Thank you. I'd like to invite all the speakers to come over here to the panel so we have about 45 minutes for panel discussions. Dr. Egli, Michael Bruno, come over. Naja. Yes, switch to me. Yes, thank you. I think we may need two more chairs if we could. In the meantime, any other questions from the audience to any of the speakers before we start the case discussions? Okay. Yeah, we can. Yeah, let them get comfortable. Go ahead and have a seat. Have a seat, have a seat. There are six of you and three moderators here. So let this be totally interactive. The three of us, each one of us will speak for about 15 minutes showing you cases. Martin, Martin. No, no, no, there is room. Well, you can't speak with a microphone, let's say. There is one more room. Luca, look, there are two spots. I think you're avoiding us, that's what you're doing. Okay, well, you have a microphone? Okay. If you have a microphone, it's fine. Oh, can you connect that other monitor for us? It went blank. Is that it? That one, yeah. The left one. We got it, we got it. You got it? Okay. Fifty-four-year-old female, headache over several hours, worst of her life, lasted for two weeks, followed by a transient left six nerve palsy, lasted several days, admitted to an outside institution. They did CT scan, LP, it was bloody CSF, MRI, MRA, DSA angiogram, transferred to me, at the time she came to me, hyperreflexic, left six nerve palsy, unsteady gait. I repeated the studies. You'll see why in a second. This is a CT scan on your left. Notice what's happening in front of the brain stem there. This is a coronal CT scan, and you're going to see a sagittal CT scan. This is MRI on the left, T1 without, and on the right, T1 with contrast. And at the bottom, you're going to see T2. You can see a hematocrit level in that. This is the MRA. I'm going to show you next an angiogram. I might as well show you the 3D angiogram. We could not appreciate an aneurysm filling on this 3D angiogram. This is a KISS sequence, again, coronal, MRI T2 weighted. And Luca, I'm going to start with you to punish you for standing there. Tell me, let's see, what is this? What's the differential diagnosis? How do we treat it? Okay. Well, I mean, the differential, the first thing one could have thought of was an aneurysm indeed, so it's still there. But you showed, I mean, the angiogram looked really good. And it's hard to say for sure that's an aneurysm. So that opens the differential diagnosing of something that would not be an aneurysm. I mean, I don't think the aneurysm is 100% excluded. You could think of a completely thrombosed aneurysm. But you have that T2, and again, the images are great, but still, we went through pretty quickly. But you have that fluid hematocrit level, fluid hemorrhage level in the lesion. I probably would go through the images again, you know, thinking of could this be a cavernoma, like an extraxial protruding cavernoma. With the calcification at the rim, remember early on. Well, that's true. The CT was very calcified. Yeah. Martin, any additional thoughts? You know, just meningioma could still happen. Just meningioma could still be calcified around it and can bleed, but it's rare. So the aneurysm still is not out of the completely thrombosed aneurysm. It still could be possible. Anybody on the panel? Go ahead. Maybe the presentation with the very strong EDH is in favor. I'm sorry? The clinical presentation with very strong EDH are maybe in favor of a vascular disorder. It was a subarachnoid hemorrhage. LP short blood ECSF. So it means that it could be thrombosed aneurysm. First option. Yes, I think the first option, aneurysm. Aneurysm. Completely thrombosed aneurysm. I know it's not my role, but I think the panel is still, you know, we always tell the residents one diagnosis is never good enough. So you have to come up with something else. There has to be a differential. Maybe a tumor bleeding? Tumor bleeding. Okay. Nagia, what do you think? Any germa? I think it's a thrombosed aneurysm. Cavernoma, it's not cavernoma because it's an MRI. We didn't see the typical image as the popcorn image as cavernomas. Cavernomas is not, for me, it seems not cavernomas, but thrombosed aneurysm is the first diagnosis. Can you show again the images? No, I know. I went quickly. Which one do you want to see? The beginning. The beginning? Okay. Here, let's start again here. So, rim calcification. Again, on coronal and sagittal, you can get an appreciation. Because obviously it makes... The MRIs, just