All right, well, welcome, everybody. As Adam said, this is really going to be an informal, but I want to be interactive. And I can't emphasize enough, this is really a fantastic course, and I think it's one of the best out there. I wish, you know, when I was way back, I have more gray hair on my head than probably most of people in this room, but we didn't have anything. I was one of, I think, maybe five or six neurosurgeons who did endovascular, and so it really wasn't much in the way of anything that was hands-on. It was pretty much, you know, you can't do both. You have to do one or the other. You're a neurosurgeon. Why are you doing endovascular? So this is a great course, and I would urge all of you to really take advantage of it. And when I say take advantage of it, meaning, you know, challenge us. Challenge the faculty. Ask questions. We're here for you. You're going to be, the models that you're going to see over the next couple days, in particular on Saturday, are fantastic. And you're going to be one-on-one with faculty, world-class faculty, who will, oh, wrong one. There we go. So you know, really push us. Ask questions. If you don't understand something, if you want us to show you something on the model, if you have a question during the didactics, raise your hand and ask. So tonight, what I want to talk to you about is really, and kind of coming the full gamut, and have been doing this for a little while, is we really refer to ourselves now as comprehensive. And I think the future really rests on all of your shoulders to kind of take things to the next level, to continue to advance and to continue to take this field to the next level. I think this is one of the most exciting times to be in neurosurgery, and obviously I'm biased, but I think to be a cerebrovascular and endovascular neurosurgeon, what we refer to as comprehensive, which there's an energy group which kind of came up with that term, because we're not really open, we're not really endovascular, dual-trained kind of, it just doesn't fit. Comprehensive fits. So there's no more, there shouldn't be any more discussion ever about CLIP versus COIL or OPEN versus endo. It's comprehensive cerebrovascular. You have all the tools at your disposal to treat the disease. These are my disclosures. The biggest one is that I'm biased. We all are. Everybody gets up here, and we're biased based on our training, we're based on our practices, based on what we see, based on what we're comfortable with. And I think this kind of summarizes where we are. If you look all the way off to the left, you've got two ends of the spectrum. You've got the blind of people, you know, the earth is flat, and I don't want to question it, and this is it, and this is the way we've always done things, to the reckless, where, you know, if you look at the timeline of technology, kind of jumping into technology and taking it to the air before it's ready. If you look at the great minds of the past and the present, and hopefully the future, they can take from both. They can take from the past, they can take from the future, and they can take what they have in their hands right now, technology, and then do something great with it. And to me that's really, that I think is where you guys should be thinking, and, you know, we all want you in that middle part, to be able to learn the basics, learn the foundation, learn the fundamentals, but then look ahead. And I'm going to kind of go over that tonight. And in no way, in any way, shape, or form is this any type of neurosurgery is better than radiology. This is from several years ago. Alex Berenstein, arguably the father of modern endovascular neurosurgery, I'm kind of a grand kid of his. He trained Robert Rosenwasser, who trained me. John Barr, radiologist, two radiologists, brilliant minds, great people, great teachers. So this is not about us versus them. And this is Adam's brother, no. This is, this is a, this is, this is why we're all here, because this is a guy smoking cigarettes outside of Baptist Hospital, which I still can't believe, Adam and I were, a couple years ago we were, I came to the hospital, we were doing something, I was driving out, and the guys were like smoking cigarettes, literally right out in the street. So as long as there's people like this and there's Memphis, we're going to have patients. So God bless them. So you know, you are a specialist of the disease, and it's really important. Not the procedure, not I can clip an aneurysm, can treat an AVM with open surgery, or I can coil an aneurysm, or I can use a pipeline, or, it's a disease. And that, that's really what, what you have to keep in mind, is it's a specialist of the disease, not the procedure. And all of you in the room are the only one that can do this. As a comprehensively trained vascular neurosurgeon, you're the only one that can do and treat the whole gamut of the disease. And