All right, we're going to start the supravascular section, session two, for this afternoon. Thank you, everyone, for coming. We're going to start the session just before the Donahue lecture with a very significant and heartfelt thank you to Dr. Greg Zipfel, who has spent the past year serving as the chair of the CV section, who has dealt with plenty of controversy and important issues and been an incredible advocate for both our section and for our patients. It's personally been an incredible privilege to serve with Greg for the past decade through the CV section. And I'm glad that he still has to stick around and do things as the past president because we'll miss him as he moves on to other things and even larger roles of service to neurosurgery. Thank you very much, Greg. All right, thanks, Jay. I very much appreciate it. And again, appreciate the last year that I was able to serve the section. So today is a great honor and exciting for me to introduce the last keynote speaker of the year, and that is the Donahue lecture. And this year's recipient is Anil Nanda, which I'm very privileged that he accepted the invitation. So let me just go through a couple of slides and kind of introduce where this lectureship started. It turns out this is the oldest and longest standing CV section lectureship. It was started in 1998. I had trouble putting all this on the same slide, but there's a lot of distinguished cerevascular surgeons and leaders in neurosurgery listed here. And it's a real honor to add Anil Nanda's name to this list. A brief bit of introduction to Dr. Donaghy. He was born in Quebec, Canada. His medical school was at University of Vermont. He actually completed both a neurology training at Montreal Neurological Institute and then neurosurgery training, first at Lahey Clinic and then the majority at MGH. In between that training period of time and becoming faculty back at University of Vermont, he served in World War II as a leader of the Mobile Neurosurgical Unit. He then went back to University of Vermont, actually was offered the chair position of a department of I think nervous diseases or neurosciences, which he turned down, but did accept the chief of neurosurgery position at the University of Vermont to focus in on surgical aspects of neurosciences. Many of you know, but I'll just review briefly some of the highlights of his career and why this lectureship was established. He established the world's first microsurgical research and training laboratory back in 1958 at the University of Vermont. He was the first to publish about a microvascular MCA embolectomy in 1960 and a couple years later, a series of MCA embolectomies. So at the very forefront of that type of procedure. With that type of work, realized that adaptations and developments in the operating microscope were required and worked with Zeiss to adapt the microscope to neurosurgical diseases. He was one of the first two STA MCA bypasses performed one day apart in 1967, and importantly, and I think really the largest reason why this lectureship was established is that he trained so many in microsurgery, over 500 per his biography. So Dr. Nanda is this year's Donaghy lecturer, and there's a variety of reasons that I chose this, and I thought I'd go through some of his personal background and how it led to asking him to serve as our lecturer. So Dr. Nanda was born in New York City. His dad was an internist at Columbia, but at one year of age the family returned to India where he was raised throughout his early years, including all the way up through college and then medical school where he graduated from Jitmer Madras University in Pondicherry, India. After that, he had a series of training periods of time in different cities within the United States. Started out in New York as an intern in Sloan Kettering Cancer Center, followed by general surgery residency training at Rush in Chicago, neurosurgery training at Hahnemann University. Thereafter, he completed a micro neurosurgery and skull base fellowship at the University of Pittsburgh under the direction of Dr. Janetta. Along the way, later, he did receive his MPH from Harvard School of Public Health. After training, he was recruited to LSU Shreveport, and he was right off the bat assistant professor and chief of neurosurgery. And then he oversaw the transition from a division to a department in 1995, serving as associate professor and chair, later as professor and chair up until 2017. And just very recently, he has allowed me to announce, perhaps to many of you who don't know, but he's accepted formally the professor and chairmanship at Department of Neurosurgery, Robert Wood Johnson Medical School, New Jersey Medical School, and will serve as the senior vice president of neurosurgical services at RWJ Barnabas Health. I think LSU's loss will be New Jersey's gain, without a doubt. Some of the qualities that led me to feel that he would be a great Donaghy lecturer are as follows. He's clearly a prolific cranial and vascular and actually beyond that type of surgeon, performing well over 2,000 surgeries on