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Sennai, Surgical Neurology International, and SI Digital, a new video journal which is interactive with discussion.
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In association with the Sub-Saharan African neurosurgeons
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are happy to present
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the 18th in a monthly series of Sub-Saharan International Neurosurgery Grand Rounds held on the first Sunday of each month.
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These meetings have a general category of global solutions to clinical challenges in neurosurgery.
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A moderator is a Strata Bernard, assisted by James I. Osman, for an
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international audience held on Sunday, December 6, 2025
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The first talk in this 18th Sub-Saharan African International Neurosurgery Grand Rounds is by Marvin Bergsnider, and it's on the diagnostic and management challenges of
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prolactinomas. Dr. Bergsnider is at the UCLA Department of Neurosurgery, where he's the Donald and Vivian Belisario, professor in the
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Department of Neurosurgery at the
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UCLA David Givenskula Medicine, and he's the co-director of the UCLA pituitary and skull-based tumor program
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A second talk is given by Al Hassan Tassana Adani, who is at
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the Greater Accra Regional Hospital on the Management Decisions for Phillamic Tumors.
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Dr. Adani is the CAANS, the
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ENS Scholarship winner,
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which is awarded to only a few people who will hide achievement.
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He works at the Ghana Health Service and the Greater Accra Regional Hospital as a resident there in the Department of Neurosurgery.
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Ghana is a country in West Africa, as you can see in the map. On the coast of the Gulf of Guinea, it's a relatively small country and area and population. One of the leading countries in Africa,
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partly because of its considerable natural wealth, and partly because it was the first black African country south of Sahara to achieve independence from colonial rule. In the red circle is the city
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of Accra where this presentation is from.
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We will switch gears, Dr.
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Hassan, from the Greater Accra Regional Hospital and Ghana will be our next speaker and he will be discussing an interesting case about patients with a phthalamic tumor and I think this discussion is,
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and I hope there will be a lot of participation as discussion
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revolves around discussing So, discussing. Issues not only about surgical management, but some of the social issues that can be prominent in
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medical decision-making. So, Dr. Hassan, are you ready?
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We didn't improve, yes, I'm ready.
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Dr. Hassan is a resident at Greater Regional Greater our crime regional hospital. Okay, good evening, at least to participants in Africa and good morning to those in the US. I hope my screen is
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visible enough and I'm audibly enough. Okay, great. So, my name is Hassan Hassan Andani. I'm a resident in Greater Caribbean Hospital in Ghana, West Africa. And today, I hope to this, so we
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can have a discussion on monitoring decisions for the 11th teamers. of Benad has stated, more of a combination of what literature sees, academics, and sometimes situations underground involving
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socioeconomic factors.
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Yes. So this is the hospital cetetra facility in Ghana. There are six teaching institutes of facilities which offer neurosurgical services to pay their government and this is one of them. However,
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in Accra, the capital city, there are just three facilities and the other three are spread across Ghana. So we just go through the case summary, some relevance anatomy, then we take to the
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decision making discussions, then we'll conclude. So we had an 18 year old female who came to us from the central region, actually referred from, can't I refer from two preferred facilities on an
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account of altered level consciousness when they suspected she had a brain tumour after doing a CT scan. But however, her condition produced about three months when she had left sided weakness first
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began from the upper limb then later gradually and got the lower limb too. She had been sent in three different peripheral facilities that alone threw into light a bit of difficulty in coordinated
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efforts in the peripherals. She was sent discharged and eventually returned back to one of those facilities in one of the
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regions. Three weeks prior to presentation, trobin, global headaches associated with two episodes of fever, then was managed as a more of an acute fibroid illness discharged home once again. Then
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a week prior to when she started having the altered level of consciousness, one of the attending physicians in his wake-up included a head CT scan, then the space occupation was diagnosed, then the
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call was made to our center, arrangements were made for special treatment care. So, Grossly, she was mildly ill, she wasn't warm to touch, at least when she was in her vicinity, she was
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uniteric. Those are the vital signs, which were relatively normal. But what was
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peculiar or the positives in the physical examination, if I missed her, gross local mask was 10 out of 15. Her pupils were 3 millimetersical and reacted to light directly and consensually, left
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hemiplegia, hypotonia, hypo-reflexia, then babiscus, unable to work on. There are other circumstances where I'm a remarkable. So, as part of our investigative wake-up for four block counts,
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each bill is
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125, plateless weight 206. However, initially, the WBC weight was 115, upper limit normally is about 8, and there was a differential of neutrophilia. Renal functions, liver functions, quantum
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profile, and serology were normal. chest x3 also so unremarkable and ECG likewise so I was thinking as surgeons we knew that we had to intervene especially with the presentant signs and symptoms
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they came in with a health CT scan this a health CT scan um axial there's non contrasted face uh immediately we requested for a brain MRI but here from the CT scan we already can appreciate what is um
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uh how it begin more like a mass in the deep core structure with the middle line shifts together with also really an extension into the ventric calls with associated prelitional edema but from this it