that's, that's something that, you know, I think why most of us went into neurosurgery. So you know, a comprehensive neurosurgeon, or again, a cerebrovascular comprehensive, you do open vascular surgery, and that's all aspects, bypass, AVM, open, carotid enderectomies, spine, AVMs of the spine, fistulas of the spine, endovascular surgery, again, the full gamut, radiosurgery. You should be able to look at an AVM and think about all the tools that you have at your disposal. A micro catheter, scalpel, and radiosurgery. And you should be able to do all of those, or at the very least train in all of those so you really understand them. And then critical care. It's one that we forget about. You can't have one without the other. You have to be able to do the full gamut of critical care as well. So you know, hopefully this isn't a discussion for any of you in this room. I don't, I'm, you know, I used to say this and I got criticized a lot for it, but I don't think anybody questions much anymore. If you're going to go into vascular neurosurgery, you need to do both. Period. End of story. There's just, you will be obsolete by the time five or ten years come out from your training. You have to do both. And let me see by a show of hands, how many of you are doing rotations in endovascular? Or during your cerebrovascular rotation, you actually spend meaningful time in an endosuite? Yeah. We could have asked that question four or five years ago and maybe two or three people would raise their hand. So it is now part of the core curriculum. So just like when I was training, doing spine instrumentation was kind of an orthopedic thing and, you know, it was this hybrid, yeah, that's how old I am. For you guys for vascular, it's the same thing. So what I want to do is get you guys jazzed about what this specialty is and what you can do with it. So right now, specialties performing endovascular, obviously neurosurgery, neurology, which is fairly new, radiology, cardiology, yes, yes, our colleagues in Buffalo, and believe it or not, emergency medicine. There's a faction of emergency medicine physicians who want to start doing this. So it's definitely opening up. And guess what? They're doing it everywhere. The days are gone of you just do this in academic centers. This is being done everywhere, private, academic, and then private-demic where there's kind of hybrid programs which are becoming more popular. Now if you're a open vascular neurosurgery, to put this in context, this is your disease. This is your disease that you can attack. Aneurysms, AVMs, open carotid surgery, and then basically hemicraniectomies for your partners at 2 o'clock in the morning and on Saturday and Sunday, particularly your endovascular partners who don't do open and, uh-oh, the brain's swollen, I'm going to be at my son's soccer game, but I think the guy really needs his lid popped. This is what you are as a comprehensive vascular neurosurgeon. Intraarterial stroke, intracranial stenting, extracranial stenting for carotid vertebral artery disease, provocative testing, we're going to talk a little bit about what that is, tumor embolization, angiography, all aspects of angiography, both cranial, spinal, doing WADA testing, kyphoplasty, vertebroplasty, and then angioplasty for disease and for acute problems like vasospasm. And one of the things that I want to challenge everybody with in this room is that we need to take the technology we have, the devices we have, and do something better and more meaningful. Because if you think about all the technology that we have, and you're going to see over the weekend, in the next few days, all the things that we're capable of and the tools we have, what do we do with these tools? We're fixing bumps in arteries and abnormal connections in arteries and unclogging pipes. That's it. It's kind of limited. There's a whole world of what we can do. Blood vessels reach parts of the brain that we could never get to before. So you have to kind of open your mind to that, and I'm going to show you some cases of some things where we're starting to do that. So let's look at some cases to kind of put this in context. So this is a 80-year-old woman who comes in with this, completely physiologically a 40-year-old. She has no medical problems whatsoever. She's actually still working. She actually looks like she's 60, and she's a grade one subarachnoid hemorrhage. So she's in really good shape. She basically has a bad headache, believe it or not, with this. So what are we going to do? She's pretty concerned about a vascular problem here, right? This isn't a subdural. This isn't traumatic. So she needs an angiogram. So this is a 3D. That's a real problem. That's not something that's easy to fix. So you've got an older patient. Yes, she's healthy. You've got a very dysplastic calcific vessel. Do we have any ... Oh, here we go. And you can see, here's a carotid ophthalmic. This