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And right. And so we're moving on to the Australia Asia and Africa section. Uh So, first of all, we have doctor Muse who's come over from Australia. Welcome, talking about hybrid cerebrovascular neurosurgery. Jack of all trades. Master of none. Yeah, Peter was actually with his 2011, 2012 and uh I had the pleasure of working with him for a short while, but he was the first trainee to break the Berlin Wall with neuro radiology. Yeah, and be allowed to perform procedures with them. You may be spared. The disaster of my talk was having some technical issues, loading it up. So just one minute. Okay. Um Sorry about that. Uh So good afternoon, I'm Peter Muse. Um I'm Australian neurosurgeon. I was here as a fellow in French between 2011, 2012. I currently work as a dual trained open and endovascular neurosurgeon in Canberra, Australia. Um And for those of you who don't know where Canberra is because it's the the unknown capital of Australia. It is actually the capital and it's located over here on the, on the eastern seaboard, uh about 200 miles southwest of Sydney and 400 miles north east of Melbourne. Um So my talk is a little bit in a different vain to all the one or the excellent talks. We've already heard that there's not gonna be any reminiscing or looking back. Um My talk is really an obtuse commentary on, on the international contribution of uh international reputation of French. Uh Because I think that when I was here, I became the first neurosurgeon to be trained in neuro intervention in French, a hospital and possibly the UK, I'm not sure about that, but that's not something you can do as a career pathway in the UK. Um However, back home, that's kind of what I'm known for is the person who went to, went to Bristol and learned your intervention. So what I really wanted to do was give a call to arms or an advert or a plug uh and see if we can come up with a way to change that in the, in the UK. So, historically, brain aneurysm management comprised really a choice between the natural history of the disease, which is pretty terrible or completely fine with not much in between or a progressive evolution of different surgical techniques until we entered the modern endovascular era at the very end of the 20th century and early 21st century accommodating in publication of two seminal trials that some would argue really was the end of open vascular neurosurgery as we know it. Um But um for my training you know, whilst the debate was clipping versus coiling, I would argue now that we're really in the, in the era of clipping and coiling. So we go ahead. Um And it's an unfortunate tourism that, you know, if all you have is a hammer, then, then everything looks to you like a nail. And for masters of either open vascular neurosurgery or endovascular neurosurgery or interventional neurology that's called here uh in isolation. Unfortunately, that can lead to uh at times unnecessarily invasive, aggressive or ineffective treatments being offered on patient's. Whereas if you're a dual trained neurosurgeon, you can offer both and you've, you've really got the whole toolbox available to you. So now not everything is a nail, you might see a nail in which case you can use a hammer. But if what you find is a screw, then you can drive it. Um And so what I was going to do, but I might skip through some of these um is just run through just a series of different middle cerebral artery aneurysms just by way of eggs. Um exemplifying the versatility of someone who's trained in, in both techniques. So these are all cases that I've treated in the last six months. So start with this young woman with the history of subarachnoid hemorrhage in the family incidently diagnosed to have to reasonably simple middle cerebral artery aneurysms. You could quail them with probably a balloon assist or maybe a stent assist. But a pretty significant recurrence risk. You could try and flow divert it and there'll be a lot of centers that would do these things these days, but we opted to treat it with a very simple old fashioned clipping procedure, two hours a day in hospital fixed and she knows that her aneurysms are treated. You have to wait a year for the 15% chance that the flow diverter doesn't work or, or wait and see if her aneurysm. Rikers. Um you know, she, she's done and dusted and she, she does have a small recurrence rate, but it's much closer to 2% than 15%. So a very simple case. Um on the other hand, you have this complicated calcified largely thrombo is irregular middle, cerebral artery aneurysm. That would be just an absolute bastard to clip. However, it's really well suited to a flow diverter. Um And we go to the next slide uh and just click on this. This is a movie, just start the movie. You can see the calcified outline of the of the aneurysm there. Uh it's not projecting very well, but already with the placement of the flow diverter. On the conclusion, angiogram, there's already stasis in the in the aneurysm. Uh next slide. And on the six month, Mr A, the aneurysm is gone with no ischemia uh and no symptoms. Uh This patient hasn't come back for his one year angiogram yet. So, so I can't show you those pictures next slide, please. Um take this uh this 72 year old lady who's obese. She's got a F she's got a few other medical problems. She's on anti coagulation, but she's found to have, she's actually um investigated for deafness and has a small acoustic neuroma but found at the same time to have growing bilateral middle cerebral artery aneurysm. So you can talk all day about whether, you know, the ethics are appropriate to treat electively treat uh aneurysms in someone who's in their seventies and eighties. But we're not allowed to have that discussion in Australia, just have to treat them. Um uh And, and she was terrified of