0:08 Hello, I’m Jim Ausman. And
0:12 I'd like to introduce you to a new session That we have cold Scrub with me.
0:18 It's a video presentation. It's the first time I know that has been done where we take a video that a surgeon has recorded and interrupted many times so that the audience and the moderators can enter interrupt the neurosurgeon. Who is viewing the video of himself and answer questions that you can do if you're in the operating room or the surgeons operating, or it may be difficult. Under other circumstances, The coal moderator of this is Eric. No spa. America is a
0:59 very talented neurosurgeon Houston, St, Paul, Minnesota, He's done several thousand vascular aneurism cases. Very complicated cases, cases that are sent to him from around the world, very knowledgeable person, with a lot of practical experience You How your harness. Niemi is the person who is speaking. We have some videos from boot. You has collection, that's on surgical neurology International
1:28 located in the
1:31 in our library, and you can carry over twelve hundred videos you can find a few. I looked for his, so the book in there and and videos of neurosurgery You'll find many many videos to select from.
1:49 We had some technical issues during this
1:52 presentation, so that we couldn't show you actually the excerpt. We we showed some clips, but they were interrupted for or so for reasons that we've now corrected, but we did. I have a long discussion. Both Eric and I with you. How about as the principles he follows in doing a surgery, How he approaches surgery? What he? What does he do with temporary clipping? What does he do with spasm? Does he do angiography? How long does it take 'em and just to give you an idea takes him of forty to sixty minutes to do a case, skin to skin.
2:36 Very accomplished, I've watched them opportunities and excellent research, and I hope you enjoy this. We hope to have a a corrected version on site
2:50 in the future. If you're watching this video, you can still get a great deal from it and audio. You'll basically hear an interview with you. Ha, I hope you enjoy it. Thank you very much,
3:04 good morning, everybody. I, I'd like to introduce my friend and colleague. Eric. No
3:13 hurt. You can wave to everybody there, and Aric is A. Is a very talented neurosurgeon Gs, and St. Paul. As practices in St. Paul. He's done some three thousand aneurysms, or any skull base tumors. Operator of people who come from low to middle income countries, andor publishing just an absolutely astounding condition report just a few weeks ago, in search of neurology International, I and I am going to say that's Eric, and now you hike a wave to everybody there
3:53 you. I heard his name is is non, Everybody. He is an extremely accomplished
4:01 neurosurgeon. Michael neurosurgeon that doesn't in a small hut, and he has a is a outstanding, a
4:13 thinker and a technician and er and surgery. We asked him to come because we wanted to go through some videos that niesr. He's done and we want you to. This is a different experience. This is like hour yesterday. This is a new way of presenting video. Sanford videos were going to go through your videos. He has over a thousand of them and surgical neurology International, and I'm just taking some samples from there, and while we play, the video will go through the video, and Eric and I will ask them questions. Have you have questions in the audience. You can send them up to us and we will. I try to ask you what your. I asked us, so you can ask him why he's doing what he's doing in the operation. No question is A is a is a bad question, so
5:07 let's go Mike and will star with this is a
5:11 an unruptured enter communicating artery aneurysm and I. We want to assure you this to give you some principles.
5:21 You you operate surrender? Ah,
5:26 so this is not a long video. Ha,
5:32 Ha, I want to stop it. There, Mike, Okay, how so loud to go back one. If you can go back a little bit. Anyway, It was an inch. You're communicating aneurysm. It looks like it's pointing to the right side from the left, Have you at Luxor? I don't know where the rich he called the radio One is, but or any other current, nothing, engine room
6:01 or your,
6:03 Oh okay, usually I call from the side of a dominant Avon,
6:12 today, the thirty communicating, I notice, and so he already see that this right, just a smaller one.
6:23 Well,
6:25 how about something I have?
