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SNI, Surgical Neurology International, an Internet Journal with Nancy Epstein as its editor-in-chief, and SNI Digital, a new 21st century multimedia neurosurgery and medical information resource
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for the world, with James Osman as its editor-in-chief
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Our police to present another interview with neuroscience leaders in its series, and this presentation will be by Professor Hugus' default
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on brain surgery of the future, redefining uncle-functional outcomes and the quality of life.
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This particular session will be on multi-stage surgical resections, applying basic neurosciences to diffuse for you more. and it's part of a series of nine lectures from Dr. Defoe on his new and
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innovative pioneering techniques in the management of brain tumors and brain relations.
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SNI, Surgical Neurology International, is the third largest readership in neurosurgical journals. It's been published for 15 years as over 600, 000 years as a year on its website and a global
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audience
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and its web address is SNIgold. SNI Digital is a video neurosurgery information resource. It's seen in 158 countries in the last two years.
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It has 24, 000 viewers a year
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and 15,
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000 podcast listeners every year And it's web address at snidigitalorg.
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Both information resources are available for you, everyone on the internet 247365. The goal of the foundation supporting these information resources is to help people throughout the world.
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Dr. Defoe is at the Gui de Cholieck Hospital in Montpier, France His telephone is listed and the email address is also listed
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The lecture series consists of nine lectures. This is session three on multi-stage surgical resections, applying basic neurosciences to diffuse glioma. The previous two lectures are already on the
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SNI digital website, and the next one will be a long-term on confunctional results of the connectome-based surgical resection series
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All Professor Defoe's lecture discussion video sessions are available on SNIDigitalorg and video, audio, and printout formats and on commercial podcasts, Apple, Amazon, and Spotify, and can be
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downloaded to your computer from SNIDigitalorg free
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The moderator of this session will be Estrada Bernard, who is a member of the Duke neurosurgery faculty and former head of neurosurgery at the University of North Carolina. His special interests are
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neurosurgery in general and spine, brain, and pain. He's on the board of directors of SNIDigital, he's head of SNIDigital Grand Rounds Programs, and those programs are now surveying some say here
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in Africa and Latin America
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Dr. Osmond is the other co-moderator with Dr. Bernard, he's the creator and founder and CEO of SI and SI Digital, former professor at four universities and head of neurosurgery in two centers of
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Futures to Entrepreneur and Healthcare Consultant.
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A technological format behind all of these programs of SI and SI Digital is marshaled by their chief technology officer, Mike Chile, who is the principal and the firm of Graftic, who can be reached
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that the phone number is listed.
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Introducing professor Defoe will be Andre Servio, who's head of neurosurgery in the neurosurgery, neurology, and rehabilitation institute in Buenos Aires named Flenny
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and these are some of the references to the talk which you take an screenshot of this for your records. All the references are cited by Dr. DeFoeh throughout the program. With this introduction but
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I can tell you that everything's professional process, believe me, is true because I saw him in the
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pretty theater and in the present day with the market put so many pressure to push the surgeon to use different new devices. I am not against the market. Sometimes most of these techniques, new
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techniques are, of course, very useful. But when you see Professor DeFoeh printed on, you know that the most important thing for a younger surgeon is the knowledge of the anatomy, the knowledge
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of the function of the brain. You need to study, you need, you're learning cube, and of course the important of the awake surgery and the interpretive monitoring.
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If it's the first time for you to see one of the talk of Professor before, you will enjoy a lot. And it's necessary to understand the way of thinking he put in this type of surgery. So again,
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thank you very much, Hughes, for being here and to allow everybody to see these outstanding presentations. Thank you, Professor Osman. And really, thank you very much, and think what you said
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is, do you understand the thinking that he has is really the key to all this? 'Cause it's almost the reverse of what you've been taught. You say you're absolutely right. Just from a minute,
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Hughes, I'd like to introduce some of the people. Dr. Kansari was from Persia. He was trained in
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France, and he's in the United States in UCLA. You know the
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Andhraattis. Professor Andhraattis, a neurosurgeonum.
