I kind of, on the plane, threw something together so that we can kind of give you guys an idea because it does get confusing and everybody does something a little bit different. And it depends what shop you're coming from, it depends on where you're training, it depends on a lot of different variables even after you do your fellowship of making a decision of clipping and coiling. And actually, it's pretty funny because I had to go back about ten years in my talks to actually like six years to find a talk that was coil versus clip because we've really gone so far beyond that. But I think what is important is if you ask, who are we clipping now? Yesterday, we were talking about this among the faculty, it was really astounding. This is the first time since we've given this course, it's the first time I've seen anywhere where residents are actually doing more heavy on the endovascular side with their experience than they are on the operative side. And I think we're going to start to see that trend because as we go along, there's going to be, there's more and more centers doing open surgery all over the place, they're not just being done at large academic centers and the more that we treat endovascularly, that open volume is going to get less and less and training is going to be an issue. That's exactly why we have courses like this and tomorrow is pretty much going to be strictly an open day. So you're going to get access to that. So what I put together, and this is my personal, this is the way I look at things, you know, which can be scary, I guess. But the way I look at how I make a decision of who I clip and who I coil. So there's a huge paradigm shift and there was a paradigm shift. You know, we started first doing endovascular, it was, if we can't clip an aneurysm, then you go to coiling. Coiling was kind of the secondary, it was the really old patients, it was the Hunt-Hess Grade 4s, the 5s that improved to a 4 after a ventriculostomy, medical disasters, things like that. And, you know, we've now switched to the paradigm of, if we can't coil it, we clip it. And that's, I think, more and more for various reasons. And we're not going to, you know, I'm not going to go into beating the data, but this was really the first landmark study, the ISAT, that looked at subarachnoid, that looked at ruptured aneurysms, and looked at outcomes for the endovascular group and the open group. And, you know, you can, when this first came out in 2002, I mean, this is all the CNS, the AANS we're talking about, I mean, all the sessions where I sat and doing mining of the data and nitpicking. You know, the bottom line was there's a relative risk reduction of death or disability after the first year that was 22% lower in the coiled group. And it was intuitive. For most people that were doing endovascular, and certainly those that were doing both, we knew that for the ruptured aneurysms, if there were no complications with the endovascular, that those patients tended to do better, period. I mean, it's not rocket science. If you don't have to crack someone's head, if you don't have to retract, no matter how good a surgeon you are, it's just a lot less invasive to a brain, particularly for a ruptured aneurysm where you already have injury. You're introducing forms of secondary injury. The case is longer, the anesthesia tends to be longer, you know, so is surgery over for aneurysms? And the answer, obviously, is no. There's clearly going to be a subset. And for all of you in this room, until the end of your careers, you will be clipping aneurysms as a vascular neurosurgeon, 100%. It's just a question of what those aneurysms are going to be and the volume. And there's some other data that I'm happy to share with you as far as, you know, the argument of follow-ups and the arguments of recoiling for recurrences. And we just published a few years ago through the ENERGY group, the Endovascular Neurosurgery Research Group, the incidence is about 1% of recoiling in aneurysm. And that was over, I think, Bernard, do you remember the overall number? I have the thing. I mean, it's like 1,000 patients at six centers across the country. And follow-up angiography was like a tenth of a percent of a serious complication. So this argument of recoiling in aneurysm, if an aneurysm recurs at, oh, my God, it's the end of the world, it's not. It's not something you shoot for, but it's lower than we think. And actually, when I was going back to kind of, for my older talks, it was interesting. I look back from 2000, we first started, and this is way, way back. This is back when, you know, keeping in mind that FDA approved, I think, in 92 or 93 for GDC, we were 50-50. And that was like, you know, heretic at the time of, oh, my God, you're coiling 50% of your aneurysm. That was like a really big deal. At this time, really, most of the aneurysms were kind of relegated towards, again, that certain population of things that weren't amenable to open surgery. If you look at the shift, 