that are
54:01
watching your lecture and are interested in doing the things that you're doing, what is the pathway or what do you think is the pathway for that these days?
54:14
Well, I think in lab, going to the lab, anatomy lab, I read many books before, you know, whatever becoming a skeleton. I could not understand the anatomy until I drilled myself in the Kadaveri
54:29
Club. I was a fellow with R. Day for six months. I wasn't the Fellow of Rotten, but I would go in Gainesville in the evening and drill. Temporal bone was complete mystery to me. Until I drilled,
54:43
I swear, it only took me a few weeks to understand what I had been trying to understand anatomically forward. months and months before. So you've got to go to dedicate yourself to understanding to
54:55
mastering neuroanatomy. I think that's the first step. And the rest is, I don't know, I'm not sure there is one magic formula, but deliberate training, you know. Again, I'm not,
55:10
I'm not claiming this
55:12
is the only model because it's not. I mean, there are really what is, think of it, there are four models. There are the dedicated skull base surgeon masters at endoscopic and open skull base.
55:24
There are the third physician scientist Greg Ziffel is a perfect example who do open vascular and excellent translation research doesn't do skull base. There are, of course, the most, the
55:40
cerebrovascular, open vascular, hybrid, endovascular models.
55:46
But I think if you are passionate about
55:50
Microsurgical technique, neuroanatomy, I think this model works very well. If you're not, don't follow this path. But it does, I mean, you know, it requires obviously lots of cadaveric
56:05
training and obviously fellowships, and I'm not sure how else to answer your question, but that's
56:12
something. The question would be what fellowships are you recommending for to gain this expertise? Yeah, well, there aren't too many.
56:22
I mean, there is mine, there is Bill Caldwell, who's very similar, I think, to what I do.
56:30
I mean, Mike Loughton, of course, spectacular, vascular, but not a lot of skull base.
56:39
Mustafa Bashkaya in Madison, who's unbiased, he's an old trainee, Mustafa is doing tremendous work in Madison. Who am I missing?
56:49
Yeah, Harry is slowing down a little bit, so it's severe or agazi in Tampa. There used to be Johnny Della show many years ago. He offered those two, but I don't think he has that in Tulane.
57:04
Who am I missing? I'm missing few people, but not a lot. I mean, we all get, oh, sorry, Sammy Youssef in Denver. We all get the same fellowship applicants every year and we're all good friends.
57:20
Go ahead. Yeah, great talk. Clearly, the OC Fusion was the best part of the whole
57:25
thing. I appreciate that. Thank you for stabilizing the rest of us. Absolutely. Backbone. How do you bounce back from like a crud injury and then you got to do another case like the next week?
57:39
How do you mentally get yourself back when the last time you did it on one of your three, you got in the crud and how do you bounce back and you got to do it the next time. when you've got to read
57:50
the best article written this year by this guy, Morcos, about forgive and remember neurosurgical complications. I answer you in that article. It's a small little essay I wrote. Anyway, talking
58:05
exactly about how you handle complications. What I can't remember what, I can't remember if honestly, I think it's a red journal.
58:15
And actually here's what, if you have time just read it, then read Walter Jean's letter to the editor, where he had some interesting thoughts. And then my response to him, I don't think it's out
58:29
yet, talking about exactly that point. You have to get back on the horse, as I say, in my response to him.
58:40
You have to know how to compartmentalize. And I'm certainly was not necessarily as good at it,
58:48
as I am now, I mean, compartment early on. It comes with time.
58:54
You just have to believe that,
58:57
I mean, unless you really screwed up, let's say it's unindicated surgery, or if you fire, as I say in this article, if you have to judge yourself, you sit, you're your own jury, you decide
59:09
where did I screw up? Is it the technical mishap? Is it the disease fault? Is it bad luck? If you've screwed up because you were unethical and doing surges unnecessary, maybe you don't deserve to
59:23
get back on the horse and carry on. You just have to be honest with yourself. Luckily, we all work in an environment like this where we have residents that hopefully feel the free to talk to us and
59:35
say, Marcus, why are you doing this three millimeter pineal cyst today or whatever? And so the honesty part hopefully is taken care of by us. working in an open space where we are open to
59:52
criticism. If it was a technical issue, you just learn from it. As I said, forgive, and remember, meaning forgive yourself. Remember the mistake. I mean, in all my talks, whenever I talk
1:00:04
about something, I always actually remember the worst mistake I've done in a similar case. And that's when I'm operating, that's what I'm remembering. I'm saying, six years ago, my hand slipped
1:00:15
and did this. I'm not gonna do that today That's how you become better, correct, all of us. But I go home, I never, I never talk to my wife about anything to do with work, almost. I go home,
1:00:30
that's it. I shut off. That's how I can function the next day. I go back the next day. I'm not thinking about home, I'm thinking about work. I don't know if that's the best model, but that's
1:00:40
the model that works for me.