quickly. MRI, yes, sure. Let's do T1 on the left without GAD. T1 on the right. Brainstorming. But the one below me, yeah. And this is now two weeks after her initial presentation with the six nerve palsy. Here is a T2. I still think there is a difference. So, what to do now, Luca? Obviously, I'm faced with this lady. What do I do with her? She's good. She's wide awake. Six nerve palsy. You see, the way I think about this situation is, which lesion is threatening? Immediately that I have to do something right away. And that would be the T2. Immediately that I have to do something right away. And that would be the aneurysm, right? I mean, the aneurysm would be the most threatening of all the lesions we can think about, especially with a subarachnoid hemorrhage. However, there is absolutely zero lumen visible on any of the angiographic imaging you did. Are you saying completely thrombosed aneurysms cannot rupture? No, no, no. I'm just thinking loud right now. And so then the thing is, if it still is an aneurysm, it's a completely thrombosed aneurysm, and I mean, what treatment can I offer that would improve the natural history compared to the risk of the treatment? I would not treat it right away. You would not treat it right away? I would not treat it right away because, you know, what treatment could I offer her? Resecting it? She's myelopathic. She's what? She's myelopathic. Myelopathic? No, no. This is not a spine session. This is cranium. It's the sixth nerve. It's the eye. Right. Well, she was unsteady, but she got better. All she has is a sixth nerve. That would be for me. I wouldn't know how to treat, I mean, I wouldn't know how I could exclude an aneurysm that is already excluded now, and resecting it wouldn't make sense. I would explore. Yes, I repeated it 3D, looking very carefully. I'm looking for any irregularity. I promise you there wasn't any. There was mass effect. You saw the mass effect on the upper vertebral and origin of pica. Yeah, I would explore. With what plan of, like, you'd explore it as you're exploring? Most likely not an aneurysm. Okay. Anybody in the audience would like to put a pipeline stent, assuming this is a thrombosed aneurysm that could re-canalize and re-bleed? Raise your hand. You'd like to do that? No. No, I would agree with the first one because I do not trust the lumbar puncture in this case. Number two... No, no, there was blood on the CT. Well, I didn't see it, though. I didn't show the initial CT. So that may change it, but right now I don't see it. And if the patient is stable, I would just wait and see if there's any progression. If there's a progression, then the cause is the mass effect on the brain stem, so you need to decompress the interior. But I don't think you can excise. It does not look like anything other than calcified aneurysm. Okay, I'm just going to cut to the chase because we have many good speakers behind me and good cases. So six neuroradiologists in my institution said this is a thrombosed aneurysm. I disagreed. I explored. It's a meningioma that hemorrhaged. We usually see the opposite situation. We see people who present... People think they're a tumor and it's an aneurysm. This is the opposite. I'm not going to show you. I did a far lateral approach, hemorrhage. So I tell you what the clincher is, that coronal seat MRI. I could convince myself that there is maybe a narrow dural base at the jugular tubercle. This is a jugular tubercle meningioma, mimicking thrombosed, whatever, basilar aneurysm. Unusual presentation. Almost perfect match-up for a subarachnoid hemorrhage. I'll show next case. Let me know when my 15 minutes are up. Let's see. I only have time for maybe one more case. Okay, this one is interesting, recently. Okay, patient, 37-year-old, presented with a headache, blurry vision. CT of the head back in November was negative. She was discharged. Returns a month later with a new hyperdensity adjacent to the midbrain. You're going to see it right now. She has left ICA occlusion. You will see an abnormal tangle of vessels around the A-cum and around the basilar top any minute now. This is an initial CT, completely normal. Kiko, you can't comment on the case. You just saw it this morning. And this is now the hyperdensity, new. Look at this funny-looking A-cum region. The left carotid is occluded. Look at this aneurysm, not of the basilar itself. Look where it is. It's here. This is a basilar tip. It's playing with the 3D. I'm going to call it AVM-like lesion. And