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in Argentina, and it's why you say clinical psychologist, that's true, you
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know, Dr. Salim is from Syria,
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and Lauren Dina is a Romanian neurosurgeon just starting a career. Carlos is a student in Mexico. Deepak is a school-based neurosurgeon in Mumbai, which is Dr. Perique Vlad is also another one
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from Romania. We have all the neurosurgeons from Romania here today. I don't know the other Professor Joffrey Rezert and Ahmad or Stefan Sandi. I haven't met them. And Mike Chealy, I mentioned to
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you,
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Alexander Himmstand is in his final stages of residency when in neurosurgery and has been trained in an excellent school-based center. So that gives you, we've got people from all over the world
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here and they're here to listen to you. I try to, I want you to start because I almost forgot to put this on record.
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Well, I know nothing to add, Jim, a great introduction. Please, Professor Defoe, let's get started. He already is sharing his screen. So let's see what, let's listen to his excellent
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discourse.
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Thank you so much again for your support and for your kind introduction I will try to answer some questions raised during the
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past session based on this concept of multi-stage surgical restriction and, of course, applied to surgical neoncology. As usual, I will start by a few cases and then to show some slides. And
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after that, we will open the discussion. You will see the first case, a 38-year-old.
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Man manager with no previous medical in its three of these is and we experienced
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Huge we did did you start sharing screen cuz I don't see your image. Yes, we can't I'm sorry Jim you see it Yes, what's wrong with me?
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I Don't guess everybody have an image
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Yes, we have yes,
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I think yeah the image is being displayed No, I don't want to stop sharing. I don't know. I can't see the image. Well,
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I can stop sharing and No, right again, if you want everybody else seems to have the image except me
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Let's try that let him stop sharing and then and then start again Okay, let's see if that works. You're the leader here tonight, so I'll
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Okay, then here's this reset and let's see how that works. Yeah, okay, I mean, it's going to work.
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I got it now. Okay, great. Okay, thank you. Thank you. Thank you. Thank you very much. Okay. You guys are ready.
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So the first case with nothing very speak from young patients and heart seizures with a normal clinical and your psychological examination, you will see that it's an imagine typical for diffuse
10:16
logarithmium evolving at the orbital frontal part in the left of so-called dominant hemisphere and this right-handed patient with also an invasion at the level of the anterior insulin. What I did is
10:32
awake surgery and of course I will not insist about the concept of your plasticity and awake surgery I developed during the past sessions.
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I would adjust it to insist on the fact that I did a complete resization according to the post-proative MRI. And that we did not perform any adjuvant treatment because the patient recovered. And
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he had no seizures. He returned to a normal family and social professional and sporty life. And we did more or less nothing, except, of course, a regular surveillance And on your path,
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pathological examination confirmed the
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diagnosis of logarithmium and, more specifically Oubre II,, IDH-mediated astrocytoma. Nonetheless, as you know, it's very difficult or even possible to cure a patient with a diffuse glioma. And
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you can see that slowly, but regularly, there was a re-increase of the eye or signal around the surgical cavity. especially at the airport. And five years later, finally, I decided to propose a
11:51
sick surgery. Once again, the patient enjoyed a perfect normal life, so in a pre-vontive way. And again, we did an awake surgery here, according to the same concept, relief in property,
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mapping and cognitive monitoring. And you can see that this time, I increased the position that delivered after a frontal lobe. And again, the patient recovered. Nonetheless, I would like to
12:22
insist on the fact that I was able to go more posteriorly, and you can see the error corresponding to the
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pre-central sulcus. So the one, the tag one, was the Vontran Primo del Como. in using an anaphria when I stimulated by using more or less the same parameters in comparison with the first surgery
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performed five years ago. So nothing very special because the preservation of the connectivity in the depth allowed a perfect recovery again and we decided why the patient had now more than 40. So
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against the classical recommendation not to give any adjuvant treatment because it was still a upgrade to IDH mediated astrocytoma and then we again the patient had no seizures and no more family
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social professional life and continued to be very active. Nonetheless as usual it's very difficult of course to cure patients with low grade layer may be because a diffuse tumor so you can see and
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write that five years later so 10 years after the first surgery, there was a re-increase of the flare-iprocynone and you will not be surprised. I proposed to the patient to re-operate him
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pre-ventively thanks to a pre-operative cognitive assessment demonstrating that he perfectly compensated in the meantime some mechanisms of neuroplasticity developed in the first session. And again,
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I did this on awake surgery and you can see the intraoperative imagine that the some trans sulcus so demonstrated by the arrow now was very very the pre-sontrans sulcus I'm sorry pre-sontrans sulcus
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was the posterior part of my resection so allowing to continue to push the resection more behind thanks to mechanisms of network. reconfiguration, explaining why
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the patient had known any deficit before the flood surgery. And you can see that again, I tend toward a complete restriction according to the post-proative MRI, so 10 years after the first one.