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was noted that this looked like a heterogeneous lesion the MRI came back at least this after six hours the T1 with contrast were able to appreciate multi-systic trilogular
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This seminar from the atomic region, you can see an extension into the posterior force such as the brain stem, and also does an extension to the lateral ventricle too, with the associated metal ion
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shifts and a lot of structures involved and also the oblitration of the right
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temporal home. So here, continuous series at T1 phase, coronal sagetal, T1 phase coronal sagetal,
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and we also included the angios and the MRVs. So as they wake up, as we knew it, it was a physical population. We, the WBC high ESR, I might say, was 346, which wasn't very significant. We
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had an additional wake up, which was the MR spectroscopy and the spectroscopy had, high levels of colon, and that's what
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we see here. So with our wake up, we had a differential of a high-grade glomer, a GBM, and also to a cerebroapsis. But bear in mind, the patient was really receiving about four days of
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antibiotics, which was a
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calf triaxone together with metronidylzoal. On our rivator, and we included vancomycin, because we hadn't ruled out the possible infection, too. So we just grossed through what has been the
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background of thalamic tumo stages. Way back in 1932, Habikushin was one of the pioneers who actually operated on a young woman. Then, as seen in 1958, it had a few series about 18. The radical
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resections also included other parts of
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the core in the Biza Ganglia. Then Greenwood in about 1970s had some 16, a series of 16 thalamotemos babbittae high mortality of almost about 70. Then Frasini in Italy in 1994 reported our 70
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patients who he had the interventions on and a three-year mortality rates as below. So the history proceeds and way back in
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2002, case reports of 18 children with thalamotemos, 16 underwent total resection and doing new modalities. So it was important to note that already this location of these thalamos is in a core
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structure, very difficult to reach, even with the best of technology and best of infrastructure. But nonetheless, we still continue to have some challenges in terms of the management and surgical
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treatments of these cases So, relevantly, as we know and not to take too much time on it,
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The thalamus or thalamus, they are two avoid egg looking shape structures of the diencephalon, which are about 20 to 25 millimeters, both sides of the fed ventricle in their medial aspects. And
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they are actually, they extend anteriorly So anteriorly, they are going to extend with a portion of the ventricle foramen, then posteriorly, they lead to
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the
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posterior commissure. There are about two or three anatomical variants, tens of the school of thoughts in terms of how to differentiate them with the groupings, where there are some who group them
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into anterior,
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posterior, lateral ventral, and then fuel our services, but in general. Using this appreciation from Yassa Gill's approach in 1996, the division of these regions were made from region 1 to region
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6, which has the anterior division, the lateral dorsal, lateral posterior, the pulvena, the midia, which has the intermediate connection fibers, then the ventral lateral, ventral intermediate
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and ventral posterior. So, with an exial flow of a catabric dissection, it's appreciable to note that the thalamus is actually due its media to the third ventricle. We have to
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understand that it has also very related structures to the internal capsule, other related structures to
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the basal ganglion, anything, understanding this and any increase in the sizes of mass associated conflicting spaces over there would lead to. some of the unfortunate neurological conditions or
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neurological presentation we find ourselves in these patients. So, immediately, as stated, we have the extension of the dead ventricle, well, literally an association of a complex with the
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insular complex with the basal ganglion complex with the internal capsule, with the associated rest
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of the fibres, which are related to them So this is an interventricular view, great relations with the deep internal cerebrovins together with the
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lentical thermostripe vessels and also some associated thalamic radiations, with four pateruncles, which could be the
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anteropadicals, clues in the anterior medial aspects, the superior posterior inferior pateruncles.
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So this again, a pictorial view of the groupings of
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the Talama. So with the arterial supply, is this basically summarizing to three of the PCA. So they telemogenically that the posterior choroidal and the pico will be the telemopedratus and the
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anterior choroidal regions. So with the venous drainage, there's a very good relationship with the internal cerebral veins. Thus, superior medial, you have the telemot straight veins which runs
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on the flow and the lateral parts of the ventricles And, sincerely, they're actually joined by the septal veins near the parts of the foreman of Monroe, and as stated earlier, the intimate
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association with the internal cerebral veins, especially at the region where both the lower
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joints together. So, reviewing the
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literature, there are certain considerations which are done, especially when there are some criteria to investigate or criteria to meet before surgery One question is future access.
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technique to intervene, then we ask ourselves the question, what is the nature of the lesion, is it solid or cystic? Are there any heterogenicity and is it multiple or
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not?
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Does the imaging give any guidelines or any ideas towards a suspected pathological type? Yes or no, they also have an algorithm. And in terms of, does the patient present with some early
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complicated issues of a conflict or species that's being a hydrocephalus,
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then some issues of relieving the pressure would be addressed, whether depending on facilities available and also depending on the staging the patient gets into us. So in some treatment strategies,
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it's important to note that for some telemic or most telemic glimmers, we have to appreciate the issue that they are already difficult to reach difficult to read, particularly because of what one
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difficult to recall access.
