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Yeah, I think we're live. Good evening everyone. Uh Can we just pop in the chat if you can hear and see us? Ok. Uh Please hear me and see us. Okay. Okay. Just a quick. Yes, we'll be absolutely fine. Anyone. Yes, brilliant. Okay. So my name is Omar, I'm one of the education team members that are juniors and today I've got the pleasure of hosting doctor Malik, who is one of the consultant, your radiologists and intervention on your radiologists at Nottingham University Hospitals and he's the current clinical lead for Mechanical Thrombectomy. He's here at NUH as well. He'll be giving us a talk about intracranial aneurysms, how they're sort of present the diagnosis and their management from a neuro radiological point of view. We'll just give it a few minutes for people to continue to join the talk and we might begin in a two or three minutes. So just get, get a drink, get some water and hold tight for the next couple of minutes. Okay. So I think we might uh go for, just give it a start doctor matter if that's okay. I might give it another minute or so. Uh What Yes, Doctor Matter. Are you happy to store it? Yeah. Sure. Okay. So welcome everybody. My name is uh woman Malik. Everyone knows me as lucky. Um Like all my said, I'm one of the interventional radiologists uh working at Hair at Nottingham University Hospitals. Um a, a bit of a furniture in the place. Um I'll take you through um uh aneurysms, neuro aneurysms uh as part of this talk. Um But it's just wanted to say it's great to see that. Uh I didn't know about Ir Juniors. I have to be honest. Uh when I started uh radiology training, um there was very little known about uh interventional radiology, you know, particularly amongst medical students, also in foundation doctors to the point that my first proper exposure to neuro Ir was when I actually left the country, I went on a medical elective to Candida in my sort of test in my fifth in the penultimate year uni um and it was a neurosurgery elective. See. Uh and you wanted to do since then shorty exists and really, it's a, it's one of the fastest growing specialties and very excited to be a part of. So without um carrying on on my uh speech about ir I'll just uh give you a brief outline, all that we'll want to talk about. So I'll just tell you about aneurysms to begin with and why they are a problem and we'll take you through uh extreme of um detecting aneurysms. I will talk a bit about the different types of aneurysms and ultimately will spend most of our time talking about how to tackle each of these different types. Um So uh feel free to put question chat uh at the end, um and uh leave an email link at the end if you want to approach me and ask me some other questions in the future. I guess an aneurysm is as you know, is a focal outpouching, a focal localized at A T. And the main problem is that these, these outpouchings are prone to rupture. Now, they're a lot commoner in the general public than we think. So up to uh 3% and some, some population studies even show up to 5% prevalence of uh aneurysms in the adult population. So if I was to scan 100 random people on, on the street who are adults, uh doctors cover uh an aneurysm in every 20th patient which is quite high now as a clear female to male election fight. Sorry, I think that we can see this light. Can you not? No, I don't think they're shared. Okay. I've got a sharing window here. It says stop sharing. So this time what I might do is um share the whole screen and see if that makes a difference. Yes, I can see it now, uh I can see it now, I'll go back with the list and maximize this. Tell me if you can see that. Yeah, thank you. Cool. Just yes, not me, whatever. Um So yeah, so it affects females twice as often as it affects males. Um and it is the leading cause of hemorrhagic look. And when it's when a patient presents with a subarachnoid hemorrhage, there's an 80 85% chance that it's due to a spontaneous subarachnoid hemorrhage that is not traumatic. Um 85% chance. It's a brain aneurysm which has caused it. And when you do have an aneurysmal subarachnoid hemorrhage, um is an overall 5% of all strokes. Again, it's, it's quite a large uh disease burden and particularly when you take into account that ischemic strokes often an effect elderly population. Whereas aneurysmal hemorrhage, hemorrhagic strokes affect relatively young people despite only being 5% of overall stroke is actually comparable to ski Mick strokes. Um Now, in the UK, um what we know is that when aneurysm ble the ruptures spontaneously, uh up to 15% of patient's don't make it to the hospital. So it's a obviously a life threatening event and uh even the ones who survive and have treatment, there is a up to 30% more time. Uh and some of them are left severely impaired. So it really is a quite a life life change. Uh the one who needs treatment and what needs treatment and when um in terms of risk factors are quite important to consider, various population studies have, have demonstrated that well, the loads of loosely connected risk factors, but there are only three which have clearly been demonstrated to have a direct impact is having a strong family history of aneurysms, having high BP, which really block because of the aneurysmal development etiology is thought to be due to flow down up pressure. Uh working is directly been linked and the closest second secondary risk factors are your connective tissue disorders. And um so lifestyle lifestyle can definitely have a clear impact on developing and uh enlarging aneurysms. Um in terms of um etiology of aneurysm, it's not so clear because depending on what exact type of uh Bio Communist type is a secular aneurysm, which is the focal outpouching as you're seeing in the sort of picture a has a sort of a narrow ish neck and a broad dome. However, they can come in all sorts of shapes and sizes that can be distal micro aneurysms, a fusiform type aneurysms. I'll go into more detail a bit later on about these. Um But essentially, they can all have a variety of different pathophysiology. Ease. The Communist pathophysiology is thought to be affecting saccular aneurysms, which is like I said, by far, the most common forms of brain aneurysms, um it's thought to be sheer stress at uh bifurcation points. Um And since there is the most turbulent flow at the points of bifurcation, when an artery divides into two, any sort of intimal injury at that point can over time um come up as a blister and then further grow with different with the flow hitting the aneurysm, the blind ending sac and over time that can, that can increase in size and eventually um look like what we recognize as a secular brain aneurysm, a brain and berry aneurysm. And these are prone to rupture. Here's a diagram that shows the distribution of how often we find them in what locations? Um The Communist locations are these four that have been listed here. Um That's the anterior communicating artery aneurysms, uh posterior communicating artery and the aneurysms. A middle cerebral bifurcation, aneurysms or basilar tip aneurysms. Having said that if this pathophysiology and this etiology, if we know it to be true, um it can affect any beautification point. And in fact, that's in clinical practice. Yes, these are the commonest sites, but you can see it at any point. Um The typical configuration of, of secular aneurysm is a, a neck which connects the parent artery with the uh the sack of the aneurysm and has a well defined uh outside margin with a clearly defined dome. Um And when we're talking about micro aneurysms, which are far, far less common, there are two main varieties. So you're either getting them at usually much smaller vessels. So you tend to get them in vessels size even less than no 0.3 millimeters. Um So they are often found in these sort of locations in the basal ganglia arteries. So these arteries are coming off your middle cerebral artery and they're known as the lateral anticholesterol got arteries that supply the basal ganglia tissue here. And these micro aneurysms have an eponymous name. They're called charcoal go kart aneurysms. They're seen in patients with chronic hypertension. Um However, they can also be seeing an end artery so more much more peripherally as the arteries subdivide into tiny little vessels over the surface of the brain. And uh those aneurysms more often than not a result of uh an infectious source. Uh So it's a septic embolus in somebody perhaps with the infective endocarditis uh or less commonly. But also we've seen, I'll show you an example of this later is traumatic uh micro aneurysms. Mr Lee, um these are quite tricky to treat and particularly in the case of hypertension. Um micro aneurisms, they are rarely treated and I'll show you an example of this later when aneurysms, the saccular variety or when they are larger than 25 millimeters, um they're referred to as giant aneurysms. Now, there are, they're given the but mm when the size gets certain because of the degree of mass effect on the surrounding tissue and how it sort of relates with the surrounding environment, impacts on how