aneurysms and skull base surgeries. He also is a prolific academician, publishing over 460 manuscripts, over 110 of which relate to the field of vascular neurosurgery. He's published two neurosurgical textbooks and has a very high H index of 52. He's a passionate educator. When he started the program or came to the program at LSU Shreveport, very soon thereafter, he began a research and clinical skull base fellowship and has trained well over 70 fellows during that time. In 2002, after the department grew under his leadership, he established the Neurosurgery Residency Program at LSU Shreveport and has trained over 15 residents since its inception. He's also an accomplished program builder and just to march through that, again, began as Division Chief of Neurosurgery in 1990, established the department in 1995, the first gamma knife unit in Louisiana in 2000, the Neurosurgery Residency Program in 2002, a neurointerventional suite in 2007 and a surgical movement disorder clinic in 2013. And I don't have the numbers, but the growth of cases and patients cared for over this period of time is absolutely through the roof. He's also a very well-recognized visionary neurosurgical leader, including serving as the president of North American Skull Base Society, president of the Southern Neurosurgical Society, president of Society of University Neurosurgeons. He's just stepped down as vice president of the Society of Neurological Surgeons and then at this meeting has been elected to become the secretary of the AANS. So if you look at that background, I don't think it necessarily would have suggested that he was going to accomplish everything that he possibly has done thus far. And it made me think a little bit about why him and how does he do it? What are the qualities that have led to such success, perhaps not coming from the most traditional background? Is it because he's a dapper dresser? That's possible. Is it because of his eloquence, which I'm sure you'll see here in a bit, perhaps. I would argue it's the following four characteristics. I've gotten to know Dr. Nanda probably over the last 10 years or so. And we never had, I never had an opportunity to train with him as a fellow or have any of that type of interaction, which is a special interaction. So I haven't had that. But why was I drawn to him and why have we become close? I would argue it's a few things. One is he's a dynamic personality without a doubt. He's the kind of individual that brings you into his sphere, makes you want to be part of his world, and really inspires you and motivates you in a lot of different ways, even if you didn't have that direct connection with him from a clinical training perspective. I think he's passionate about lots of things, passionate about neurosurgery. And not only is he passionate, it's infectious. And people want to follow that passion, his passion, our passion about neurosurgery, and join him on this journey. We heard today about drive and what motivates people to accomplish. And I would say that he clearly has his own personal drive, but it also is one that inspires and motivates others to go along with that drive. And we all, our drive all is greater because we're in his presence. But I think the single most thing in my mind that stands out is you can do all those things, but he does them with a personal touch. And I think that that really, in my mind, sets him apart from many. And there's lots of examples of that. When I was early on and he was a senior and someone I looked up to, there were moments in the meetings where he knew my name, knew what I was doing, and remembered things early on was meaningful to me. I do remember when he was a visiting professor at Wash U. He's absolutely the kind of person that's not only going to thank me or Dr. Dacey for the invitation, but he sends out thank you letters and e-mails to a variety of faculty residents and fellows that he came across during that time. And it's that personal touch, I think, that draws people in as well and motivates them to be the best they can be. So with that, Anil, it's a real pleasure to have you as our lecturer today and look forward to your comments, and congratulations. Thank you. So, Lyndon Johnson. We're in the south. So, Lyndon Johnson once had a very flattering introduction and he says, you know, I wish my parents were here. My dad would have enjoyed it and my mother would have believed it. So, I would take that with a piece of grain of salt. So, thank you so much. I'm very honored to be here. And I picked an interesting topic. I just thought I'll talk about aneurysms. And, you know, I feel like I'm a dying technician of an art that's dying. But I'm here not to defend it, but I want some equipoise. And that's why I labeled this uncertainty versus toxic doubtlessness. I'm pleased to tell you that come July 1, I'll be a drucker. So, I'm very fortunate. The bottom line on this story is you marry a girl from Jersey and she's going to make sure you get back to Jersey. So, I think Donahue is a great surgeon. He did a lot of stuff in the microsurgery course. I