I just want to thank Adam and Arol and Mike when he gets here for inviting me and being able to present today. My name is Louis Kim. I'm from Seattle at the University of Washington. And if some is good, more is better is the way I look at it. It's basically a variation of what Arol just presented, which is sort of my algorithm. When you talk about wide neck aneurysms, you're also sort of going through the same argument of, you know, how are we going to treat this, what are the options, what are the choices in this case, what are we going to do, endovascular versus open surgical. These are my disclosures. And so we're all recognizing that this is an ever-changing aneurysm treatment paradigm as Arol, and a lot of this is repetitive, but again, I think it's just good for you guys to see these concepts over and over, see these cases, and I'm going to present a lot more case examples, try to go through a whole bunch of things, rather than, I think Arol has kind of laid the groundwork for sort of the rationale, and now we can kind of blitz through a bunch of cases and look at different ways of looking at different problems. But as he mentioned, we're evolving away from which modality, this whole passé argument of clip versus coil, that's basically out the window, rather when to use endovascular versus microsurgery in selected cases. And I'm going to make the argument in my talk today that distal pica aneurysms, for example, like this one that you see here, this dissecting aneurysm right here, it's really one that is just, it's still a surgical disease. There's no endovascular solution in 2014 that even approaches safe or efficacious for a lesion like that. You have to do a trapping, plus or minus a bypass in this case, and you can end up with a really good result. On the other hand, I think that the paradigm has completely changed for paraclinoid and cavernous aneurysms. We can take these horrendiomas, everyone's seen these beautiful pictures, and you can just turn them into really, we've tamed these kinds of aneurysms with endovascular technique and flow diversion. But then there's this. There's no good solution for these aneurysms. And the point here I'm making is that there's certainly a subset, a large subset of aneurysms that we're still defining what the best treatments are. And frequently there isn't a single best treatment, rather a best treatment for that particular situation. So you're all here because you need to master the art, okay. The fact that you're here shows me that you're interested in being on this path where a first step in your shoes is to dedicate yourself to mastering all these techniques. And it's finite. There aren't a hundred things to learn. There's only a small number of types of cases that you need to be trained in, to be comfortable with. But vascular neurosurgery in particular takes a particular intensity and focus and dedication to the craft. And that's why you're all here today. And that's what's going to make you a good vascular neurosurgeon, trained in both techniques. You also have to be able to embrace technology. This is a sine qua non of cerebrovascular neurosurgery. If you can't do that, then you should be in another field, subspecialty of neurosurgery. You need to embrace technology and change. The history of neurosurgery is the history of technology. And certainly that's the case in endovascular and cerebrovascular. And so you need to not only embrace it, but also vet it. You need to be skeptical. You have to have a certain degree of skepticism with every new technology, with every new treatment. And hopefully, in your shoes being young people, you can then think outside the box and come up with the solutions that we haven't been able to come up with so far. So what are our choices? These are it. This is your list. So if you can master all these, you're done. You know how to do everything in 2014. And it's a very specific and focused list. You've got Hunterian ligation, balloon remodeling, stent coiling, flow diverters. Intrasacral devices are just on the horizon in America. We haven't even really, there's a trial that I think Adam is spearheading here in the United States. But otherwise, it's still coming around. And microsurgery, it's been around forever. So clip reconstruction, bypass and trapping, skull-based approaches, and standard approaches to the cranium, and then combined. If you can master these techniques as one thing, applying the application of these techniques is another. So they're sort of parallel processes. Know how to do it, and know when to apply it. And that's sort of the point of today's talk. So how do we apply these tools? Play to your strengths. You're going to be good at some things, maybe not so good at others. You've got to be realistic. You've got to focus your practice on what you're good at. Again, not every aneurysm has one solution. You want to have a multi-modality, sort of a team-based approach. Be in a situation, especially when you're starting your career, where you have some people around you who can help you think about these problems, and maybe even help you out in the angiolab or in the OR as you develop those skills as an attending. You want to take out the financial incentive. That's a really important piece that you'll see as sort of a motivation for how we treat aneurysms. The other piece while you're here is to train neurosurgeons and open an endovascular. So don't be a hammer where everything's a nail. You want to kind of have a more custom-tailored approach to aneurysm treatment. Of course, there are patient-specific considerations. I think Arol went over these really well, anatomical considerations. Obviously this dictates a lot of why