likely it is to, to rupture and, and like, like it says here that unlike smaller secular aneurysm untreated giant terrorism uh as a bad, um quite often they're not picked up uh after rupture because if mhm, often, uh mass effect can be the reason why they present, whether that's because it's causing hydro catalysts, it's compressing the ventricles, um, or whether it's causing um, compression of the brain tissue and there's direct symptoms of focal neurology as a result of that seizures, etcetera. Um, either way, uh they have some of the worst prognosis. Um, and they probably have, uh despite being a small proportion of overall intracranial aneurysms. Now, the poorest prognosis, um, fusiform aneurysm. Um You'll be very familiar with what you're thinking about. A classic abdominal aortic aneurysm is a classical example of a fusiform aneurysm. We've got widened and thin segments of the artery with sort of disease, thrombosis. Um um clot and thrombus segregation to the walls of the aneurysm um as a result of sort of into more damage and uh and, and sort of the down, um, he'll sort of spiral of that. Um Here's an example in the brain aneurysm of seeing something similar. So you've got a uh I'm not sure if this is protecting very well, but you've got to vessels coming off here, this branching point. Um There is a well defined round sac with a defined neck secular aneurysm, whereas the fusiform aneurysm incorporates almost the entire uh circumference of the vessel itself. So for it to be really, technically fusiform aneurysm, it really ought to um uh affect more than 270 degrees of the vessel circumference. And here you can see that the entire artery uh appears disease, disease compared to um the on the other side where there's a focal outpouching. You can imagine how these can as a result, be very tricky to treat because you need to try and save the parent vessel. But the parent vessels entirely involved. I'll show you some examples of this. Later. We'll also look at some special types of aneurysms, the dissecting aneurysms, blood blister, aneurysms, um and a specific type of giant aneurysm, uh which is essentially uh what's called a giant serpentine aneurysm. What happens in a very large sack is that your um you start to develop thrombus. So this is an aneurysm, the a calm um location. Uh You've got this very large sack and the red arrow points to this um a mixed signal demonstrating thrombus within the sac and as the different layers of thrombus developed within the sack of the aneurysm, what happens is is that your blood flow tries to form a, what it can look like is a essentially a snake like configuration amidst all the chronic clot and, and that sort of forms uh this serpentine appearance, there are sort of a low risk of rupture, but because of the size, uh they can have mass effect and symptoms as a result of it and they can be very tricky to treat. Um But I don't have an example of a serpentine in reserve it will probably be going through all the arrests. I'm going to move on from this. So in terms of clinical presentation, either they are picked up incidentally. So, uh there might be a symptomatic or having a scan for a medical health check or they might be having a scan for any other with the most common incidental pick up that we have is a, uh went to GP for a headache, had a GP uh scan, often MRI scan and that picks up an incidental aneurysm. Uh if it's an adult and you have one in 20 up to one in 20 chance of picking up a incidental aneurysm. Um Now, so we'll talk about the management that separately. And the, the other way we see these patient's is when they present to the hospital following rupture of the aneurysm with subarachnoid hemorrhage plus minus multi compartmentalize hemorrhage. So here is a uh schematic that shows you that the this blood, this sort of red represents blood. In this diagram, you can see it's sort of going into the different cell cool spaces, which is the subarachnoid space. Um And the reason why you get subarachnoid hemorrhage with aneurysm rupture is that your blood vessel that are supplying um your uh supplying your brain tissue are all within this subarachnoid space. So all the arteries and veins. Yes, they do traverse the dural layers, but um predominantly uh the intracranial arteries uh stay within the space and this is a space that, that we worry about when it comes to subarachnoid hemorrhage. Um Now, in terms of clinical presentation, the classic thing is that thunderclap headache, um which is a sudden onsets, worst headache of lifetime, um sometimes accompanied by collapse. Uh people who have um this actual classical presentation, which is actually quite a lot of patient. So this is uh I would, I would probably say um majority 80% when they describe the headache they had before the subarachnoid hemorrhage at the time of the aneurysm rupture, they do describe it as a classic uh sudden onset, like a thunderclap, uh type headaches so that the history can be quite a giveaway. Um And in terms of um sometimes patient's do present a bit late and when you take a history, uh what happened a week ago and it's that classic case of I, I did have the worst headache of my life, but I took some paracetamol went to sleep. So that that's kind of your classical history and as the meninges get irritated, um you can also get focal neurology if you also have uh associated intraparenchymal hemorrhage. So if for example, the MC aneurysm also bleeds into the and the basal ganglia or temporal lobe, you might get focal uh here's a result of it. Now, depending on the blood load, um the mental state can also be affected. So, patient's who are the best grades? So good grade patient's are they have the classical history, they have summer act on hemorrhage, but they are very much with it. They're not confused. There are essentially a GCS 15. Whereas uh the poor grade patient's essentially are much lower down in the sort of Glasgow coma scale, um posterior fossa, um uh Frankie more bleeds can also lead to vertigo or dizziness. And in terms of the compressive effect, the classical one is a posterior communicating artery growing artery aneurysm, going and pressing on the oculomotor, uh getting a surgical third enough palsy if there are sort of uh if you're looking at uh a potential that these are rare. Um This is, you know, way beyond the, the usual that we see, you might see this once every few years that it may be that there's a history of infection and you're looking at a septic or mycotic aneurysm presentation. So when you do get an incidental aneurysm, um as they're usually picked up on CT MRI prompt from for over a reason, um they get referred to our regional neurovascular MDT. So for Nottingham is the, excuse me, Nottingham is the regional Neuroscience Center. It covers all of these Midlands. It's about 4 to 5 million population and any sort of aneurysm which we discovered is sent over to our neurovascular MDT. Here we have uh a bunch of my colleagues or Einars uh neurosurgeons specialist nurses. Um A uh we recently also have a stroke positions or a vascular neurologist and together we discussed what's the, but the 10 year is. Um so you either decide that it requires treatment and if so, we'll, we'll think about what type of treatment and I'll go into the details later. Um Or we think it doesn't quite require treatment, but we can't really draw a line under it. So we'll keep them under surveillance or we will discharge them to say they're, well, either it's very low risk or um essentially it's inoperable. So either way the patient will be seen and discharged. So that's the kind of the paradigm for your um, incidental aneurysms. We either treat them or we most often surveil keep them under surveillance. Um Now when it comes to diagnosis of ruptured aneurisms, um often when, when you get a headache of that nature, very few people, um uh tend to sort of um uh sleep it off. Uh If you're lucky enough to survive it, if you're one of the 80 odd percent who didn't immediately die as a result of the aneurysm rupture, um people eventually within the first day or two get medical help. Um The first thing that the medical, uh I was clerking them in a ed when they hear that sort of history, um will get a CT scan to exclude a brain bleed. Um Now, just a little pause here. Uh This can be quite tricky. So when you are, I mean, another, lots of medical students here and, and uh, junior doctors and everybody tends to describe the headache as the worst ever had, differentiate a thunderclap headache and one from which is just a very bad headache. Now, the truth is you can't differentiate it, but because of the fact that the nature of the condition that you're dealing with and you will, I'll show you the risks of missing the diagnosis, um, is that you would rather over investigate and under investigate And it seems to be the way with a lot of things these days. But it's, it really is not a diagnosis you want to miss because they're young patient's um it really if it does at all sound like an aneurysmal um type severe headache, then they ought to have a scan. So, and you OK cases and the usual um