the reason I say that, there is no early draining vein. So there is this appearance here at the basilar apex region. There is a similar appearance at the A-cum region with an occluded left carotid. So while you're thinking about this, these are successive micro-injections. I worked closely. I don't do endovascular. My colleagues are excellent at this. I asked them to individually catheterize these vessels to try to understand this lesion. And that's the injection that led to the aneurysm. So let me first start asking the panel, except for Kiko, what is this? It's not an AVM. What is it? People would just say, oh, it looks like an AVM. But if you don't have a shunt, it's not an AVM. And you say it's no shunt, so it's not an AVM. But you say there is an occlusion. So you could think about angioproliferative something that is trying to revascularize a region that is hypoxic or hyperperfused. So I would try to look into understanding where they're coming from. Could it be this, you know, we'll call it Moyamoya-like or whatever, something proliferative without a shunt? And I think that I would try to understand, is the occlusion of the carotid anyhow correlated with this? And then if it is, like a spontaneous, slowly appearing collateral flow that can have hemodynamic surcharge and develop an aneurysm. Any descending opinions to that nice summary? We all agree with Luca? No, obviously not. What shall we do? My endovascular colleague says he cannot reach this aneurysm. It's too distal. So was there bleeding or not? I missed that. Well, there is a new hyperdensity. No, no subarachnoid. Headache and a new, you saw it, the CT changed. Hyperdensity in, maybe it was thrombosing or partially thrombosed. Partially thrombosed, yet it's still filling. Anybody from the audience would like to offer advice what to do? Has the patient any infection? No. You're thinking mycotic aneurysm, you mean? No, no infection. So can you help us out a little bit, which doesn't connect to what? This was the most important point. The rest is less important. You could still, I mean, if we think there has been a hematoma, which is, what we see is not only an aneurysm, but it's a hematoma. No, it's not, but it's a symptomatic aneurysm. I was not satisfied leaving it alone. So what we did, surgery with a proxy, but it wasn't easy to figure out which vessel to take because a bunch of, for serotheloma perforator, I just put a clip on the proximal, on the vessel that matched the micro catheter injection that leads to the aneurysm after the last perforator was given. You know, you couldn't take it too early because you'll give her a big info. This is a basilar tip, and it just, once you got the right vessel, it just, you put a clip on it, and that's what we did. And aneurysm intraop angio was stagnating, and by two days post-op, aneurysm is gone. She's doing well. I had not seen a case like this myself before. My good friend, Giuseppe Lenzino, when I dig the literature, has described 12 pure arterial malformation he's seen on angiograms, didn't have to treat anything about them, but obviously described without a shunt. I'll stop here. I'll have my next co-moderator go. Let's see. We switched those two, I guess. No, I clipped the parent artery. I never saw the aneurysm. But the etiology, what were your thoughts? Exactly what you said. She's atherosclerotic, carotid, vasovagal. Classic. For once, you were right. I did mention meningioma before. Good afternoon, everybody. My name is Nirv Patel. I'm from Brigham Women's Hospital in Boston. Thanks for having me. It's been a real treat to hear all the great talks this morning. I'm not trying to speed us along, but I prepared nine cases, so let's go. It's like a little tic-tac-toe. You can click on what you want, and we'll see where we go. But Dr. Marcos asked me to cover dissecting aneurysm, which I think is fitting for the last case. So let me show you this case. This was a 45-year-old woman, Hutton-Hess grade two, had a congenital large posterior fossa cyst, subclavian aneurysm, and a positive family history. Her mother died of a brain aneurysm. You see the rupture. The midbrain is not pushed now. This is chronically like that. Her midbrain is like that. So this was the angiogram. You can see a dysplastic-looking right PCA. I don't know, this is different to Dr. Marcos or what, but it's got that knobbly appearance and is ruptured. What are the options of the group? How would we treat it, and would we treat it? Maybe I'll start