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Again, the patient had no adjurant treatment, no seizures, and enjoy it on the more life. And this time, it seems that finally, I was going to take a margin around the flare hyper-signal because
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now we have 15 years of flood and not yet any modification of the MRI and the patient enjoying an active life, as I said, but also with monitoring thanks to an MRI every six months. So you see that
15:29
in this example, with 15 years of flood, my vision is almost 50 now. We did not use any chemotherapy or rare therapy, and the patient continues to be totally active without any adjuvant treatment,
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without anti-apleptic drugs, with no seizures, demonstrating that the brain was able to reorganize over years in adults.
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And I definitely can show you that, thanks to the prison trial Salkers, which was the landmark during the first second and third surgery, and you can see that each time I was able to remove more
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brain invaded by the tumor, by preserving the connectivity limitation of neuroplasticity, knowing that each time I brushed the restriction according to the individual functional boundaries In the
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works, the brain reorganized. And there was now modification over yours, thanks to intraoperative demonstration during the first, second, and third surgery. And the goal would be why not
16:50
re-operate him in a few years if needed. And of course, if there is no invasion of the connect to him in the dead.
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I will show you immediately the same concept But now, you will see with more for that. 26-year-old man marketing, no previous medical history, partial and seizures, normal clinical examination,
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nothing very special. And you can see an image, it's become for a left diffused, low-grade glioma. Now, invading the so-called superior frontal gyrus in front of the supplementary motor area.
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You can see the first surgery performed by myself 20 years ago, so I mean.
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2006. And I will not insist on the fact that the patient had no any adjuvant treatment after the first surgery, just a regular follow-up, a normal active life, including familiarly, socially and
17:53
professionally speaking and, finally, with a regrowth of the flare, posteriorly, of course, at the level of the supplementary motor area, the SMA proper, eight years later, I decided to do a
18:06
second surgery and do a wing mapping. You can see the phosphorytive MRI, so in
18:14
2014, and again, the patient enjoyed normal life. It was a no-di-good and whole gliomyoma in this case, grade two, and no adjurant treatment, no chemotherapy, no way for a pin on my life and so
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on. And finally, because you can see a diffusion around the surgical cavity now in
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2022. So 16 years after the first addiction, I decided to propose at least to the patient to do a third surgery, again, preventively, and the patient at a perfect collaboration during surgery are
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allowing us to increase the extent of the addiction as you can see each time Why? It was a voluntary cover. And this time, I will push a little bit more because I did a fourth surgery past year.
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So now we have 20 years of lab in a patient who had no adjuvant treatment and still a bone to enjoy perfect number life, working from time now 46 year old And of course, I said to the patient, I
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would not recommend, despite the fact that you are more than 40. So against now the classical recommendation, because you know that after 40, we should apply the concept of rhinotherapy plus PCV.