procedure is to for them to go on to have a lumber puncture. And if so, subarachnoid hemorrhage is confirmed violin puncture or plain CT head will go on to a vascular imaging most often in the form of a ct intracranial angiogram. Um plus minus uh catheter angiogram will come to come to that in a second. So this is what a subarachnoid hemorrhage looks like. So instead of having uh CSF in the subarachnoid spaces, CSF is black as, as you can see the uh interhemispheric fissure inter pedunculated to since then, you've got the Sylvian system a lot of blood. Now, um so this is what we call a cisternal pattern if you had subarachnoid hemorrhage entirely peripherally. Um It's less concerning for aneurysm. Um And uh usually the aneurysm rupture, uh you get a very cisternal pattern, not a peripheral pattern. So a central pattern of subarachnoid hemorrhage. Um you may also have um associated subdural parenchymal bleeds. Um And if there's a high pressure bleed, uh what you might also get is reflux back into the ventricles because normally the CSF is uh being produced in the lateral ventricle and and it circulates out into the CVS uh subarachnoid spaces, it can start to spill back into the ventricles and you can get ventricular hemorrhage. And overall, that presence of blood can also um uh block the reabsorption. And as a result, patient can present with hydrocephalus um which in this scan in front of you is a very subtle sign of what's what we call early hydro catalyst. This, this temporal horn compared to the side is starting to balloon up and this is the earliest. Yes. So if the if the city had wasn't as obvious as that and it was completely normal, but the history was raised or that you haven't missed the summer act on hemorrhage. This is what you would do. You get to see yourself sample to look for xanthochromia and important to remember is that a lot people don't know this, that it can be positive up to two weeks post the the worst ever headache event. Uh So that's the actis. So 22 weeks, post victor's, it can still be positive. So, um that's one thing to remember whereas um it gets harder and harder to see evidence of summer active hemorrhage on a CT scan as the blood sort of starts to get re absorbed and become more essentially microscopic and macroscopic. The next thing we do in all these patient's when subarachnoid hemorrhage is confirmed is we look for an aneurysm or any other arterial abnormality. So, CT and an angiogram is your um fastest, cheapest, most readily available tools. So, uh whether you're having a subarachnoid hemorrhage in Boston or Kingsmill or having a derby or big teaching hospital like Leicester, um they all have the same test available. So it's quite a good test to have um as it can be used across the population. Um and it can be positive in most cases of um subarachnoid patient's um uh is is gives you a pretty good detail. So this uh admit view. So what we do is we maximize the signal of the vessels. So you see them quite nicely on this image and you can use that raw data on the CT scan er to do what's called reconstruction. So you can remove the bones and move the other sort of structures and just get the scan er to show you the vessels and that can be quite handy to see where the aneurysms are and also for planning treatment. Now, if a CT. Um In this case, you can see there's an example of a anterior communicating artery aneurysm. So here is a ac A uh the right side, that's the A C of the left side. And here's the akon vessel on which there is this aneurysm. And these are the distal uh right and left uh A two A C A anterior cerebral artery branches. Um But if you were to not see an aneurysm, the next thing we tend to do is uh do a uh catheter angiogram. So this is done. This is gold standard for assessing vessels. DS A is order stands what it is in the stands for digital subtraction, angiography. And the way that works is that when you, when you do an angiographic run, you, the, the X ray machine takes a mask image which becomes a control image. And after that, as the contrast runs through, it takes a continuous series of images and to show you this classical DS a image appearance with every image that it acquires is subtract the elephant. Then you will see is a new radiopaque substance which enters the margin. So essentially which is just a contrast, anything else was there before? So it gets obstructed out. Um So, so this is how A DS A is performed um has excellent spatial resolution. So you can get amazing detail down to submillimeter structures. Um The best thing about it is dynamic. So you'll see different phases, you're actually seeing real time con Drass coming into the arteries, going into the capillary phase, pranking or phase and out through the veins. So that dynamic nature of allows you to pick up uh even the finest of abnormalities. And although aneurysm is the main thing that we're talking about today, which is by far the communist thing that we find um in sort of a uh central pattern of sah. But you do tend to get other uh s a hated as arteriovenous chancer dural fistulas uh am Selectra. So um is a invasive test. So it's done by going entering the artery in the groin or the or the radial artery. So, femoral artery or radial artery access, you feed your catheter, turn by turn in different cranial arteries, your carotid arteries so that the vertebral arteries and you do direct runs, that's far more invasive than a CT angiogram. That's why we do this as a reserve test when you can't find the abnormalities. T scan the concerned. So this is what the different phases of the scan looks like the, the arterial phase, just seeing what the arteries and after a few seconds, um you've got these sort of early venous phase, veins are starting to fill the complexity, cerebral veins are filling. And then as you go further in the late venous phase, you can see the um the dual venous sinus is a feeling. Um And on the sort of early venous phase, you can also see a parenchymal blood, the staining sort of a light grey staining all across. So, if you've got tumor's and other abnormalities that may have caused a problem, they can also reveal themselves. So you've done all these tests, someone's come with a subarachnoid hemorrhage. You've done a CT angiogram and uh or a DS A for that matter and you've discovered an aneurysm. Now, what do you do? So, uh the thing to remember is is that if an aneurysm has bled, it has a very high risk of re bleeding again. And if the patient has survived the first event, so if they've been lucky enough to be one of the 80 85% and actually, some studies quote that up to a third of patients don't survive the initial bleed. Um And so if you're lucky enough to survive the first bleed, you've got a 72 hour window where the, the aneurysm has a very or percent. And actually, there's a thought to be. Um, so this is the trouble with missing the diagnosis, which is why you want to over investigate rather than under because, um, if you miss the diagnosis, chances are that they may well bleed again if they do bleed again, the chances that they won't survive the second bleed, even if the first one wasn't too bad. Um And uh, mortality rate is particularly high when it comes to a rebleed rate. Um, uh, it comes to rebleed patience. So essentially what needs to happen is these patient's need urgent to have a best chance of survival. Now, treatment options for aneurysms are and this kind of break them down doing nothing is only sometimes appropriate, was very rarely appropriate. Uh tends to be in the case where um let's just say it's a, it's a, it's a very uh poor grade patient. They've got a very low gcs and looking at the brain scan, the degree of hemorrhoid, a degree of mass effect, the degree of damage to the brain tissue already. Uh You may think that actually it's probably best to not intervene any further. Uh Chances of survival tends to be very low anyway. Um The mantra of the treatment is that you're not trying to treat the um do anything about the blood that's already there. Uh The, the primary motive of the treatment is to prevent a rebleed. Um And if somebody's initial uh event, uh initial brain hemorrhage was very significant that GCS is, you know, below seven chance of them surviving that initial event, it's not very high at all. Now, in terms of uh the options of doing treatment, um we are talking about either open surgery. So micro surgical clipping, I'll show you some examples of that or it's endovascular approach and these days it's first line in most cases. So, um 20 odd years ago, clipping was pretty much the only option. Um And now I'll show you why over time this is now, I think in Nottingham, particularly 95% of patients treated with endovascular treatment in a year where we do about 300 aneurysms, aneurysm treatments um of which 50 50 or so are elective patient. So they come through the outpatient clinic after being discovered incidentally and if they are deemed high risk enough, we offer treatment by and large. Most of these patient's are the come following rupture, well, going to eat uh different options available and where it all changed