with Kiko, could you tell us, again, ruptured PCA? Complex case. Well, we only chose complex cases for you all today. Do you want to grab a mic? Who else has got an opinion? Someone from the audience? Good, good. Some interest. There's no tricks here. It's a young patient, has a hemorrhage, has a subarachnoid hemorrhage, and we find a vascular anomaly, which looks like a dissection of a vessel. So I put that together, 1 plus 1 plus 1, so it's a ruptured dissecting aneurysm on a posterior cerebral artery. Intracranial, intracerebral, high risk of re-bleeding. And the patient is doing well, right, despite the hemorrhage? So a grade 2. So natural history, in my opinion, is worse than treatment. And now the question is, how can we treat it? So obviously, it's trying to reconstruct it, preserving the flow, and I would have some thoughts, if I cannot reconstruct it, would I be accepting sacrificing? And then I would have to understand where the perforators, where the posterior coroidals come from, knowing that, you know, actually the posterior cerebral has a pretty good collateral throw over peel, collateral. So I mean, can you help us out in where are the coroidals, and I mean, how far back does it reach? Yeah, I agree with everything you've said, and I guess the other options out there, would anybody suggest an endovascular occlusion, or even a pipeline device? Those were all options on the table. Anyone want to take a step otherwise? I'll just go forward with say what I did, I agree. Oh, and by the way, all these cases have been operated by me, so there's good, bad, and ugly to look at. I had the same thoughts, where are the perforators? So we operated, but with the thought of a bypass potentially, so, you know, we got that ready, OZ went down, and this, that's a laminate terminalis, but this lady had a dissection also here, this is the MCA, this is, and then now this is the basilar top, PCA, and we've cross clamped the proximal end of the lesion, and then taking it off her third nerve, which she also had a third nerve palsy, and as Professor said, looking for those perforators, not seeing anything distinct, so went ahead and cut the back end of the aneurysm and looked for the retrograde flow, which I thought was very good, and so went without a bypass, and I thought it was an interesting case, one, because we were supposed to talk about dissecting aneurysms, and because we got to cut it out, here it is, you know, there's the vessels, you can put them together if you need to, otherwise we just finished it off, but because we got to cut it out, this is the postoperative angiogram, she did very well, there was no extra stroke, she's doing well, here's the pathology for those of us interested in that sort of thing, you can see the dissection in the vessel wall, here in the top there, that's the dissection, and then there's also an aneurysmal component, as you can see, large aneurysmal component, so that's the rub of it, would you, any comments about that? Great case and great treatment, compliment. So, you know, we were talking about dissecting aneurysms, like this one is another one, a 42-year-old with a sudden severe headache, positive LP, what would people do here? You see the aneurysm on the vertebral. Where's the pointer? Here. Here's the aneurysm, it's small, but real, it's this round ball coming off of the vert, this guy's perfect, he just had a sudden severe headache with positive subarachnoid blood. Take down the vert, anybody? Pipeline, surgical occlusion, Dr. Zippel says pipeline. Yeah, that's what we did, and there's the result, and that's the aneurysm, pipeline deployed in one year, so it can preserve vessels as well, the one that comes off at the aneurysm, worked well in this case. Could I ask just the timing of that? Did you delay it a few days or a week before treatment? Yeah, because of the aspirin and Plavix, but I'm a nervous person, so did it right away on aspirin and Plavix, loaded him right then and there. It's a good question. Do you want to give us some details about how, I mean, just straightforward pipeline? That's what we did, that's what I did, yeah. Or like two pipelines with coils in between, like a sandwich? No, no, no. That's a great question, when do you use coils on top of the pipeline, so forth? Or even, you know, between two pipelines, like sandwiching it in? I guess, you know, once I put the pipeline in and it started to stagnate, I felt very good about that that was going to be a good treatment. Are they