is a carotid artery. You kind of see a little bump here, and then you see this whole circumferential pseudoaneurysm. This is pre-pipeline, and even then, this is a flow diverter. This is an acute subarachnoid hemorrhage. So we're not really going to be thrilled about anticoagulating this patient. So what can we do? Can we do open surgery? We can. It's going to be morbid. And don't let anybody fool you that, well, you can do this. This is a morbid procedure in someone this age, 80 years old. And in a 30-year-old, this is not something easy. It's very proximal to deal with, and the whole vessel's diseased all the way up the MCA. So the tools we have now, we can do things and think outside the box. This is not something we're just going to send home, either, and let this go away. This obviously has to be treated. So one of the things that we started doing, and this was at the time, was Onyx 500, which is basically a form of a glue and a polymer. And so what we were able to do is blow a balloon up in this vessel with a micro catheter trapped in here, and then inject this glue, which circumferentially kind of fills all the nooks and crannies in the disease, leaving the lumen open. And when we deflate our balloon, you can see that we have a nice picture. There's this, which is this up here, which we're not going to do anything with. There's our PCOM, still wide open, and we've completely treated that circumferentially. These are things that we can do to think outside the box. If you only have one tool, then you really only have one option, which may not be the best thing for the patient. So here's a case we did actually, what the hell is it today, it's Thursday, I think Monday, I don't know what the day is. We did this a few days ago. So this is a young 34-year-old woman with a vertebral artery injection. What do we see here? Shout, anybody. What do you see? What is this? A? There we go, good. Good for you. ABM? And what about this, what's that? It's not a trick. What is that? It's a big blister, it's coming off an artery, what do we call that? An aneurysm. So she's got an ABM and an aneurysm. So what of these two is the most dangerous? What's the one we worry about more, the ABM or the aneurysm? Aneurysm, exactly right. And particularly in AVMs, because these are often coming off the feeding pedicle, which have a higher pressure. So where is this coming off of? It looks like it's coming off the SCA, and that's right. However, it's really not that clear. If you look at kind of an early arteriole, we see the SCA coming here, and then we see this kind of anterior temporal branch coming off of this P1, and this is early, you're not seeing the ABM fill quite as much. So how can we sort this out? Because we need to understand our pathology, right, before we can decide are we going to do an open procedure, are we going to do an endovascular procedure, or are we going to do nothing? How can we sort out where that's coming from? What's that? Yeah, so you can do a 3D, which you should always, always, always, always try to understand with looking at your views. Because the 3Ds can be very, very deceptive, and especially the younger generation relies on this way too much. But it's a great tool, and so here it is. So this is a little busy, and here's the basilar artery. We're looking sub-metal, we're kind of coming up from below. Here's the basilar, here's that PCA, and then here's the SCA coming off. So is this aneurysm coming off the SCA? No. So it's coming off of this mess somewhere around here. So now how can we figure it out? We're still spinning it around, and we can't really 100% tell where the neck of this is, the vessel it's coming off of, and what that neck looks like. So what's another way we can sort this out? There we go. Good. Selective angiography. So we can do, this is kind of their gross view at 30,000 feet. We can get a micro catheter up here and start doing micro injections, and there we go. So here's our micro catheter, and here's that aneurysm filling off. So where this is coming off of is that, this is kind of a dysplastic origin here, and it's coming off of this anterior feeder branch going into the AVM, and there's just a wide dysplastic neck. So that's the run. So what are we going to do here? What are we going to do with this? And there are some normal branches coming off of here, going to some pretty critical areas. So what can we do with this? Well, there's a lot of different things. We can take them to the operating room, and we can map this out. Not really going to want to get into a brain stem AVM in the OR. We do need to treat the aneurysm. So you could make an argument to go in there and clip this and try to reconstruct this, leave the AVM alone, do something different with the AVM. What do you think the odds are that you're going to keep that branch open with doing open? Not very good. Or you're going to leave a lot of it