So, no further ado, I'd like to ask my very good friend, Dr. Naja El Abadi, from Morocco, to talk to us about her experience with aneurysms. And I love her title, and I'm not going to read it. She's going to say it herself. And please, Naja, welcome. Thank you. Thank you, Jack. First, I would like to thank the organizers for giving us this opportunity to share with you our experience about management of a raptured aneurysm. First, as you know, to help our patients, we try our best, and always with, of course, a smile. That's why I choose a smile and cheer for my title. However, for us, there is also tears in the management of endocrine aneurysms. Many times, we operate some aneurysms, grade 1 WFNS, and we are very happy. But the evolution with the vasospasm and other complications may hurt us. Sometimes sadness takes place of happiness. That's why a small, small aneurysm doesn't mean happiness. Preoperative rapture doesn't always mean sadness. A complex aneurysm, a real challenge for a vascular surgeon, doesn't mean a therapeutic limit. New surgical techniques and devices in endovascular could represent another alternative for the treatment of these patients who will have this session. So sometimes, in the deep moment of happiness and achievement, we find ourselves speechless and weak, maybe sad sometimes. This is why I choose to start with you, to share with you this history of this case concerning 60-year-old man who had a subarachnoid hemorrhage, grade 1 WFNS, revealing an anterior communicating artery aneurysm. The patient underwent colon with a nice control, as you see here. Three years later, just a few months ago, he had an acute headache, angiography showed another aneurysm, could not be operated or have endovascular because a severe cardiac problem for which he was operated with a good result. Two days before, planned the surgery for his aneurysm. He had a new acute headache, but at this time, followed by a consensus trouble and coma, and it was a new re-bleeding. He was grade 4 of WFNS, and 10 days after endovascular occlusion, he passed away. And this is why I choose to talk about the tear and smile in our management of antracanial aneurysms. My talk is about our experience in the management of raptured aneurysms. We compared this management in two hospitals with two different ways of administrative process. We mean public health versus private hospital in Rabat, Morocco. Also, we try to compare endovascular treatment and cleeping in both hospitals. So we realized a retrospective study during eight years from 2006 to 2013 in the two hospital, Ibn Sina University Hospital as a public hospital, where I was working until 17 months ago. And the second one is Sheikh Zayed University Hospital as a private one, when I have worked for eight years from 2005 to 2013 and reintegrated again recently. So we choose to stop the study more than three years to have enough follow-up to compare the two procedures, especially according the re-permeability of aneurysm with the endovascular treatment. As a result, we have managed 201 cases of antracanial aneurysms. We divided our series on two groups. The first one, which represent the patients treated in the public hospital, and the second one including patients from the private practice. 76 patients are in the group one and 125 in the group two. The first difference between two groups is that we use more endovascular treatment than the cleeping in the private group. The second, some information about epidemiological data, nothing special. We notice that women are more present in our series. The menage is almost the same in the both group, whatever is the type of treatment. And in all series, only 40% of patients arrived to the neurosurgical emergency before three days from bleeding. But if we analyze this result by hospital, we can conclude that almost 60% of patients arrived to the public hospital before three days from bleeding, and 60% of patients in the private hospital are admitted more than three days from bleeding. In our country, more than half citizens do not have a medical insurance. More that, they should pay a part of the medical fees before getting admitted to the private hospital. Maybe this could influence this difference. In the public hospital, every patient is admitted to the emergency and to the neurosurgical department without looking for medical insurance or sometimes something else. The common point between two hospitals that the fees of angiography should be covered before anything. As a result of this process, a patient in the group one have treatment for his aneurysm in a mean of six days. In other side, he will need three times less to have treatment in the private practice. About the clinical statement of those patients, likely 80% of cases is in all series where WFNS grade one. We can also notice that just 3% of patients are grade four in the public hospital versus 18% in the private hospital. 36% are grade three and four in this group. One important information is in the group one, I mean the public hospital, seven patients every year died in the emergency department before having an angiography. Those patients are not, of course, included in this study and this factor gives it this work. For 201 cases, we found 224 raptor aneurysm, 65% are secular. Depending on the timing of angiography, for the private hospital, all patients underwent angiography during the first 24 hours after admission to the emergency department. However, this delay is much more longer in public hospital because there is the unique public neuroradiological department with only one, actually two senior doctor in Morocco who take care of all Moroccan patients with the raptor aneurysms and sometimes from some neighbor African countries. Well, we should manage this aneurysm in both teams. We propose the clipping in 38% of cases versus 62% cases who had endovascular