still dual anti-platelets? Yeah, yeah, yeah, we took them off, dual anti-platelets, at the six-month mark. Did you delay the treatment? No, no, immediate. Because in our experience, this is the best location for acute placement of stentin. It was the first location we used, and I don't know why, but it's... When there is a discussion about the acute use of the stentin pipeline, but this is the location, the best location for me, for a bleeding case, to put a stentin in. I don't know why, but our results are the best. Yeah, I want to move to this case, because I need to learn from the experts in the room. May I ask you about the dual anti-aggregation? Yeah. You did it one week before, and then you sent it. We do it on the table. We load the patient, aspirin plavix on the table, and as long as there's not an urgent need for any kind of EVD. If there's a need for EVD, place the EVD, then do the anti-platelet device. And Dr. Patel, why did you not choose pipeline, then, for the PCA aneurysm? That's a great question. You know, if I wanted to be perfectly honest, I learned to do pipeline after I treated that aneurysm with the PCA. That's probably true. Although, I think you can treat these things in more than one way, plus the PCA in that dysplastic vessel, I think that would have been hard for me to land directly against the basilar, and I think I still would probably go with microsurgery for that PCA-dissecting aneurysm. Yeah, one last case. This lady presents with just a headache, really, AM1 aneurysm. You can see it's got perforators. And so how would we treat this patient? Who can I call on? Nadia, please. Is this a tear or a smile? It's a tear, maybe. It's not a smile in this case. She's not ruptured. Yeah, it's a giant aneurysm, and maybe the first, it's complex aneurysm to treat. Surgically, maybe what I have to discuss with the endovascular before. I guess some people might do pipeline. Yeah, surgically is maybe very difficult. It's a complex surgery with maybe bypass before treating, but I think it's more useful to treat it with endovascular. All right, endovascular. Any votes for a pipeline stent in the audience? Yeah. It probably might work. I mean, those perforators are lenticulous triates, so I was worried about that. Professor Wregley? I'm not doing endovascular myself, but obviously I'm very happy that it's evolving like so well. But we kind of are taught that if you don't have at least some position of the stents to normal wall, it will not work. So I mean, I would not see how, I mean, this looks like 360 degrees, so I wouldn't be very faithful. Yeah, I think that's right. And this is a very oligosymptomatic patient, so if you go with a treatment where it's not because there's not a perfect treatment that you should do a bad treatment. So I'm obviously provocative here on purpose just to steer up a little bit the discussion. Martin, what do you say? But what is the argument that the flow diverter is going to work on this one? I don't get it. I think it's giant aneurysm, natural history is very bad, so we should be active. We agree. I agree with you. And I would, and the perforators don't go from the neck, I think. It go proximally, and the neck is free. So I would do, or I would recommend a prophylactic bypass and then a series of fenestrated clips. Okay. Clip reconstruction with bypass. For sure. The pipeline issue, I agree that if the vessels aren't against the lumen of the stent tines itself, they may not stay open. And this is not something I would choose to do pipeline, but maybe anyone else comment that they would? No. Yeah. Okay. I would say in this case, this is very complex. I hate the M1 because of the perforator. Here you have a portion of M1, very important for me, very good. It's not always the case. And proximally you have an early branch, not a real perforator, very proximal. So the thing here is that I can assess the perforators coming out of the aneurysm in this, but I guess there are some perforators coming out of the aneurysm. So you can do the bypass distally to this trunk. You can put more blood and try to do a distal clipping of the aneurysm. I love that. That's great. I'm going to cut you off and just say that's what I did. Distal clip bypass. Anybody say something different? Because the next part is what I need to learn from the experts. So there are perforators posterior to the M1, like we were saying. Here's the, I'll speed that up. But anyway, the aneurysm is found and we do the normal thing. There's