out. So once again, what we were going to do is put some quails in here, and they prolapsed out. What we ended up doing was, again, putting just regular onyx in here, 34, and we were able to embolize the entire aneurysm and keep the branch open as well. So now we can attack this with radiosurgery. Again, when you're looking at these things, you have all the tools in your disposal. So you're thinking of everything, not just, well, what can I do from an endovascular standpoint? You're thinking about radiosurgery. For this case, I want to get this smaller and then do radiosurgery. And if you do all those things, you have a much better understanding of what your end goal is. So here's a 25-year-old who comes in with this acutely, is hemiplegic and a little lethargic, but is otherwise awake. So what are we thinking here in a 25-year-old AVM? 25-year-olds generally don't have this unless there's cocaine abusers or there's some type of... It would be very rare for this not to be an underlying vascular etiology. So what are you going to do with this patient? They're in your ICU. The family's there. You're talking to them. What's your plan? What's the first thing we need to do? You think you're going to do anything with an EVD with those ventricles? You're thinking in the right way, but most likely this patient has to go to the OR. We know they're going to the OR. There's nothing that we're going to really be able to do with this. But before we even start thinking about what we're going to do in the OR, what do we need to understand? You need a vascular study. And whether you get a CTA first or do an angiogram, what I tell you is when you have all the tools, you're going to lean towards angiography a lot more readily, especially now when you have hybrid rooms and things like that. But I will tell you, it is a very bad idea. And don't ever, ever, ever do it. You will. I did. It's just part of it. You'll do it when you're young. You never go into a lesion like this without knowing what you're getting into. And oh, it's a PCOM and a C. Always have a very, very good understanding so you know what you're getting into and you always have a backup plan. So as a vascular neurosurgeon, you're going to consult an interventionist. You have to. You're going to have them on standby. You're going to want an angiogram, even if it's after, even if you get a CTA and you're happy with what that looks like. And you're going to kind of have this back and forth. You have one tool, and you're going to use that one tool. You're going to take them to the operating room after you get your study. And then you're either going to say, I can take them to the OR or I can't. If you need to do something endovascular, you're going to have to talk to someone else, consult with them, convince them to do something. And I see nods in the head for programs where there's a neurosurgeon and there's an interventionist. And you're not going to use all the tools available. And this idea of this collaborative discussion, yeah, that works great when you're in a multidisciplinary conference for elective cases. It doesn't work so well when it's Saturday at 9 o'clock at night and you've got this kid sitting there. It's much better to be able to do everything yourself. So now you and your duly trained, comprehensively trained, and assuming you are well-trained and this is a big, big caveat. All the things we're talking about, this takes time. These aren't weekend courses. This isn't I'm going to spend six months somewhere, I'm going to go down in a lab and do. You have to dedicate to really, really understand how to become an endovascular neurosurgeon, which happens after you learn how to be a cerebrovascular open neurosurgeon. So you have this. So this is a patient that we took to the operating room. And we have a hybrid suite, so we can do an angiogram and see what's here. This patient needs a craniotomy to get this hematoma, but we want to see what we're getting. This is an angiogram before we open the head, and you can kind of see there's this, and then there's these kind of little feeders coming deeper in. So our first goal is to open up the head and take out this hematoma, which we did. We started to resect. We started to get into the proximal nidus, and then it started getting deeper and deeper and deeper and deeper. And then we encountered this, and then on the backside are these really, really tiny little fine vessels, and they're kind of going deeper and deeper and deeper and oozing and oozing and oozing. So at this point, we have two options. We can just keep going, which is, you know, if you're nice playing, you don't have to really get scared where you are. Usually the AVMs will have, especially the ruptured ones. We're starting to get deeper and deeper into his basal ganglia, and we're starting to get oozing. We don't have that great of a feel. This isn't profuse bleeding. This is just