50%, 53%, 61%, 68%, 62%. The last year that I started keeping track was 427, 73% of those were treated endovascularly. So you saw this shift. And then from here on out, I would say probably hovering around 80% endovascular versus open. Again, this is at a center where all the interventional, I shouldn't say we're interventional, all the surgeons are dual trained or comprehensive. So there's no radiologist, there's no neurologist. So there's not complete loss of bias, but the biases is minimized because everybody does both. So for me personally, who do I clip? How do I look at when an aneurysm comes in, whether it's elective or subarachnoid hemorrhage? First of all, any wide necked AECOM, I have a very, very low threshold for taking these patients to the OR. I think, again, personal, I can count on my hand how many AECOMs I've stented for the elective population and for the open as well. You get into trouble with the AECOM for the same reason that you do the MCAs. The reason is, why do we say, oh, it's an MCA and you shouldn't coil? I've coiled lots of MCAs and there's no problem with it. It's the anatomy. Every anatomy is different. You can't just say MCA should be clipped and not coiled or basilar should just be. The reason is most, the anatomy of AECOM and MCA, why is that different than other locations? An ICA bifurcation, a basilar, superior apophysial. What's different about an MCA or an AECOM? Think about it. What's the anatomy look like? You've got a pipe and what does it do? It bifurcates and there's branches. What's the caliber of that pipe? The M1 is how many millimeters on average? Three, four, sometimes you can get large. And then the branches, what do they do? They get bigger or smaller? They get smaller, right? So how many of you have seen flow dynamics of aneurysms, real time flow dynamics where you see what the blood's doing, what you see what the capacitance is, what you see what the velocity is? It's like a river. You have high pressure, high volume going through a pipe and then the river narrows and you've got a fork. What happens to that blood? Becomes turbulent. So if you have a neck exposed with metal, if you have a stent in there, your risk of thromboembolic complications or thrombosis of these small distal branches is much, much, much, much higher. And it is in a five, six, seven millimeter proximal aneurysm where you've basically got flow that's bypassing it. So that's really the issue. And when you start putting metal, when you start putting interface of coil mass at a wide neck that's going to encounter that blood, you're going to get thromboembolic complications even with anticoagulation. So that's my philosophy with these and this is why, you know, I've rarely regretted clipping an MCR and ACOM. There's a lot of times where I've regretted coiling them. Small vessels. Same concept. A distal pica, a distal ica, a distal periclosal. We can get out anywhere now. You know, the microcaptors, the wires, technology, we can really get anywhere. But the more distal you get, unless it's a really perfect neck, the more you're going to get into trouble. So those are ones that I think are generally more amenable to coiling. Now, if they're really distal, you can just take the vessel and you heard a little bit when I was talking last night, those are great cases to stick some sodium amytal in there and do the patient awake and see how they do. Every patient's different. You have to, you absolutely have to keep that in mind. You can't just, the one thing you can't do is just come up with a protocol. Every patient's different, every aneurysm's different, and you have to treat it as such. You just have to have all the tools. So for my practice, you know, I don't think about it, you know, not can I coil it, but should I coil? If you're well-trained and you will all be well-trained, it's really, there's no aneurysm you can't coil. There's really no aneurysm that you cannot get to in this day and age. The question is, is should you do it? Are you going to end up with a disaster or not? Getting a micro catheter and plopping some coils in isn't the hard part. The hard part is the judgment of is this the right thing to do for the big picture? What's the big picture? Well, if it's elective, you're talking about patient preference. And you're not scaring them out of one or the other. How many of you spend time, and I mean when I say spend time, like really do dedicated office hours with a vascular neurosurgeon? Okay, good. Those of you that aren't, you need to do that. Because that's the stuff you're not going to learn when you're out on your own. How to go over that, discussing these things with the patients, and you know, watching someone do it is a lot more educational than just kind of, you know, sitting in lectures and hearing about and spouting out data. So you really have to be honest with patients. And what I tell my patients is, listen, you have an aneurysm. You can treat it one way or the other. And this is given the