some perforators there. So that's all that room that Kiko's talking about on the M1. So that's perfect place for bypass. And that's put in. It worked great. And then distal clip occlusion. And then I thought, oh, great, this is so wonderful. Look, post-op day 7, the thing is small. Post-op day 21, it's even smaller. I think, Dr. Wrigley, you wrote about distal clip occlusion. So here's what happened. The story continues. Post-op 5 weeks. One question. Did you put him on aspirin? She's on aspirin, 81 milligrams for the bypass. So she's got this hemorrhage that's asymptomatic. And the aneurysm is nearly still gone, 5 weeks. But look at this, 3 months. It's a recurrence. It's enlarging. The bypass looks like it's dying, maybe due to flow that's coming proximal now. So something has to be done, I decided to coil occlude the residual on the spot because I was worried about the bypass dying and hemorrhage. And you see the bypass starts to get better as soon as the coil occlusion is done. And then she, look at this terrible, the flare. There was no flare pre-op. Post update one, two weeks, two months, it's resolving. But unusual, that's not what I expected. So I wanted to hear from our experts as to why that happened. Do you have a point to that? Or maybe Greg does? I was just going to say, you seem to relate it to residual flow from the proximal aneurysm, but I don't know how it, I don't understand how that would affect the bypass flow since there's a clip in between the aneurysm that's residual. Oh, I meant to say, what I was suggesting is if there's flow coming proximal to the aneurysm going to the cerebral hemisphere, the hemisphere is not going to draw as much blood onto that bypass. That's what I mean. Oh, I see. Because there was proximal anterior temporal arteries and others that maybe picked up flow. That was the theory. But I've got an expert right here to speak about it. I mean, it's a great case. One thought because of that edema is, you know, we talk a lot about vasovasorum. And we probably don't, it's something we talk about, but we don't really understand. The thing is, though, what you changed with the coiling is you occluded a part of the vessel more proximal, which was still patent. And we kind of think that the vasovasorum come from the proximal part of the aneurysm. So what I think may have changed by putting in coils, that you may have killed some vasovasorum. But that doesn't explain the bypass story, but it may explain the edema part. But it's fascinating. I mean... Greg. Okay. The final 15 minutes. In eight minutes? No, no. I'm kidding. I'm kidding. Can I ask one more question about that case? One take home that I just learned there is that in the segment where the aneurysm is on the M1, you do not expect perforators to be in that region. Is that accurate? One of the speakers mentioned that. Sorry. You're saying you don't expect perforators at the aneurysm? Exactly. I think there are. I mean, that's what I saw. Okay. So this is a 50-year-old woman who had a progressive visual decline over six months. Really pretty healthy woman. But as you see here, by the time she came to see me, she had very poor vision, especially in the right eye. Had this MRI. This catheter angiogram. Dominant left A1, smaller right A1. The left A1 does fill both ACAs. 3D reconstruction of that. So I guess to the panel, what are your thoughts about treatment? Mika, how do we treat this in cold Helsinki? Microphone, microphone. Yes, for the visual loss, I think we should treat it. To start with, yes. Surgically for decompression? Yes. Okay. Anybody disagree? Pipeline options? Okay. Is there anything? So we agreed with that. One thing we did do, I had them embolize the right A1 in preparation so then as coming from the left side, we'd have proximal control from the very beginning. So they did a balloon occlusion and they occluded that preoperatively. So you're closing one possible salvage option, particularly if you lose the left A1 clipping. That was gutsy to do that. I think so. I don't know what the panel thinks. I thought that was ingenious. Well. Go ahead. I don't take too much of your time. That wasn't an issue, but we did do the surgery after that embolization. Left, over the zygomatic approach. Here's your left A1, the two A2s. The embolized A1 is on the contralateral side and this is all the aneurysm projecting inferiorly. Temporary trapping, proximal and distal. Now here we truly did have complete control. Suction decompression of the