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And my question is why? If you can continue to control the disease in a patient with an active life. And I will push a little bit more. You haven't understood the concept by showing this case now
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with five consecutive surgeries, not because the tumor became maclic nut, not because the enhancement, not because the patient had seizures but pre-inventively. And now I have 23 years of lab in
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this case, knowing that finally we decided to give an adjuvant treatment and especially radiotherapy just this year. So in fact, 24 years after the start of this disease, clinically speaking So
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showing that. Of course, I arrived at the limitation of New York plasticity. And if I do not recommend early radiotherapy, you will understand why a little bit more later today and during the next
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session, nonetheless, I'm not against radiotherapy when you cannot re-re-re-re-re or pray because now invasion at the level of the why matter attract the limitation of your plasticity. And of
20:59
course, I hope that thanks to radiotherapy, the patient will have, again, a control of the disease, but price to pay could be to have a decline of the cognitive functions within the five next
21:12
years and the patient is perfectly aware about that, of course. But we will arrive, more or less, in five years, about 30 years since the first surgery So, if you haven't understood the concept
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of multi-stage and multi-step. surgical management and of course adapted to this ever-changing modification at the level of the meta network we developed during the first session. And this
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modification of the interactions also between the glioma re-growth because each time, of course, I re-operated that because unfortunately the glioma relaxed. But also in using further mechanisms
22:02
from your plasticity allowing me each time to increase the externalization while preserving a perfect quality of life. So we have definitely to try to understand what happened when we met the patient
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for the first time and to try to anticipate what will happen, not just speaking about one surgery, but the bifbitular modification between the gliomag growth and migration and the network
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reconfiguration. And this is the concept of your plasticity. Of course, I developed initially a window to do a very expensive visualization, according to the functional boundaries, and not by
22:51
thinking about the tumor itself, because we know that we have tumor and sounds far beyond what we can see on the preoperative MRI. But now I would like to develop a little bit more how to anticipate
23:07
the next surgeries before mackling on transformation and by postponing a treatment, at least radiotherapy. And you will see in the next session that I will say that MRI and DTI are not so reliable,
23:24
unfortunately, which is true. I do individual in the operating theater. But you can use them. Launch it to the NALI, because of course, there are in essence, none invasive, before and after
23:39
each surgery, in order to better understand mechanisms of reorganization at the individual level, especially before the restriction of the left SMA, exactly what I did in the second page. And the
23:54
message is very clear You can see that you have bilateral recruitment of both hemispheres.
24:03
Just by using a simple movement task, you can see that you have an activation at the level of the snub of the hand, but also retrosant rally, because you need somatosensory feedback in order to
24:19
control the movement, but also by using the contralateral SMA
24:25
And, Primoco takes. in order to create a new bilateral network critical in order not only to be able to move and to avoid any pleasure or to recover after a transitory a teenager, but also to be
24:42
able to make very, very accurate complex movement. And this equilibrium between a misverse is absolutely critical and can be regularly for loved and if you're living by using fMRI and especially
25:01
resting state, thanks to of course the advances made in fMRI while it was impossible 20 years ago because resting state did not exist. And typically, I will show you this case of a vision I
25:17
operated on the first time for a left premodered logarithm discovered because of C-jolt. and this patient is a guitarist. And it's very exciting to see that there was an invasion of the so-called
25:35
Poisson trial jarrus, so the snob of the hand. And finally, I decided to leave the numbers 40, 49, 41 during the pro-surgery, because each time I stimulated, each time a patient had some
25:51
movement reaction, a rest of movement or dystonic movement as I mimicked. Again, no ray of therapy, which is against your plasticity, normal life, and the patient continued by playing guitar to
