Robert M Starke MD., MSc., Miami, FL Videos

Giant AVM removed
What an incredible strong & special child. Arrived comatose with unreactive pupil & inability to move left arm or leg. Large brain bleed due to giant insular #AVM was squashing the brain. Bone was removed on the right side to provide more space & chance for survival & transferred to our hospital. Gradually he improved but with inability to move left side face, arm or leg. We embolized select deep arteries & then removed his #arteriovenousmalformation over a full day surgery. Months later the bone on the right side of the skull was replaced. With rehab he is running again with symmetric smile and great strength in arm. Hand strength will likely get back to normal. He made honor role & recently won the Leslie Sallade Award. Such an inspiration that we can always do better! A reminder to all the #stroke #aneurysm #AVM fighters out there that with hard work it can get better 🙌💪🎊🎉🥳. Used with patient permission.

Thanks so much for the invitation. Looking forward to this excellent meeeting and discussing AVMs, aneurysms, and transvenous approaches.

Last Thanksgiving we did many ruptured aneurysms including 4 endovascularly. They all came back this week for follow up imaging showing no residual doing great. The patient from Caymans brought this awesome mug! This Thanksgiving we have already clipped 2 and thankful both before 7am. Hope the day rest of today is free for food, family, friends, and fun! Feeling extremely fortunate and thankful for so many things. Hope it’s the best snd healthiest Thanksgiving for everyone!

For aneurysms it shouldn’t be clip vs endovascular. Optimal treatment based on patient & disease characteristics. Pt w giant ruptured MCA aneurysm clipped, made full recovery. Returned for endovascular treatment of 4 opposite aneurysms.

Thanks to @timururakov for hosting his annual neurosurgery ninja challenge 4 residents, fellows, families. Proud of these incredible young drs who work, play, & train so hard 💪🙌

5 UNCOMMON OPEN VASCULAR CASES FROM PRIOR MONTH: although I prefer minimally invasive endovascular approaches, sometimes open vascular is best (safest & most durable) option: 1) lateral cavernous sinus wall fistula ligated 2) giant partially thrombosed ACOM aneurysm prx acute vision loss, clipped/removed, vision improving (red arrow aneurysm; white arrow optic nerve before and after decompression) 3) 5cm AVM w 2.5cm venous varix removed 4) growing MCA aneurysm clipped w ICA aneurysm & removal growin meningioma 5) far lateral 4 ligation brainstem fistula

Pt w 12 aneurysms & matching massive aneurysms (>30mm). Right growing & treatment attempted and aborted 8 years ago by another provider. Right growing further treated w flow diverter coiling no residual 3 years later (balloon anchor technique 2 get system up). Left with growing aneurysm thrombus & embolic strokes treated w flow diversion 1.5 years fu. Pt intact on follow up. 💪 team effort and thanks to all the folks that keep making better devices to make our job easier!

3 year follow up on first Shield Pipeline stent for brain aneurysm. Hard to believe it has been so many years since treatment Of this ruptured dissecting basilar aneurysm. Patient made a complete recovery & 3 year imaging follow up looks normal (top row). The coating should decrease risk of thromboembolic complications. Nice to have Shield Pipeline with FDA approval for patients now. First 3 patients treated: dissecting basilar, 5 ICA aneurysms, clinoidal aneurysm (bottom row). Will be amazing in the future to have stents without need for antiplatelets but not there yet.

CEREBRAL ANEURYSMS CLIP OR COIL? It is not which is better but based on Pt & aneurysm characteristics what is optimal for individual patient. 6 cases from 1 week w 3 on LF treated endovascularly & 3 on RT microsurgery: 1. PICA 1mm aneurysm w progressive growth after coiling outside hospital treated w new tiny flow diverter 2. Giant ruptured partially thrombosed SCA treated w coils 3. Ruptured dissecting VA treated flow diverter & coil 4. ACOM coiled outside hospital w rapid growth pseudoaneurysm clipped 5. PCOM w CN3 palsy clipped 6. 0.5 ruptured SCA aneurysm clipped

CLIPPING RUPTURED RIGHT PCOM, LEFT A1/2 ACA & LEFT OPHTHALMIC ANEURYSMS. Pt presented w CN3 palsy from ruptured PCOM that was clipped from right side approach. Aneurysm dome removed & Pt now able to open eye again. From the right side we clipped left A1/2 ACA & left ophthalmic aneurysm. In this case I think microsurgery is a better option with higher rate of recovery of cranial nerve 3 & ability to treat all 3 aneurysms. Great work making this video by our fellow Nick Khan showing fenestration lamina terminalis & entire circle Willis. He will be missed as he takes a job Semmes Murphy in Memphis. #futureleadersinvascular