6:30 It about the approach here, so you're going to go from your left side under my Go ahead, Received no one the tank before you go, You have when you look at when you do you do your preoperative work -up Europe. Do you do a Cg and your grammar judo regular angiogram, since two thousand really to it after any channel and diagnostics. The she'd the saw us operate on him, Oratory did immediately said the Angio, and then in twenty minutes we had beautiful pictures to go to a very central, so I just read it fast. We didn't actually not do any Dsc. And you are different than here in China. Very interesting. Okay then at the gem. Can I ask a question short, Please do on. Now, No wait in this case, you end up going from the right, thanks. The left the left her scraggly beard there, I. I know that dive in from the right. I think the site mark is wrong.
7:35 Okay When you. When you have a large aneurysm that's directed at you, You ever coming from the opposite side, Not from the dominant. A one simply be to avoid coming onto the dome of the aneurysm
7:51 At, I go through the dominant downside. Always a hurry. I can put a temporary clip on the dominant they run is very effective, and then you'll surely the. I noticed when you die a basis at this site. Where the dominant a running. It's more easy to clip, and then if it just ruptured Donaldson, the news at the rupture site is pointing away from the dominant, A one to three reasons. Okay, I might get one in advance the video that ago.
8:28 I stop anything from here that you get an. We need to do enough of those sequences, A or the latter.
8:39 These are regular
8:41 two D C The your salary that it's very quickly. Three. D. I'll get there salivating coming here. Yeah, Okay, Go ahead could operate with that because we're gucci to the side of the night, but can you go back a little bit and? Ah, Okay, anything on that video that? It looks like there is a. There are two a one. A ones
9:12 will just need bigger. Yes, the loved ones bigger. I. Actually. I should go from the left side. Okay, Let's see what I'm doing it. I keep review. Let me ask you another question too high If the patient does not have post. You're communicating artery aneurysms, so that means the circulation is isolated. Is it me it doesn't make any difference in terms of collateral and clipping or temporary clipping
9:43 for entree? Communicating? Yeah,
9:47 No, I'd never thought about that. Okay enough about. No,
9:53 Oh, Okay, Go ahead, Mike, thank you,
9:57 so it's a fortified to five millimeter aneurysm.
10:02 When you're approaching it from looks like the. The left are sighted approach from the left side behind chicken, always
10:11 okay, Mike.
10:14 Can you go forever Okay, Now Let it go for awhile. Air can view and stop them. At any point, just say pause
10:24 alright,
10:28 so you're you're a lawyer and the.
10:35 Enter. The current to the eye and optic, or out of trying to their
10:42 mic, and it's just plain eater your charity.
10:47 The sham problems is not running videos running.
10:59 Okay, there we go okay.
11:12 He didn't mention the you've got the optic nerve.
11:26 Totally in contrast, what I said that I call always from the site of weird began a run. Now I'm going.
11:35 I'm not doing that Okay So much kindness.
11:41 Okay now you're just trying to release all the all the
11:47 subarachnoid the bands, so you can you see the applicators in there so you can begin to. To expose the aneurysm, I notice you how you used to instruments melee years a year or three years a bipolar forceps. You use it as sucker. Which is yeah, it looks like a with the sizes, but it looks like a micro soccer, but it's a sucker in a reasonable sides and clay case, You get bleeding
12:19 and the news. She used a limited number of instruments his era.
12:27 Yep, he goes to the chance to ask them to say it takes time, and I have learned to use a few installments, so when going down a shop front thoroughly, so I used to soccer and the bipolar Fellowships day, I like to read track thoughts, so I, I, I travel and crawl under this under the frontal open to you. Then into their Us, aussies danced Csf is coming out, and if needed, then I opened lemon at elementalist. These are the tricks and all slowly liquid membrane. It name it in rupture turnover, Since
13:05 the girl see, I guess were having trouble with the video or Mike. If we can't get this video will go to the second video will
13:14 thicken the. Yeah,
13:18 right? It says the audience show you'll see some pre -surgery progresses you have does not use retraction. Why is at your her?