aneurysm and clip reconstruction. The intraoperative ICG, which I'll show here in a second, it was two tandem clips, but the contralateral A2 was an issue. And so it took several different clip approaches to maintain patency of the contralateral A2, which was the one issue. I don't know if maintaining that contralateral A1 may have helped that. I'm not sure. So you see that this is, that A2 is kind of sluggish. So backed off and ultimately left a little bit more remnant, or a little bit more of a neck remnant to allow that contralateral A2 to have good flow. With that, so I'm just kind of short here and then leaving a little bit of additional at the neck. Checking the contralateral A2 with a flow probe that showed good flow and then the entropy angiogram showing good flow of both. Post-op looked pretty good. And then after that, let's see here. Yeah, so initially she actually was blind in the right eye, but then in late follow-up, a few months later, actually had a dramatic improvement of her vision. Returned to work as a librarian and was actually cleared for driving. And then six months later on an early angio, so there started to be a recurrence already, and so we did have that coil embolized and following her over time. So don't do the contralateral A1, Jacques, is that what you're saying? Well, I mean, in giant aneurysm, you need plan A, B, C, D, intra-op, and I hate to lose any vessel before I even start it. Yeah, yeah, that's interesting. My plan B was having the bypass ready for the A2s, yeah, but okay. May I ask you, I would be afraid about arterial recurrence in the right side. What's that? Recurrent artery. Oh, Huberter, Huberter. Yeah, we did a balloon occlusion of the A1 to test before occluding it with the coils. The second case was, this lady is 41 years old, presented in delayed fashion, so four days later with acute onset headache and seizure, was postictal for a bit and then recovered, smoker, hypertension. She had this CT scan, again, this is four days after her initial event, with clear intraventricular blood in the fourth ventricle, a hint of subarachnoid blood over the edge of the tentorium, and then clear ventriculomegaly, if you scroll through everything, including temporal horns. So we were convinced that she had a subarachnoid hemorrhage. The imaging showed this, on the left, internal carotid, this 2.2, this is 2.6 millimeter aneurysm that we felt was likely intracavernous, proximal to the ophthalmic artery, and then this 1.5 millimeter distal internal carotid artery aneurysm, just proximal to the ICA bifurcation. So, options and thoughts about treating this? Dr. Bruno? Treat or not to treat? You want to show him the angio again? Sure. I think that the clinical history is in favor of a treatment due to the hemorrhage. Well, the first question, I'm sorry to interrupt, do you think this explains the hemorrhage he showed? Or is this an incident? We are four days after. Yeah, it's four days after with this CT scan, yeah. I think it could be, yes. It could be in relation, there could be a relation between the aneurysm and the subarachnoid hemorrhage, so I will favor a treatment. And would you do it endovascularly or surgically? I will discuss with my endovascular colleague because they have no very soft coils, and they are able to enter in very, very small aneurysms, so after this discussion, if he's able to do it carefully, he can do it, otherwise I will keep it. I'd like to hear your endovascular opinion. I don't know if I should be the endovascular opinion, but I could definitely say that in this room, with mastery of surgery, I think it's better to operate on small aneurysms than coil small aneurysms. Even if it can be done, it should not be done. I think the hemorrhage rate of a ruptured, coiling, two millimeter aneurysm is 10% interop. Now, the funny thing about that is, these patients seem to do all right when you rupture them interoperatively in the angiosuite, but I look at my own self and say, well, why didn't I just clip that? On the other end, the surgical treatment of very small intracranial aneurysms less than two millimeters is also very difficult due to the very small size of the aneurysm and the size of the clip. We tend to operate on small, tiny, not small, tiny ruptured aneurysms like this. Personally, I think if she would have come in immediately and had that CT scan, I probably would have thought it's not related. But the fact that she came in four days later, who knows where the subarachnoid