actually went there as a resident and did a bypass on a dog. I spent the two weeks there in Vermont. It's a great course. And I think people don't realize, but Yasagil got his microsurgical training. He did his first course in Vermont. So, it's kind of nice to see that connection. And I've met a lot of previous illustrious people that have done this. Fadi is sitting there in the audience. I'm very honored to be with these people. So, just to quickly go a little bit of history. I always like history. And this is Lankesi first uses the word aneurysm. And Antilles first describes it. Galen is supposed to have described the disease. So, there's a long history of aneurysm, be it in the belly or in the brain. This is my personal experience. In 27 years in Louisiana, I was blessed to do over 17,000 surgeries, about 6,000 craniotomies. So, I'd operated on close to 1,100 or almost 1,200 aneurysms, ruptured, unruptured, a combination of cases. So, what I'm going to do is take you on a quick trip on aneurysms, right from unruptured, some technical points, what I've learned, where it stands. So, you look at unruptured aneurysms. We had a nice study from the Japanese this morning. And I thought we'll get right down to the meat of the business. This is a 30-year-old nurse that came with this bifurcation aneurysm. An endovascular person wanted a stent coilet. I thought it would be better to clip this. This is a relatively straightforward clipping. And you can see the fissure being split there. And this is an aneurysm that comes straight up. We can darken the lights a little bit. And relatively straightforward, where I think, you know, for a young person, even if she was a smoke or hypertensive, I think this is a straightforward case that has real merits to fix that way. One of our fellows, Dr. Savdekar, just looked at all of our aneurysms with our fellows. And we looked at the bifurcation, the angles they go at. And I think those small perforators, it's kind of easy, good to identify those and be comfortable with that. So from that, I want to move to other unruptured aneurysms. This is an MCA. And you would argue, why would I operate on a 73-year-old with a 9-millimeter MCA? I asked her one question, how old are your parents? And she said, well, my mother is 98 years old. She's 73. We know if it's close to 9 millimeters or centimeters, there's risk. But I didn't tell her. You know, I said, you can think about it. And she opted to get this fixed. And, well, here you can see the actual aneurysm right there. And I will talk about this a little bit later. I really like the bipolar aneurysms. I think this is a new computer, so it's stuttering a little bit. Yeah. But you can see this. You know, I kind of bipolared it, brought it down, and we were able to get a fairly good. And you can see a small, it actually got a rupture on this. And I'll talk a little bit about intraoperative rupture. I think doubtlessness is where you really need that when it comes to a rupture. So you can see this. We're getting the clip right on it. And we were able to reconstruct that very well. And she actually did well. I have a five-year follow-up on her. She's now 78, and I think she's going to beat her mom. Her mom is still alive, so it's kind of interesting to see that. But I think you have to tailor the approach. Yeah. Here's a younger person with an MCA, a fusiform MCA, that you could argue that may should have been, should have had a bypass instead. But I decided to reconstruct this. And here you can see we're reconstructing this with a fenestrated clip around the MCA. We were able to reconstruct that very well. And she did well. So the issue comes up with unruptured aneurysms. You know, I know with ruptured, we get ICESat. And I think we have good results. But here's a neurosurgeon. He's 45 years old. And the moral of the story is you shouldn't own your own MRI. He owned his own MRI. And he took an MRI of himself. It was actually his neck he was checking. And sure enough, he has an ACOM aneurysm. So he gets multiple opinions. Anyway, we decided to clip this. It was a left-sided ACOM. And you can see I went from the right side. I tend to go from the right. And you can see here, putting a clip right across there. And, you know, you worry about cognition and you worry about things like that, especially with an ACOM. So I really went from the right. And I had some anxious moments with this because the first two weeks he had several short-term memory issues. But fortunately, he recovered completely and was fine. So we published our series on ruptured aneurysms with our fellows. We had about almost 200 unruptured aneurysms. And very interesting, in our hands, we actually had a pseudo-inflation of poor outcomes. So if you divide it into five years, the last five years, my outcomes are worse. And the explanation we have is that we're seeing more difficult aneurysms. The simple ones are getting coiled. The more complex ones, the ones with branches coming out are getting clipped. And so our mobility is increasing, not decreasing. So I think that's an important point to