aneurysm, so she definitely want to treat it. And so the thing that matters most in that sort of a patient uh is having the lowest possible treatment risk. And so for her left, sorry, her right side of aneurysm. I chose a good old fashioned uh coiling with no balloon assist, know anything else, you know, 2% ischemic risk. Um And FXC matters a little bit less in this sort of a patient. Next slide, please. Um Whereas her left side of aneurysm was a bit better suited for a web device which probably doesn't project very well, but if you just hit next, uh there it is. Um So next slide, we'll just skip this one again. This is just a six month Marae showing that aneurysm is obliterated, not to skip. Um This is a more complex aneurysm. So, you know, use some simple surgery here previously and and then some endovascular techniques. This is a slightly more complex middle cerebral artery aneurysm. Because next, um it, as you can see, it's got a sizable branch coming right out of the apex of the, of the dome of the aneurysm. And that's a problem from an endovascular perspective. You know, it's not suitable to any sort of coiling with that standalone or stand assist. Uh It significantly reduces the efficacy of flow diversion um and also increases the risk of ischemia in that branch. So this lady um took many, many opinions from different surgeons and interventional radiologists around the eastern seaboard of Australia. But what we ultimately decided to do was basically to uh just go next. Uh things aren't popping up. Um What we basically did was clip the aneurysm and then amputate and then re implant the the ranch from the, from the dome into the post gen um to uh and so she left hospital three days after surgery with no aneurysm. No ischemia, no problem. Um Next please. Next. Um This is a case that I treated just before getting on the plane to come over here. So this is a young man who presented with a ruptured, dissecting um distal middle cerebral artery aneurysm. And as you know, dissecting aneurysms respond really poorly to both uh standalone coiling or clipping because there there are false aneurysm don't have a wall, there's nothing to, to reconstruct. Uh He's a young guy, he's in his forties. And so we discussed a number of different um endovascular options, both reconstructive with flow diverting stents, um questionable whether that's a good idea in an acute situation and also uncertain whether it will result in remodeling or not. Also discuss, discuss destructive options to sacrificing the branch. It's pretty peripheral, it's in the non dominant hemisphere, probably get away with it. Um But in the end, what we did next was we and he opted for this, we took him to theater and excised the aneurysm uh amputated the, the inflow artery and then just did an end to end SDA to uh M three anastomosis and again, three days after surgery, no problems home. Uh basically sorted. So that, that's just a demonstration of the versatility. It's, it's not to say that I'm particularly good and the vascular or open microsurgeon, there's plenty of people, plenty people in the room who could do all those things and more. Um But it's just an example of the versatility and being able to choose the right approach for the right patient. Um uh without having to sort of pass it off to someone else or, or wonder whether someone else is gonna have the same thought process that you do the next side. So some of the arguments offered against hybrid neurosurgeons is well, you know, um you know, it's a foreign skill it's not surgery, so surgeons can't learn it or vascular neurosurgery is dead. So, just let the radiologist have it. Uh, and, and probably the most common one that I've heard is that, you know, you might be able to train in it, but we impossible for you to maintain skills and do both things equally safely. Um, I would actually argue that the skills and knowledge required to maintain, uh, sorry to manage neurovascular pathology doesn't change regardless whether you started off your training as a radiologist or, or a surgeon. Um It's just another procedure. Now, registrars learn procedures from day one of training and endovascular techniques are no different than um you know, uh endoscopic or stereotactic procedures compared to open cranial surgery. So, it's just another skill that they can learn. Um We find when we're training radiologists and training surgeons that both craft groups pick up the skills with equal ease neurologist, take a little longer to train. Um But, but you know, if you're used to learning procedures, this is just another procedure and there, there are numerous publications that, that tell us that neurosurgical trainings actually want to be exposed to endovascular neurosurgery. Uh And that, that applies the same no matter where in the world you are. Um uh And let's just remind ourselves of the, of the history of endovascular neurosurgery. Just the next. Um The first report of cerebral angiography was actually described by a neurologist. Um Next, the first endovascular treatment of brain AVMs with with latex particles was was performed by a neurosurgeon. Next. Um As we're the first treatments for for aneurysms using endovascular attachable balloons. Um Next, and even, you know, if you think about the death knell of vascular neurosurgery with the development of the GDC coil. Uh Guido Julie Elmi is a neurosurgeon. Um Next, so we've been a part of this right from the start. Next slide, please. Vascular neurosurgery is not dead. We've already heard some excellent talks from, from colleagues about, you know, the role of open neurosurgical techniques or hybrid techniques for complex cerebrovascular pathology. Uh And even if you, if you disregard that, you know, there, there are many domains within vascular neurosurgery where open micro surgical techniques have clearly shown