blood was. We felt like we needed to interpret it as a ruptured aneurysm. We took her to surgery and we found what I think was an unruptured IC aneurysm, which you see depicted right there. There was nothing of the second aneurysm I showed. But we were there and felt that it should be treated. It did look a little thin-walled and kind of reddish, so it did not accept a clip at all. I tried a couple of different attempts and ultimately did this wrapping technique, which did allow not only wrapping it, but, you know, clipping it. It gave a little something for the clip to grab onto. So we did that and then did an ICG that looked good and did the flow probe to make Dr. Charbel and Dr. Amin Hanjani happy. No, no, I use it all the time. I really like it. And we just did this wrapping technique. And I didn't have the, the post-op looked great. I promise you. Yeah, yeah, just muslin gauze. Yeah, the other aneurysm I looked and didn't see anything subarachnoid and so we haven't treated it. I think it's an intracavernous tiny aneurysm. Yeah? I have a question. If we were absolutely sure there was no other lesion to explain the subarachnoid hemorrhage, what would be the case against using a vascular reconstruction device to actually take care of both of those lesions in one go in a much shorter time? Well, I think the rationale for exploring was we thought surgery was, you know, we thought it could very well have ruptured recent subarachnoid hemorrhage. If you're going to treat endovascular, you're going to need dual anti-platelets plus the issues of a, well, I guess you're arguing that we're not going to coil it, so flow diversion. But I think the argument against that was dual anti-platelets in the face of a recent subarachnoid hemorrhage. We talked a little bit about it earlier case. I mean, the numbers, I mean, I know you can get away with it. We can show cases where it works. But the numbers, there's, Emory has a nice case series. There's three or four really nice case series. It's about a 10 to 15% hemorrhage risk, some of which has to do with re-rupture of the aneurysm, some of which has to do with distal hemorrhages in the case of a ruptured subarachnoid hemorrhage and doing flow diversion with dual anti-platelets. So we tend not to do that acutely. If we do, if we're forced into it because we don't think surgery is any option at all, we actually delay it by about a week. And then we do the dual anti-platelets and seem to have a lower hemorrhage rate, but we're accepting some risk of re-rupture, so. You have a question? Go ahead. Regarding the clipping of a small aneurysms, I think most of us have learned from Yazer Gilad, he uses a lot the coterie. I was looking at the early big giant ones, and I wonder any in this panel does coterie to remodel the shape of the aneurysm and make it clippable. Like the small aneurysm you just showed. That, the professor would have just burned. Coterize and over with it. And sometimes large aneurysms, he shrinks them to the point where there's no more aneurysm. So for the panel, any of you uses remodeling, coterization with careful irrigation, and leading to very easy clippage of the aneurysms? I'll answer first. I love it for large aneurysms. It's, I teach the residents all the time, you transform a tiger into a lamb. You, but you're right, irrigation, or if you have non-stick bipolar, to understand the 3D of it, he's, Yazer Gilad was absolutely right, made it, so you're right. Now these, I don't disagree with this treatment. I think this is perfect. I mean, you know, what if it had burst on him, irrigating a very thin wall? Mika? So we have studied a lot of the aneurysm wall in Helsinki, and remodeling large aneurysms to smaller ones, if you don't touch the neck, is okay. But you should never coagulate the neck. I have seen cases where the aneurysm has been coagulated, an unraptured aneurysm, so that there's no substance left. And then you put a clip, they may turn into ruptured aneurysms later. So I would never, ever coagulate the neck. And I think it's, it may cause degeneration to a larger area, thermal effect. I wouldn't coagulate small plebs. It may break later on, the wall may degenerate. And never the neck. I think it's time to thank our wonderful panel, my co-moderators. Thank you for being here. Have lunch. Please be back at 1.45 for the tumor module.

panel discussion

aneurysms

neurosurgeons

treatment options

surgical clipping

endovascular coiling

subarachnoid hemorrhage

visual decline