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And talk. Welcome Professor Nick Khan again from, from Memphis to tell us about his, his experience in skull base and the influence of Bristol. Next time, uh go back one slide. Uh Nicolas Con, I'm from Memphis, Tennessee. Um I spent some good time with Mr Porter here, so I'm back to show what I'm doing now. So I thought in the little time that I have, I like to show some of the what I've learned here and what I'm doing in practice now. So we'll try to make this a little fun uh next slide. So these are some quotes um that I got when I was here and these are things that I still think about today occasionally. So, um Monday in clinic, I was with this reporter and we're talking about does somebody need surgery or not? And he's like Mr Khan, they just need a proper haircut and that was it. So, um next quote, two clips are better than one. I can't imagine why he told me that. But um I still use that. And then last, but not least, I've not been able to find another pair of microscissors like the big buggers to this day. So, um, uh, next lot, uh, next, uh, one more, um, go back. Yep. So I wouldn't be here without Madison Michael who's in the back. So he's the person in our department who really kind of champions. Uh, the train is coming from Memphis to here. So the reason I'm here today is really because of him. And for any quotes I spent around a decade with this man. So any quote you wanna hear about him, we'll have him over a pint, not really proper for here. Uh Next slide. So what I do now, you know, I think there's a spectrum um that goes from SRS and the vascular with open super vascular and skull base in between. Everybody's somewhere on the spectrum. You know, at our department, you know, similar to the mbts, we try to strive to have if you're not an expert, everything but have somebody who's an expert, everything so you can collaborate and make your decisions. Next one. So really our philosophy, one more is a tailored approach to complex cranial pathology and that's really kind of the way we attack our problems. Uh So how do I incorporate open super vascular school base in my practice in 2023? So that's what my talk is going to be next slide. And you can just click through these. I think they all just start on their own. So there's just some, a few aneurysms from the past few months. Um, are you, can you click on them? Yeah, I'm not sure how good the video we come across, but we'll carry on anyway. Uh, so still amount of open surgery for, uh, a calm aneurysms and pick, um, aneurysms, you know, despite how good an ambassador has gotten. And then we work in a very fantastic and a vascular department kind of the fathers of the web device, pipeline flow diversion. But microsurgery still has a good role. Um Next slide you just click through, we'll go to the next one. So these are just a few cases from the past 4 to 6 months and um the next one, we'll see if we can get the video to work a little sharp. Er but um if you can go to next slide, click on these. So these are just simple peak um aneurysms but you know, p calm I think is a good case to uh exemplify the synergy between skull base and open vascular. So if you don't master the dural ring, you don't master the clinoid. I don't think you can masterpiece calms. First case on the left. Um As you can see at this point, I can show up up there. Let's see. There we go. So this is a case ruptured case, third owner policy don't have good exposure, quickly converted to climate ectomy. You can see the additional exposure there. This is a ruptured case actually. Uh Can you keep clicking through where we obtain approximate control extraorally uh before we even open the dura. So it gives you a lot of confidence in some of these cases. Uh before we actually had to work through a rupture on this case. So the clips going to go in there and then we'll open the dura. So the reason I picked these two cases to add in here was just to show some of this energy. Now we're gonna open the door and deal with the aneurysm. But next slide, uh these are just some of the results from that and we won't belabor going through the entire videos. Next live. This case is a 44 year old drug abuser. He has a fusiform pika aneurysm. Um Next slide. So there's not many great ways to deal with this. There's endovascular sacrifice. I don't think pipeline is a great option here. Um So what I did was trapping and bypass and we'll just show a quick snippet of that. Keep going. Actually, this is kind of a cool thing. So what I've kind of started to do is use navigation to identify where the occipital artery is because you can't really find it with a Doppler that well. So it's something that we picked up and started to use. Next slide. I'm not sure how the video will come out, but once we took the adventitia off, we measured it in the cup around 100 ccs a minute. So this is just the oxygen order to pika uh bypass and then trapping. So um next slide and one more and just post up on retrograde integrate flow uh after that. So this is a case to illustrate where you need the skull base with a far lateral craniotomy and you need the vascular techniques and you marry them to get a good result. Um So that's kind of the strategy that we've used our department next slide. So um actually the first one of these kind of cases, I think I saw Mr Nelson when I was here. So this is a 57 year old who had this large, I see a terminus aneurysm. Next slide. Keep going one more. So, one of my partners uh did stint colonization. I'm not saying that was the wrong decision, but unfortunately, um she developed basically occlusion of the carotid had to be reopened with a mechanical thrombectomy. Aneurysm is still filling. Uh So we acutely took her back. You can hit flight on this one for a high flow radio interposition bypass. Uh We won't go through see if the video comes out. Okay. But this is just how we do it. Um You can go to next slide. This is six month POSTOP. Uh So this case again shows that these cases are still out there and these techniques need to be preserved. And this is the rotation that I was on when I was here in Bristol learning these types of techniques. Next slide. Uh This is an interesting case. So this was a I believe, a 60 year old vision loss. So she has a very large ophthalmic artery aneurysm uh which is here. So, um you know, the options for this at our shop really pipeline coils or surgery and somebody with vision loss, I don't think the pipeline or coils or the best option. You can argue with me about that later, but that's what I think. Um So what we did is retrograde suction, decompression technique should play on the video placed on the p calm turn the well is just proximal to the anti recorder artery. And the A one to preserve flow through the A one and the Kordell artery during cross planting cross country is now performed. The common carotid external carotid artery in the neck or cross-clamp and the common