1:00:43
Hey. Good morning, great talk Two questions for you. some of our junior residents, what are your top three, you know, can't live without top three complex cranial books? Where should they start
1:00:56
in terms of their education? Complex cranial, you mean or skull, you know, I mean,
1:01:06
yeah, I mean, the roton, you know, the collection of the roton, I mean, that's the Bible, I think everybody should, it can become esoteric, you know, when he puts those fine print things
1:01:18
next to the picture, some of it is pure anatomy.
1:01:23
Not all of it is surgical applied anatomy, but of course, knowing that the anterior choroidal artery could enter the temporal horn and send a recurrent branch to the optic track is critical
1:01:39
anatomical information so that the resident doesn't go and say, Oh, I'm past the choroidal point, I can sacrifice the Coroidal Archery. and I won't get a stroke. No, you can, because there is
1:01:50
this recurrent branch. Stuff like this.
1:01:54
I like Taka Fukushima, I think is
1:02:00
a spectacular surgeon who's at the same time an artist, he has an atlas, a Fukushima atlas of skull base,
1:02:09
particularly for complex skull based stuff. And I don't know, I mean, the rest of it nowadays, very few, I don't know, it's a master lesson, how many books are they reading versus looking up
1:02:19
papers and learning. It's very different from my time, how I learned. I learned with textbooks, you're right, but I think it's less relevant today. It takes so long to produce a book.
1:02:33
Mike Loughton has to be credited for the way he was very didactic in doing things I
1:02:44
think there hasn't find it extremely useful.
1:02:50
Quick question, it's a little bit related to the other ones, which is, I don't hear this talked about quite as much as recovering from the complications that you have, is how do you think about
1:03:00
like evolving as a surgeon from the beginning of your career and moving on? For example, we all do fellowships and we see a lot of great cases, but we don't see every iteration of what is out there.
1:03:10
Like when is the first time you do a trans cavernous, basilar full of coils, like, well, you know, how do you progress as you age to more and more complex things? And what is it like to tackle
1:03:22
something, Brandon, you haven't done before and how you prepare? Yeah, well, so you
1:03:31
never really tackle something entirely new, you know? I mean, we're such complex creatures. Our brain is so complex that
1:03:41
what I'm trying to think of an example Like, there are so many things you've learned in your subconscious. that you don't realize. And this is actually what gives you the quote-unquote courage to
1:03:54
tackle something brand new for the first time. It's not brand new, it's like, you know, standing on the shoulder of giants and stuff. You are actually using something you've learned. So to
1:04:04
rephrase your question, you want to maximize your deliberate training experiences over time because you have no idea which part of whatever you're watching will serve you one day I didn't set up my,
1:04:19
I didn't have a plan on day one of my faculty appointment. Okay, by the end of this year, I'm gonna, no, you know, you just, you know what? My first case when I came to Miami was, talk about
1:04:31
the first recurrent, what was then called angioblastic meningioma of the floor of the fourth ventricle. That was my first case, and he was handed to me, my first case, I didn't know what
1:04:43
instrument they had So, you know, I did it, I was out of fellowship. you know, a very good fellowship and just keep your mind open and, and deliberate training is the only way I can answer your
1:04:57
question. Just learn, be a sponge. And I know it's not concrete advice, but I don't know how else to answer, build upon one case teaches you something that you build upon, you feel more
1:05:08
comfortable with something more complex the next time So don't let every single case has something to be learned from. So when I'm driving home over the bridge on kibis cane takes me 19 minutes from
1:05:22
hospital to I'm rerunning everything of that day in my head. I say
1:05:30
I screwed up what I could have done better. Damn it. Why did I do that? I had no more thinking about work, but in the car, in the car, it's a lot of, you know, you know, you have to reflect.
1:05:42
If you don't reflect on anything, you're going to learn from nothing.
1:05:49
there from a medical student, you know. I was pretty lousy when you stopped. Yeah, you're a great, but you know, you're just, the way you practice evolved and your judgment changed. I remember
1:05:60
it did a Venus, you know, vertebral or the basilar bypass for adulthood by antagonism and just various procedures that you kind of like maneuvered and you changed. And so it's just, it's just an
1:06:10
interesting to watch, to watch that evolve to see the cases
1:06:16
you
1:06:20
do. Yeah, I think what the experience brings you is, like they say, life is unfair. It gives you the exam because before it gives you the lesson. That's what we face as surgeons, huh? Every,
1:06:30
you know,
1:06:33
yeah
1:06:39
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