we choose what we do in a patient. Things like whether it's ruptured, what the neck looks like, where are the branches, how are they coming out of the aneurysm, the size. Can we get there? Endovascular access is a big issue in certain patients, making it, in my opinion, if you have a neck like this, you're better off not thinking about endovascular. Think about the open surgical techniques. On the other hand, for surgery, can you get there? How hard is it to get there? Is there something prohibitive or really difficult in terms of getting to where you need to go? And then previous treatments, which is a very common scenario these days. How does that affect what I'm going to do in a particular case? So really, my two main factors for developing an effective treatment strategy for complex aneurysms, as you start your careers, you'll go through this sort of uncertainty of, well, I have all these tools. How do I know which one to use? Am I doing the right thing? Am I doing the wrong thing? Really, I think if you listen to these two points, you'll kind of get there a lot faster. And the first is just recognizing knowledge that multiple solutions are very, very much possible in a given scenario. There isn't a right and a wrong. There's just what are the options and what's the right in your hands. And realize there is clinical equipoise in a lot of cases. Most aneurysms fall into this category, frankly. I'm going to show you a lot of exceptional cases, but most of them, you can clip it, you can coil it. If you're good at either, you're going to do fine. So just keep that in mind. The other is use the lowest complexity solution. Don't make it complicated. The old KISS philosophy from the military, right? Keep it simple, stupid. That's never more true than an endovascular neurosurgery. So at Harborview, at UW, what we have is sort of a coil-first approach. I think Arol alluded to this sort of mentality. But again, it's exceptions to all this is the problem. There isn't a hard and fast algorithm that you can follow and cookie cutter your way through all this. But basically, for most aneurysms at my shop, we basically try to coil first if possible. Obviously, we know what the pros and the cons are. I think there certainly is a higher retreatment rate, and I acknowledge that. As we're learning, the retreatment of an aneurysm that's been treated endovascularly is usually very low morbidity, and it offers an advantage of not having to operate in a ruptured setting or a patient with a swollen brain and so forth. So keep that in mind. And I'm not going to belabor this because I think Arol covered this better than I can. But in certain cases, we still hold a clip-first approach. He mentioned this as well. I think there are certain cases, certain scenarios and locations, I think in young patients where durability is an issue or regrowth is an issue, MCA aneurysms, distal aneurysms such as pica, and really wide-necked ruptured aneurysms, I still favor open surgical as a, when I say clip-first, I mean sort of surgery-first as an approach. And I like to do what's called avoid endovascular gymnastics. You'll see this as you do your fellowships and your training is sometimes we just overdo the endovascular thing. We make it way more complicated than it needs to be. Putting two balloons up or trying to really prove the point that we can treat it endovascularly when it could be a very straightforward simple surgical solution. Really try to acknowledge those situations and avoid them. And then the fact that you can avoid antiplatelets can be a huge plus in certain situations as well. So this is the outline. We're going to go through a variety of locations pretty quickly. If there are any comments or questions, please stop me. But otherwise, I'm going to try to move fairly quickly through a large number of cases to get your eyes on a lot of example cases here. We'll start with cavernous and paraclinear aneurysms. This is a good area of the anatomy to talk about this whole, you know, where are my choices for wide-necked aneurysms debate because, again, it's a complex anatomical region. There are multiple treatment options that are definitely feasible in this location. And surprisingly, the historical surgical data has a very high morbidity. So it opens itself to, well, can we do better? And so this is the quote-unquote simple case. A 55-year-old with an incidental aneurysm. It's relatively broad-necked in terms of its length, but the ratios look pretty good for standalone endovascular therapy. But I think there are multiple choices here. You can clip it, drill off the clinoid, do an anterior skull base approach, and get proximal to the neck of the aneurysm, put a clip on. You can balloon remodel it, of course, stent coiling, and you can put a flow diverter in the stain. This happened to be a case pre-flow diverter, I think it was in 2008. But you get the point. There are a lot of options here. At that time, I decided, in an otherwise well patient, let's just try a balloon. And if that works, great. If not, we can always move on to more complex treatments, more things with implantable stents and so forth. And this is sort of the progressive coil embolization with a balloon remodeling technique, standard technique. And at 12 months, we have a really great follow-up to see aneurysms cured. Really simple. Just start with the simple method and go from there. What about wide-neck paraclinoid aneurysms that are ruptured? Are there endovascular options for a case like this? This is a 30-year-old woman with a ruptured aneurysm. You can see there are multiple aneurysms, but it was clearly localized to this ophthalmic segment aneurysm. And I think a lot of people