know, just because of selection bias, that you're not getting the simple ones. Now what about the ones... This is somebody that was coiled twice. And I think now this would probably get one of the stents in there. But she'd been operating on it twice. She was a heavy smoker. And so despite coiling twice, it continued to grow. So we decided to clip this. We drilled out the clinoid. And I'll skip that part. But you can see we're quite... The clinoid is off. We got proximal control of the carotid. There's coils in there. And you can see the third nerve there. And when you put the clip on, the carotid actually closes off, because there's so much torque inside the coils. We clamped off the carotid and the neck. And here you can see, once we put the clip on, the carotid is actually completely clogged off. So then we decided to take the coils off. And it's funny. When you take the coils off, you don't get a refund for this. It doesn't work like that. You would say, geez, these are $10,000 worth of coils. You should get a refund for this. Yeah. So unfortunately, the local... So anyway, so you pull that out. And then it's almost like doing an extruder disfragment. You just pull the whole thing out. And I see Tom Bertuccini there. This is a Lafayette patient. So I'm violating HIPAA rules here. So here it is. So you can see that. And you can see, once you take the clip out, you take out the coils, the carotid actually just opens up, because there's no more torque on the carotid. And this is... But you know, it's interesting. So she keeps smoking. She goes home. She does well. She's a smoker. She comes back hemiparetic, bad vasospasm. So we had to work quickly on her and be... So this is a wonderful painting, The Fighting Temeraire. It's by Turner. It's voted as England's most popular painting. And it's an important painting because this is the HMS, this is the Temeraire that helped HMS victory in the Battle of Trafalgar when Nelson was fighting. So it made a pivotal role in the British one. But years later, this is the tugboat, a simple tugboat pulling the Temeraire with it. And all the glory of the Temeraire is gone. And I think I use this as a symbol of disruptive innovation, that a technology that worked and was powerful is no longer that useful. And you could argue that's the same with CLPS, that the ISAT trial changed this for everybody. It was a wonderful advance and it made it better for our patients. But if you look at the numbers, you look at the follow-up with ISAT, even the long-term follow-up at 18 years, it was superior, 18-year follow-up, it was superiority. And then you look at the BRAC trial, again, same thing. You look at six-year, third-year, three-year, six-year, there was a better outcome. So I think this is a wonderful advance for our patients. I think the issue is, what are we doing right for our patients? And if you look today, and this is a recent publication that showed that every center now more aneurysms are coiled and clipped. And that's the truth and that's an important thing. But I also think we shouldn't be plagued with a sense of toxic doubtlessness and say, this is the only way to do it. It's sort of Maslow's hammer. Everything looks, if you have a nail, everything looks like a hammer. So you just want to be careful about that. Disruptive innovation in medicine is a wonderful thing, though. You look at the history, whether it be Ambrose Paré on the battlefields, or you look at Joseph Lister with carbolic acid, or Florence Nightingale with nursing, or Marie Curie and Harvey Cushing, or even more recently, Barry Marshall with the heliobacter and using antibiotics. Disruptive innovation is great for medicine. It's good for us. It's great for medicine. You look at people like Lars Lexell in radiosurgery, you know, people when Dr. Lunsford started this in the United States, there was such skepticism. But it has worked and it's important for our patients. I think Kevin Foley has been wonderful with minimally invasive spine surgery. So I think these are great disruptive innovations. But I also think we should be cautious that those who belong to the old school, we need to adjust to changing times. Barbara Tuchman wrote this great book, The March of Folly, and she talked about wooden headedness, that assessing a situation in terms of preconceived, fixed notions while ignoring or rejecting any contrary signs. Those of us who are trained in that school of clipping cannot be wooden headedness. We cannot have a stubbornness saying this is the only way to do it. And I think that equipoise, that sense of uncertainty is good both for the endovascular school and for the open school. So what are the absolute indications for me? Here's somebody with a large blood clot, ruptured ACOM. To me, this is a no-brainer. You know, I know there's a school of thought that says just take the clot off and then you can coil the aneurysm. I think you're there. And I feel that, you know, being on the AVNS board and stuff, I feel that we feel if somebody comes in with a Sylvian Fisher clot, it's a simple ruptured MCA, you should be