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to the unfortunately present to us, especially now part of the world in LMICs, often very large in presentation. They don't appear very small. Given the history that I went through with this
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patient, three months of neurological deterioration, but unfortunately the patient gets into us, to us in that particular seat. And sometimes most of them are high grade in terms of histological
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differentiation and also their mobilities are actually difficult for post-operative care Soon, generally, they are being
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grouped in terms of their care, which can be offered. Some would try to do observation therapy based on their size and probably no appreciation of any neurological deficits or neurological
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presentation at the site of when the patient is being diagnosed. Others to probably try to look at a static biopsy, together histologically it confirms, then you proceed with care, radiation, or
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chemotherapy. You do surgery that is a wide, clearly something decompress maximum safe resection, though these days have been warned to use the temp safe maximum resection together with schema
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therapy. Or there's also a rule of endoscopy biopsy, there's some great, 30 to 45
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decompressing which has been achieved together with schema radiation. Or when technology is available to retest a video surgery, however, it's important to note that there's a rule for a lot of CSF
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divergent procedures, normally in the acute phases to relieve the pressures. But it's very key or
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key determinants for us to notice that there are patient factors. For example, the age of the patients to the baseline neurologic artificial patient, three, how was the patient's independence,
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autonomic factors? There were the KPS index. Also, are there already some pending complications, ie, is there a hydrocephalus or not? early on sets of cognitive or behavioral changes. Then
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there are some tumor factors. In terms of the tumor factors, you can see it as the type of the tumor histologically, or the electrolysis of the tumor, whether it's an e-lateral tumor, or it's a
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bilateral tumor, or the tumors, when the cases which have been followed over a particular period of time, there's a good pattern of the tumors. I added the fitting in nature into the ventricle,
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or they are,
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they're just encroachments in the posterior length of the internal capsule. Or, also thinking to consideration, the vascular proximity in terms of how close it is to the internal, greater internal
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cell ravines, or the telomecle perforators, or the PCA.
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Important to, there are also some factors, some of the imaging factors, MRI, with contrast tractography, which gives an idea. The Timor-Grace Perfusion Studies, which would tell what it is.
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high or low grade, and some CSF and disseminations. And I just wanted to draw attention to in my literature or my literature review two papers that I chance by one is by Marizon et al. In 2022,
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they tried to look at a systemic review and I'll just go to street. So they discuss in their discussion, they want they accepted that there are still challenges of surgical resections in terms of
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tumors around these areas. However, the city was very important to note that with association, whether the tumor extends posteriorly or posterior medally, that location alone can actually give a
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worse prognostication, whether it's to
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engulf the provenome region or not. And they concluded that the surgical resection actually increases in operative mobility is quite high How are you guys important to know that? with the add-ons of
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technology, there might be some evidence of a cause of treatments which can reduce their operative morbidity. Also, in 2000, just last year, the GNS I found an article which actually spoke about
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different operative technical routes, which they tried to reduce their morbidity. And these are the operative routes, the anterior interhemous ferric, posterior interhemous ferric, the suborbital.
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You also have the
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temporal, also
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the posterior temporal, anterior temporal. This page just to highlight various locations which they try to navigate with their corridors, advantages and disadvantages in relation to that. So for
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surgical tips, it's important as I have stated earlier, mobility following surgery in terms of your intraoperative management and post-op management and the location of the tumor. whether the team
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might find a dominant hemisphere, what are the intimate relationship with the internal capsule and what is the vascular anatomy? So in summary, in terms of the interventions or the surgical
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approaches, they are the trans-cortical, trans-ventricular, the interhemous ferric trans-colosa, or posterior interhemous ferric, which can be parrotospeletal, or you could have the subtemporal
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or septar-transtentorial. And, last but not least, then the scope of
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procedures which also have clear, very key role in terms of surgical difficult cases or cases that the patients, the mobilities, extremely high. This is a summary of what I just stated, and
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pictorial evidence of some of the approaches translated again by this object is agomatic. This is infra-frontal approach This in time is by Transcarissa, which can be a transferentric color.
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transformational or transcorator, and picture evidences of this entire metaphorical approach and trans-color self-resection.
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Other pictures showing.
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So it's important to note that for each surgical approach, there are complications. For example, based on the location, the extent when you go through the trans-insular approach, then there's a
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high risk of internal capsule injuries, sub-temporal approach, then there's a high risk of what's affecting the adrenal veins and also affecting the temporal loop induced with associated seizures.
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When there's a trans-frontal approach, there can be high risk of post-operative seizures or trans-colosa, which we know
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the displacement of the colosa together, it's an either-mental transient disorder and also some memory deficits. Or it could be posterior colosa with a high risk of damage to the optic radiations.