kind of annoying bleeding that's getting deeper and deeper and deeper. So what can we do here? You keep going or what else can you do? You guys said it before. We can go up. We're on the table. We have a groin sheath in and we have a hybrid suite. So what we can do is go up and do a roadmap and do selective injections. And what we found was basically this kind of nidus up here, which really because there's still some edema beneath and above, and then this kind of large venous varix. So we did a microinjection and basically saw the entire pathology. So we just casted it. Again, this is a patient on the table, heads open, everything's stable, and there's our cast. So we basically took care of it and we were able, without having to go any deeper, take care of that. So now we start with this. We have this embolized. This was all about literally 20 minutes from the time. This is not a hard catheterization to do. It's not a question of it being a difficult surgical lesion, and this is about two weeks later. You can see that there's no hypodensities here. And I think doing this open, this guy would have had a stroke in my hands. He would have had certainly at least a lot more edema. Because when you start losing visualization, the deeper and deeper you get, that's where you can use both of these tools at your disposal. And that's the beauty of it. It's not a big cumbersome thing. You're there, you're ready to go, you have a catheter in the groin. And this is the neurosurgeons, the comprehensive neurosurgeons operating room. You have, and if you don't have this, you have a C-arm. And you can use that C-arm for whatever you need from a vascular standpoint. And I'm not talking about that you have to embolize every single AVM in the operating room, but you have another tool that you can use. And I do strongly recommend doing post-op angiograms in the OR and everyone else. The other thing you can do with these tools, here's an ACOM we clipped a couple weeks ago. You see there's some thrombus in here at the bottom. We did a clip, and then we can do a 3D spin on the table. It's the same room. We just step back, bring in the lateral arm, and you can see there's a little nub in here. There's a little remnant that probably wouldn't have seen on the raw 2D. So you can do subtraction angiography and take the clip out to give you a better visualization. Again, this doesn't add a lot of time, and you're there already. So what's the next big thing? So this is something that we really want to impress on you, is that stroke is a surgical disease. And I can't emphasize that enough. And I think someone's talking on that. Right, Adam? I think the title is, Stroke is a Surgical Disease. What's that? There we go. So no matter how much you hate stroke, if you hate stroke, it doesn't matter. This is part of the disease, cerebrovascular disease and stroke. And let me tell you something, folks. This is how many aneurysms, between 30 and 40,000 aneurysms diagnosed a year are treated. There's a lot of places doing this. We're approaching a million strokes a year. So you have to start thinking about this as a surgical disease. What is this? Hyperdense MCA sign. This is the equivalent of a head trauma in the emergency room with edema that's expanding by the hour. These are patients that are about as acute as it gets. They're more acute than subarachnoid hemorrhage. When a subarachnoid hemorrhage comes in and it's stable, do we go in the middle of the night? No. Those are patients that we generally do the next morning if they're stable. We don't do that with stroke. This is a time-sensitive disease and the outcomes and the difference is huge if we can get to these patients in time. And there's really only one way to get this out. And there's one way is a surgical. And IV tPA is always the first line. We'll talk about that. But this is a surgical disease. And whether you're using, this is probably something that will be in the past, but our strength retrievers that we're using now, and we're going to use those down in the lab. You'll see them. This is the same save as putting a ventriculostomy in somebody with a blown pupil or taking out a clot from a ruptured AVM or ruptured aneurysm. Understanding what your angiography means, what it looks like, how to use it, how to use it not just to treat but to diagnose is also critical. And it's a part that will set you apart from the rest of the surgeons who don't know how to really, you know, you can read angiograms. When you do your own angiography, when you do micro injections, when you understand the views that you need to get and you also have that part of your brain that is thinking in the operating room of what view you want and what this looks like because you're constantly seeing this, but you're visualizing what this looks like in real time in a craniotomy. So this is a 67-year-old woman who had a subarachnoid hemorrhage 20 years