in the neurosurgical community, Giuseppe Lanzino and others, have come up with a reasonable concept, which is you can always temporize with coilant. If it recurs down the road, it's unruptured at that point, you can go ahead and then do a flow diversion or stent coil and so forth. And I think that's another reasonable strategy. Could you clip this? Sure. You can clip it. Same thing as the last case. But I think there are just multiple techniques here, multiple strategies, and you do what you think is best for the given case. Here you can see that we're using a balloon to coil this aneurysm in a ruptured setting. You can get a reasonable result, quibble that there's certainly a little bit of filling at the base there, but it's a reasonable result. Unfortunately, not unexpectedly, at three months, there's a relatively substantial recurrence of the aneurysm. And now, again, all the options are still possible. You can clip it. You can pipeline it. You can stent coil it, what have you. I just selected for a pipeline in this case. You can see a good apposition of the stent. And then in three-month control, you can see there's already a pretty good endoluminal reconstruction there. And again, belabor is the point of all the options are all feasible and reasonable. I think for this type of aneurysm, we all see this large, complex, multilobulated, broad-necked paracline aneurysm unruptured in a relatively older patient. I think the new standard is pipeline. I mean, there's just nothing that even makes any sense anymore in this type of aneurysm, unless they're unable to take aspirin and Plavix or non-compliant, all these other issues. And I'm sure you've seen countless papers, countless talks about this. You can take a relatively formidable surgical lesion. This would be a tough surgical case. I don't care who you are. This is a really tough surgical case. And then put a pipeline down and get these beautiful results. It really is just a game changer. That's just a fact. And I don't even think it's really a debate anymore, frankly. The morbidity is there, of course, but it pales in comparison to the surgical morbidity of that aneurysm. What about an ugly case? So this is a really horrendous aneurysm that I treated recently. You can see this aneurysm goes into the sphenoid air sinus, into the optic nerve. And it's just a disgusting aneurysm, frankly. It's a really terrible aneurysm. And it looked like one that would be reasonable for a pipeline. But the options are all there. You can trap it and bypass. You can put a pipeline in. Really those are your two main options. I think anything else is planning on failure. And I thought this was going to work. I got a six-month control. Looks really good. Pretty happy. All I got is a nub left. You can see I put coils in the nose, in the back of the nose, basically, to prevent her from dying from a massive epistaxis at the time of her treatment. And it looks pretty good. I'm pretty much patting myself on the back. Just get the routine 12-month follow-up angiogram, and I'm done, right? No. So what do I see here? I see a massive recurrence. There's an endoleak from the proximal aspect of the stent. You can see this is the end of the pipeline right here. And you can see there's a jet of inflow outside of the stent, inside of the artery, going into the aneurysm and causing a recurrence. And I just thought, well, this happens. Endoleaks happen in pipelines. What bad luck. Woes me. And so I decided I was going to retreat her. Just tack it down, put a second pipeline in, piece of cake, wait six, 12 months, and it's all cured again. So I brought her in, put her on anesthesia, did the angiogram, and what do I find is the same exact-looking aneurysm, except now that I'm paying more attention to actually putting a pipeline in. I don't know if it projects well, and the images aren't exactly the same size, but the artery is substantially bigger for some reason. And when I go back to her original treatment angiogram, it was even bigger on this intermediate angio than the most recent one. So it's for some reason probably related to her hypertension. You can see there's change in the tortuosity of the vessel, too. Her artery is dilated beyond six millimeters now. So now we have a six millimeter proximal landing zone where I'd have to put a pipeline and land somewhere in this area, because there's no way I'm going to be able to stop it short here and do a good job. But there's no pipeline that's big enough. It stops at five, right? Five opens up to 5.25 maybe at the max, and now I've got a gap that I can't just put a pipeline in. So it's sort of complicated. Now I'm left with the decision, do I want to just put a bunch of pipelines down and then tack it down with a carotid stent in her neck and leave a huge mass of cylindrical metal starting from her cavernous sinus all the way down to her carotid bifurcation? I don't know. In France, that's probably a good idea. That might sound good to somebody there. But I think in the United States, I think really my preference is to trap and bypass. And so this is a radial artery graft. We can do our M2 anastomosis. Always check the, I've done the front wall. You always check the interluminizer before you tighten the sutures up. From your back wall, and I would just say to you guys in the audience here who are going to be learning these techniques, is when you're doing your heel and your toe area stitches, whether it's running or interrupted, I would always do it in two bites. You know, take one side of the wall, pull it out, and then do the other. It'll save you a lot of grief and heartache as you go through the learning curve. And you can see that that's the proximal, the