26:07
increase the mechanism from your plasticity, because of course, the tumor grew, because there is no stable glioma. But you can see that five years later, by doing another MRI, then we showed
26:25
also, that there was a recruitment of the contractile amissur and alsoipsiligional at the level of theipsiligional amissur jump from the prison trial through the suntral circuits. And then
26:41
I say to the patient, I will propose you to be a real prey to them to decrease again the volume, to avoid Mecklingland transformation, to update histomolecular analysis, to act accordingly in the
26:54
post-breative period, but by presumving the quality of life. And it's exactly what we did, because the numbers, 40, 49, 41, disappeared. I mean, when I stimulated during the second surgery,
27:11
there were no responses, no movement, no destiny, no arrest of complex action. And it has been possible to remove a part of the prison trajarius, why, again, preserving the connectivity in the
27:26
depth. It was possible to do it for language, if I can say, too, you can see here a logarithm, I'm invading the posterior temporal lobe in the left hemisphere, including the so-calledvernicus
27:42
area. And the harness tag was not able to remove completely the tumor during the flow surgery. You can understand why, because you can see that each tag at the level of the cortical surface meant
27:57
you cannot remove it, because you can use transitory lead during stimulation, some modification of language cognition and so on. But 10 years later, in a vision who continued to in general number
28:10
life, with new adjuvant treatment in the meantime, then there was a reorganization demonstrated by longitudinal ephemeri, and thanks to the preservation of pathways. we have seen during the first
28:25
lectures. Namely, the inferior fontoxipitron fasciculus 46, the arcade fasciculus 50, the ILF, posteriorly at least, and so on and so on. What happened? Now, I think the patient returned to
28:40
an active life, including for me, that means in all cases, they are able to work. You can see this very provocative case. I did a first surgery in the left, so-called Babylon and Tamisphur,
28:54
because there was tumor initially, and no chemotherapy, no RFP. I removed the so-called broker's area. You remember that it does not exist, because a connectivity around it won't compensate it.
29:08
But unfortunately, the patient had a migration of the tumor over years, and with an invasion the current product, right from the loop, through the copy schedule. and we will see that in another
29:25
tool dedicated to the cactus chalisoma in a few months. But you have seen that I was able to do during the second surgery, a second lobectomy in the contralleteral misfer with bifurntal lobectomy,
29:42
and of course, the patient benefited from a very objective cognitive assessment for three hours. We published that in brain and cognition So that means that you cannot publish in this kind of
29:56
journal, as you imagine, just with the surgeon telling how the patient is well able to speak. No, a very extensive neuropsentatological assessment, including the mid-acted nation, knowing of
30:10
knowing. In practice, that means that patient was able to return to work, but also to drive with no seizures to take care of the family children and so on and so on. So we published two years ago
30:24
the solar at last in the literature with the dynamics between the first and the second surgery with different pattern of reorganization according to each patient, not based on the on FMRI because it
30:41
has been done in the literature, but based on
30:45
intraoperative electric constimulation, the first, the second and so on and so on And this is unique because FMRI is not the absolute truth. Intraoperative electrical mapping is, and this is the
30:58
reason why patients recover. What is very exciting that we started to model the modification of the brain at the individual level and also by putting all patients all together and finally providing
31:14
this original atlas And you know, what is the must? plastic area in the brain, not according to me, but according to statistics, the broker's area. That means that you have more or less no
31:32
reason to induce any civil permanent deficit by removing this area if, once again, the connectivity in the dead is preserved, accurate, ifof,
31:43
SLF, FAT, and so on and so on, we saw that in the first two And definitely to be objective, each time we did re-operation, even after a second, a third, fourth, and so on, patient benefited
31:58
from cognitive assessment, objectively performed by a neuropsychologist. And you can say that I had no civil permanent deficit, and finally, 94 of return to work, which is, more or less, the
32:17
percentage in my food series we've more than 1, 000 patients and of course they have not yet at least been operated on, re-operated on systematically. So that means that the fact to deal with these
32:35