fact that you could do open or endo and that they're both reasonable. The upside of the craniotomy is it's done. It's over. We do intraoperative angiograms in the operating room. We know everything's perfect. It's shut down. You're done. You don't need any more follow up. It's more permanent. There's no more coming back for anything. The downside is you're going to have a six week recovery and always upsize it. Don't, oh, it'll be two weeks. If you downsize things, you're going to end up with angry patients. So it's a six week recovery. You're going to be in the hospital longer. You have an incision to heal from. And you're going to feel like crap for a couple weeks. Your energy's going to be down. You're going to have the risk of infection and swelling and edema and all that. They're low, but they are risks. The endovascular, the upside's obvious. You're out of the hospital the next day. You're really not going to feel much different than you do after your angiogram. You're going to be flat for a couple hours. And there's really no downside to it. I mean, there's no long term side to the recovery. So the downside to it is I'm going to see you back in six months with an angiogram. We're going to be following this pretty much almost indefinitely, definitely for five years. At five years, I do angiograms on everybody to make sure, at that point, we'll make a decision if we have to follow it again. And you have a higher risk of recurrence. You have to talk exactly, you have to give them those realistic options. And whenever they pick, it's OK. Because they understand they've made that conscious decision with you. Reliable follow-up. My patient that comes in that is someone who was found on the street, and they thought it was trauma, and is a chronic alcoholic, and he's not coming back for his six, or she's not coming back for their six-month follow-up angiogram. They're getting a clip pretty much almost always, unless it's something that is really a problem and needs to be treated endovascularly. And from a financial standpoint as well, let me tell you something. Your hospital will not be happy with you if you put 15 coils in a stent in a homeless person. They're not getting it. A clip is about $100, and it's much cheaper. Subarachnoid hemorrhage as well. Do you have to stent? Is it wide neck? Do you have to do flow diverter? All these things will play into this as well. I personally, sometimes I will do a stent-assisted coil in an acute subarachnoid hemorrhage, but it's for a select group of patients. But in general, you're going to be leaning, with a wide-necked aneurysm, you're going to be leaning more towards the OR. And then medical comorbidities. And then for me, basilars, I, you know, and I'll go out on a limb here, Adam's smiling because he's like, okay, what else is new? I don't think there's any basilar artery anymore in 2014 that cannot be treated endovascularly, period, end of story. And I'm not just talking posteriorly pointing. I think especially now we have endovascular saccular devices like the web, like Luna. There's a couple other things coming out. I think basilar artery aneurysms have seen their day for the OR for the most part. So what about an aneurysm like this? We have the, Howard, did you have that pointer? Where'd our, oh, what's his face go? Anyway. Oh, thanks, here. So this is a PCOM. And this is someone that, actually I just saw, I think like last week or a couple weeks ago, was a second opinion. And you can see there's, here's a fetal type PCOM coming off. And this, she was recommended to have a balloon-assisted coil embolization of this. So if you look at this aneurysm, and it's a healthy 56-year-old. And if you spin this, look at, you can see the body. This is looking posterior. So this is looking from the back of the head. So first of all, when you start having to sit and spin your 3Ds, and the best view is the back of the head, don't forget, it's going to be very difficult to get this view in the angiosuite. You're not going to be able to get your C-arm around like that. So just because you can do this with a mouse, it doesn't mean that you're going to get your AP and your lateral to do this. And this is our best view. Here's the PCOM. So if I put a balloon up in here, I'm going to occlude some of the neck. But this is coming off the neck of this PCOM. A stent, unless I'm going to get a stent to come around here, which is, I guess you could do it. You could come up around here. Now you're starting to push technology. This is a PCOM, folks. This is a very straightforward aneurysm to clip. And you never want to say it's just a PCOM, because these can be as difficult as a basilar. But for the most part, this is not something that I think should be coiled. This is very amenable to open clipping. You're going to be able to preserve that PCOM and not have issues. Here's an ACOM, wide neck, dysplastic looking vessel. Again, what's this notch? I asked it yesterday. Optic nerve, exactly. So you see the optic