able to do it. And I think that's important to uphold the educational standards. Now, we've looked at aneurysm on multiple points of view. We published on ischemia as a form of presentation. We talked about cocaine, how cocaine has younger patients with aneurysm, but the outcome seems to be that good. Now, it's interesting how disruptive innovation happens even in the field. Like I used to use, we published on intraoperative angiography all as the gold standard. And then boom, ICG comes and I only use intraoperative angiography now for AVNs, or if the aneurysm looks a little crazy to me and I think, okay, maybe I'll do that. Again, for the residents, I think anatomy is still important. You may not be clipping basilar tips anymore, but the anatomy is important. You need to do the dissections. And this is from Roton's dissection of the basilar artery, very important. What about technical skills on some of these aneurysms? I'm a big believer in bipolaring sort of fusiform aneurysms. This is somebody that had a fusiform aneurysm and it corroded, and I'll quickly show this to you. So here we're... It's interesting. It's a new computer. There's stuttering. I don't know if it's because of the new outlook. But anyway, you can see the aneurysm here, and what I'm doing is bipolaring and shrinking the aneurysm to the point that it can be clipped. And I found this very effective. So here, as you can see, we've made an aneurysm that would be tough to clip. And by shrinking it down, I've been able to put a clip across it. And here you can see with an ICG, and we published this as well. The place where doubtlessness really works, I mean, I'm here to tell you that I'm sort of espousing uncertainty, that perhaps you should, you know, think about things a little bit more, consult your endovascular, or better still, if you can do both. I think where you really need doubtlessness is during an intraoperative rupture. I think that art is very primal. And you know, you think, oh, you've done a thousand aneurysms, it doesn't happen to you. Last week, I did two aneurysms and both ruptured, and I'll show one of them to you. So here's somebody, seven aneurysms, subarachnoid hemorrhage. You can see here, we're clipping this aneurysm. So I put a clip, torque. So you know, I think the important thing is always look back at your videotapes. Younger people always tell you to do that. So here you can see the wrong move. See here, I'm going on the actual dome of the aneurysm, which is a mistake, obviously. A couple of things I should have done differently on this case, I should probably have exposed the carotid and the neck. I shouldn't have done that move, and the torque would have been lesser, perhaps put a temporary clip on. So intraoperative rupture is a big issue, and I think that's where you really need to be sort of very cautious. Fortunately, this lady did well. And I think, you know, Hamlet puts it best, the readiness is all. I think if you had to have one symbol for these large aneurysms, the readiness is all. You have to be constantly aware of this. Most of these things, this is Bajor's paper, during most of these ruptures happen during the clipping or during the microdissection. But I feel doubtlessness is almost a necessity during this time. You can't second guess. You can't be Hamlet when it bursts, okay? You have to move decisively. And the thing is, look at this case. This is a case that I just did last week. So this is an unruptured, this is in a 3D motion, unruptured aneurysm. I drilled off the anteroclinoid, come up here. So here it is, we're putting the clip on. You know, I should have been a little more cautious, should have been atherosclerotic, you know. So you put the clip right there. I got a good dissection on it, and it ruptured right away. This happened last week. So you say, oh, you know, you're supposed to be good at this, it's not supposed to happen to you. You've done a thousand of these. And so I think this is where you have to have a sense of doubtlessness. You have to have an auto-sympathectomy done on yourself. You have to be very calm, and you can't do anything that... So what I did is I went more proximally, put a temporary clip on. And you know, you have two sections. But I think this is a skill set that you need to have, you know, you can't lose that. So here it is, we put a second clip across, put a temporary clip. It really didn't come down, so the PECOM was still feeding it. I want to thank my fellows in the audience, they helped me edit this. So we put a second clip on, got the temporary clip off, and we got bailed out. And you know, this happens. This is another one, same thing happened, choroidal rupture. And I think this is not something that just happens to us. Dr. Cuellar is my endovascular colleague. This is a basilar tip. He was coiling, it ruptured. He was able to get some control, but the outcome wasn't great. And I think there's almost a sense of nostalgia with some of these cases. So I have a series of about 89 basilar tips now that we've published. This is my favorite case, you know, so you can see