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And our next speaker is Professor Toast Milling. Um I had the pleasure of uh being a registrar with Torsten when he came across and we had lots of fun and subsequently went back to Norway and, and now he's currently uh they had uh Copenhagen in Denmark. He's also the Presidente of the Ens. Welcome to Austin. Thank you Nick and um thank you to uh Mario for inviting me and thank you for, to all the old consultants for training me and I particularly came back to meet old friends, Paul Crispin. I think he's here and Nick and Richard who I trained with. Um I will not do so much memory lane. We'll keep it um in line with, with our Australian colleague and, and the ABM that we saw that was ruptured um when I came to Bristol in 2003, uh the ice at was ongoing and of course, uh made big impact on our server vascular practice. Um 10 years later or so, uh Aruba study made similar people's um and I will take a critical view on, on their robust study. Um I will have a surgical perspective on this, of course. Uh But I've also worked in, in, in collaborate uh projects with neuro interventionist and Gamma Knife in order to have a more coherent practice in this field. Um The question is, should we treat unwrap third uh A B M's. And as I mentioned, Aruba study, that was a uh randomized trial, non blinded multi center study, many small um study centers. But it was basically to see if it um could improve long term outcome of unwrapped it brain evms without doing anything compared to intervention. You can see there were 226 patient's randomized somewhere treated somewhere, not the two groups were well balanced in terms of eight sex, uh BM grades, etcetera. Um And after 33 months, you can see the capitol my occurs uh the Kurds here, sorry. Um uh There was a significant difference between the two groups, meaning don't touch, it's far superior to treating. So that will be the end of the story uh similar to the eyesight, right? Um Some, some of us raised critical remarks basically on everything that they had done. Uh from the study center selection to outcome measures, etcetera. I would not go through the whole shebang. Um But I will highlight some of them. Um so that you better understand what the study is, not terms of endpoint. Um It's very popular nowadays to have composite end points and in the room, a study with death or stroke. And I would argue that being dead is not the same as having a stroke. Uh second stroke, the definition is also a new onset headache. And again, I would argue that having a new onset headache is not the same as being dead. Um So we really have to look carefully at these studies. Um uh Treatment I said they compared conservative therapy with treatment, treatment in this respect was Gamma Knife and the vascular or surgery. But these are completely different modalities in terms of efficacy in terms of timing or time to effect. And you can see here for instance, there's a tenfold higher risk of hemorrhage for 100 patient years after endovascular or Gamma Knife surgery compared to microsurgery. Um So that's why I called it apples and oranges. Um time to effect is of importance here in 33 months is not the long follow up effect of micro surgeries. Instant effective embolization probably requires 4 to 7 sessions typically. And Gamma Knife takes at least two or three years. If we look at published Gamma Knife series, you can see here for instance, at 33 months, um only 25% or even less will have a complete double literation rate. So to, to analyze the data our patient's undergoing who who underwent uh Gamma Knife treatment, of course, is, is it doesn't make any sense. Um Treatment risks, we know as best the Martin grade three or four, completely different animals to the grades one and two. Um And also uh importantly for us, neurosurgeons is that hardly any patient's were operated. Most of them were treated at the vascular lee plus minus gamma knife. So the gold standard was not used. And lastly, event rate was very high. You had enormous complication rates in the, in the, in the studies. After Aruba, there was a blame game, what was going on neurosurgeons uh analyzed their results, Aruba eligible patient and showing that the complication rates were far lower than in the Ruba study. Uh radio surgery colleagues did the same and found about the same complication rates as a rib, a study. And uh and the vascular did the same and showed that the complication rate was actually much higher than the Aruba study. Um So it was clear uh in, in the, in the aftermath of this, that there was probably under vascular that was causing this, let's say our problems. Then they made a follow up long term. There's a lancet paper 2020 I call it Ruba too. And we had hoped of course, that these curves would start to, to meet. They did not. Uh and that of course, upset neurosurgeons like me. Um We tried to find reasons for this. Um but this is the conclusion of the Ruba too, but again, interventional therapy. Um this is the same mix of endovascular gamma knife surgery. So we're still discussing uh largely heterogeneous uh interventions uh compared to to not doing anything, death