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So other complications associated to it And now the question is that looking at this patient. 18-year-old, very young. Already coming from the socioeconomic background is quite difficult. Three
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months evolution of what is an intracranial space occupying lesion, but we can notice that just because of limited resources, adequate care, leads diagnostics, patient risk to us in the facility,
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we try to wrap around and ask ourselves various questions. And we're actually very happy to have Prof Bernard and his team around, but they came on a very good social visit. So we discussed a lot
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and do a lot of approaches which came. However, some of the approaches can be done in our setting. What are the risk benefits? And we overall took the decision. And now our decision was to
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go to those at Transcortica, Transcocabetos, a sub-temporal approach. for a more safe decompression, then we left an EVD drain. So we'll go through that. So with the head up, we actually have
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an
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S8 neuronavigata. So the patient will supine head, so they'll take control laterally, then a little bit of elevation at 20 degrees. There's a patient, as we can see, there's a protective theater.
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Generally because of teaching facility, and we normally have two to three residents who prepare for the case together with one or two attendants. So that's the market to identify, the three
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targeted scuff from the front, the door door, the front front door operator, the waiting bell was placed. Then we planned our crinosto. We
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have also our ultrasound with us in theater. So initially, we had the idea to go through the civilian fissure. But when we planned that this time, the self-emphasia looked very, very long, more
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than about three centimeters to get to the tumour. So we went through rather a more safer and a shorter route through the circles with ultrasound guided. And
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let me see.
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Just about, you know, interestingly to note that the tumor was gelatinous,
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we aspirated close to about 80 CCO, 80 mils of the content, which was mostly if I used the term in the super-tenteral region. The part in the infra-tenteral due to
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one, the aim of the surgery was safe resectioned, adequate decompression, and not being too overzealous and caused too much issues. So here we can see our plant crunals. We use the probe
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navigators' probes to identify the so-called way we go through together with the ultrasound, and these are pictures which should.
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So, surgery was about 8 hours, eventually we closed and patient went into the
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ICU. Patient was left into beta. The next day, about at least about 3 days, patient was extubated satisfactorily But unfortunately, what's happened was that for post-operative day 5 to day 6,
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what we noticed is that during the 9th, and that even boils down to one of the key errors and critical errors in management of these cases, especially in our setting, the patient had some darkest,
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a lot of secretions in the oral A with, then I think had them to cardiac errors, then unfortunately passed. The questions we ask ourselves especially in our parts of the world are one.
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There was an opportunity or a line of thought to entertain if a biopsy will be taken either through even ultrasound or stereotypically or
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then just confirm histologically then after after getting that biopsy you plan for a second intervention, that was one second to those who saw a group of surgeons who had thought of maybe probably
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true where the endoscope entered through, it could have been endoscopic through transcological roots and possible for some tumor resectioned debugging and also getting histological samples. So the
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other option was
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you operate a cranial for me, you decompress at least within series of margins, what can be done whilst living patients are very stable
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transoperatively and postoperatively, then confirming histological diagnosis, then to proceed with adjuvant therapy. But how, all these questions or all these suggestions, which came up, there
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were those one question that we all asked ourselves. And the one reality was that, in the setting where we find ourselves, the limited ICU species, that is one. Secondly, within terms of
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financial constraints with the family, even in this case, the doctors we even had to provide a lot of medications to operate this patient, we have only one shortage go to operate this patient. So
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if you have one shortage go to operate this patient, which of the possible opportunities or possible surgical options that you can use, at least to achieve the aim that you want and be able to
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rescue in terms of this emergency situation. So these questions are open for discussions, but I'll conclude by saying that, set you to the core of the brain, so pause. or they still put the
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proposal significant challenges even to the best of facilities. However, with standardized protocols and in efficient systems, especially in higher income countries, in
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our settings, the success of surgical interventions or the surgical adventures, they are totally hinge on a lot of compound factors which we cannot run away from. Factors involving the nursing care,
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factors involving critical care, factors involving some post-operative decisions which are made anyway, factors which hinge around a lot of socioeconomic factors. And therefore SNI especially,
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this as such platform a deliver to continue, learn to continue we as that think we,,
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they get out with a lot of collaborations which are actually instrumental and key knowledge transfer to be able to mitigate and give good treatment to this population But in bioinline it's important.
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I personally, anything with my colleagues is the surgical humility and utmost respect for some of the instructors, especially in brain tumor surgery, plays a very fundamental role and all patients
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should be judged individually and the management should be tilted specifically to the patients. This is the team and thank you very much and I'm so into questions, comments and suggestions please.
31:18
Okay. Thank you you may stop sharing the screen. Thank you, Dr. Hassan. That was a very interesting case, and hopefully we'll have a lot of discussion about it, and you did a great job in going
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through the anatomy and considering the different aspects of it. Now, I saw this case where Dr. Aseid, Dr. Morgan, is on the call, and Dr. Morgan and I, and Dr. Fred Todd were in Ghana,
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we were shown this case and I
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don't know what the outcome was but I thought it would be good for us to discuss how to manage such a case. I can say that there were as
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many opinions on how to approach this case as there were new resurgence and so we had some interesting discussion but a significant part of it was also the social situation that you find themselves in
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as Dr. Hassan mentioned earlier one of their considerations is that you only have
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one opportunity to address it and so sometimes consideration of a biopsy and a second procedure is not an option, it's not something that the patient or the family would be able to to phantom and so
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there is sometimes the obligation to to do the one, just do one procedure.