distal anastomosis. We can do the proximal anastomosis here. That's just at the bifurcation of one of the branches of the external carotid artery. So I'm not temporary occluding during this time. And again, a running suture, front and back wall. Make sure you haven't back walled the stitch. Pull them all tight at the end. Adam said put a lot of videos in, so I'm putting videos in. Did you do a test balloon inflation on that? I did not because anatomically she had miserable collaterals, and so I just sort of skipped that point, but it's a very good option. So she had no good ACOM or contralateral A1, no PCOMs. And you just go back, take all your temporary clips off, check your intracranial flow, make sure you see flow. You get an ICG to confirm that, Doppler, et cetera, and then you get an angiogram that shows really good collateral flow. We've included the carotid and the neck, of course, and most importantly is that thing's gone, so you don't see anything in the patient. Fortunately, in this case, it did well, but it's a major undertaking. Wide-necked ACOM aneurysm, again, lots of choices. You have to use morphology, patient factors, whether it's ruptured or not, as part of your treatment algorithm. And I think in elderly patients, we'd all agree at all costs we try to avoid any open operation in the setting of a ruptured. This is a pretty terrible aneurysm. It's extremely broad-based. You can see the A2 coming out of the base of the neck there. There's the other one here. It's a really tough aneurysm, but really hate to operate on a 70-year-old if you can avoid it. And I think, again, it's an option, but here we can be aggressive with our endovascular techniques. Here I think a little bit of endovascular gymnastics is worth the extra effort because you're talking about an elderly patient who's probably not going to do as well if you open up their head. And go ahead and coil the aneurysm, get a pretty good immediate result, and then in follow-up. Here you can see there's a little bit of a recurrence at the base, but not terrible, and I think the end justifies the means here. The alternative is the young patient. This is a 13-year-old girl with a subarachnoid hemorrhage. You get an angiogram. You see she's got sort of a dominant left A1 and a small aneurysm right here with a relatively reasonable neck there. And I thought, heck, this is a great one to coil, and so we go ahead and do that. And see that it's not too bad of a result immediately periprocedurally. I wait my usual six-month follow-up angiogram thinking everything is going to be just great, and then a massive recurrence. The aneurysm is three times bigger than it originally was, and the coils are just sort of splayed out, hanging out at the dome doing nothing. And you can see that the neck is still surprisingly very small, but the aneurysm is just massively blown out. And this is just not uncommon with pediatric aneurysms is the point I'm trying to make. And sometimes in really young patients you need to be a little bit more leaning towards surgical techniques and surgical treatment. So you can see the coil loops here just at the base of the neck of the aneurysm. And see how terrible the video is, sorry, but you see the neck is really narrow. It's just this segment right here. And the point of the video is just to outline one surgical technique that's sort of bread and butter, which is you put clips on coils. What do the coils do? It pushes the clips down on the neck of the artery to the parivessel. The parivessel causes a little bit of stenosis, which is exactly what's happening here. I'm slowly trying to fight the coils and put my clip down, but it still slides down below where I want it to be. So what I do is put a clip on top of that one on the aneurysm side of that clip, and that allows it to sit exactly where it ought to. You take the first clip off and you've got a perfect clipping. So that's just sort of bread and butter technique, and you get a nice result there, and fortunately durable. So MCA aneurysms, I couldn't agree more with the role. I think that if I looked at my data recently, I clipped 90% of my MCA aneurysms, which is shocking. I can't believe I'm that biased, but I am. And the other 10% are horrible aneurysms. So even though it looks like I'm just clipping everything, the other 10% are those horrendiomas. And so remember, you need to know how to use everything to get to those horrendiomas, including the endovascular techniques. Here's an example case. So this is a patient that was a medical student in Louisiana. She was four months postpartum, and then she has a massive subarachnoid hemorrhage. She has this terrible aneurysm. At that institution, they temporized her by coiling what they thought was the rupture point. I thought that was reasonable. You can see they used a balloon and coils and got that sealed off, and then sort of said, see you later, have a nice life. She comes back to Seattle, where she's from, sees me. She's doing great now. She's taking care of her baby. I get an angiogram and it shows this. So very dynamic, horrible aneurysm. I think there are a lot of options here. The faculty in the audience might quibble about whether they would clip reconstruct or bypass and trap versus pipeline and more coils. In my case, this is an endovascular case. I don't want to come anywhere near that aneurysm. I don't want to open up her head. I don't want to clip reconstruct anything, because there's something called the lenticular striate arteries all in that area, and we don't want to be buggering those up. We're still going to bugger them up with our pipeline, as I'll tell you in the story, but I think this is, in my opinion, the