nerve notched out here. And this is a patient which actually didn't complain of visual loss and had formal visual fields that are very, very mild. So I wouldn't say that there's any major visual problems. But this is a very wide necked ACOM. And can we coil this? Yeah, you can coil this. There's no question. But you're going to leave neck out. And this patient's going to come back. You're going to have mass effect on the optic apparatus. And again, an ACOM is a very amenable aneurysm to treat open. And you can see here where here's the aneurysm all the way around here. What are these vessels on the aneurysm? What are those called? I'll buy lunch for anybody that can tell me what they are. Vesivisorum. So the arteries are the only, the arteries have arteries. And that's the vesivisorum which you can kind of see around here. So this is an optic nerve. This is an aneurysm all the way around here. And you can see the optic nerve here being splayed. So this is a very, very straightforward, clip straight down, very easy access. Everyone in this room has done this 100 times, a tereola. If not for an aneurysm, you've done it for a meningioma, a skull-based tumor, pituitary, craniopharyngioma, on and on and on. Another one, you'd be surprised at how many times you see people and just come to Jackson Hall trying to do something endovascularly with that. And almost always, it's someone who doesn't do open as well. This is, in my opinion, anybody that tries to treat this endovascularly is an asshole. This is just, there's no end point here. So what makes them an asshole? What trouble do they get into? Get a little more specific. I was about to talk about that, Dr. Arthur. Since you just came up, you see this, this is a wide neck dysplastic aneurysm. And this is actually, if you look at this interoperatively, this doesn't really have the appearance of a normal aneurysm. The whole ACOM complex is diseased. This isn't just isolated to this area. this whole thing, this whole segment here is dysplastic. And how are you, first of all, there's nothing you're going to be able to do with this from a straight clawing standpoint. You would have to stent or balloon assist. If you balloon assist, when you take your balloon down, you've now got this whole complex where everything is just going to plop down on you. And again, you'd be surprised that there will be people that will tell you that they'll treat this endovascular and actually you see the cases. This is 150,000% an open surgical aneurysm. So it's very wide necked. There are important perforators that come off in that area. And it can be easily accessed and clipped, right? I run into that exact same situation with basilar apex aneurysms. Not infrequently. It's not an every month kind of thing, but you are going to find broad necked, narrow I'm blinding him with my laser pointer. Basilar apex aneurysm. No, no, listen. It's okay to disagree with you occasionally. I'm not saying to disagree. I'm trying to stay on time. And we'll get into that. I'm going to show the basilar. And in case you can't tell, Adam was trained by a radiologist, so you can see he's. Which makes me more apt to clip basilar apex aneurysm. No, which makes you more apt to stick something in here. To Dr. Arthur's point, those are exactly the reasons why. The perforators are clearly one issue, but I think for this even, I mean, we do this all the time. If this was a smaller aneurysm and it had a neck, right, we would go ahead and we would coil it. But it doesn't. A lot of people. But it doesn't. It's dysplastic. And again, this is not a saccular aneurysm. This is a dysplastic aneurysm where the entire complex is diseased. And oftentimes, surgically, what you can do, and sometimes you have to do, is you take the whole ACOM complex. You literally, you just, you put two clips and you take it, and then what do you do in the operating room to make sure everything's okay? I'm hearing it at a very low muffle. You're doing an angiogram, yes, for sure, but what specifically do you have to do? To do both carotids, right? You're going to inject both carotids because you want to see A2 filling beautifully from this side because it's not going to cross fill like this, right? This is one injection that we're getting a nice circle of Willisogram here. You're going to have to go into the contralateral, and you're going to have to make sure this A2 independently is filling, and you can do it all the time. Now again, you have to, I can tell you there's not going to be any perforators here for the most part. Why? Because this whole vessel's dysplastic, and generally you don't see this. It's almost this pseudo-aneurysmal formation. And again, this is a straight seven millimeter clip. It's a pretty straightforward case. You can see there's no endovascular approach that's going to give you that type of... So I'm sort of coming around to your interoperative angiography view. You'll be happy to know I'm evolving on that. He used to fight me tooth and nail