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So I'd like to open it up for discussion. I don't know what the histology is or what the histology was, but looking at that, I thought it might be a malignant glioma. And I admit my inclination
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was to do an endoscopic biopsy And
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I have to look back at the imaging, but maybe consider doing an endoscopic thermatriculosomy since you were having some obstruction, if not a VP shunt. But let's
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open it up for discussion. Before Dr. Hosan tells us what the histology was. When you have some thoughts about this?
33:42
Yeah, thanks, Jim Well, first, excellent presentation. I can see. You must be an excellent resident there.
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Very, very challenging case, particularly, you feel that at her young age, you really want to do whatever you can. I wasn't clear what her Karnofsky scale was at presentation, but it sounded
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fairly low,
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which is troubling I'm curious whether that was mainly due to hydrocephalus and that perhaps
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CSF diversion early to see whether that improved versus if she does not improve with CSF with an external ventricular drain. That would suggest that she has a very poor prognosis with or without
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surgery but assuming that she would get better with
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external ventricular drainage.
34:48
Here, your trans-cortical approach is what I, when I'm looking at the limited images that you showed, that I think I would have pursued at the very large tumor. I typically
35:03
really only approach posterior tholamic tumors. I found that their prognosis surgically is better. I don't know about their overall prognosis, but the complication rate is lower And,
35:14
transcortically, we mapped them out with tritography to try to avoid any important pathways. And, I do it with a port. And so, they're actually very, very economical ports. I use a thoracoport,
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the same ones that they use for thoracoscopy And, in the United States, those ports
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cost6. The ports that -
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These companies want to sell you. The United States cost1, 000, but the Thorca port works well. And then I would have proceeded,
35:59
your description of the findings were very interesting. That this was a very vascular tumor. Probably you just would have taken a large biopsy and withdrawn the port and not trying to resect the
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tumor 'cause that would be a very high morbidity, but a soft gelatinous tumor that you can largely suction out through a port, you can get actually very good resections. So that would have been my
36:27
thoughts.
36:30
Okay. Other thoughts? Say, do you have any thoughts about this?
36:40
I received an article in the meta-analysis of this type of tumor. that they went through all the discussion. And the suggestion was that gross total resection is better than to do extensive
36:53
resection. And the outcome, as Dr. Berguszneri said, the outcome is not very good, but they thought that the gross total resection is better and helps the patient to live longer.
37:08
The article will come up with it. As I know, it was a few weeks ago I reviewed it.
37:18
Any other comments from the audience? So
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Dr. Morgan, any comments?
37:29
I thought it was a great presentation.
37:32
I don't have any other comments. I think the way they approached it would be what I probably would suggest, but haven't done a tumor like that ever.
37:47
Dr, what you thought about this? Now, very good presentation. And I would like to congratulate Dr. Hassan for a resident to make a wonderful presentation really for a resident. Now, from my
38:04
experience handling these tumors, it's been so disappointing that
38:11
the challenge usually we would first is distinguishing between the thalamic tumors and the hypothalamic tumors. And once we, if it's a hypothalamic tumor, than we are more aggressive. especially
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to try and find out whether it's associated with the other sites so that we can be more aggressive because they are more likely to be benign. But once it's a thalamic tumor, then invariably most of
38:38
these are very, very malignant tumors. And the outcome in spite of whatever, from our part of the world, in spite of whatever we do, is not so encouraging. So post-sagerie, you may not get very
38:55
good results. For sagerie with radiotherapy, you may still not get very good results. And the best results really we found was being very restrained, with just perhaps the lesion and set the
39:10
patient for radiotherapy Now, how would we
39:16
buy a biopsy? And I'd like to share this, we used to do what we call freehand biopsy.
39:22
Free hand biopsy, I mean, it's a, with experience, it worked very well for most of us, you know, this is no city-directed biopsy. This is really free hand biopsy. And it worked very well for
39:34
us and we'd get the histology and then after that sent the patient to polydiaphylapy, but will be more restrained from being aggressive because our results were not so good.
39:47
I presume if you're in a highly developed world, where you have facilities of all types of assistance in terms of aggressive surgery, then one may be tempted to go for aggressive surgery, but still
40:03
at the same time, one needs to also examine the outcomes and long-term results of the cases which you are doing, or you know, does it really, really benefit these patients?
40:19
Can I make a few comments?
40:22
I'll sign that was absolutely superb presentation. Just an outstanding job and an outstanding job of teaching. If we look back through history and we just have to go back probably 100 years. If
40:42
patients presented with masses in the brainstem and at that time, we didn't have advanced imaging. We had pneumoencephalography, and you would see enlargement in the brainstem just by the
40:53
displacement of error and the images look like that. At that time, they were all treated the same with radiation therapy, the presumption of was that glioma or something like that, and nothing
41:07
more was done. It was the same for pineal regional lesions. They were very difficult to get to the morbidity and mortality He was very high with surgery. of standing surgeons that tried this and
41:18
still were not successful. There was a Dr. Poppin who was in the Lehi clinic who was successful in the 20s and 30s taking these out. And then we began to get more imaging in that microsurgery in
41:35
the 70s and 80s, which told us about these things. And we've gotten to the point where you can identify that there might be different lesions in the brainstem. It could be an abscess, it could be
41:49
a cyst, it could be a glioma. And people would look and try at least yet to the point in a pediatric, people are doing this now of getting a tissue diagnosis. And they were able to have some of
42:01
those that were successful. Ben Stein in New York worked on the pineal region, tumors and found 30 were benign. And so surgery on those, in those areas became technically feasible with
42:15
microsurgery and development of techniques.