ago in Russia. And back then they basically stuck you in a corner and closed the drapes and it was quiet and either sank or you swam. It's true. That's actually what we used to do in this country a long time ago. I guess maybe some places still. But she came to the States. Twenty years later, a primary care doctor heard this story and said, yeah, you probably should have a study done. That doesn't sound good. So she has this big A-cum. So this is, what are our options here for this? Grade zero. She's a cardiopath. She's a pretty high surgical risk. She's got three coronary stents. She's on Coumadin, COPD. She's a big Russian lady. No neck. What are our options? There's two options. There's three options. Follow it and say, the Lord saved you back then. Let's continue to let the Lord save you. The other option is open and the other option is endo. How many people would try to do something endovascularly with this? There's no wrong answer. How many people, okay, I've got a couple of hands. How many people would do this open? How many people want more information? There we go. Everyone's hands should go up with that. Okay. So if you do your native run, now here's a 3D and you get volume averaging and you start looking at what are these little nubbins, you start to see these branches coming off the back and these aren't Huebner. So you see here's A1 coming in, A2. You kind of see this little A2 on the contralateral side come back. It's really not clear. If it's not clear, you cannot treat endovascularly. You have to 100% understand what you're coiling, what you're gluing, what you're diverting with a flow diverter because there's no going back. Once you put coils in here, once you put anything in here, you put a stent across, that's it. There's really no going back and you start losing these vessels. You're behind the eight ball. The goal of having great outcomes is staying out of trouble like everything in the basic tenet in surgery. So because of this, I didn't know what the hell I was looking at. So you know what? Ludwilla went to the OR. And I'm really glad that I did because this is what this thing looked like. And you can see here's kind of inflow, outflow. This whole thing, not that this is any picnic, all this yellow is calcification. But if we coiled this, these are gone and her leg is gone. So in the OR, what we have is we have the ability to look at the anatomy and reconstruct vessels. And we also have the ability to do an angiogram. And if we don't like something or we start getting changes in our neurophysiologic monitoring, we can take a clip off, reperfuse the brain, and reposition it. And that's a luxury we have. So this is something that we had to get a couple clips on. And you can see here, see how those clip blades are splayed like that? It's because this is just this calcific tissue coming together. But you can see we got a beautiful result. We're able to spare all of these branches because we could reconstruct this. This is a woman, a young woman with a carotid ophthalmic artery aneurysm. What's this notch right here? What do you think that is? Well, I'll give you a little clue. She was losing vision. That's why she went to her doctor and he got a MRI and then got an MRI. So what's lying right across there? Optic nerve, right? So the carotid ophthalmic, she's losing vision. And you can see that the aneurysm is actually molding around her ophthalmic nerve, her optic nerve. So what are your options here? Is this something you want to treat endovascularly? Getting some nos, I'm getting some yeses. So if we're going to treat this endovascularly, do we want to put coils in there? No. What's going to happen with that? She's going to lose her vision because now you've got, there's always going to be some perianeurysmal edema. You're going to basically, these coils are going to push this aneurysm up and it's going to continue to push on an already angry and inflamed nerve. So flow diverters now, is that an option? It is. Flow diverters are good options for aneurysms with mass effect. But you have something small like this and if you have somebody who's acutely losing vision, it's probably a good idea to do open because you can immediately decompress the vessel. And that's what we did here. And you can see this very thin, there's the optic nerve. You can see how it's just completely splayed over this ophthalmic aneurysm. And actually what we were able to do is to deflate it, get a clip across it and then just do suction irrigation to deflate. And this is just, I'm not going to go through the whole, we love showing ourselves operate, that's like one of our, but this is just to show you where the optic nerve is here. You can see the aneurysm, we're seeing the neck. What we did is we went in with a spinal needle, popped this after we had a clip on the base. So that's vascular. And we can sit here and you'll, there's, obviously we can do