safest way to get at this aneurysm. Why did I put coils in? Because this aneurysm grew a lot in three months. So I'm going to take care of this aneurysm as quickly as I can. I don't want to wait the six months and hope that the pipeline works, and what if it doesn't kind of a thing. So the coils kind of just facilitates the whole process. But it also adds, I think, in my opinion, to the thrombobolic risk or the stroke risk to the patients. I haven't seen a good paper on that, but I think we ought to probably publish one through the NRG, is when we use coils and pipelines, I bet you we have a higher rate of complications from thrombobolic events a roll than if we don't. They actually think it's safer. Oh, really? They didn't see a thrombobolic increase. I see. Periprocedural or long-term? It was published. Huh. So at any rate, you know, this looks great at eight months, but during that time she had two discrete TIAs, one with hemiparesis, which resolved and she's doing fine, and thankfully this is not dominant hemisphere. But the point is, is there's no perfect treatment here. You're going to have to accept a relatively high morbidity, whatever you decide, and they're all good choices. So don't think that this is the only way this could have been treated, but rather this is just one of many options. And then again, it continued to remain relatively stable, but still she had those two events and it's real. I've kept her on aspirin and Plavix through this whole period of time and only now started a wiener. So what about our surgical techniques? Of course, you know, these sorts of really broad-based ruptured MCA aneurysms are just perfect for surgical clipping. I just wanted to point out this one technical example of using sort of the picket fence technique from Dr. Day, Art Day, used to talk about, where you can actually lay them perpendicular to the axis of the parent artery you're trying to reconstruct and then lay a whole bunch of them down and it allows you to sort of more precisely control the neck, particularly when it's broad-based and thick-walled and it's hard to, you're worried about keeping the lumen of the vessel open. You can see the clips in place there. When you look at distal, unruptured, or ruptured MCA aneurysms, I think you can pipeline these, but there are two branches coming out, one here and one there, and you've got to pick one of those to pipeline and one of them you can't. One of them gets jailed, as they say. So what happens to those arteries? Sometimes they stay open, sometimes they don't. I've had good luck with some and not with others. And so I think that open surgical technique is still an option in this case. And this is the distal branch coming out here, the posterior branch. This is the superior branch up here. This is part of the large aneurysm that's sitting in the sylveon fissure. And so I cut this, do an STMC bypass to that, and then clip reconstruct that other branch and call it good. I think we could probably talk about, the faculty could talk about, whether a pipeline would have been an alternative here over this. But again, two good options, both with pros and cons, and you have to sort of pick your poison. So you check the flow, do an ICG. You see the branch here is filling nicely. And then you just clip reconstruct that artery that's coming out this way. And you end up with a good revascularization of that territory, and the aneurysm is gone. Clips are here. A special case of MCA aneurysms haven't been discussed yet. Mycotic, of course, are its own entity. Frequently, the best treatment is just trapping them. If it's a large vessel, you have to bypass downstream. But coil or open surgical trapping is usually the primary treatment if it's ruptured. Dissecting aneurysms, again, just like that M1 case, very complex. The whole gamut of options available. And then this case, traumatic. This is a patient who's a 35-year-old with GBM in the dominant hemisphere. Had a recurrence, went back to the same surgeon, had another operation. During the operation, all of a sudden, they got a lot of bleeding. Didn't know where it was coming from. Bleeding everywhere. He packs it off, and it sort of stops after a while. And so he decides to wait three months, get another MRI, and make sure his tumor is not growing back. And he's got this funny little bleb here. So he sends it to me. He says, I'm really worried about an aneurysm there. And I said, I am too. It's absolutely an aneurysm. So look at this MCA. This is a pseudoaneurysm that was the problem. So this is a bite mark in the MCA for some reason. A hole that was bleeding. It stopped. He packed it off. Probably within the hematoma or the tumor or whatever is surrounding this artery, encasing this artery, formed this pseudoaneurysm. So there's no wall here. There's no neck. This looks like a nice aneurysm. It's not. There's nothing there to reconstruct or clip from the outside. So in this case, this is one where you could either trap and bypass it, but it's a two-time redo GBM with no STA. Or you could do a pipeline and coils. Pick your poison. But I think in my hands, I think this would be a safer option than the open surgical because of the specific factors involved. And I don't have follow-up, but you can see that periprocedural. There's good stasis in the aneurysm. I barely put any coils in it. You can see it's relatively hypodense on the true angiogram. And that's because I didn't want to move the artery too much and cause tearing or bleeding and so forth. And then if we could just move to the posterior circulation and show some additional case examples. I think this area is, of course, intrinsically more difficult to access for surgery. And I