here, an older lady. And I used to love looking at this view, so it was like, oh my God, this is something you don't do. But I think the technical skill set is still important, because I think it helps you do other cases. And there's a wonderful Australian word, it's an Aboriginal word called eritjeritjeraka. And what it means is it's a sense of nostalgia, a feeling for desire for something that is lost. And I can, you know, I'm 59, I can talk about something like this. And I do feel there's a sense of nostalgia on basilar tip aneurysm, because it's become an endovascular disease. It's rare to clip these. And here's some of the cases, still like this one I did about three years ago, just to show you a different basilar here. Because in this case, the neck was most superior, inferior rather than medial lateral. So we put a side angle clip out there. And you know, we were lucky, and she did well. Superior salabellar is a different ball game. Here's somebody that they had difficulty coiling. And you can see this is a nice angle on this. And we split the fissure really wide, go way down. So here you can actually see the PCA. And I know there's a big controversy on using retractors. There's a big school of thought, don't use retractors. My feeling is if you clip it in five minutes or 10 minutes, the retraction time is not that much of an issue. So I have felt that if you are quick at what you're doing, then it may not, even if you look at MRI changes, there's not much changes with that short burst. So here you can see the neck of the aneurysm, and fairly easy clipping with that. Superior salabellars are a different ball game, no perforators, easier to do. We've done this for modified approaches for posterior circulation, for the far lateral approach. I really like that approach. I think you get a good exposure. And I think these are some of the ones that are still needing clipping, especially the picas coming off through that region. We had about 22 of these that did well. Here's just a picture, an intraoperative picture, showing the far lateral. The biggest problem we've had with pica is hoarseness. And sometimes they have trouble swallowing. But it seems to get better. Mid-basilar artery aneurysms, we don't clip those anymore. It used to be we'd do a petrosectomy and come there, this has become entirely endovascular domain on that. Now coming to ophthalmics, I think the one thing in our series of close to 100 ophthalmics is that 77% of ours, when we clip them, the visual outcome, vision improved. So I think though there's now data from the endovascular world that even stent coiling, the vision does improve. But that used to be our argument to say that for large ophthalmics that you should clip them. What about giant aneurysms? I think giant aneurysms are like the fabled story from India where you had the elephant and everybody comes and feels the elephant and says, oh, I think it's a tree. I think it feels a tail. Everybody has an opinion on giant aneurysms, and I don't think there's a real consensus because the results are not great no matter what you do. So we looked at 59 of our series of these cases, and when there's traumas in the anterior circulation, unruptured, this is a giant MCA, unruptured, but you can see it's calcified. The only time on an aneurysm I used the CUSA and you couldn't do it, so I had to take the Bowie. It felt almost like I was not being very sacrosanct about this aneurysm. But the poor clinical grade, a ruptured aneurysm, posterior location, poor outcomes associated with these giant aneurysms, yeah. So you can see some of these here. And you know, sometimes this is a 76-year-old attorney with a really large aneurysm. You could argue I should have probably done a bypass on this. We were able to reconstruct it. She did well, and she was hemiparetic initially, almost plegic, but she got everything back, so we were lucky. But here is something you see, and this is a Louisiana patient again, here you can see a large ACOM with edema in the frontal lobe, cognitive issues. So in this case, I felt it would be better if we could reconstruct it. Here we were able to dissect this out fairly easily. And you can see, we put a temporary clip on, put a clip across. And I think if they have edema, they have mass effect, at least with us, I think that tends to do much better. But you know, some of these cases, this is my partner's case, the giant ophthalmic. This is with a pipeline embolization device. Beautiful result. You know, this is 12 months. Dr. Cuellar, my partner, did this. So I think the needle keeps changing. So how do you feel? I mean, do we feel like dinosaurs doing this art? Is it a dead art? And I think, I still think there should be a real good dialogue on cases. I think doubtlessness is important when you're in the OR and when you're operating and you're sure what you want, especially when you're getting something like a rupture. But I think uncertainty is important. I think you have to have a nuance that what you're doing is best for your patient. Whether it's, you know, I don't, I mean, I'm sure