efficacy or risk advantage or both when compared to endovascular alternatives. Think about a BM thinking about carotids, stenotic disease. Um And you know, we all recognize that a straightforward micro surgical clipping can often be lower risk to the patient with a higher efficacy than a very complex in the vascular procedure with multiple stents and inter saccular devices and whatnot. Next, please. It's impossible to maintain skills in both techniques. This one really gets me. Um Yeah, where I'm maybe not the case in the UK, but where I work pretty much, every neurosurgeon does cranial surgery and spinal surgery and nobody questions that um you know, school based surgeons will often do endoscopic and open procedures and nobody questions that. So why is it any different to end the vascular and open? It's just another way of looking at the same pathology. It's just another procedure. And fortunately, there are numerous publications in literature demonstrating both European and us. And I think some Australian experience showing that hybrid procedure lists can have um good experience, good outcomes in both techniques, both techniques and maintain that over an extended period of time, please. What are the arguments in it for a hybrid neurosurgeon? Well, yeah, it allows the procedure list to offer a nicely balanced consideration of the pathology and the patient knowing directly the benefits and the drawbacks of both treatment techniques. And you might argue. Well, that's what an MDT is for and sure a well functioning ideal MDT can have a nice balanced outcome and offer the patient the best decision for their pathology. But I think if we're honest about MDTS, most mbts are not ideal and certainly none that I've ever been a part of. There's always some inherent bias, there are different personalities involved. And so you don't always end up with the right decision being made for the patient even though that's the sorry, the intent, dual trained people are very cost effective for institutions. Uh In my place, we've got three interventionist because we're a relatively small hospital with a relatively small population. And uh two of the three interventionist surgeons that that helps us to um provide for a necessary on call roster, particularly with the advent of 24 7 stroke intervention, but gives us other things to do during the day. We're not sitting our hands waiting for an elective aneurysm to come along because we've got other stuff to do. Um And I guess the other thing for, for anyone who works in a health system where your remunerations is directly linked to your referral base. So if your private funded system, for example, uh the more versatile you are, the more employable you are. But I think probably the the most engaging argument for dual train neurosurgeons um is the opportunity to develop new hybrid procedures that utilize both skill sets. Um And, and the obvious one is the emerging evidence for middlemen, middlemen and deal artery embolization for chronic subdural hematoma. There is an absolute groundswell of evidence that is developing and and is about to be published and it's going to change the management of this condition completely uh in the future. Um But a dual trained neurosurgeon is ideally placed in those cases where there's a role for surgical decompression or evacuation of the hematoma because of direct mass effect. Yeah, the hybrid can do that. And then in the same anesthetic, same setting, same theater embolized middle meningeal and essentially guarantee against recurrence is that effective therapy. But the best one was one that I learned only learned about last week. And I can't believe that I didn't know about this next slide, please. Um There's a group of researchers in the US pairing with some researchers in Melbourne University in Australia um who have just published and presented their series of four first in Maine implants of a brain computer interface, which relies on an endovascular delivered device called a stent road. It looks a lot like a, like an intravascular stent, but it's got 16 of the electrodes on it tunneled through the venous system down to a down to a transducer in the pectoral region. And four patient's have had these devices implanted, settle to detect motor activity and sensor activity from the adjacent paracentral lobule be transduce two and people have controlled computers of these things and that's going to be an absolute game changer for people with locked in syndrome, with motor neurone disease with traumatic spinal cord injury and, and who knows what else. Um Now, the first four patient's were performed or treated in very extended procedures performed by an interventional neuroradiologist and a neurosurgeon jointly hybrid can do the whole thing. Um And so I think that's, you know, these novel hybrid procedures uh is the strongest argument for, for hybrid neurosurgeons to to continue to exist. So, in summary, I would argue that hybrid vascular neurosurgeons have been a part of neurovascular care, right from the inception of endovascular neurosurgery or interventional neuroradiology. Uh It's a practice model that has demonstrated safety efficacy and cost effectiveness or efficiency. And unlike some other realms or subspecialties of neurosurgery. It has both an evidence base and a growth potential. Uh And I think that, you know, those of us who train registrars and neurosurgeon in the future, oh, it to them to expose them to the option of endovascular neurosurgery. Uh And so why did I talk about this? Well, like I said, I was, I think the first person trained in first surgeon trained in your intervention in the UK. It's not currently a career path available to UK trainees. I wonder if French with its reputation of being an innovator and a leader can play some role in bringing this back to the UK. Uh And.