really was this landmark trial was published in the Lancet and tell them to call the ice a trial of the international subarachnoid trial. Um It was run in 43 centers in the world. Um and the single biggest contributing center in the world towards this trial was actually not in the, so this claim to fame. Um and this trial was uh stopped early by the Medical Research Council because the um the the very first one year post treatment schools showed there was a significant reduction in the number of patients that were disabled or dead uh between the two arms and overall, there was a 22% improvement in patients' treated with coils. And this is going back, you know, more than two decades now. And I have to say that even in the time that I've been in the specialty over the last eight years, uh there have been huge advancements and safety profiles. Of devices, um the tools for the right kind of uh abnormalities. And I think if this trial was done again, there's no echo echo pose for anymore. That, that, that difference may well be more stark. Uh Needless to say that the procedure is a lot less invasive. So you don't have an open uh scholar approach, you're going from the inside of the blood vessel. Um you can reach areas which are inaccessible by open surgery. Um And as a result, I think what's happened is over the last 20 years. Um We are not only doing the aneurysms that previously were deemed to be sufficiently clickable. Now, we are able to, to treat aneurysms of all shapes and sizes which were previously thought to be untreatable because it's the various different devices and tools that we have available to us in terms of a brief over your surgical techniques. So the prominent, most common ones that still prevail are sort of simple clipping. Um uh All wrapping if clipping is not possible. Um um Previously, they used to do things like temporary artery occlusion to see if you can from both the aneurysms. Um This is certainly very rarely attempted these days. Um uh And bypass techniques can still be considered very rarely done. Uh but are an interesting approach to some otherwise untreatable aneurysms in which you are trying to uh bypass a segment of diseased artery by plumbing the proximal artery with a distal segment but it's, it's, it's a, it's a very invasive technique and can be quite, quite tricky to do. Uh One of the things that they do do in uh into procedurally these days, uh is this uh microscope integrated um uh near uh IGIGC video on geography? It allows them to see patency of vessels that shows some examples of that. So this is a uh just uh an image to show you what, how they approach the aneurysm. So this would be a, a terry on uh craniotomy, a dive in dissection through the dural layers to expose eventually the uh Sylvian fissure. This is your thought to be a middle cerebral artery, uh bifurcation with this aneurysm in the middle. And the key is to identify the neck and make sure that there are no other smaller vessels um nearby and then placing a clip across the neck to seal the aneurysm. It's a bit like tying a string around a balloon until you uh to, to see that off. Um So this is the, this, that ICG video and geography I was mentioning earlier. It's not something that I've ever uh we ever get to use. So it's just uh something of interest. Um So here's a, again, an MC a verification aneurysm. Um And you can see the two main vessels coming off, but you are quite blind to what's potentially behind it. So, here is a angiography um after injection of this material and you're seeing all the different branches around it. And after placing the clip, you can repeat that process to see they're all still patent again, a small minority of patients having this done. Alternatively, what we can do is by accessing um, uh the arteries from the inside, eventually getting fine tubes into the aneurysm themselves and releasing a number of platinum coils and you size of the aneurysm and choose the right loop diameter of the coil. And it's sort of like a Russian dolls effect. You start with the biggest stiffest coil to form a frame in the aneurysm and you're trying to fill it with sort of a softer, more pliable uh smaller loop diameter coils to essentially get a good pack of metal in the aneurysm. And what that does is encourages thrombosis of the aneurysm from within. And that's essentially what wrapping looks like. If it's a uncoil, it'll untreated. Uh, the aneurysm, you can wrap, you can wrap it essentially in this sort of material and clip alongside it. Um, uh speaking to my neurosurgical colleagues, they, I don't really like doing that because I don't really think it works. It's sort of a thing if you've gone into clipping aneurysm, but for some reason, can't safely do it because of the vessels uh place in the area or other anatomical um, uh restrictions. Then this is a sort of a backup option. Um, this is what a bypass potentially can look like, but we also skip past this bit and talk a bit more about the endovascular treatments, which is obviously what interests me and that's what obviously interests you since you are. I are juniors soon to be the seniors in the future. Um So this is what a biplane theater looks like. So we do all of our work in a biplane theater as opposed to the single plane that's required peripheral. I are. So here you've got, you can see this might look fancy, but we've actually just brought two of these machines, fork, um, see their soon to be installed is that your see, Seaman's Icona biplane. So this has got one plane in this direction, the other one can essential to that. Um The reason why you need to buy plain because you're often treating um tiny little abnormalities amongst areas. Uh very important arteries are coming off. So you need to be absolutely precise. So you need to triangulate on two planes to make sure that you are where you are. Otherwise, the problem with x rays is that if you're only looking at one plane, you could really be anywhere along that plane and you wouldn't really know. Um which is okay when you're looking at, for example, a, um if you're doing a popular till artery angiography because um uh there isn't really that much anywhere else you could be. Um, in terms of the vascular anatomy is not as complex and the risk is lower. Um Even if you ended up in a small tiny branch, um you know, being in that branch is not going to give the patient a stroke. Um So this is how it happens. All of our cases that are under general anesthetic and you access the artery via the femoral, the red lottery eventually get a large catheter. Um or what we call a guide catheter in the in the neck from there In each uh angiogram would do a three D angiography. There was a rotating aneurysm of the uh the first couple of images. The um the outline slide had that rotating angio angiogram. We do a sort of a planning angiogram which is an extremely detailed way of looking at. The last you can plan the different angulations and the projections you need on the screen. Um because that will tell you at which angle does each plane need to be for you to be able to get the exact view that you like. And once you've got those views, um you will take a microcatheter or a number of micro catheters to then treat the aneurysm. So it could be something as straightforward as this. No aneurysm has ever looked this nice to treat. So this is a perfect aneurysm to treat with a very narrow neck with a very sort of a good domed neck ratio. The reason why this is pleasing to the eyes that um no matter what size coil you might place in here, it's not going to fall out. The problem is that if you undersize the coil, the, the neck was much wider. And if you have to say the neck is three millimeters, why would you put a two millimeter coil near the neck? It can fall out and migrate and cause a stroke down that territory? So, um it would be very nice that aneurysms were like this. But quite often you need help of other devices either uh to micro catheters to play and make a conglomerate mass together all using balloons and stents to assist and protect the parent artery um to, to get a coil to sit in. So this is the example of doing that. This is a uh although it looks crazy complex, but unfortunately, it's closer to the truth than this is. Um in which case, you've got a much broader neck. That is an example of a battle of tip aneurysms. It's diagram to show that because of how Broadneck did is you're never going to get quills to remain in the aneurysm. So what you can do is put stent devices, they've got sort of um stiff wires that have a high radial strength. Um and they can essentially put, give you scaffolding through which you can keep the coils in the aneurysm. So over time, this will include and the stent will stay open because you will need to put them on dual anti platelet medications, alternative to a, a stent would be a balloon. I'll give you some examples of this and other examples of different devices here are intra cycler devices which are designed for wide. Next, I'll show you them in a second. And these, these special stents which have really revolutionized aneurysm treatment called flow