42:19
And so what you're, and there's a presentation we have in Mountain S and I digital by a doctor from a Baghdad who looked at post, pulled in our lesions. And because the physiology is such
42:36
that none of the neural tracts are located, if you approach it posteriorly, you can do wider sections and become very successful
42:44
And we're going to have a presentation. We're going to talk to a surgeon in France, Dr. Dufault, who's
42:54
in Marseille, who's taking out Corpus Colosseum lesions. Incredible. So we'll have that information in another week or two, but it's done an incredible job. So what I'm trying to outline is if we
43:05
got into lesions that are very difficult throughout history to treat, and we're now getting to the point You can do this. And what I admired about what Dr. Hasan had done is they took lesions that
43:18
most people wouldn't want to do much to do. They want to do a biopsy or they remember years before people in both in the UK and in Egypt, if your imaging showed what looked like a GBM, they said,
43:34
don't do anything. Well, were we beyond that? And what you showed was excellent anatomical approaches to these lesions, we've got new technology, new imaging, fibertrank imaging may be helpful.
43:50
And so some of these things that were before believed untreatable are not treatable. The corpus callosum lesion we're going to hear about is in certain instances, they have very long survivals and
44:05
tumors we all gave up on years ago So I think this is just a superb job.
44:13
And the question is, how many people around the world, Dr. Hassan, how many people around the world, are doing work in thalamic tumors that are similar to what you've reviewed?
44:34
Dr. Hassan, do you have a idea? Thank
44:39
you very much for the comments. However, in relation to people around the world who are doing this, honestly, I didn't find them a lot, so I cannot answer them specifically to that
44:58
So, can you tell us the histology? Yes. Before you do that, Sam, I see you coming on, coming into view. Do you have any comments? Sam, it's a bit of a conservative when it comes to this top
45:15
of religion
45:18
Health insurance is not very
45:22
much available in our part of the world. People are paying out of pocket, and one family is wearing a child with this sort of problem. and you give them the pressure that something can be done to
45:37
save the young man, or young ladies' life. You know, they are motivated. But they get disappointed when the resort is bad. So this is my concern. How in the consulate before they saw you, what
45:53
do you tell the family? Is it that there is hope or that this is a difficult and bad case and the prognosis is poor. I think it's important because if you give an impression that, 'Oh, the surgery
46:06
is possible. You can do this. You can do that. ' And at the end, they are disappointed. It's usually disastrous in my butt. If they virtually fight you
46:16
when they get disappointed like that. So I would, in my centre, say, I probably talk to you anyway. So we are cautious about, we know the cost implication of the family. We know that for For a
46:27
long time, intensive capacity, the cost implications are terrible. And even sometimes, they can become very less independent. What do you do? So we try to be cautious. In this sort of case, we
46:41
can avoid the
46:42
CSF if they had a self loss, it's obvious. And then we try to get a safe biopsy to confirm the pathology we're dealing with. If it is something that you cannot send somebody for the therapy without
46:56
evidence of a malignancy So we have to at least assist on getting a biopsy to confirm the histology before we take the next step. But aggressive reception in my center we don't encourage it for this
47:10
type of vision. Thank you. Okay, thank you. Thank you, Sam, for your input.
47:19
Dr. Hassan, would you name, did you have another comment? Yes, I just wanted to add on some comments which are really a pattern or how we handle this in this part of the world. It goes over the
47:32
relatives, the expectations of the relatives. You know, and most of our patients really pay out of pocket. And when they pay out of pocket, they expect good results or they expect the patient to
47:48
recover. So now when it becomes a precarious situation, then it comes very difficult to try to explain to them what exactly happened and why you didn't get good results. So
48:07
I think when
48:13
we practice neurosagerie, this part of the world, we have to bear in mind the socioeconomic situations which we deal with Most of our patients don't have insurance, they pay cash, and in some
48:24
countries there is
48:28
government insurance, not all government supported insurance. but it may not really be able to cut for the whole treatment. So that's the other aspect you have to bear in mind. Now, what do I
48:43
teach my residents? Really, I teach my residents as when they encounter this type of tumors, they have to remember that the outlook is not good. And it's much better for them to do biopsy. And
48:55
then after they get biopsy results, then send the patient for
48:60
radiotherapy But I always wonder why it's only these thalamic tumors that the pathologists insist on biopsy, while when it comes to brainstem tumors, they can accept to give radiotherapy without
49:16
biopsy. Because when we have these tumors, in terms of the other tumors, which we hardly biopsy them from this type of the world, especially nowadays, when we have a situation when we can do MRI
49:27
spectroscopy, which can guide us as to exactly what type of tumor we're dealing with. So once we know that it's not an abscess, and this is a tumor which is likely to be a tumor, not an abscess,
49:39
not infectious, then we can send this patient for radiotherapy.