on that. There's no opinion I won't change. But the other thing that's kind of fun to do with those ACOMs is to put a temporary clip on an A1 and start your ICG injection, and then remove the temporary clip while you're doing ICG and watch it. Because actually you can really see a lot of flow patterns with that. So explain that. Explain that to the... So one of the nice things in surgically approaching an ACOM is to have a little bit of a discipline of thought. One of the things that I think happens to us in the OR and in the angiosuite is we get hypnotized, and you'll see it at various stages, right? You're watching someone split the fissure, and they'll get hypnotized by the superficial dense arachnoid and start working on that instead of actually getting into the fissure. They'll see an aneurysm and get hypnotized by the dome and start screwing with that instead of getting proximal and distal control. And with an ACOM, what you need to do is come across low in almost every case and get your contralateral A1 first. And there's nothing wrong with putting a temporary clip on that contralateral A1 whenever, whenever you see it, as long as you've got a good ipsilateral A1. In fact, that allows you to have great control in the event of a misadventure. Then you can finish your dissection, contralateral A1, ipsilateral A1, contra A2, ipsi A2, Huebner's on both sides. Once you've got the aneurysm clipped, you can inject ICG, watch it coming in through your ipsi A1 and filling ideally both A2s and your Huebner's. And then while it's injecting, you've got, you know, 30, 45 seconds of ICG. You can remove your temporary clip from your contralateral A1 and plunk it down in your ipsilateral A1. And then you can see how that aneurysm complex fills from the other side. It's an interesting way to play with. I think there's, you know, we often, there's no question there's more new technique and technology blossoming in endovascular than in open, but that shouldn't be used as an excuse not to think creatively about what we can do. And there have been times, and this is only something I've started doing the last couple years, where I've learned a lot by changing clips during ICG injection, which is not to say there's no value to interoperative angiography and ICG is everything. There's also even the color ICG, which I haven't learned anything about, but there's some good stuff in the literature about that, too. Yeah, no, absolutely. And I, just as a practice, I mean, I always will, before I let the fellows even touch the aneurysm, they have to find ipsilateral and contralateral A1. They have to find that before they even start dissecting, and I often will trap, especially in a subarachnoid hemorrhage. I'll put temporaries on both. So, yeah, no, it's a good point. So, here's a... Well, there's a question if you do that even when you have hypoplastic A1s. And that's another, I think, important point, is we will often say an artery is missing or hypoplastic angiographically, and then you go in the OR, and it's almost always there, right? I've seen a ton of angiograms with no A1 on one side. I've never clipped an ACOM and literally seen no A1. I've never seen it. Maybe there's somebody out there who doesn't anatomically have an A1, but I've never met them. And most importantly, talk about the time that the aneurysm dome ruptures, and there's no A1, and you have a temporary on the one that you think is there, and there's blood coming out with the same flow. Right. Angiography is not reality. So, hypoplastic one, absolutely, because hypoplastic A1s can give you a lot of bleeding. I have a whole series of cases that will show when you take the ACOM complex, and there's no A1 on the other side, or it's very hypoplastic, it becomes robust. We can't forget, arteries are dynamic. We're not looking at a glass tube. It's not like looking at a model on an angiogram or a picture, right? There's muscular layer there. So just like they go into spasm, they can expand, and you get adaptive narrowing when you have a severe carotid stenosis, the same happens up in the head. So here's the way that you have to kind of, you know, again, this kind of comes into having all the tools. So a 38-year-old lady with a family history of subarachnoid hemorrhage, heavy smoker, elective grade zero. She has this on her right MCA, and there's basically three separate aneurysms here. And you can see this kind of at the bifurcation, these little kind of nubbins down here with these branches. And so I don't think there's many people that would argue that these shouldn't be clipped. There's really not much you're going to do endovascular there, particularly with the size, the shape, but also the number. Another one that I will take to the OR is when there's multiple aneurysms on one side. The longer you're up with wires, the more you're up there, the higher your thromboembolic complication rate gets, especially if you're going to do multiple aneurysms at one sitting. In the OR, you're