a whole weekend and a lot of this is. But the tools we have now, we have to start thinking outside the box. So one of the things that we started to look at is why can't we attack other diseases? We can get everywhere in the brain. We can get into the thalamus, we can get into the caudate, we can get into the posterior circulation, we can get into the pontine perforators, right? We can perfuse with drugs, with catheters, with whatever we want. So here's a GBM and this is a young guy, has a frontal GBM, resected after radiation and chemotherapy. About six months later it came back, right? This is what GBMs do. And you all I'm sure have seen recently this young girl who basically committed suicide a couple weeks ago because she was diagnosed with a GBM. And everybody talks about, oh, you know, why don't you do that and fight? Everyone in this room, you guys have all been around long enough to know what GBMs are and have seen that and lived through that, that most of us are probably like, yeah, we probably would do the same thing in some way, shape or form. The point being, we really have done a crappy job of treating high-grade cancer in the brain, really crappy job. The outcomes really aren't much different from 50 years ago than they are today. Length of survival is a little bit better, quality of life is not. So this is this case, this is someone who's recurred. And what is this? That's tumor blush, right? Every GBM has this. Every single GBM has this. As a matter of fact, I'll never forget at one of the early, early Jackson Hole complication meetings, and I urge all of you to try to go to that. It's one of the best meetings out there as far as learning from other people's mistakes. And you see a lot of us and our colleagues and junior people, senior people go up there and show their worst mistakes and disasters so that we can learn from it. And I'll never forget this young guy who went up and showed a case just like this and embolized it and embolized it and took it to the OR and resected it and it kept coming back. And Robert Spetzler raised his hand and said, you idiot, that's a GBM, it's not an AVM. And that kind of always struck me and it was the first time I really saw an angiography with a GBM. So look at the route we have to be able to access this. We give chemotherapy through a vein that absorbs the body. A small percentage of it actually penetrates the brain. So look at this blush. This is a perfect roadway to treat this type of disease. So what we've started doing is using intra-arterial delivery of Avacin. Actually, John Buchvar, Cornell, is one of the first people to really start looking at this. And what we did is we actually got the first FDA-approved trial for an extremely high dose and to do it consecutively every three weeks for a total of six doses. And we also realized that Avacin's probably not the best agent. But I'll tell you something, we're seeing some unbelievable results this early. We have a 34-year-old guy who's undergone two resections, a STEP regimen, radiation, and despite that, over two resections and maximal medical therapy, he now has a progressive expressive aphasia and his, actually it should be right arm is going. And these are the patients that we really, this is what we started with. This is after a second resection and radiation and a STEP regimen. It's coming back. So we've all seen this and you've all seen it in clinic. What do you do with these patients? Is this really uncomfortable? Well, you know, we're going to stem the tide with Decadron and we're going to fight this and we generally push it off to our neuro-oncology colleagues. So this guy was a perfect candidate to start doing this. And as you can see, here's a craniotomy site and here's our micro catheter. Up here you can see the little dot and through this little micro catheter, through an SL-10, we can inject and find the pedicle. And what we can do now, and you can see this whole thing coming around here and all this little blush is that tumor and we can douse the hell out of this with the chemotherapy directly. This is what we started with and you can see it just melts away. It absolutely goes away. Are we curing this? No. Is it going to come back? Yes. But let me tell you something. There's no side effects. It's one day in the hospital and we're a year out with this guy. So this is what happens. The blood vessels, the tumor stimulates VEGF. VEGF is excreted, which actually stimulates the micro circulation, which then continues to feed the tumor so it's this vicious cycle. That VEGF that you see, when you see that edema and flare on MRIs with GBM, that's what that is. That's the VEGF within the parenchyma. And this is a tumor. There's that vasculature. The VEGF is excreted and then you get more vasculature. You get growth of the tumor. What Avastin does is it binds to the VEGF and then you interrupt the blood supply. So why not deliver it