13:28 I adored that there are honest deceased, enhancing them extremely skillful, so even in the presence of became one with the, the brain was lack any way, actually wondering why I doing or emergency operation, because it's our snow or lack of space, but the.
13:49 It wasn't just Anastasia money than five hundred before opening the skull, and then propofol anesthesia is intravenous anesthesia fish better set than if they had more tricks shared, She got freaks head high about a cardiac level and then to reduced to Venus pleadings, and the then I always persistent, might myself to head. At all but no opening opened other cases myself, so this was a very important for me mentally to prepare. How do I noticed was that and I will ship putting the patient into Scala clamps, and I was thinking how. And In which direction Yeah, I noticed me. Some describe where we were discussing with the Philips, both with Uber, which direction to Anosmia, financial, thinking how to blog that and so. So it's five hundred treasurer grams, or mannitol, and it's propofol anesthesia in Finland, and that was produced a good slight brain head up high, and you like to position at yourself, Because in your mind you have a three dimensional view of the aneurysm, and where you're going, is that right
15:08 guy always think how the animal comes back, sat inside your head spin there are. Well, the dead, so you have to think how are not that, and you go there, usually out you are right, but of course with the retraction of the Craig's of a position of energy may change, somehow, not recommend getting another since it may change
15:33 okay, so migrants just keep going.
15:39 This is not the first video
15:43 is not the second one. Yes, he gets better and it's the only advanced
15:52 Go ahead. You are.
15:54 Now you can see that there are two golden flakes an avon, like we were discussing with the Eric. Here. Said this is our policy to put two temporary keeps on a ones. First the content of the ipsilateral anterior down place, and now it seems to already that Theresa. Sleep on the A I the base, so I think it is not good to sulk at, because if you don't know the case, so very difficult to understand, Okay,
16:27 have to shake. It was running well and we could take that. Yup. I think Mike will go to the next video and I was probably aren't the problem, but let's talk about what you just said so. You use the temporary clips on both a ones because you've exposed the a one of the internal carotid other, and there is on the operated side, their high, and then you go across the as 'em and you see the A one from the other side, You see that, and you are approaching the. The bifurcation is where the neck is, so you stay away from the dome. Zeray. Yeah,
17:10 Pcs. It is the principle of principal time following shop, so worried that if decent naked second case is running, so we will see where that is shiplap. At the bleeding site. He sat there. I noticed them. What kind of get to second. We do. Now there is a second aneurysm. This is ruptured. Has come
17:35 look at this.
17:41 Okay, slump their money.
17:45 You tell us what you're saying there, and how you think about that more is not better to channel orange dice sit around and meet him at the. At a calm. I noticed money at the end of the notice me see a small teeth.
18:02 Welcome, come with the unknowns from the other side,
18:07 so it's just what Eric said You don't operate under the thinnest part of the aneurysm, which is the dawn, and which had already ruptured here. You want to have proximal control. I grow from the dominant side. Right
18:23 This is expecting. Okay. I asked, so you weren't using retractors for the unruptured aneurysm. I get a little nervous sometimes not having a retractor in with a ruptured aneurysm. Could you comment on me just because I worry that I might need both hands. If it bleeds. Could you comment on? Do you also not use retractors for all your ruptured aneurysm?
18:49 Not, I think, In this case me, I would have not using you can say, never never, but the depends on the situation, and also on the direction of the I notice most for should. In the first case, Dan noticed the direction was so that I had to make us more titles for erectile resection open, I put the small red to support the rain, met the
19:15 actual snaplogic many times my truck, Those in the last ten years in Helsinki,
19:23 fifteen years
19:26 in users,
19:28 alright, right tissue? If you have that kind of tossed and use abuse issues, always
19:35 always. When you are thinking something, then you. It is better to be careful. Okay, I've usually still make a lot of space Be Anastasia. And taken Csf out Open Colombia, Panama, Then you have a slack tray, and when you have a slack brand, if the operation is totally different if the French tight.