there, you have everything laid out. And that's not to say that the morbidity, actually, Bacher showed this years ago that, you know, each aneurysm you clip sequentially in the same sitting, the risk goes up. If you have something like this and they're all in the same branch, I think it's fairly low, you get all three of these at the same time. She has this on the contralateral side. So what's the thought process here? How do you attack this? So the right side, non-dominant hemisphere, we have these that need to be clipped. And then we have the left side. We have this kind of pear-looking thing here coming off the anterior temporal artery. So the thought process here was clip these, and then she's going to come back another day for this. And this one is probably more amenable to endovascular. So we clipped these three, went very smoothly. This is an interop angiogram showing that everything's gone, that little branch is coming off normal. This is what the clips look like. It's AP and lateral. Well 48 hours, she's ready to go home, and she screams and has the worst headache of her life. Here's our craniotomy site. And what does she have here? She has subarachnoid hemorrhage in her sylvian fissure. So the other one, this lady has no luck. So she bled. She was a grade one. She still had a bad headache. So now what do we do? So you have that pear-looking thing. She just had a clip on the contralateral side two days ago. It's her dominant hemisphere. Go back and clip or coil. Well, this is one that is perfect for coiling. I don't have to put a stent or anything. And so we went up and we did an endovascular approach here. Because you don't want to do a craniotomy on both sides of the head several days apart. Now if this was wide-necked, it would change. Why would it change? If I have to put a stent up there, how does it change my thought process? We've got to give her anti-platelets. We have to anti-coagulate her. She's from a fresh craniotomy. So you kind of have to be able to use the tools at your disposal. And that wasn't the case. And this was an acute subarachnoid hemorrhage. We wanted to try to get her out and just recover. So now to a basilar artery. So here's something. Here's a wide-necked, very nasty-looking, Hunt House grade one, again, 73-year-old, very healthy, was gardening, had the worst headache of her life. This is just a nasty aneurysm all the way around. These are aneurysms that, and it's not posteriorly pointing, stent, you can see we actually migrated the stent. And this is the first generation of neuroform. Here's our microcatheter in the aneurysm. And by going up with the stent, going up through the microcatheter, we kind of pushed the stent up and it migrated across. And we actually turned out to get a beautiful result. And this is something that we said, huh, because when we're coiling basilar aneurysms, we're only occluding half the neck. There's this false sense of security that you're basically, you can just start packing. You're not. We put a stent up. Unless you're doing a wide stent, we're really protecting 50% of the neck. If you can get across to PCA to PCA, which is ideal, now you've got this kind of barrier going all the way across and you can aggressively coil these and you get a very nice result. Nothing's going to fix this part of that P1 in the OR or anything else. So our goal in a 73-year-old is to protect the dome. That's where she bled from. So that kind of gave us the idea when we started looking at these wide necks and understanding our angiography. So here's a wide neck basilar. But if you look at her carotid run when we were doing her four vessel, look at this pipe she has. It's this beautiful, short PCOM. So we're going to use that to our advantage. So we can go in through the carotid artery and the anterior circulation, take our catheter or stent through the PCOM anteriorly and cross. You can see the outline in the PCAs and here's the basilar. So through the carotid, through the PCOM and what we can do is now you can see the stent coming out and we can very easily, especially with a second and third generation, this is a little more difficult to do with a first generation neuroform, but now especially with the EZ coming out, the Enterprise, much, much easier to use and navigate. You just drop this right here. We won't go through the whole video of it coming out and then you get this nice, beautiful cross coverage. There's no better neck coverage than that. It just doesn't get any better than that. And now, look, I mean, this is like taking a candy from a baby. There's really not a lot of mischief you can get into. Now you can just pack this off and not worry and you can get a very nice result. So that's from the posterior circulation. Now let's, these things, here's another one. Here's an MCA artery aneurysm. So this is an MCA, elective one, we just did a couple weeks ago. You can see, look at this anatomy. How are you going to get, first of all, coiling this, you're going to have to leave