diverting stents, stents. And here's a little example of that over here, which is a much more finely braided, many more wires. Um It's a very clever stent um And it helps as it says on the tin divert the flow away from the um the aneurysm. Finally, we can also use liquid embolic agents. Rarely, usually for distal aneurysms often to sacrifice the vessel if it's a if it's otherwise untreatable uh condition. So we'll go through some examples. Um I just wanted to take a pause and just make sure that um I've got sufficient battery because it was making some noises earlier. So it seems to be okay. Um So here's an example of a simple coil embolization. So this is the kind of like the aneurysm that we saw in that nice diagram. So this is the example of a three dr A. Um So this is a three D rotational angiogram that you do on the, on the theater table. And it gives you this beautiful image of um of the image, very exact uh idea of what the neck is, how wide it is, what the size of the aneurysm is. If it has any blebs and you can also see any vessels are rising in the region that you need to protect. Now, um this little man here is an important thing because as you are rotating this image, I'll tell you what angle the tube needs to be at for you to be able to replicate that with an angiogram afterwards. And that's that, that angiogram will become your, essentially your road map that you will follow. Uh for the rest of the procedure will tell you where you are. So here's an aneurysm. You can see you've got a large bore catheter sitting in the IC A over here and this is your IC A is making its turns, this is your A C A and is um see A and this is the ipsilateral uh A two, a one vessel changes to A to when it comes across the a, a calm vessel. So here's the a calm and it's also this angiogram is also filling the contralateral a too. You're not quite seeing the A one on the other side because the angiogram is done from this side and it's revealing this aneurysm in the a calm and we've done is from here taking a microcatheter. Um We've navigated it into the base of the aneurysm itself and from here, we are starting to release some platinum coils and a number of platinum coils are released just like that. So this is what the actual extra image live screen looks like. But because you've done because you've done an angiogram already and you've asked the computer, the biplane uh machine to tell you that I want you to mask this image and pretend as if I'm screening on this. So it gives you your actually navigating on this whereas it actually looks like this. So it's quite clever way of treating it. So once you pack the aneurysm sufficiently, it trumbo's is off, you can see plenty of coils in there. And when you do the angiogram while and the aneurysm has disappeared, all the vessels are present and this and this aneurysm is treated. Um This is I'll show you an example of couple of micro aneurysm. So this is a classical hypertensive bleed that patient's can get in the basal ganglia. There's a CT angiogram shows a tiny little dot here which is confirmed. This is not the same patient, but this is what they will look like on a DSA, a tiny micro aneurysm because of how small these vessels are. And they're very tricky to reach into quite often. We just watch these uh the only way of treating it would be to either sacrifices vessel or go distantly and included. Um And uh so, and if they are not possible for us to navigate through, um and the mass effect from the hematoma is large enough to the nearest surgeon might want to go and remove the clot anyway, then they would try and resect the aneurysm at the same time. Um This is a, an interesting example of a case that we had. It was someone who came in with a acute uh sub Juul um hemorrhage and CT angiogram showed this, this aneurysm which we did A DS A for. Um and here is this uh little distal aneurysm. So all the aneurysm we you used to treating around this area circular Willis, but this one is much further down the A C A territory. This is sort of you're a four, a five territory of the anterior cerebral artery um on serial ct angiogram that showed that it's uh it was increasing in size. So what we did is um uh we use a liquid embolic agents by getting very close to the aneurysm. And you use this liquid anabolic agent to slowly fill the aneurysm up with, it's like a glue like structure. In this case, we used anabolic agent called Phil. But the others you might hear off like onyx um squid. Um and, and, and so on. So an actual glue we can you, you actually use medically Great Blue at times to, to do the job. So this will seem to be the right uh um uh tool for this job. Once you've filled it with the liquid embolic, you can only do this in vessel that you're happy to sacrifice. Because if you did this in proximal vessels, then essentially you cannot, you don't really have that much control of the, the glue where it goes and you don't want it to go to embolize two territories that you don't want. And that'll be too catastrophic. But because in this case, we got very close to the aneurysm, but we weren't able to place a coil in it. And the only way we could treat it is by sacrificing that little branch and essentially getting rid of that entire segment. And you can see the DSA afterwards shows that uh the aneurysm has disappeared. Now, an example of uh when we need helps of help from balloons and stents or coiling. So this is a 62 year old GP had headaches for three months. MRI for the headache and showed this uh left. I see a parent thermic aneurysm. Um uh When you start the treatment for this aneurysm, you realize how broad the basis and it's covering a lot of the vessel. Um And it's quite as we tried to play some coils in this aneurysm with the microcatheter, we realized they were, they were trying to sag into the main artery. And the issue was that if it continued to encroach, it would potentially uh threaten the parent artery. Don't want to include the I see a obviously because then you're going to have a major stroke on that side. So what we did was we use the balloon. Sure, you can appreciate it as a hypertense sausage like structure which is in the actual parent artery with contrast in the balloon. So we continue to coil with the balloon inflated, temporary balloon inflations. And in the end, you've got a very dense pack whilst keeping the parent artery completely open. So that's, uh that's where if we didn't have a balloon to help in that situation, you'd be, you'd be fighting all day and probably will end up with some encroachment and possibly a stroke. Um, a little bird on dissecting aneurysms. Um Most are traumatic acrogenic, either he calls them or they're spontaneous. They tend to be a background of tissue disorders, um which makes them more likely to have it. It often starts the little tear in the intima. But then as the blood force shares into that space, if all like a false lumen that you bleed into, and then they can create a very ugly looking pseudo aneurysm. And the thing to remember with these sort of things for us is that uh the entire uh segment of the art you can use coil, you often have to sacrifice the entire segment. Um Sometimes that means that it's going to result in a stroke, but it's either that or, you know, chance of re bleed in those cases are very high and you have that conversation with patient's and they often choose to have the treatment. Um They have a propensity to affect the V three V four junction, that's the vertebral artery as it enters into the skull base. Um This is the segment of the artery that was dissected famously. And uh um in a cricketer, Australian cricketer was hit by a cricket ball and this is the segment that was dissected because of direct trauma, usually that done to the stroke, but it can also present as dissecting aneurysm and subarachnoid hemorrhage. Um And so, um I'll show you an example which is not exactly the same location, but it's keeping up with the theme of the anterior cerebral artery. So here's a CT angiogram in which you can see the amount of blood load, there's a lot of blood. Uh There's a big blood clot here adjacent to this round um aneurysmal structure. So clearly this is this uh aneurysm which is bled. There was, there was a history of trauma in this patient. Um She was uh poor grade multi compartmentalize hemorrhage, ventricular hemorrhage, as you can see in the fourth ventricle here, third ventricle lateral ventricle. So during the three D angiogram in the, in, in, in our treatment, we found this very ugly looking aneurysm. So this is your, I see a and that's um see a looking very normal, but your A C A the entire segment is sort of looked diseased and there's this big pseudoaneurysm sticking out, poking into whether big blood clot was. So the only way of treating this would be to actually treat off this entire artery segment. So this is what we did. So this is the angiogram during the study. So you can see it looks horrible. Um Trouble here is that this A C A on this side is also supplying the rest of the ipsilateral A CIA territory. But because we know that some contrast is spilling over to the