49:45
Brainstem, they accept.
49:49
Thelamic, they still want a biopsy. So I'm still trying to convince them, but they always refuse and say, You must do a biopsy I think probably it's because the chances of the patient coming out
50:01
of the surgery with biopsies higher, while the chances of the biopsy for malignant lesion for brainstem is more precarious than the situation the patient may not come out of that. So I really
50:14
congratulate the presenters, number one, for their brevity. They're very brave in the surgery in my part of where I'm coming from. uh, you would find it very difficult to convince the other
50:29
neurosigens why you are doing that side, you know, and, uh, you'd, you really have to sort of like, uh, convince them that you're going to get good results. And it's not as easy. So most of
50:43
these cases usually would just be up. Say, thank you. Thank you. Thank you. Jay, Jay, you had a comment. I'll see you have your hand raised, Dr. Moore. I'll try to be brief. Yes
50:55
Dr. Hassan's presentation, as everybody has said, has been absurd. And one thing I have to reflect on after being there in Ghana is that the level of care and expertise was very high. I was very
51:09
impressed by the neurosurgeons there, the way they approached this,
51:14
how they approached this with the technology they had, and it was amazing to see I had no idea being in Reno, Nevada. would it be like to go there, but it was eye opening. And Dr. Hassan is
51:31
representing, I think these neurosurgeons are
51:36
very classy and very good, so very impressed with them. Very good, difficult tumor, and I think the outcome in many cases, even in the best of hands, would have been about the same.
51:49
Thank you, Dr. Morgan. Dr. Bigway, do you have a comment? Let's see your hand raised. Yes, sir. Thank you, Dr. Bergshan, either. And thanks, Dr. Hassan. Both talks were really
52:03
educational. I'm not a surgeon, I'm a neuro intensivist. And you know, Dr. Hassan made a good point that despite the good surgery and the dedicated surgery, they performed the patient collapsed
52:20
and passed away in the ICU, for most likely an aspiration pneumonia, So I wanted to stress a point that
52:31
just as investment and collaborations are made in the surgical side of things, we should also really invest a lot in the critical care side of things. And Dr. Sam made a good comment, Professor
52:46
Sam made a good comment about advising and telling the family about a prolonged ICU stay and what the outcome would be. And, you know, you can have a good surgery, but mortality is always very
52:60
high in the ICU, specifically in this part of the world, like I'm experiencing at the moment.
53:07
Hello, you're in Tensei D'Archo. Yes, sir. And how's it? You just got there about four or five months ago and how are you doing? Really good, we're making good progress
53:24
Dr. Bigway was at UCLA. And so now he has the ability to compare the infrastructures and the setups at both places. So well, thank you for your insight and for your input. And by the way, since
53:42
you're here, have you implemented the non-invasive ICP monitoring program? Yeah, we had, you know, I'm working with Professor Hado with Cornell and we had ideas to implement that, but arriving
54:01
and seeing the situation on ground, we had to de-escalate and really start from the fundamentals, start from scratch. The IC was not ready to have such a device yet. So unfortunately, not yet,
54:17
but we're still utilizing ultrasound for clinical decisions. Next month, actually, the Colorado group on the surgery, near a surgery, and then your ICU team will be coming down and they're
54:31
bringing in transcranial dopplers and also bringing in two high-tech ultrasound for optic nursery damage. So we want to start education, but the ICU does not have the capacity for any kind of phase
54:46
one or phase two clinic with trial.
54:49
Okay, well, thank you We look forward to getting a little follow-up from you. So let's go back to Dr. Hassan for the final word on the histology and any concluding comments.
55:07
Okay, thank you very much for all
55:10
the comments, the discussions, very insightful. So I think there was a question on What was the
55:17
attack on the corner of his core before we started?