CLIPPING MCA ANEURYSM & OPPOSITE OPTHALMIC ANEURYSMS X 2

The optimal therapy for aneurysms needs to be a balance of patient and disease characteristics weighed against the positives of all treatment characteristics (microsurgery & many Endovascular options). Ruptured HH4 (coma) 3mm ACOM aneurysm. Younger, good grade Pt with less swollen brain, I would favor clip for anterior projection wide based, small aneurysm. Bovine, type 3 aortic arch favors arm approach. Ulnar artery larger & ulnar kink reduced (arrow). Rt brachiocephalic kink (angle) favors lager (088) catheter to L ICA 4 balloon coiling (no rt A1). 6 mo fu angiogram shows no changes & pt now independent lives alone wo deficits. #aneurysm #neurosurgery #endovascular #SAH #stroke #radiology #neuroradiology #bleed #unstoppable #EMT #brain #brainbleed #cerebral #aneurysmresearch #stent #coil #clip #embolization #surgery #u_miami_neurosurgery #umiami #universitymiami #trauma #paramedic #police #premed #resident #fellow #cityofmiamifirerescue

Juvenile nasal angiofibromas can grow to massive sizes. Often present child nosebleeds, congestion, frequent sinusitis. Very vascular lesions. Embo can make surgery easier/safer/faster/less chance for blood transfusions. Critical to know the collateral connections between feeders and normal brain arteries. Lucky have great ENT team ranked top in the country. This was uneventfully removed via endoscopic transsphenoidal approach and patient doing great.

BRAIN ANEURYSM COIL PACKING DENSITY: Coils often provide minimally invasive treatment option. Larger aneurysm size, wide neck, & low packing density leads to recurrence, retreatment, &/or bleeding. We hav previously published on percent packing density. Here u can see multiple imaging modalities help to fill in all spaces leading to dense packing & no residual filling. #aneurysm #neurosurgery #endovascular #SAH #stroke #radiology #neuroradiology #bleed #unstoppable #EMT #brain #brainbleed #cerebral #aneurysmresearch #stent #coil #clip #embolization #surgery #u_miami_neurosurgery #umiami #universitymiami #trauma #paramedic #police #premed #resident #fellow #cityofmiamifirerescue

RIGHT RADIAL TO LEFT VERTEBRAL ARTERY STEPBACK MANUEVER: Sometimes it is difficult to access the left vertebral artery from the right radial artery due to limited support and the medial origin of the vertebral artery. After placing the catheter into the left subclavian, pressure can be used to place the curve of the catheter into the descending aorta. This allows the catheter to be twisted to point medially into the vertebral origin. Often a radial approach is easier, safer, more comfortable for patients.

Coronavirus in Spain
Coronavirus in Spain: My sister sent this. Everyone is quarantined unless going supermarket, pharmacy, hospital: “Tribute to doctors and sanitary workers. 10 pm every night. Every one cooped up opens the windows and hollers.” Great work everyone! #corona #coronavirus #CoronavirusPandemic ‬

SPINE AVM: Pt w weakness incontinence lumbar vascular malformation fed artery Adamkiewicz (thoracic) stuck 2 nerve controlin foot & rectum (below the spinal cord). Rarest of many spinal vascular malformations not part of the original classification. Separated from nerves, removed wo issue, confirmed w ICG dye & intraop angiography #aneurysm #AVM #neurosurgery #endovascular #neuroradiology #bleed #unstoppable #EMT #spine #stent #coil #clip #embolization #u_miami_neurosurgery #umiami #universitymiami #trauma #paramedic #police #premed #resident #premed #radiology #fellow #cityofmiamifirerescue

VASCULAR BRAIN BYPASS: Sometimes when the brain is starved of blood flow we attach a vessel from the scalp or arm to increase blood flow to the brain. Most commonly done for moyamoya, vascular occlusion, complex aneurysms, giant tumors. The stitches are about 1 / 10th the size of a strand of hair. The green dye shows blood flow through the microscope. #moyamoya #bypass #neurosurgery #endovascular #stroke #radiology #neuroradiology #bleed #unstoppable #EMT #brain #brainbleed #cerebral #aneurysmresearch #clip #embolization #surgery #u_miami_neurosurgery #umiami #universitymiami #trauma #paramedic #police #premed #resident #fellow #cityofmiamifirerescue

VASCULAR BRAIN BYPASS: Sometimes when the brain is starved of blood flow we attach a vessel from the the scalp or arm to increase blood flow to the brain. Most commonly done for moyamoya, vascular occlusion, complex aneurysms, giant tumors. The stitches are smaller about 1/10th the size of a strand of hair. The green dye shows blood flow through the microscope. #moyamoya #bypass #neurosurgery #endovascular #stroke #radiology #neuroradiology #bleed #unstoppable #EMT #brain #brainbleed #cerebral #aneurysmresearch #clip #embolization #surgery #u_miami_neurosurgery #umiami #universitymiami #trauma #paramedic #police #premed #resident #fellow #cityofmiamifirerescue