other side, the right A one from the left, a one tells us there's a good a calm artery which meant that allowed us to safely occlude this without worrying about the stroke. So we essentially filled that segment with coils as you can see on there. Um And ultimately doing an angiogram on this side, you're not seeing the left A C at all. But to show that actually that still exists when you go on the other side, the angiogram and the right, I see a demonstrates that actually the both A C A vessels are patent. As you can see the distillation territories bilaterally are filling. Um That's your dissecting aneurysms. Um The giant aneurysms are completely different uh cattle of fish. They are sort of uh on somewhat of similar theme to the last case quite often when they're that big, the best treatment option is to actually sacrifice the vessel if the patient can, can take. You know, this is probably the biggest aneurysm I've personally ever treated. This is a as a young man with prominent TB a poor self hygiene who essentially presented with um uh we'll scan uh to look for signs of, uh CNS TB because of a headache and ophthalmoplegia. And they saw the tennis ball size of an aneurysm in his head. Um, um, the entire sack size is about five centimeters by four centimeters. But you can see that the filling segment is just this bit here. Even that in itself is very large. The rest of it is way thrombosed. Now, when you look at the, you can see the lateral view that there is a big filling segment of this aneurysm. This is the distal I see a and the right hand side with a big thrombose sac. Um This is a three D angiogram view where it looks again equally as horrible. Um There is a very important artery coming here which supplies the internal capsule, uh which essentially with where your corticospinal tract goes through. This is your anterior Cordle artery. So you have to do the treatment and try and keep that artery open. And then because this entire segment of arteries disease, the only treatment option for it really would have been either uh a surgical bypass which after speaking to the neurosurgical team, they didn't think he was a good candidate for. And the alternative is that we essentially treat this aneurysm with vessel sacrifice. So before you do that, what you tend to do is do what's called a balloon inclusion test. Um So in your internal carotid artery lower down where you can do is um uh you inflate a balloon temporarily while the patient's awake and you go on the opposite side and do an angiogram to see if there is cross filling from the a calm, whether it's from the A com or the um from the posterior communicating artery via the vertebral artery and the basilar artery. Um And if the patient has good flow across and they don't develop any clinical symptoms with the balloon inflated for over 30 minutes, they essentially passed the balloon occlusion test. And so what we did here is fill this entire segment with coils um and put what's called an Amplatz, a plug in the in the lower down cervical uh corrected. And then in the end, when you do the angiographic other side, you can see that both MC territories are simultaneously filling with only a slight half a second delay. You can see that this is filling up at that point and it's gone beyond one more segment. That's, that's a normal finding. So, so that's uh that's how you often tackle giant aneurysm. They're not always treatable. Um uh But, but this is often a if the patient has a good circular Willis, this is a pretty elegant treatment. So now, since like I said, in the last 20 years, lots of devices have uh you know, the aneurysm treatment has come a long way. Um Just like uh no one knew about Coyle embolizations or coiling of aneurysms. 10, 15 years ago, including myself when I was coming through medical school. Um These days, people don't know about the next level of advancements. Um So which is why I'm here to, to show you. So this is uh these have been around for 8 to 10 years. So this is what's called a web device. Um stands for woven end of bridge. Essentially, it's got a, a single layer of um multiple up to about 48 wires are woven together. And the comment sort of pre shaped sizes and they're designed for wide necked aneurysm. So where a coil might be prone to falling out and necessity using a stent and even then sometimes you don't get a perfect result. Um And the stent, what the problem the stent is that you're leaving a lot of metal in the actual parent arteries. And that means the patient needs to be on dual anti plate that's for life or for six months at least. And then one anti plate for life and in that time, they can have complications as well. So, um so this is what it allows you to do is essentially without the use of a stent or a balloon, you can size the right size of device according to the aneurysm. And you use the radial force of the device to essentially hugged the inside of the artery and you open the device into the aneurysm. It's a single device. Um and it's quite a quick treatment and essentially a sealed the aneurysm off in a cause clotting within the aneurysm. Um So these are called intramuscular devices. Um What's have been made off late web is probably the most successful one. But because of its success, there are loads and loads of new device is coming out with different properties and different uses. Um The other more common one, the other two that I've used are contour and extent. Uh contour is basically half a web, web and extent is the same thing. But it also allows you to, allows you to get through the struts and coil the aneurysm as well. I'll show you examples of this. So this is a patient that I had actually not long ago, maybe about 22 months ago um with sort of a widespread subarachnoid hemorrhage mainly in the anterior interhemispheric fissure as well as in the prepontine system. Um CT angiogram showed right in the middle of that was a fairly wide neck perry close an aneurysm. Um And here's a three D angiogram showing you that. So it's a really wide neck. I was worried about losing these vessels if the coil was to encroach. So instead, what I decided to do was to uh during the treatment. Here's the guide catheter here in the neck. So you can see the DS A is showing you that wide neck of the particulars, an aneurysm and this with an eye of faith, you might be able to see much finer tube called a micro catheter is just, they're sitting inside of the aneurysm there. So you track the catheter using a micro wire and then you leave the microcatheter in there and through the microcatheter, then you deploy this device and I'm just going to run this video. You'll see the angiogram with the device to the attached to my catheter and you can see it's already causing stasis in the aneurysm. Um, you can see that's not feeling nearly as well it was before and whatever is there sort of hanging around for a little bit, that's exactly what you want to see. Um And once I've detached the device, you can see the catheter is back in the artery and now that aneurysm is almost already gone, uh straight away. Um Another example, this is an elective patient of mine with who was under surveillance and had a growing anterior communicating artery aneurysm. She grew this horrible looking lock, you'll on the aneurysm, which is always a bad sign. And similarly because of the how broad the uh the base was, we decided to place a web in the aneurysm which is now in, in position in there. And you can see very nicely. The angiogram afterwards shows that the contrast that managed to seep through the device is now sitting in that lock you'll and is unable to get away all the rest of the contrast is washed out. But that means that this is almost certainly gonna thrombose off and it's gonna be a robust treatment for this aneurysm. Um, this is an example. That's not one of mine. It's, it's one that I've got from the internet was a very nice example, um, of a patient who's a young female host, writing instructor. Good grade. Shh. Um, and was treated with a web. Um, and actually they've also got a, we don't tend to do six month follow up the DS A. This is the immediate post treatment and they had a six month follow up DSA. We tend to do Mr A which shows that almost a complete perfect occlusion of the aneurysm. So lots of different devices for, for aneurysms that were previously untreatable or very difficult to treat. Now, flow diversion is uh is the next revolution I would say. Um again, it's been around for a long time, but it's, it's going through its different iterations and now it's probably um in its phase where it's uh many different competitors are making very, very good devices. So you're starting to see uh the best uses of it. Now, it has gone beyond the experimental stage. Essentially. What this allows you to do is a very high metallic coverage um but it can depreciate from that little Jeff is that there's loads of little time me pause in it. So there enough pause in there to keep any vessels that are arising from that segment of artery to remain open. But there's enough metal coverage that it allows the flow to be remodeled. And like