directly? Look at the edema. This is when he, this is that same patient. You can see this into the temporal. This is where he started to lose his speech and his strength. And you can see what we have now. And this was his last one when he finished the treatment. You can see that whole area there is pretty much, this is just kind of a surgical rim. And you can see the edema on the flare is pretty much gone. And these are just stupid PR thing. But you can see the point is that he's talking and he's walking and he's moving. This is, I know, it's embarrassing. And I usually make fun of my colleagues when they show these pictures. They're hugging in the halls. This is a 71-year-old guy. And I think this is the more dramatic. This guy had a resection and chemotherapy radiation. You can start to see the edema, which again is all VEGF. This is his last study. It's almost gone. And this guy's 18 months out now. So there's something here. But the point, the takeaway of this is start thinking outside the box. Start thinking about the technology that we have and do something meaningful with it. So with new tools and new treatments, we can actually create the future. Now this is a great, this is to me really what epitomizes what I'm talking about. This is a young girl from Uganda who has, as you can see, a very severe intention tremor here. And a colleague of mine sent this to me and said, was doing relief work there, and said, can you help this girl? She basically was a survivor of the genocide. She watched her entire family bludgeoned in front of her. And she was, because of this, since a child, she was an outcast. They thought she was possessed. The village kind of like pushed her out. She's just an amazingly sweet girl, 16 years old. So I said, there's nothing. I'm a vascular neurosurgeon. I'll talk to one of my functional colleagues. Let's get an MRI. We need to start with an MRI to see what's going on, because that's what they're going to want. Well, look what she has. She has a thalamic AVM, very racemic vessels. So we actually got a fund together and we flew her over. And the first thing we started with was an angiogram. And you can see, no big surprise here. She's got this kind of racemic, diffuse, thalamic AVM with multiple feeding pedicles off of the lenticular striates, some from the posterior circulation. So what we thought about here was, clearly this AVM is part of her movement disorder. And what we did was we did her awake and we did provocative testing. So the idea was, OK, what can we do for the AVM? Because this is certainly a problem. But the bigger problem for her was this movement disorder. And so what we did on the table, we kind of just gave her conscious sedation. Then we woke her up with our microcatheter placed here. And we did a selective injection with sodium amytol. And when we did this injection, she had her hands up and we kind of gave her something to point to. And she started doing this. And when we injected, her arm went down, facial, she went completely out. The tremor went away, but so did everything else. So we're like, OK, we can't do this. Because clearly, this is going to vital tissue. But we kind of whittled away. And we got into this pedicle and we did the same thing. And the intention tremor went away entirely. And she had no deficits whatsoever. So we went ahead and injected it. And we did these selective injections the whole way until we were left. We started with this and we were left with this little posterior thing here. We did a cyber knife and we sent her home. And we cured her tremor. Now, she's going to come back and hopefully this goes away. But that's something that we need to start thinking about. These are the things that we need to start doing with our tools and our technology. And not just looking at blood vessels as these things that get bumps and holes and can bleed, and plugging them and sealing them. We need to start thinking about the treatments that we can do. And there's a whole world that opens up. It's functional neurosurgery. It's neurosurgical oncology. It's vascular neurosurgery. And it's also one of the things, and I challenge, I want one of you people in this room to go out and do this, is I think that the big future here in functional neurosurgery is we don't use the word psychosurgery anymore. Chronic pain, depression, OCD. We're sticking needles and probes. The blood vessels can do the same thing. We just need to understand them and we need to have a better understanding from a functional standpoint so that we can deliver therapeutic agents to help with this. And so one of the things we're working on right now with the director of our pain program, Ricardo Cruciani, is to treat chronic pain patients endovascularly. So this is what comprehensive neurosurgeon is.

neurosurgery

advancements

tools and technology

aneurysm

chemotherapy

movement disorder

multidisciplinary approach