treatment. But if we analyze this data in every single group, we will find that in the public neurosurgical department, 76% of the patient had a clipping surgery. However, in the private practice, I mean the second group, 83% of the cases had an endovascular treatment. Perhaps the kind of the institution could influence the proposed treatment because the private hospital vascular team has a long experience in both techniques by discussing all cases to make the best therapeutical decision for the patient. But we should look for other factors. To continue in the same idea, in the private hospital, I mean the second group, all patient with WFNS4 had endovascular treatment and most of those with WFNS3 had endovascular treatment too. In the public department, just two patient had WFNS4, one of both had an endovascular treatment and less than half patients with the WFNS3 had an endovascular treatment. We had less patient with a low level of the WFNS grading in the group one comparing to the group two. Because we couldn't include the patient hospitalized in the ICU, the medical files are insufficient, it seems obvious that just one endovascular neuroradiologist for all public national neurosurgical department, among them three located in Rabat, should be available every single day. This problem could be solved by offering more job opportunities for radiologists and neurosurgeons in this specialty. Regarding the location of the aneurysm, I can see that for the posterior circulation, endovascular treatment was done for 60 patients among the 18 patients. I mean almost 90% of cases. For the anterior location, we can notice that there is no big difference between both group of between the clipping subgroup or the endovascular one in each group. As described in the literature, we use more clipping than coiling in the middle artery aneurysm, of course. So if we consider the morphology of the aneurysm, in all series, endovascular technique were used in about 70% of lobulated aneurysm. Beside, when the aneurysm is sampled, both of techniques were used in almost equal proportion. The architect of the aneurysm may influence the choice of the therapeutic techniques, as you know very well. Our endovascular experience show that the total occlusion is near to 80%. Group 2 included more cases than group 1. And as you know, using clipping or endovascular coiling doesn't let you away from complications. For every technique, we have complications, which are, as far as I'm informed, near to the data in the literature. So concerning the outcome, if we exclude all patients admitted with WFNS grade 3 and 4, the results are the same in both groups. Unfortunately, as I already said, seven patients per year with the WFNS grade 4 passed away without having angiography for diagnosis or any treatment of their raptor aneurysm. They had only an angioscan to confirm the diagnosis. And according to ISAT and the Barrow study compared both techniques, clipping and coiling, for the ISAT-Bow technique, they have the same outcome, as you know very well. However, with the Barrow trial, others conclude that rebleeding is more seen with the endovascular treatment with long follow-up. We noticed that in the last three years, we have three cases of rebleeding. And this fact is not retained in our study. And neuropsychological tests are better with the coiling. In our study, we could not realize this test finally. So, dear colleague, all in all, every day we find ourselves to face a major problem, lack of endovascular doctors and materials. In my opinion, we should propose to offer more job opportunities to radiologists or young neurosurgeons to learn and practice both techniques, both endovascular techniques and microsurgery. It seems to me that is the first step to offer a better access and therapeutical management of antracranial aneurysms. In our study, we compared the private department and the public one. I hope that both teams could work and share experience together. By teamwork, we can offer better healthcare and finally better prognosis. Before ending, I would like to invite you to the two events. The first one is the Mediterranean Association Neurosurgical Meeting, which will be held in Naples in June. And the last one is the Pan-Arabic Meeting, which will be held in Marrakech. You know the fantastic city in Morocco. Welcome to Morocco. Thank you so much for your attention. Thank you, Nadja, very much. What a model of being exactly on time. Is there any burning question from the audience? Please. Are the microphones on? Microphones? Yeah. Sure. The difference between the private numbers in endovascular versus the public, could it have, number one, anything to do with patient choice? And secondly, maybe in the public hospital, perhaps the endovascular is more expensive, so that's why clipping. Was that a possibility? Yes, of course. In the public way, of course, we need material. The cost is one of the limit to push the team to clipping more than using the endovascular treatment. The first question is, yes, of course, you know that we work together with our team, endovascular, our anaesthetist, but of course, the choice of the patient, sometimes maybe more than 50% is predominant to choose, of course, the technique. Especially in our private hospital, because we receive many patients referred by neurosurgeon to our neuroradiologist first, and then we discuss together which technique we are choosing. But knowing that they are coming for us with the decision that they would have endovascular treatment. It's a difficult task for us to compromise with my radiologist to deciding when neurosurgeon referring to refer to this patient to our hospital for endovascular to change the decision for clipping. But sometimes it happens. Thank you, Nadja, very much.

ruptured aneurysms

managing ruptured aneurysms

complications

aneurysm management

endovascular treatment