mechanisms on your plasticity by removing more brain each time you go back to the OR, did not increase the risk, not return to an active life. And I will publish these people in general
32:51
neurosurgery in two months, so this is really a scoop, not yet shown before. Based on more than
33:02
500 patients who underwent awake surgery for the Greg Leema, under awake mapping and so on and so on, and so on, and understood the principle. What I am most rated in that, if you can return to
33:15
work,
33:18
you increase the chance to be repropriated done. Why? Because of course, if you work, you have to deal with more complexity so to increase the cognitive load every day. So that means that you
33:37
push more plasticity than you increase the chance to remove more brain invaded by a tumor 5, 10, 15, 20 years later With an increase of externalization, with preservation of quality of life, and
33:52
finally with longer survival. And this is the concept. There is no unco-functional dilemma. More you remove the brain, of course, invaded by the great lemma, more the patient will live longer
34:09
because he will enjoy perfect normal life. But it's possible only if you play with mechanisms reconfiguration so if you give time to the brain and the goal is not to try to remove everything during a
34:28
first surgery with the risk to reach the limitation of your plasticity and finally to decrease the quality of life of the patient and then to decrease the median survival because everyone knows it has
34:42
been demonstrated far beyond me that if you cannot enjoy a perfect life and especially if you keep severe problem on the opposite
34:55
your survival will be shorter. Now I demonstrated the reverse more you are living well more you will live longer so the unco-functional dilemma does not exist the concept is solved. You can tell me
35:14
yes it's true only for no-go-no-no-no-no. Now, I published paper combining grade two and three. Of course, I'm not speaking about glioblastoma, I explored interest in one year, of course. But
35:29
if you mix grade two, three, so the so-called nowhere grade glioma, and if you can play with these mechanisms of reorganization in patients in general life after first, the second, and the third
35:46
surgery, you can see the median survival almost 18 years by including anaplastic astrocytoma andor oligodendroglioma.
35:60
Definitely the limitation is in the depth. If you start to see the tumor migrating along the connectivity, you cannot cut it. Of course, you can, but you will use permanent deficit. And
36:12
sometimes neurosurgeons are not aware about that in using modification of the condition and behavior not in an emi-plagic patient. And we'll speak about that in another tool. Insisting on the need
36:29
to redefine the quality of life, because if the patient is not emi-plagic, but not able to take care of his family andor to work, maybe it's not in agreement with its expectation. We have just to
36:44
discuss with the patient before to go to the operating theater, not only speaking for a first time, but also speaking about fifth surgery 10 years later, to be honest, I did not yet perform a
36:59
sixth surgery, but I needed to have maybe more for that. So definitely, if you started to see on the first, second, third MRI, whatever the strategy you used, You see migration. along these
37:18
y-matter tracks we developed before, then you know that you are not going to cut back. But if it's true for your sergeant, I would like to insist on the fact that it should be true for a real
37:33
therapist. Because if you irradiate this connectivity, you will use a decline of the connective functions. And it's not my view Here, I used papers not from my experience, not from Mont-Pauli.
37:49
In order to tell you that, if you objective by doing connective assessment everywhere in the world, you will obtain the same results. After five years, you started to have at least half of
38:01
patients with a decline of cognition and her behavior.
38:08
And recently, not from Mont-Pauli And I will insist much more about that in the next talk in one month. but I would like to introduce the fact that, if you do early radiotherapy
38:23
in low-grade layer,
38:26
and if you compare to delay radiotherapy, not only do we have a decline of the cognitive functions, I hope that everyone understood that in the world now, but you will have a decrease of the median
38:41
survival, early radiotherapy is against the long-term survival of the patient. So by doing early radiotherapy, you decrease the quality of life and the survival. That's crazy. We are wrong for
38:58
more than 20 years.
39:02
So we have definitely to differ radiotherapy. And as I say that I'm not against because I start more and more to propose to my patient be radiated. But 15 to 20 years later, when I cannot
39:15
re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re-re
39:45
glioma, two, three, and sometimes also some fusae of grade four. Of
39:54
course, if you did an extensive realization, if you were able to re-operate, if the patient is well and so on and so on, not an explicit tumor, but just some fusae in the middle of the tumor.