think even more so than the anterior circulation favors an endovascular first algorithm. So I'm sort of in both Errol and Adam's camp with the basilar aneurysms. But here's an example that I think is really worth presenting to this young audience. It's a technique that is seldom used or talked about anymore, but it's just sort of part of the armamentarium that we all need to be aware of. And I think Adam referred to it earlier when he asked me about tespoline occlusion. So this is a 61-year-old woman with a symptomatic large vertebral artery aneurysm. You get the angiogram, and you can see this terrible lesion, broad base. And the pike is actually coming right out of the dome, as you can see here. So that's really coming out of it. That's not an artifact. And she doesn't have much of a V4 on the other side. Hypoplastic vert on the right. This is a left-sided aneurysm. But fortunately has some pretty good PCOM. You see a large left PCOM, medium to small, medium-sized right PCOM. So I think this is somebody who might tolerate a proximal occlusion. You can see I shoot the externals to make sure that if I want to do a bypass to that pica, I have an occipital artery to go to and so forth. So what are your options? Well, do you want to do tespoline occlusion? Absolutely. You want to know what the patient would look like if you just sacked this artery. Do you want to consider a pica bypass trapping? Hunterian ligation, which, as you know, is just trapping of the parent vessel. Stent coiling, flow diversion, pipeline. This is a pre-pipeline era case, so that wasn't really an option for me at the time. But I don't think I would have considered it anyway. So we did the tespoline occlusion, actually. That was a key step. You can see nice filling down, retrograde the basilar trunk right here all the way into pica. You actually see the pica branches filling as well. And she passed it clinically. We do it with a hypotensive challenge to make sure that the patient can tolerate it. And so I thought, I think maybe the safest choice to do a Hunterian ligation or coil occlusion of the aneurysm and the left vertebral artery. But I didn't want to occlude the sac of the aneurysm because there's still that pica there, and I figured I'd let it gradually close off or recantalize, whatever it's going to do as the aneurysm thromboses. And you see a nice occlusion of the vert there. When we do our post-embolization runs, you see that nice reflux again down. Yeah, into the dome a little bit, but also into that pica. So you see the pica filling out through the aneurysm. And this is an unruptured aneurysm, so we can tolerate a slower occlusion rate then if it were ruptured. And what we see very nicely is this immediate thrombosis of the aneurysm and progressive resorption of the aneurysm, and then at nine months it just disappears. And so that's a sign that the aneurysm is truly occluded. It's not going through cycles of thrombosis and recanalization or any of those terrible things. And so this is a very reassuring finding. Basilar aneurysms, I think we're obviously on to something with these two guys arguing about the basilar. I wasn't aware of this debate that you guys have going on, but I'm going to present a better case for your rule, but I would make the case that there is still a role for clipping a basilar aneurysm. This isn't necessarily one, but I think this is an example case where clipping is reasonable. It's not that you couldn't balloon remodel this in a ruptured setting, but that it's just tougher. I mean, it's a very short aneurysm. It's very shallow. You see the rupture point is probably over here. It's fairly broad-based. Other views, you can see it's posteriorly projecting a little bit, which makes it bad for surgery, but it's just a really short and wide squat kind of an aneurysm. It's above the posterior clinoid, so it's pretty easily accessible from a transcavernous approach. And so I think this is one that is reasonable for clipping. Could you have coiled it? Sure. You could have balloon remodeling, all that. But could you clip it? Yeah, I think so, too. I think that this is a reasonable one. And it's good to see a video of a basilar apex aneurysm clipping once in a while. It's good for your edification here. You can see that there's a little perforator right back there. You want to dissect out the neck of the aneurysm as best you can. That's really the key part of the case. It isn't putting the clip on. It's clearing the perforators, right? That's the key part. The clip is relatively straightforward once you've done a good dissection. You've cleared the perforators. You know where they are. And what I'm going to do is slide the clip into that area where I know it is. And then most importantly, which is why I'm showing a relatively long version of this video, I apologize, is once I get it into where I think it's in good position and I've cleared the fenestration into the P1 ipsilaterally, is I want to see the tips of those clip blades on the opposite neck. So the most important part of this is to see the other side of the aneurysm, make sure I've occluded the contralateral neck of this aneurysm. Because if I get into trouble, that's the part I wish was closed first, not the part that's close to me. The part that's close to me I can deal with, because that's easier to get to. It's accessible. So right there, I'm just barely seeing the contralateral P1 and the aneurysm neck and then the blades go down. That's all you get. You don't see this wide open beautiful view on the basilars. That's why these are treacherous things. But that's the key step there. I've obviously left a little bit of neck here. And all you have to do is put a second