20:00 Okay, Mike, can you have answered? Do you have the high bandwidth? Mike?
20:09 Okay, here we go, Alright, This is going better
20:15 for Raj, Okay,
20:19 she left her. Now this is left side. Now, yeah, I quote is difficult that it hasn't ever used to see the pictures like Roman. Yes, I get that right this right then.
20:32 The site marks are different differential. I don't know how the fellows have taken them, so I go here from the left side. Yes, visit, A wine is going on, then the and the Irish, Mr. Pointing with its deep throughout the other side of the van, Waterhole, Yeah, when one layer, opening, medical tread traction with the sookie the system, and then making with two catch a small,
20:58 Let the natural product, Ah flap.
21:02 And at this craniotomy is very low. It's right above me. On the severity of a ridge. Is that correct. Yeah, Yeah, it, they said, then I detach to do it on, Then it with drill, I go to and the Lord are also not reflect. And here are
21:25 that orbital that supra orbital ridge. Do you ever do that you find helpful or not?
21:32 If I
21:35 opened a ticket on
21:38 with a or magic approaches to him, in that or even less than that, just the orbital that orbital red roof their orbital rim to Earth and you drove down the orbital roof.
21:52 No, I, I didn't take much note. Let's stop there, A, Because Eric's asking a very crucial question, Mike and that. At Eric's ascii whole, hold it there, or do you use skull base approaches to get to the aneurysm My in any any aneurysm
22:11 I didn't use in any. I notice
22:14 the holes, but the danger can carry. That's a good, honest. There she we didn't need. I always read and hear that you have to do the trick Amatic approach to come, for some unknown reason was to have a good angle. I, I tried, but they didn't see it necessary, and I actually. I think this will delay thing when you open the victim. So the cosmetic results is not good hope. This is a very good fast approach it connected with and is this yet I have been always happy to
22:52 piano. Lessons. Of course. Galway approaches them. If you have put our stomach. I understand, y'all making periodic to me. And so on, but the
23:03 it at Caniff real Big skull base approaches, I have not been using Thanks to the dentist. She and some surgical tweaks
23:13 or cure Europe's different experience. I'm no, not really. I mean I tried early on using some of them and didn't find it that helpful, but I do drill down the orbital roof pretty extensively. Sometimes it'll expose the Harry Orbiter. And I sometimes will take off. I don't really use the true orbit as like Amatic, but sometimes rope take off just that lateral aspect of the orbital rim at orbit that superbowl are, and for a very large inter communicating aneurysm, sometimes I would would do that, but less and less over the years as you become more comfortable working without that, I agree exactly with the professor. It, it may worsen the cosmetic results, so we didn't use it as much overtime to Dr. Drake, and
24:06 truly Dre huge. Any skull base approaches, Because he did basically arrange your instant zone kinds of others. Are you how you spend time with them and Soda Jerk
24:16 Know he didn't do any scalp based approach. He did all the case which were possible to do by September approached more than one thousand as if a notice sent. Is the analysts looked very high? Then he made a steady on? I'll approach them to, or if that rare, The other, I noticed multiple Another reason so
24:39 many
24:41 ever opera for real, He didn't. He did everything with a giggly sauce. Yeah, that's true. I am another thing, Question know you if the patient has spasm.
24:58 And The The Ceta I did angiograms on everybody, but if if a patient has spasm, does that change your timing of surgery at all, you, your
25:11 my main path of these almost, but operated to not cook until you didn't have in his past the first first day, second day, or even charity of other day of rupture, but if he had that kind of case with delight. Diagnostic then to the patient's condition was stapled, not deteriorating, so he operated on, but keeping the blood pressure higher, Because chinking philosophy was that this past may not preventing announced rupture of the
25:45 shaker. It. I notice, a man then went higher with a black pressman, have to. After keeping good.