the start of the uh talked, we talked about the etiology and how flow dynamics has a huge role to play in developing aneurysms. Um changing the flow around the neck of the aneurysm completely changes how an aneurysm behaves. Um So what eventually happens in the aneurysm shrinks over time? This is a very good treatment options for particularly foreign ruptured aneurisms for tiny blister aneurysm that you can't get any coils in. And for sort of very dysplastic fusiform aneurysms again, which are untreatable. Otherwise, uh often we also treat them for recurrent aneurysms. I'll show you some examples of that. So this is the concept is that you've got an aneurysm here and I think these are all flow models, not, not real patient's and this is a, a flow diverting stent. You can see it has pause in it that will keep this artery open, but it will shrink this uh aneurysm over time. And because this this process happens slowly, it allows the artery to sort of re uh model and the collateral supply may take over from a different location. This is a prime example of that. This is a posterior uh cerebella artery aneurysm that was ruptured a couple of years ago that we treated with coiling. And after surveillance over time, you noticed that the base of it was starting to grow, which is a concerning sign, but you can see how wide the base of the aneurysm is. And this vessel, the piker artery is very much incorporated in the, in the aneurysm regrowth. So it's very difficult to place some more coils in there without threatening this artery. So we thought that a flow diverting stent would be used good treatment for this. Um This is a um uh vessel analysis that we do during the procedure um to see what kind of size of stent, what length we will need. So you can see this is part of planning that we're seeing that we want to stand to sit here to divert the flow away from the sac. And hopefully the vessels is open with the eye of faith. Often deployment, you might be able to see there is a faint tubular structure just at the base of these coils, which is the flow diverting stent that I placed. And this is an interesting uh concept that I just talked about the MRI scan preop show that this large occurrence at the base and this quite dominant looking piker artery here. But after six months or into the re scan, the recurrence is almost completely gone, uh has been remodeled and their vessel is only faintly if at all visible. Um So you might think, oh, they must have had a cerebellar infarct, but actually, in fact, shouldn't completely asymptomatic. And on the MRI scan is absolutely no evidence of any damage. And it's quite often what we see is that the remodeling happens over time and the collateral supply slowly grows and takes over the territory. Obviously, there is a risk that you might cause an occlusion. And that risk is um in the order of 5 to 8%. And, and, and the risk of stroke with simple coiling is about 5% of the slight increased risk. But in terms of uh treating things that you otherwise aren't able to do. It's not really that much of a complication penalty. This is just another example. I just keep checking my battery status because the, the fan keeps making funny noises telling me that uh it might be coming to an end. Um But again, there's another example, another victory for Floater version where uh this is a patient that I had on my very recent bank holiday weekend, 55 year old male, good great subarachnoid hemorrhage CT A was negative. But the bleeding pattern on a CT scan on this plain CT was concerning. So I did a DS A for him which showed this tiny anterior communicating artery blister where there's also an important little perforator vessel coming next to it. And you can see that it's likely wider in his base and it's high. So this is only about 1.5 millimeters in death. You can imagine trying to get a micro calf to sit there and place a coil is going to remain there. It's gonna be one hazardous because you might disrupt your through it. Uh And two is not really going to be possible because when you look at the lateral view, it's got this sort of a seat shaped appearance. Uh And, and there was no way that any coil was going to sit in that the only treatment for that is a flow diversion in despite the acute phase. Uh because we tend not to want to put things in parent arteries. Generally speaking, because um patient's require dual anti platelets uh for these stents. And when somebody's had an acute bleed, that's not something you want to uh to do because sometimes it can make the bleed worse. Um particularly the patient needs a ventricular drain putting in afterwards. Um that can complicate the procedure for the neurosurgeon. So we often have a MDT A joint discussion as we did participation to see whether they've got any other treatment options for this. And it was, it was thought the flow diversion was his only option and best options. This is again a treatment protection for you to show you what the, what it's going to look like um to the DS A or it shows that sort of a very shallow study looking aneurysm. And this is the uh snapshot of what the flow divert it looks like afterwards. You can see it's covering the anatomy there. Um We're still waiting for six month follow up for this patient, but he did clinically very well. He, he went home and I asked the plan for a few days of recovering from an initial bleed. Um This is an example of a, uh I've taken from a paper online. It's uh it's an extreme example. Um but it showed that it's possible. So this is an entirely dysplastic and diseased segment of the internal carotid artery. Um that the only other treatment in the years gone by would be um a vessel sacrifice um or um uh a sort of a vessel bypass. Uh but the, but that's not always possible because of the rest of the anatomy, not everybody has a complete circle of Willis. Um So this patient did not uh for to lose this artery. So instead what, what they've done is treated with a very long and telescoped uh flow diverting stents and eventually what's happened over time, you can see the entire artery has remodeled, this is immediately post treatment and this is after some time, you can see the entire vessel is sort of shrunk around that um uh around the stent. And the most importantly, this vessel is coming off at this level is has remained open. So that's, that's a sort of a whistle stop tour of sort of what we can do for aneurysms these days. The future is also exciting and the new devices and uh techniques are coming out to treat things that we currently are finding it difficult to treat because of the anatomical uh limitations or uh other reasons. Um There are other in neurosurgical interventions that may in the future be doable by interventional neuroradiologist such as um I was in a conference uh called brain conference at the end of last year where we, they, they showed how they were able to go from the, from the vein, unionist side, going to the inferior petrosal sinus. And from there essentially puncture through and create a shunt between the CSF space and the vein to essentially uh to as an internal ventricular drain, sort of speak, as opposed to the extraventricular drain where you have to piped through the frontal frontal lobe. Um interesting. Uh we are already using um uh A I tools for our stroke work where um and, and, and I module that's introduced uh in all the our referral sites or across East Midlands or patient has a CT angiogram and it detects a large vessel occlusion. I got a ping on my phone even before the patient gets off the table. And I think eventually the same company that I've been working with are also working on um algorithms to for aneurysm detection and it'll be just a matter of time before they can, they can do that. Um And in terms of devices in catheters, there are some really interesting uh new developments in the field which you know, if you're interested that I'd recommend going to some conferences, brain conference that happens in London. Uh It's a particularly good one for innovations um if you're interested. Um And I think that's uh probably about all I'm going to say. Um Thank you for listening. Uh I've been taking the questions, here's my email. I leave on the screen um for anybody who uh wants to contact me and ask any questions. Thank you very much, Doctor Malik. That was, that was a brilliant talk. I definitely learned a lot there that a lot that we just don't do a medical school and definitely not in our foundation training either. Uh We've only got a couple of questions. So the first one is to do with just aneurysms in general and talking about polycystic kidney disease. Uh So in people who have polycystic kidney disease plus minus any known family history of berry aneurysms, when would you investigate or initiate investigations? That's a good question. So in terms of polycystic polycystic kidney disease, so that's in itself is a high enough risk factor for us to screen those people at a sort of an early age at the time of diagnosis. Um in terms of the family history in general, the um our sort of, uh the risk is not high enough. It's just one person