fenestrated clip on top of the first. Interestingly, you'll see as I close the blade and reopen it to readjust, there's a bunch of bleeding. That's the aneurysm popping and bleeding. But I've got complete control at this point, so it's not a big deal. You get your postoperative angiogram, and you see just a little bit of maybe stenosis of that P1 segment from the fenestration, but otherwise a good result. On the other hand, and this is the same case that Earl presented, so I won't belabor this one, is this is a patient with unruptured aneurysm, previous coiling of a right PCOM, making it really hard to get to surgically here. You've got this big coil mass in your way. Don't want to come from the left side if you can avoid it. It's just dominant hemisphere. And it's an unruptured aneurysm, so you can probably treat this endovascularly, and it's the same sort of a case. You can come trans-circulation through the PCOM across the top, get your really good stent placement, and then coil the aneurysm, and just see a good long-term result there because of that advantage of the stent. Can you use stent safely in ruptured aneurysms? Well, yes and no, right? So this is a case where I had to use it because I got into trouble. So I'm coiling the aneurysm with a balloon. Everything looks great. But as I continue to pack the aneurysm, it encroaches further on that right P1 segment. It occludes partially, and you get thrombus formation. I tried ReaPro and all that stuff. It's not getting better. So I'm sort of stuck. I end up putting a stent in, immediately flow restores. You've restored that P1 perfectly. It's flowing nicely again. But now you have a stent, and you've got to anticoagulate. You've got to put them on aspirin and Plavix and sort of do that whole dance with the EBD and possible shunting and so forth. And of course, she had a very small tract hemorrhage from her preexisting EBD, but fortunately otherwise didn't suffer a bad complication. But they happen, and we see them not infrequently. So can you do this? Yes. But I think judicious use is the key. You don't want to have 100 of these cases a year for sure. You just want to use them when you absolutely have to and there's no other way out. Similarly, there are cases where you have to put stents in the setting of ruptured, but you really want to use that as your go-to first choice, not as a salvage or as a backup. And this is a case where she was considered angionegative, but I'd point that out to you as her first angiogram is very irregular. She gets a repeat angiogram five days later because of the high degree of suspicion. And voila, you see there's a larger dissecting basilar trunk aneurysm. And this is one that's just ideal for stent coiling. I mean, you don't want to do anything else but this in this case. It's hard to get to. It's a fragile lesion. And so what we do is you gel a catheter, you place a stent, and you end up with a pretty good periprocedural result, but then in long-term follow-up, really a beautiful reconstruction of that dissection, the endoluminal reconstruction, and it's done well. It's not normal. There's a dissection there, but it's healed. And then for the horrendioma and the posterior circulation, you talk about these horrific large and giant VBJ aneurysms. This is a 33-year-old with just headaches, unruptured. What are you going to do with this aneurysm? You can trap and bypass. Yeah, right, okay. That's a relatively high morbidity kind of a thing to do to somebody. If you had to, you can, and I certainly have done it, which is why I'm moving away from it. And I think the alternative is flow diversion. Is this easy to do, endovascularly? No. I mean, every one of the experienced faculty here knows, man, it's going to be a pain in the ass to get through this, keep my position, not slip out, or have all these complications. Am I going to get one device to span that whole area or not? And so I had the same problem. So the hedge was that I'd get across eventually, but I couldn't pull the loop out, or rather I chickened out and I didn't want to pull the loop out. So this is kind of around the dome of the aneurysm instead of pulled tight around the neck. And that's okay because the device still works if you do it that way. The problem is that I left myself open to a slight persistence or residual there. You can see that this is filling beautifully, but there's just this little trickle channel between the two artery loops here along across the neck there. And so I retreated it. I put a short device here and a short device here thinking, well, you know, it's a treacherous aneurysm. I better do everything I can. And you end up with this result where it's still there. You can see it. It's not perfect, but I think I'm done. I think this is about as good a result as I'm going to get. You just follow it really carefully and make sure that in a young woman you don't see recurrence. But my God, I mean, this patient went home in a couple days. You know, I mean, this is just such a great alternative to what we would have had to do 10, 15 years ago. And you don't need to have seen that to know that that's a better mousetrap. I alluded to this earlier, distal pica aneurysms. There's no question that surgery is still the right choice for this. You can try endovascular techniques, but you're either going to have to just do a parent vessel sacrifice, which may or may not be tolerable depending on the location of the aneurysm. Or as I prefer, I like to do a distal bypass and then trapping of the aneurysm. And I think it's good to see what that looks like. Since this is a techniques-oriented course, you can see I've dissected out the tonsillar loop of pica. And I bring