carotid artery is punctured with, with a 20 gauge angiocatheter has previously shown that it's threaded into the internal carotid artery. Retrograde suction is then performed taking great care to slash the lumen with heparinized tape. So just a case to example of, you know, utilizing the marriage of the skull base and the vascular in order to achieve a good result and her vision got better. Uh I think that's very safe surgery. Most of that's extradural. Um If you can preserve the techniques and the experience next slide, um how are we doing pretty good on time? So, we can go through this one. So uh next. So this is a patient actually use a nurse. She had a pipeline stent placed in a sc a aneurysm, five years didn't go away. Um So we used half subtemporal, half trans Sylvian approach in order to tackle this one, you can click play on this. Uh We're now widening the optical carotids cistern and the A one is visualized. There we go. So this is just anatomy created basilar apex post your clinoid third nerve. This is kind of a variation on the trans caverns approach. So, unroofing the third or the roof in the fourth nerve, cutting the tent, flipping it up and widening the corridor and then the p calms adherent to the dome here. Um So we're gonna dissect it off, but having a nice exposure here allows you to be more facile and making your maneuvers. This would be a lot more difficult with less of exposure. So uh you can fast forward. This involves a combination of both blunt and careful, sharp dissection. Mhm One next like what? Um And this was actually an interesting case from maybe four weeks ago at our at our shop. So uh this is a 29 year old male. He had one year of left sided weakness, arm and leg presented with respiratory distress. That's, that's what he came in with. So um go to next slide. So this is what he had. So he had this giant vertebral basilar uh aneurysm here. Um So this was his MRI here with a mural channel there. Um So how I managed this, I married Endovascular Open and school based altogether to achieve a good result. So this is a balloon test occlusion uh in his vertebral artery is right verts, nondominant. It's really minuscule ends in pika left. That's the big one balloons in the left vert. He has great flow, good pecans all the way down to a ICA. So it's not gonna be a flow problem would be if it's anything that's gonna be a perforator problem. So I didn't think I needed to do a high flow radio, the PCA or SC A bypass, which was our alternative that we had considered um if he would have failed the BTO. So what we did um is we basically coil sacrificed just to the level right there after carefully studying where anterior spinal artery was and that was our distal occlusion uh because we were never gonna be able to get to that in the or from, from that approach if you want to click on the video. So this is far lateral and a little bit of retrosigmoid approach here. These are both for people arteries. Um There, this is the aneurysm. So we do an ICG, we kind of identify where all the perforators are, where the entire spinal artery is that we're gonna transect both where people arteries off the aneurysm. And then open the aneurysm and thrombectomy. Is it the strategy here was not to resect the entire aneurysm. We wouldn't, did not want to pull the medial wall off the brainstem because we thought the risk of that uh was, was high for a perforator injury. It would not achieve our surgical objective, which was decompression of the brain stem. So here we are just checking with a Doppler and ICG should pop up in just a second showing where all the perforators were. And if you want to maybe click through half the video or something, just kind of move it on a little bit. Yeah. Anyway, uh so that's what we did. Uh We took out, let's say a reasonable amount of it. We left the bone off to duraplasty, but that's a very hard problem to solve unless you have either a team or experience in different techniques and are able to synergize them. So I think it's something in my philosophy on this and I've learned from my mentors, Mr Porter, Mr Nelson, Mr to Madison, uh lots of different people is you should tailor what you do to the subject that shouldn't be competitive, it should be synergistic. Um We'll skip on to the next uh These are uh pretty uh straightforward case which means click the room. These are just the different types of STDM. See is that we do from Moyamoya. Um We can go to next slide. So we actually uh kind of do a nice one called the one donor to recipient, where we'll take one branch of the ST A and we'll do a side to side with the bottom part of it, the temporal and then decide to the frontal. And that way we did it, published paper on this and Jans and the flow is actually higher because it's like electrical circuitry in parallel. So something interesting to think about, we do combined occasionally depending on their collateralization pattern where we'll do an it as plus a direct, we'll do double barrel if they don't really have good collaterals. This depends on the situation. But again, we try to tailor it uh to the pathology, not be too dogmatic about it. Excellent, you keep going. Uh So these skills are completely translatable um into tumor surgery and skull base surgery. You know, the focus of this is primarily on uh vascular. I do a lot of skull base surgery too. So this is the first clinical meningioma that I got in practice. So it's 3 60 encasement of the carotid. Um But these skills are translatable. You know, I think if you're the better you are at vascular, the better you are at skull base and vice versa. So, um I think the synergies really evident in those types of cases and these are just some of the publications that we've done next slide. A lot of the cases I've shown you been published an opera neurosurgery. Thanks to the resident team that works with me a lot of these things. Um So next slide, uh a few final thoughts. So uh as I've said before, I think it should be complementary, not competitive, modern open CV needs in the vascular experience knowledge don't have to practice it, but you really need to understand it. Um And school based techniques, um the cases are harder and they need more creative solutions. You don't get the easy mcas and P calms uh as much anymore. The cases you get are typically the harder ones. So, uh unfortunately, the training is less um training experience matters. If you want to do this type of stuff, you have to seek out these opportunities, you have to make yourself better, you have to go get it, it will not come to you. Um And I think it's still worth keeping, you know, I, I do a lot of work in my department now with this kind of stuff and help a lot of patient's. Um And it's, it's fun, you know, seeing some of the results afterwards to and thankful to all the folks in Bristol for letting me spend a short amount of time here with everybody. So maybe I'll take a pair of the big buggers back with me if I can. Okay.