40:09
You can see the survival rate. If you did not any adjuvant treatment in this so-called low-grade layer map today, according to the new classification, we should consider that they are grade three,
40:23
four, which is not the truth, because this tumor is heterogeneous. The five-year survival rate is more than 95. Why to postpone adjuvant treatment to preserve the calitin five, to preserve the
40:41
potential of plasticity, and to give the opportunity to re-operate, typically, a patient I operated on, 2002, so now 24 years of her life, she's still alive and enjoying my life. And you see
40:58
that at that time, it was a grade three, with announcement in the middle of the tumor. I did a so-called super editorialization, to be honest, it did not really exist at that time because I did
41:11
not really. describe the concept, but in my mind, it was clear. No chemo noriotherapy. It's exactly what we did. You are crazy before this patient will die. Yes, but after 25 years, because
41:26
what I did in the meantime is just to follow her. Finally, you can see that there was a recurrence. Of course, I cannot cure diffused lyoma. And what I did, so 15 years later, is to reapply her,
41:41
thanks to mechanism for neuroplasticity occurring in the meantime, and I kept radiotherapy in case. And to be honest, we're now doing radiotherapy after
41:53
24 years. Definitely, I cannot cure them. But after more than 20 years of the whole life.
42:01
So the concept is used.
42:05
This mechanism for neuroplasticity a ring ransed. After our first surgery to do Nothing, except if you had a very extensive invasion in the depth gliomatosis lack. Then the patient will enjoy your
42:21
life. We'll push plasticity, especially by working or doing what he wants. Art, sport, familiar issues. We'll develop that in next tools. So pushing brain plasticity. And then you will
42:37
reappate four, five, six years later Approximately, this is my media. Then you will decrease again the volume. Then you will update the histopathological examination. Eventually, you will
42:52
postpone a German treatment at least for your therapy, and so on, and so on, and so on. So to decide if you can reappate or not, this is the question the most frequently raised in meeting. And I
43:09
can understand why, because it's very dependent on it. dependent on each patient. You have to take care about, to know, the natural history of the disease. Of course, the tumor is growing
43:23
faster than you have less mechanisms from your plasticity. Speaking about low-grade glamour, but you remember that the growth rate could be less than one millimeter per year to six to eight
43:38
millimeter per year. So that means that even if you have the same molecular pattern with different kinetics, the mechanisms, the potential of reconfiguration are totally different. Second, the
43:55
pattern growing versus migrating. If it migrates, it's not good, of course, because limiting the possibility to cut y-matter tracks. Third, the patient himself pushing is plasticity, working,
44:14
doing sport, art, what you want, or doing more or less, nothing. As every human being independently of brain tumor, if we are doing nothing, we are not pushing plasticity. This is the
44:28
principle of learning, meta-learning.
44:34
It's crazy to consider that
44:38
These characteristics, critical, change our own life as a human being, are not included in
44:48
the current young-cological good lives. They are interested by one thing,
44:56
the molecular pattern of the tumor. And that's it. And in the vast majority of tumor board, I visited in the world on the five continents, First question, what about the neuropathological
45:11
molecular profile. No, migration is, first of all, what about the quality of life of the patient? And what it wants? Because, of course, we have to integrate the molecular profile. But in a
45:28
plastic brain, in order to push this plasticity and to decide when to reapprate, typically, you see that if you have this invasive pattern after first insulin surgery, it's impossible to consider
45:48
a second surgery. And the molecular pattern, we change nothing about your decision. It's just the
46:01
proliferative versus migratory profile of the tumor itself
46:06
So now we have the choice or. to continue to apply protocols,
46:13
which are in essence very static based on the new classification probably next year based on Matilum. It will change nothing about the fact
46:25
that if we do not want to take into consideration the dynamics within and between networks of the patients, we will not be able to elaborate this kind of really
46:41
personalised strategy. Everyone speaking about personalised medicine is totally untrue. It's just based on the molecular pattern, not on the dynamics of the brain. But our brain, remember, is
46:58
ever changing So they don't miss that low-grade lemma, low-work-grade, in fact, you can include two, three, and Evers and Forzaia with grade four. So we excluded just real gliomlastoma. If they
47:10
underwent multiple awake surgery, awake in order to
47:20
preserve the quality of life, thanks to the understanding of limitation of neuroplasticity, they will have an increase of both survival and quality of life.