many of these are now dual trained, and you can think this might be a better way to do it. And I think that interdisciplinary dialogue is key. But the data is very clear cut. In cases where the aneurysm is equally effective by coiling or clipping, you should go with coiling. I think there's an issue on that. And I think you look at, I tend to look at a younger patient, smoker, hypertensive, I'll tend to clip. But, you know, it's interesting how patients can come up with their own ideas. And some people are extremely averse to getting, you know, to getting their head open, and they're not going to do it. So I think in the end you have to have a brutal sense of honesty. This is Czesław Milusz, the Polish poet, who said, in a room where people unanimously maintain a conspiracy of silence, one word of truth sounds like a pistol shot. I would urge the residents and the younger people in this audience to be like that pistol shot. There's no straight answer. Some of these problems are very difficult. Here's somebody that, a giant aneurysm that I clipped, I thought I did a great job. You can look at the post-op angiogram, real small residual there. I felt very good about myself, patted myself on the back. Three weeks later she came back. She had a small hemorrhage, the aneurysm had regrown, they put two stents in, and she still died. So, you know, no matter what we do, sometimes the disease can be implacable. And this is another patient with a fusiform aneurysm who we were deciding what we should do, and, you know, back and forth, six weeks, maybe we should do this, maybe we should extend coelate, and had a subarachnoid hemorrhage, and he died. So I'm reminded of words by Auden, those who will not reason perish in the act, and those who will not act perish for that reason. And I think that self-assessment is very important. This is Rembrandt's self-portraits of himself, and you notice how honestly he portrays himself, his aging process. He didn't Botox himself, he didn't make himself look better. And I think we need to be careful about our results, that we don't Botox anything and do what's best for our patients. And so I don't think this art has declined. I think I was very blessed to have an experience of over 1,000 aneurysms. Will those numbers keep increasing for the younger generation? Probably not. But I think you'll be good at what you do, and I think the reports of my death and clipping of aneurysms is largely exaggerated, and, you know, as Hamlet would put it, the clip or the coil is the question, what's nobler in the mind? And I think it's not clear-cut, but I do think uncertainty is important, you know. Uncertainty is something we always look down upon in medicine. And John Keats, the great English poet, talked about negative capability in a person, that you can have uncertainty, you can have mysteries, doubts, without reaching after fact and reason. And I think that's where the art of medicine comes in, and that's where the art of aneurysm clipping comes in, that there is uncertainty, and there is doubtlessness. But I think in the end it's the joy of what we do. So this is a case we did last week. This guy had an AVM that was gamma knife 10 years ago. That time he had a choroidal aneurysm, and we didn't think much of it. We thought it's flow, it'll go away. And he comes back, and it's a straightforward aneurysm, you can look, large subarachnoid hemorrhage. This is a simple videotape of him. Straightforward aneurysm. We went ahead and clipped this, and that's the joy of aneurysm clipping, or the joy of what we do. And I think that's as real, it's a wonderful feeling to do that, and a great blessing to do it. And I think I'll end with Mattis. You know, Mattis was a great New Orleans surgeon, and Halstead and Mattis were great friends. Mattis was from New Orleans, and he's the father of vascular surgery, described papal aneurysm, operon that. He had a hydroseal, he got operon by Halstead, went up to Baltimore. And they were very good friends, and Halstead, of course, talked about training. But Mattis spoke about the soul of a surgeon in 1915, and he said, let us love the spirit which animates and guides her true knights, which she makes her sons and daughters. Better, nobler people, because surgery is a sublime inspirer of the most useful, the most humanitarian efforts, inspirer of sympathy, of kindness, and of pity, and of the feeble and the miserable and unfortunate of our kind. In the end, this is a great art. We're blessed to practice this art, but we have to be judicious in how we exercise it. We have to be open when the art changes. We cannot be resistant and have a sense of doubtlessness that says, no, this is the only way of doing it. And I think it's sometimes hard, because you have a sense of nostalgia, oh my God, it's great opening the fissure, clipping a battler tip, but the cheese has moved. So it's been a great honor giving this talk. Thank you so much. I really appreciate it. Yeah.

medical conference

neurosurgery

aneurysms

treatment options

surgical techniques

interdisciplinary dialogue

patient care