26:40 The I think in the,
26:44 and when I was training in your soul to the devil saw the time being discussed on, we special drop rate on opponent Nineteen eighty, Begun to do a quick search results are discussed in the strictness of that is that patients will pass my favorite long time, but under discuss a window, operate on my. Integral, swear that if the patient is stable, not deteriorating were dispatched from where we can operate on A, If the condition was getting worse than it really would have to operate, and we're racing. I used to, and the patient died.
27:22 Yes, germ from my perspective. There is a paper published in the sixties. Mine came out a Van, Duke Samson and Kemp Clark from Texas, saying that. I interrupt of rupture their results or three times worse and ended, The, the other thing came from Japan, experience that Ah, the only way to prevent an aneurysm from bleeding gets to deliver it, and then as a carpet, then you can treat the spasm, I If it's not if you don't clip it, You can treat the spasm, either, So I to me you just if you sat in the armchair and thought it out, you just have to clip the aneurysm so. Basically what I think that the job of yours yet so that's interesting. Go ahead. Mike.
28:12 Okay, Let's see. Let's see from there. Okay,
28:16 Alright, I'll go back a little more cars. We'll show you put on the temporary clips.
28:23 The readers like champing. Yeah, I do. Oh, okay show. What what's your John Deere? Is your? Where you can tell us your exposures? They can exposed the on both sides and those are the yellow clips and moser the temporary corrupt rain.
28:44 Yeah, I read the and color of their breakbeat, and in this case been on boat, A, anyone's okay. You can like a video, go, Mike,
28:57 Alright, That's good, so now you're
29:03 I gotta keep going.
29:06 The kick so you can interpret quotes can
29:14 keep you keep going, and maybe isn't bandwidth problem. Like
29:21 Okay. There's a permanent clip going to say that your. That's your pilot. The bread
29:29 that'd be spite of sleep is going on the base of the I him
29:34 so. So you as expose the base of the aneurysm, he's not expose the doll member of this had a very large aneurysm Of the
29:42 weakness in the dog. He's exposed the base of the aneurysm and he's putting on, and this is his philosophy, a clip and a and a necklace, much as you can see of the aneurysm, so you have control of the bleeding and surgery Is that right,
29:58 Yeah, this is Uh, important to select the right to sleep, so that. Length, just a glimpse would be one point five times the base of piano. The decision important, and you have appropriately. Not too long. Not too short. Okay, Alright, let it go. I think we should probably let it go night. Because it's a doing. She finally did that. So he's putting this on there you go.
30:23 I will just keep it Keep going. How much time after you get the temporary clips on you. Ha, Ha, Now you've got the The. Is a pilot coupon and it looks like you got into some bleeding from the aneurysm there? Okay,
30:40 Let it keep going yet,
30:43 and and so what do you do? You're down and bleeding situation? How'd you try to readjust clamp? Motor? What do you do?
30:53 I don't care a clip of. May I know I'm calculating down, begun. I think, Yeah,
31:01 okay.
31:05 The white rupture It's difficult to understand why isn't up to the. Sometimes you don't know why Trump's now. I regret that. Now the announcement. Then I put the clip back that it is not bleeding heavily Because you have the temporary clips on the boat events now as a clip on the base of Donald's and I continue about relating doubt the I notice him.
31:33 When he was using to bleeding is coming from the dome, or do you think?
31:39 What
31:45 did she mean? Media is champing? So I can see well, and of course.
31:50 I remember I shall cheer exactly, but of course then you'll wind up bleeding begins. When you put put the clip. Then you always suspect that your perforated the. I noticed. Somehow. Of course a venue with a clip. It then downloads may rupture because they spend Sunday, and then if the clip is not properly or along the base, so these other possibilities, so,
32:16 in this case, I. I reacted to that type I took to keep out. Let the unwholesome expanded. Then I calculated down and then we worked on it and put the near clip,
32:31 So so why you're doing this is Eric were saying before you have the sucker and hand or your system As the sucker in you're working with both and Susan. How are you doing this?