or symptomatic stroke. Again, the composite measure, but you can see only four patient's died in the intervention and two in, in medical management, two of the intervention that would not related to a BM. So it doesn't make any sense to lump the two and uh symptomatic stroke again, of course, is the new onset headache and death. Um We had some supplement data that came out afterwards. And if we look here, you can see a symptomatic stroke or death, 50% of the endovascularly treated patient's had complications. So our presumption that the complication rate was due to an avascular therapy was correct. Um And of course, you have this phenomenon, you see the blue line, it shifts, it should be a plateau. If the ABM was cured, it would not have any, any re rupture rate. But here we clearly see that they, they did and why? Because a lot of the patient's with Gamma Knife therapy, they had not yet had their effect of the treatment. Um We raised some again, some criticism uh to this and we compared a huge uh database of, of uh you can see here almost 14,000 A VM patient's from a meta analysis, Gemma with, with, with the Ruba study. Uh and basically just showing to the left surgery, middle and the vascular and to the right Gamma knife that the complication rates are just completely off the wall. Um So, uh we sarcastically, I would say uh that we agreed with our decision making as mirrored and the Ruger should be avoided at all costs. Uh It had consequences uh us data here, for instance, uh this is pre imposed Aruba and you can see to the left, the number of or the rate of ruptured A BMS and to the right, the mortality of AVMs. So this study has actually had some detrimental um detrimental effects Here, you can see pre imposed Aruba study, the number of patient's coming in with ruptured A BM. Uh So perhaps we have done uh disservice to our patient's. And again, um uh we have been quite vocal in our criticism that it should not be extrapolated to, to clinical practice. Uh So the current perspective to sum up and 33 months is not the long time for a BM patient. Uh This is a lifelong disease often and we cannot divide the, the, the life into slices of 33 months as into the right, but rather have a long term, full life perspective. Um There are so many nuances in this discussion that cannot be uh looked at in one study. If we looked at gliomas, everyone would think we were crazy because we had the glioblastomas, we had the low grade gliomas, we had the even the pilocytic, these are different animals. Um and treatment modalities, of course, these are clearly not the same and you cannot call surgery or lumped together um we differentiate between MBM grades. This is well known and this is why the Specimen Mountain grade was uh created of course. Um But this is a bit complicated here, but it's very important. This is shows you the risk of a drop of level of neurological function as measured by modified ranking score by more than one. And you can see um in the red, there would be a special Martin grade three or four in blue. Uh Spencer Martin grade one and two. And the green line shows the natural course ie doing nothing and the risk of rupture and you can see down the green line crosses the blue around after five years. So if you have a Specimen Alton grade one or two, it makes sense because if you have a five year perspective, you have equal risk. But if you have a 10 year perspective, it's better to treat than not to treat. But it's also a very depending on age. And you can see here, young or old patient's and old. Unfortunately, most of our colleagues here are old, 39 years older. Uh But again, you can see to the left even in young patient's, it might be reasonable to offer some treatment even for grade three or four. If you're older than 39 probably not, or you should have very good indications. Aruba is not all garbage almost. But I think that it pointed out that uh the, the treatment that we offer. At least the endovascular treatment is not as benign as we thought. And the long term risk or the natural history may not be as bad as we thought. Um, again, we, we do not recommend treating a BMS uh or using Aruba as a guideline for our ABM treatment. Uh Well, we see it now if we have surgery uh for Spetzler Martin grade one and two and some three Uh Gamma Knife for, for some, that's a modality diffuse neither, for instance, deep perforating arteries, large size. And then of course, we have a yeah, uh surgery. Perhaps we failed Gamma Knife that did not achieve complete obliteration and the vascular therapy, um with single feeder, perhaps inter needle aneurysms, of course, and flow related aneurysms. Um, there are some for surgery after the vascular, after failed, uh DVT or pre op flow reduction in some and last but not least you have no, sorry, it's not the last after a failed Gamma Knife surgery. And the vascular can also be an option. And now it's the last but not least, perhaps some needs some so called downgrading. You have a specimen to grade three or four and that can be used, uh, can be downgraded to perhaps two or three by these adjuncts in order to do surgery. Thank you. Thank you, uh, Austin. Thank you very much.