55:23
the Carnotius course was 40, I think that was just to answer that. Secondly, there were a few comments on knowing the socioeconomic background and the part of where we are, LMI's, in terms of the
55:39
discussion, so progressification to relatives, yes. Actually, some, their relatives even were okay with any outcome. If I say okay, reason being that this surgery was, everything was supported
55:57
by the hospital because we have a dedicated sector in terms of difficult situations or socioeconomic groupings in relation to that, so it's important to make that comment too. Thirdly,
56:11
interestingly, the histopathology came out, that's the first phase, we are still waiting for the second two stages. The first day they came out with it, it was a high grade glioma, grade 4. But
56:26
probably an interesting thing you used to know was that the cultured E. coli,
56:34
yes. And the pathologist, and it's important to also state that Ghana, we don't have a neuropathologist So the pathologist requested for some ISCs and also some biomarkers which hopefully we can
56:46
have. Then maybe I
56:54
will share it with you, then it can be passed across to the house. So those are the comments that we have. And then we've learned a lot from this, especially with your guidance and with your
57:08
visits. And we hope to make greater threats And I understand everything my senior African professors have said, trust me, we live with every day and we understand the situation. when people think
57:21
that once there's going to be surgery, after surgery, the patients walk out of the hospital. So the expectations, especially culturally and socioeconomically are a bit high on the stage ends here,
57:32
but we also take it upon ourselves to make sure that the education is very, very well. And our counseling sessions actually, we have a protocol of five counseling sessions before, what we deem as
57:45
high risk surgeries, for example, a surgery like this, and do some comments Any further questions or address, please? I have some comments, and then I wanted to ask Marlon a question. I think
57:56
what Dr. Arson has just said, it obviously could be a neoplasm with that's infected, or it could be an abscess. And we don't know that for sure yet, but it only supports what I told you when I
58:09
reviewed the history. And that is, you don't know if you assume everything's bad. And so I think Sam and Nimmer, right? Because economically, And practically, you can't do this in everybody,
58:22
but if we had a practice where people would come to us with where everybody had given up and they said we wanted you to do everything you can to help me, which gave us a selective sample to look at.
58:34
I'm wondering, I wanted to ask you this question. We have two Terry tumors, you said, very common tumors. We've known them for years. It is the most accessible tumor that you can have to study
58:46
its biochemistry, its pathology,
58:51
as you look down the road to the future, it's always disturbed me why we cannot have a biochemical pharmacologic treatment for pituitary tumors. Is it the fact that, for example, in prolactin
59:05
tumors, there are multiple factors that can lead to their growth? Can you give me an idea? That's kind of a speculation as to where the field's going.
59:18
Jim, you always ask difficult questions. I will tell you that
59:24
we do send 90 of our subjects tumors for research. Anthony Haney is really a brilliant in the chronologist. And he is culturing these tumors and running He's able to - he has an assay now that can
59:47
go through thousands of medications that already exist. And for instance, he found one that Cushion's disease,
59:58
corticotropes, were actually very sensitive to an existing medication that no one thought of trying. That doesn't really answer your question. But we are looking for medical treatments When I
1:00:11
consent, my patients for research, I tell them, literally, I'm trying to put myself out of a job.
1:00:18
And so that is the goal, but like everything else, our initial thoughts and understanding of what pituitary tumors are, where they come from, is evolving. And I think someday we will understand
1:00:35
them, whether there's a target medically that's yet to be determined, that is the goal Okay, thank you.
1:00:47
Anybody else?
1:00:50
I think, Jim, I think we've had two excellent presentations, Professor Bursling, and thank you so much. Dr. Starata, if I can make a comment, please. Go ahead, Ali. Okay. I had a patient
1:01:04
who was operated by one of our faculty at our county hospital He had a cancer can be a mass, they were thinking of the glioma, but when they went there, it was an abscess.
1:01:17
And they drained it and the patient recovered. But the cause of the abscess was a defect in the atrial septal defect. And so it was a major big hole in the heart of the patient that the bacteria
1:01:29
went to his brain. And then after the brain surgery, he had to go through
1:01:36
it. Massive cardiac surgery to close the network. That was one thing I wonder if Dr. Has, although it was not aimed at this procedure if they had done any cardiac studies on this patient, because
1:01:49
this patient later, they found that they had a, with echocardiogram, there was a defect and all.
1:01:57
And the patient did very well with the, at the ringing the abscess, and it didn't come as a tumor, and later on here, he had a major cardiac surgery, and thank God he survived and he's doing very
1:02:11
well. And that's something I just wanted to add you're going to have an abscess at that area.
1:02:21
Yeah, well, on that matter, I should point out, and I don't know if they have the software there, but the ADC map of the MRI can be useful in differentiating whether there's an abscess or not.
1:02:36
So I don't know if they have that sequence there, but that can be a very useful tool for determining by MRI if a lesion might be an abscess Thanks.
1:02:52
Well, I think we had some superb talks. Sam comes from a country where there's 230 million people and the population is growing by leaps and bounds and you have to make practical decisions and what
1:03:09
it tells us and the NIMMS has the same thing is that given your circumstance, you do the best you can and that's what you do And so we've had - Today, we've had a survey across the world of people
1:03:26
who are very talented and very good at what they do and are doing the best they can under the circumstances they have, which other parts of the world don't have. And some areas can do more
1:03:42
in detail or in technical studies and so forth, and so they can go a little further So the basic proof we get to is there are bright people everywhere in the world, which Dr. Hassan has proved just
1:03:56
an elegant presentation, and you have to, no matter where you are, do what the best you have with what you got. And we see that every month, just outstanding people who have done great jobs. Yes,
1:04:10
very well. Okay, well, we're near the top of the hour, so I think. We'll conclude this session. Thank you everybody for your participation and the stimulating conversation. We'll sign off now
1:04:27
and plan to resume next month on the first Sunday. Thank you all. Thank you very much. Thank you for the invitation. Thank you, Marvin. Thank you.
1:04:40
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1:04:43
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