32:45 I mean the soccer. I do. I'd take the bleeding out and then. Is this the bipolar here are operating? I notice now that the video is jumping
32:56 back and thought.
32:59 Ok. It's difficult to play now exactly how it goes, but the data has begun to plead when I put the first clip and I think a pair for eighty three. I notice them. It might be. I saw that it was a good opening of the clips. I don't think it was the perforating the. I notice them, but it ruptured at the. Do and the clipless not chocolately around the base of it was to caution that night. I began to calculate down management.
33:35 You go ahead. It.
33:40 At one point, I saw that you actually cutting into the dome of the aneurysm, Is that to people to see beyond that, or is that something you typically do to make sure it's adequately clips?
33:52 I read two reasons to cut the analyst rim collected. Many are close to one hundred. I noticed some sacks, though basically says, but there's also that it to see better on the other side, so I opened the announcement. Go right down, and then you see below the others. I told you I was like overhearing the. I notice. Mom's. It
34:17 calculated down at Nmc The pace
34:20 now day, Sir, Icici.
34:24 It is said that I'm sure is that this video to Champix coexist before of even for me very difficult to understand what I'm doing here. Yeah, I'm leaving a cut that thinks that the lamina then monopolies to eliminate Jeremy knowledge which I opened to get more space and open. Did you did you? I see that, did you leave a catheter in for drainage, or was that just a temporary
34:51 notice he said when I? Open to nominate their monopoly stage a whole, and then after clipping, I put this small tin Cadet Cadet day inside the turret A, and draw it out. This is for
35:07 entertaining Trezor, measuring, and also a drainage of fluid to hear. It is going in inside.
35:14 They also have a very that that you cannot put a ticket at that, Because it is coming through the judgment will wall so. Must be special tin cup at that, but received very nice. I assumed it to E v D. In this case it I used went to a small capital. I'm in a pyramid and honest, and then had a space and slack pregnant, and left for
35:41 recording for their intensive care is a catheter that like you said here many times, he'd been fairly loopy. Two are in the posterior part of. Adventurer the the pacing, knowing the poster about the Dutchman ventricle. I do see the cancer coming out to your car, and you leave it in
36:04 advance of the case of cost it. I left the cut that they. Only if the patients, a patient had a reddish easier to separate 'em or was a poor, Create one In T cases, I left a patient was a good conditions. I didn't do that. We didn't lately at all. It depends on the ship to it. Things are training. A pressure was high and needed a patient needed drain. You saw it for so several days there, but then the situations stuff realized. Then we took it out to prevent infections.
36:35 Another question when you use temporary clip. See and the audience should know the temporary clips are or have a very low closing for, so they're not as strong as permanent clubs. How long how long were you? A good temporary clips? On the on the circulation? Would it'd be five minutes or ten minutes? Or? What? What? What what do you have a time limit?
37:01 No five minutes. I tried to remain under five.
37:12 Editions Eric. I'm getting there. I studied, studied those cases where Doctor Drake made as he lot of pollution.
37:25 Atlas, but you can always, if the temporary clip was less than five minutes, The recent outspent nearly always good, Oh,
37:37 and if you put repeatedly separately, If the talked all the time much less than fifteen minutes, results were also good, so it went about those five five minutes, single temporary clip or. Fifteen minutes repeated clipping total time saw you had good results of the long a time. Then you have poor results. Of course, budget. Arthur is different than though all
38:08 attorneys. You are using temporary groups are different, so you have a coat.
38:15 You have a. In the three, you have it be calm, His mails feed the law deep and.
38:24 And but the and there, but then a animals. When you don't have that kind of good call it, The Russia hit in those years To have less than five minutes. I don't count. I don't like that. My time is counted. I just want to do good chop to cooled down. I don't please. And if somebody saying one minute two minutes Three minutes, I just do it as greatly and then I note that that potential has been done him tool. Three or four minutes, The more importantly record shop. Then a panic
39:04 come back to that Eric jury. Do I have any difference Entrepreneur?