has had an aneurysm in the family that you, I think have a only 0.5% higher risk than general population to have another aneurysm. But if you've got to first degree relatives, then that's that risk is significantly highest like between 5 to 10%. So if you've got, let's just say a father who was known to have a brain aneurysm and your sister has been detected with one, then you should be screened. Uh and all your siblings should be screened. So to first degree relatives is a, is a, is a reason for um for screening and polycystic kidney disease as far as I'm aware in, in, in not, they do get a screening Mr uh once they're an adult. Thank you. Uh Glen, ask two questions. So, um we mentioned earlier that you came across neuro ir during neurosurgery elective. Uh The first question is, what way do you towards neuro interventional radiology? And the second is what, where precisely did you see your elective? And would you recommend it because they are currently researching electives for summer? Cool. So, yeah, so I, I did mine at mcgill University in uh in Montreal in Candida. And at that time, I was hell bent about, you know, doing neurosurgery. Um I mean, I really liked your anatomy, so I wasn't really that I was quite practical person and I really liked neuro anatomy. So I kind of made the obvious connections on neurosurgery point makes sense. Um So I just went for the elective and uh it was a fun any time to be there because a lot of their middle grade doctors were striking at the time. So it meant was that as a medical student, I was like upgraded to uh at least an sho so I was doing things um started turn up at 4 a.m. to do ward rounds and all that sort of stuff. Anyway, so I remember doing this one, a core manual zone. By the way, this is a story that got me into radiology training because it's uh they asked me my interview and this was a real reason. So I spent six weeks to bring the neurovascular block um where essentially we were treating aneurysms most days. And there's one, a calm aneurysm that we treated swear, it took like 10 hours and very sort of an invasive operation. And um obviously, you use this microscopic neurosurgery cyst micro surgical techniques. Um and a very long time the next day when I came to see that patient in the morning, you know, they had all sorts of new signs and this is an elective operation by the way. So this is a patient who came well, the day before this guy is in, you know, in the bed one and itu and you know, it looks like a mess. He's got now some visual loss that because the a calm often you go past the optic high is um and you know, in your dissection down or you're not that far from it anyway. And even at the end of the procedure, the neurosurgeon said to me, we might, this guy might wake up with some I signs and I was like, oh God, okay. So the following day, um so happened that my consultant said to me, you know what, we've got a bit of an opening. So why don't you go downstairs to the neuro IR suite and see what they're doing? And I kid, you know, I had no idea what he meant by neuro. I are. Uh it took me ages to find the department and I realized, oh, radiology. And they had a very similar aneurysm. They were treating, it took him an hour and a half. The patient woke up with a tiny little nick in there, you know, in the groin and, and he went home the next day and I was just sold and I was like, well, there's one thing looks barbaric and archaic and one thing looks like the future and I'll take the future. Thank you. And it's lucky that in the UK, you don't have to train as a neurosurgeon to become an interventionalist. And order you have to train as a neurologist, uh which often is the case and a lot of other parts of the world where here you, you're a radiologist, you have a shorter run through scheme of training. And so, yeah, I don't know how to highly recommend that. Um But there are other centers for neurosurgery for neuro ir electives. Um, Candida is big for neuro. I are so I would go to maybe Toronto is probably the best one. but Montreal is pretty good. Um, uh, Calgary's, it's a very prominent center. Um, there are lots of places in the UK as well. Um, Australia again is, is pretty well advanced. Um, you won't have to do the whole US, uh, kind of the checks that you have to do before. You didn't even elected over there, which has put me off years ago. But, um, yeah, I mean, I uh yeah, I think there is no comparison. Uh The good thing with radiology iron are also is that you are, you've got a pretty good balance. So half of your time, you are also still a diagnostic neuroradiologist. You know, you don't have any of the ward path. You've got sort of the clean work and you do really interesting interventions and uh they can be very complex and very challenging but very rewarding, particularly with stroke. Stroke is very much our thing. And that, that's a, that's a very big uh next big thing. So um yeah, I I think, I think that there are many pull towards uh neuro, I are over neurosurgery. One of the other things that you might not know, but the future of chronic subdurals impure patient's to keep coming back with subdurals. The future of that is who would have thought mm A middle manager artery embolization. The trials are going to be published um later this year, starting next year and all of them essentially show that embolization is superior to uh chronic, you know, continuous birth, whole surgery. So, um and I think it's going to happen to more and more interventions. And if you can do an intervention without, you know, sometimes we do joint clinics with neurosurgery about the interventions that, you know, uh when both with an aneurysm can be treated with both options. And there's an argument either or so we'll see them in dual clinics. I can't remember the last time a patient chose open brain surgery over and the vascular surgery and ultimately bear your customers. You know, there are people that you want to keep happy. And so, so, but obviously having said that if you have a passion for neurosurgery, there's a lot that a neurosurgery can do that. We, we can't, obviously there are there clinicians, they're very skilled and they do lots of different types of neuro surgeries. And um but yeah, as long as the neurovascular work is concerned, I think it's a, it's a no brainer part of the uh thank you very much. I think that's, I was asking if there any available audits or projects. Um I'm sure he can get in contact with you and if it's possible arrange something. Yeah. Sure. Yeah. So my email is just uh just email me, contact me where, where quite an active group here and Nottingham. Uh So you always have stuff, stuff going on. Um uh more than happy to for you to get involved. See a question about whether it's competitive ST four level. It all depends on your luck, to be honest. I mean, it's getting more and more competitive. Um, but I have to say it's, it's one of those where it's incredibly satisfying. I love it, but it's the best thing ever. But it's also not for the faint hearted because, you know, you don't really have, um, you either have extreme euphoric successes or really bad downs, you know. So your complications aren't that, you know, you've got a bit of a bruise or infection on the site. Your complications are, you've got to now a debilitating stroke. I'm sorry, you know. Um So, so having said that's not every tends to pick it. So if you are really somebody who has a passion for it and is driven towards doing it, uh you'll find a center that you can train in. Um And uh but, and as the, as a specialty is evolving, what's happening is that a lot of people who got into Einar 20 years ago didn't get into the iron are that it currently is, uh and then get it, get into it for those reasons. So they are slowly trying to sort of, they are coming to the retirement. There is a bit of that change of guard is going to happen in the next 5, 10 years naturally and we're still short staffed, you know. Um at um see I'm one of four Einars covering a 5 million population. Really, we should be eight or at least six. And so, uh it's competitive because there are certain centers in terms of limited to how many they can train at a time. But you will find, you will find a training person, you will find job for sure. Thank you very, very much. I think just in the interest of time. Uh well, uh close off here. Thank you very much, Doctor Matic. It was fantastic talk. I think we've learned a lot and we just opened our eyes to a lot of different things that we don't usually get exposed to as medical student foundation doctors. Uh really wants to like, like White Cell said that he wants to uh potentially do a public with us. If anybody else is interested, more than happy to entertain, people want to come and do a taste a week just to see what we do for a day, you know. Uh Very welcome. Thank you very, very much. Thank you. Thank you, everyone for attending. I'll just pop the feedback form into the chat. Uh So if you just fill in for us, thank you very much. Everyone. Have a good night. Thank you. Thank you. Thank everybody. Have a good evening. Oh, boy. Okay.