neck out. And again, you're getting into a bifurcation with very small branches. These aren't big PCAs coming off. You're going to get into a very high rate of thromboembolic complication rate of losing one of these branches, a superior or inferior division. And putting a stent up here just is not reasonable, especially if you can see the takeoff. And again, this is a little wider than it appears on here. So this is an aneurysm, again, in my mind, getting back to MCA, that you really, really want to clip. And this doesn't project well, but this is that aneurysm that's kind of an oval. It's like this, looking straight at you. So when you're in your about 30 degrees turn for your tereonal, the aneurysm is coming right up at you, and the branches are tucked beneath. So this is a great, great technique that I use all the time now, where you just stack aneurysms. You get your blades, and you can place your blades directly along. So here's the aneurysm. And you just start stacking your clips, and as opposed to having to kind of come around and blindly see where the neck is and the branches and the perforators, you come down and you get your tips coming right up to that bifurcation. And you can place them within a millimeter to get a really, really pretty picture. And almost always, you get these perfect, perfect pictures. Don't get stuck into this idea that you have to have one clip. You know, it's like there's some prize for putting one perfect clip. There's lots of different shapes, sizes. There's fenestrated. There's 90 degree angles. And keep it simple. Your goal at the end is, when you shoot your angiogram, is to have 100% occlusion of the aneurysm and having normal filling of all your vessels. So I'm just going to get into the kind of last category of aneurysms that we clip. So this is a 40-year-old guy who came in with a hypertensive hemorrhage. That's how it was billed to us. And we started looking at the films in the morning. You can kind of see this rim here just didn't look right. So we actually ended up doing an MRA, which was essentially normal, and we did an angiogram. And what you see here is basically a giant thrombosed ICA bifurcation aneurysm. The problem is he had hemiparesis. So this is something that, from the mass effect and just from the edema from the thrombosed aneurysm, he was getting compression with the hemiparesis. And you can see, here's the inferior aspect of the aneurysm filling here. And then this is the outline of the aneurysm. There's really not a lot you're going to do here endovascularly. And even if you can kind of define the neck, this is a thrombosed aneurysm. What's going to happen? What are the two big risks with treating coiling, stent coiling, or even doing a flow diversion for a large thrombosed aneurysm with mass effect? So one is, what are you going to do when you go up with a micro catheter and you start putting coils in there? It's like roto-rooter. You're going to start kicking all that clot out, and you're going to have a high risk of thromboembolic complications. But also, what else is going to happen? You're going to basically add to the mass effect, and you're going to be back in a month, two weeks, recurring. Because as that thrombus resolves, as it will, especially if you anticoagulate, you're going to keep treating these, and treating these, and treating these, and have a very high recurrence rate. These are aneurysms that need to be clipped. And a lot of times, they're a pain in the ass. So this is a guy who's 40 years old, and he had the arteries of a 90-year-old. I mean, come all the way up, even approximately, everything was just rock hard. You can see all this atherosclerosis. Atherosclerosis. And again, what are these little vessels on the artery? Basal vasorum. All right. So you learned something. And you can just see, this is kind of dissection. So what we had to do here was literally cut, you can see, look at, here's all the lenticular strides. Look at these perforators. So we had to cut the dome of the aneurysm open. This is, we're kind of going all the way down, and the dome of the aneurysm is coming all the way down into the, immediately into the basal ganglia. So we had to open this up, and then basically coosa out the clot. And then we got enough of a bind. Here you can see the bottom. You can see all the way the bottom of the aneurysm from inside. You can see the calcific rim. And once we got enough tissue together, we could reconstruct it. So that's kind of an outline of what we look at. So in summary, it's really ACOMs, MCAs, wide-neck subarachnoid hemorrhages, aneurysms with thrombus in it, large aneurysms. Those are the ones that we think about from an open standpoint, and again, you need to learn these techniques because they're not going to go away in your lifetime. And there's fewer and fewer cases, so you really need to get comfortable doing them.

aneurysms

clipping

coiling

endovascular procedures

ISAT study

ruptured aneurysms

decision-making process