39:10 No, not really, I mean, when we put temporary clips on, I usually tell the nurse to let me know one five minutes have gone by and I prefer to have it off by five minutes, but. Know if you can't you can't and I, I mean I appreciate what the professor said. I think you just have to do the job, and in a case like this, it looked like there was reasonable backflow Also from the Etudes two, so you may, so you might think you have a little bit more luxury of time, and if you saw no, he's not just a trickle of back. I'd be more worried about it. You know I. I have my. I'm always thinking that again. Open budget law, three, the implosion and Mth trump bullshit of the patients are
39:55 doing extremely well, So why are we worried so worried about a couple of minutes just to do a good chuck, Not to occlude and important arteries, but not to panic until at Duke,
40:10 I think early on I went to Japan, and nineteen eighty or eighty, one two and Suzuki operate and he. He had a cocktail that he gave patients sir when he did temporary clipping, and the show is based on some good research. I know Lindsey Simon engines, apps, Trump in a in England and Denmark, to to animal experimentation and they came down to an answer. I think I was a short like you were saying.
40:42 I agree with you. I think that what it says to the. Is it to the people who are watching until the surgeons are do this? Is you have to be prepared at the time you're going to be using temporary clipping and clipping To have a set of clips of the scrub nurse can have that are ready. That'll set the configuration of the aneurysm that you've thought about studying angiograms and looking at the anatomy, and in his view, I said at the very beginning there should be no time wasted, I, if if if from? If if if the procedure one doesn't work, then you go to procedure Jew, then you go to a procedure two, three or all you're prepared every second to do something, so no time is wasted. Is that correct in your idea you are. Now. This is exactly. You have to discuss me. Scrap Now stand on this issue. Now we uplifting temporary leaps, so we have to temporarily trendy, and then also the project leap forty. I notice everything is ready that. So you are not catching for the bleep shot and to it, and then the
41:53 so mentally, I think always that some people ran one mile below for me, needs, so neurosurgeon can do a lot of things when somebody's running a mile, and for many saw we can do so many things it, I call it calls me down enough and some people run five kilometers. I far below fifty minutes, so so Rica. If this long time this four or five minutes,
42:25 Yes, that's one of the reasons I did die angiograms. You're wondering to see what the post you're communicating, Said the collateral flow was because it also entered into that decision. The the negative to that is said, Hey you it takes. May take an hour to get that done and that maybe an hour that's critical, but but I like to know what are the collateral circulation as because it influences what am I thinking it so that that's my thinking, so anyway, Any other questions on this for you have Erica will go to the next video. Yeah, I have a quite personal question and you know, obviously you've done a huge number of aneurysms and when I have an aneurysm like this that ruptures. I always get a little nervous. I mean it's embarrassing to admit, but you have to try to control that at this point in your career. If an aneurysm ruptures like this, do you get all nervous or it's completely routine for you. This never routine, So I, I never think that the any notice sheds generational thing, Even niche game show called Daisy Cases may may be difficult, but then I notice ruptures during operation What I'm doing. I'm sorry Eric was wearing very strong. I sat on a particular fee, nice, and this means that now it is Olam, and everybody's can just concentrating for work, and it is if this or
43:52 the situation, it down with very side within, not retire without then is helping those, no, no big shouting in operational test, the first warning alarm, swearing, and then to see the damn business. I whooped road bus stop there We want, do that. I wanted to ask you another question. That's very saving. You even notice rupture adenosine is beautiful. I didn't have seen. When unknowns rupture shoot added machine. Then you have
44:27 some
44:30 may be one minute, thirty seconds one minute to have to to possibly do
44:37 to. Take care of the identity in it. I notice that may rupture rethink before operation with that we have added had inherited them seemed ready to be checked. It organised insomnia, Our gave an especially unusual sewing, the screens now disbelieving at this thread, so I didn't see him and then recruitment menace to see to it.