in my occipital artery, which is a real hassle to learn how to dissect. So I recommend all of you spend a lot of time in the lab learning that. In this case, I use interrupted sutures, this is teno-interrupted sutures, because the vessels are smaller. And once the bypass is completed, we like to check it with Doppler and ICG, make sure everything's flowing. First, we're going to trap the aneurysm I misspoke. You can see that that's proximal to the aneurysm. That's distal to the aneurysm. Sorry, it's not centered. Then you'll see it in better detail here. So there's the dissecting aneurysm there. You can see the rupture point is about there. Very ugly thing. It's trapped. You can see the clip proximal, clip distal. And then we do the ICG. This is the pica branch here, distally. This is the pica going toward the aneurysm, and you can see it's just trickling towards it because there's a tiny perforator there keeping it open, but a nice result. And you can see that the aneurysm's gone and the pica fills nicely. So I'm going to be finishing up soon here. Two cases that I consider special cases worth mentioning. One is the carotid injury case. So this is a 30-year-old with a transphenoidal operation, and my partner who does this is a fantastic surgeon, but you're going to get this for once in a while. He got into massive intraoperative bleeding after cutting the dura at a certain location. They realize immediately it's a carotid injury. You get an angiogram, and it doesn't really show much. There's sort of a fullness in this area here, but we repeat the angiogram in a week, and she's got this pseudoaneurysm right along the junction of the intracranial, extracranial carotid. And I think, again, there's lots of options. You can pipeline it, as I did here. You can trap and bypass it in a young patient. I think those are all reasonable options. But I think the key here, as we're all learning as a field, is it sometimes helps to put two devices inside of each other to try to facilitate that thrombosis. There's always a little bit of a hairy waiting game, so I put the devices in. It's immediately post-procedure, and you still see there's just a little bit of filling. You see, the rest of the circulation is filled well during that, at this point in the injection, and there's just a trickle in there, but still, it's a pseudoaneurysm. There's no wall to it. It's just hematoma. So you kind of have to nail-bite for a few months and get your repeat angiogram several points along the way, and this is the latest follow-up she had. You can see a little bit of instant stenosis and luminal narrowing, but again, a really good result, and she's cured. The other is the dreaded worst type of aneurysm, the blister-type aneurysm. They're always in young women, 33-year-old females, sudden onset of headaches, subarachnoid hemorrhage, and then this non-stereotypical aneurysm. It's just not at a branch point. It's not in a stereotypical location for a carotid paraclinoid aneurysm. It's a blister aneurysm, so red flags go up when it looks funny like this. It's just not in the usual location. They're always short, shallow, broad-based. They can be dissections. They can just be defects in the wall, and again, I think the world is moving toward flow-diversion treatment of it. This is a case in subarachnoid hemorrhage where I think the morbidity of aspirin and Plavix is justified, because the alternative, I think, is a little bit higher risk, trapping and bypass and so forth, and so again, two devices. You can see that our image technology is so good. You can see that this device inside the first hasn't quite fully opened, and you see just a little bit of an endoleak there, which we ended up ballooning, ballooning androplasting, and you can see the aneurysm goes from that to that and follow-up, and that patient fortunately has done okay. There's the long-term follow-up androgram there. You see the aneurysm, which is all gone. So this is, I just added some apologies to Earl, so this is the Basler aneurysm that should definitely be clipped and not be treated endovascularly, and that's the compliance issue, which I'm tongue-in-cheek about this, of course, but this is a 28-year-old schizophrenic who thought that his medications were mind-controlling devices by the FBI, et cetera, et cetera, so this is a case where you definitely could treat this endovascularly, there's no question, but compliance is a big issue, and we've all had problems with that in some of our patients who forget or for whatever reason don't take their aspirin and Plavix and end up with problems. You could have ballooned this, yes, but I think that it's going to be a relatively high recurrence rate with that neck-to-dome ratio, and so this one gets clipped. So in conclusion, I'm sorry if I ran over time, use all the tools available, seek the lowest complexity treatment, the KISS philosophy again, just keep saying that over and over in your mind. The existing literature is merely a guide, it's somebody else's experience, it's not your experience, so use it as a guide, but don't think that that's the way to treat all of those Xs or all those Ys, use good judgment. Play to your center's strengths, you're going to have strengths and weaknesses, and individualize the management, have a team, have radiologists, have neurosurgeons, have everybody, I think the more the better, and train neurosurgeons and endovascular techniques because we're in that position to really control the patients and understand what's best for them, and that's all I have.

aneurysm treatment

endovascular

open surgical

patient-specific considerations

anatomical considerations

vascular neurosurgery

individualized treatment