45:01 Okay, Okay, Let me ask her a question you're been working not. In the developing world, teaching them aneurysm surgery, you seen what's happening in the developed world with an interventional approaches to aneurysm? What is your thinking about interventional approaches coiling and so forth to aneurysm surgery.
45:29 What can I say when for example in my husband down here in and apparently shot people to out? One thousand two hundred, I noticed once or more a year, Three thought I have endless spa treatment. It cause some stems who is coming to keeping poor people who don't have money to pay
45:54 expensive and less clout treatment. This is one of the main differences and certainly likely wrote down with peerless at that the.
46:06 The perfect clip on the base of these deadly sex, so I think it, if you can put them perfectly without listening to patient so damaging to the patient, and if this best treatment still the best treatment, the skills are going down, Act of costs are also here at function between China this big. Romo that it is dangerous to open the hit, and this is misused a lot, so the clear indicators are different and the Midi kind case, or so, so the indications are not
46:48 so patients as electing endless clock. Even The with what it should be clipped, all a cliff for that Tibet in developing countries, like I. I was working one ye nipple, I saw that. Patients and patient went home because they didn't have money for a clip with ruptured and autism, So this is the situation. I think when we discuss about the what kind of stance and class resorts, Both pipelines. Are, so this is the first that disgust in many places developing countries. You don't have that kind of possibilities, limping unit, skillful threats around it is existing there. Like in Africa, so you have excellent migrant citizens, keeping download some so, and so deceased is a long discussion. I have done it twenty five years,
47:50 Eric here every year. We are getting closer in a few minutes.
47:55 The conversation we talk about this all the time. You know just because you have the option to treat something endovascular lead doesn't mean it's the right thing to do. I think most asko neurosurgeons still believe that there are some aneurysms that are best treated with open microsurgery that could always change if the endovascular technique to get better, but most of the middle cerebral is a lot of the answer, communicating aneurysm or somewhat wide neck, and I think we can really cure the patient with open surgery, still, but more and more patients. You know are being cheated, Endovascular lie, and as a professor alluded to in the microsurgical skills go down, and it becomes a problem. Especially, I think it's going to be a big problem in the future, and when people who you don't have not had so much experience are the ones doing the clipping. Because for now you have people like the professor who can do this, probably you could clip almost any aneurysm with less risk than in the vascular, but. I can't do that anymore and the younger people will have even more trouble with that, so it's it's quickly evolving.
49:06 Are you? How long does it take you to do it and he notices an easy question. An average case, skin to skin for an aneurysm,
49:17 they say said is not a good precedent that the record is twenty five minutes from skin to skin, the one I notice. And then the second one I spent eight minutes, but the disease said, I know exactly when we got the Id technology in Helsinki. I didn't know that my Angeles basin was coming inside operation room and left operation room average to two hours Forty minutes, So this is burial time,
49:53 so preparation. Alistair, mostly extremely fast. He couldn't go to eat, because as just were so fast, but the also the makeup takes time to move. The patients been conceived now, so this takes time two hours. Forty minutes. It means that to end the regular working time you go to a tree. I notices
50:18 It's a very good where we've we've just got to run his left and I want wanted to think.
50:25 Deric for coming and sharing his experiential learning, Thank you for doing this. You can see these videos An S and I
50:36 go to the menu, and you'll find posts and their ebooks. Erin Unger, He Berkshire annual all the aneurysms that. Yoga has done. And I think you can go through them and I learn a great deal on Eric. Would you like to make any final comments?
50:55 I'm still thinking about twenty five minutes. As first
50:58 It was like it's my honor to be here with both of you and
51:03 your master in your region. That
51:08 with why and I t t prolonged.
51:16 Extraordinarily impressive work. It's it's it's absolutely my honor. Okay, same thing. I thank both of you for the audience and I will finish a surgeon. We appreciate everything and I thank you for all your time and preparation. Okay, Thank you very much. I have a good day.