47:33
I never understood the concept of dilemma, which seems to be a dilemma only for neurosurgeons and young colleges, but not for the brain of patients, I took care. So now the discussion is of course
47:50
open. Based on this concept
48:00
of when you see a patient for the first time, you have to try to anticipate many years to eventually many decades ahead, at least a few steps ahead
48:05
and not just to apply. the current protocol based on five years in the vast majority of cases and that's it. It's not adapted to patients able to live more than 20 to 25 years now.
48:26
Outstanding, just outstanding. Ross, you want to go ahead? Yeah, sure. Well, no, thank you. Thank you very much, Hughes, for that excellent discussion. If you want to stop sharing your
48:39
screen, we can open it up for discussion. Yep. I
48:45
mean, I think you drive phone the message very well about the role of the functional assessment and plasticity, especially that correlation of function with survival. I mean, I think it's really
49:04
changing the way that many of us were trained, that perspective, but with more functioning. And then you specifically driving the patient to engage in complex activities to promote that. and
49:24
neuroplasticity after every section.
49:29
I'll open it up to any questions. Let's see, I'll see a couple of things in the chat.
49:38
Okay, so there's a question about the grade of tumor from Aishad Perik. How in a recurrent,
49:47
when you have tumor recurrences, how often do you see changing of the tumor grade?
49:55
I think that's the question. No, modification of the tumor grade. Fortunately, no, not systematically, because my goal is to arrive before the Maglin transformation of the tumor. So that means
50:07
that more, I am confident on mechanism from your plasticity. I studied for almost 30 years More, I can propose the patient to be reapprated and earlier when the patient is perfect. clinically
50:21
speaking, neopsychologically speaking, why to arrive before the modification of the behavior of the tumor to reduce against the volume and remember the main rule in the great lemma. If the tumor is
50:38
smaller, the risk of mackling non-transformation is less. And this is the reason why you can postpone chemo and all right therapy knowing that unfortunately here, of course, after 10, 15, 20
50:52
years, so you can have some foci of mackling non-transformation and at the time could be the first
50:59
to say now, this is a good timing to use. Adjourn treatments were kept in case of, but by starting by chemotherapy first, because I will speak about that in next lecture. Chemotherapy did not use
51:13
any decline the cognitive functions even after 20 years, why? It's untrue for radiotherapy. So we have to deal, of course, with now new treatment, especially anti-IDH, but this is another
51:30
discussion for the next group.
51:33
Sure, so Professor Jaffrey has a question in the chat. Professor Jaffrey, do you wanna ask the question?
51:46
So he's asking does follow-up MRI, tractography and functional MRI for eloquent years invaded by tumor, which is more, is that more important than psychology, assessment or awake assessments?
52:03
We already had this discussion and I will dedicate specifically one session to that
52:11
I am the first to use fMRI tractography before and after surgery. I was the first 30 years ago. Never I will use tractography or fMRI in the operating
52:25
theater, simply because I will demonstrate to you in the seven talks that. It's totally untrue. I do individual level of fMRI is unable to tell you what you can remove Yes, no, it's not because
52:40
you have an activation that you cannot remove it. and I spent my life to remove tumor, not selected for surgery by other surgeons because fMRI was not
52:56
supporting surgery because activation within the tumor. And in fact, it has been possible to remove in hundreds of patients, these activations without any severe problem. That's second,
53:09
tractography, I will say it again This is not a function intrinsically. This is not my view. This is just a structure or constructed by bio-mathematics based on movement of water molecule.
53:31
This is not a
53:33
function. So
53:35
you cannot replace tractography and to avoid to use neuropsychology and intra-operative or weak mapping. You can, but I'm still waiting. The results live more than 25 years for that.
53:52
Okay, another question in the chat. How do you navigate tumors in Proca's area on the left when planning the initial surgery? That's from a whole ratio of Fontana.
54:10
Proca's area does not exist. All undo does not exist. I'm now, I have a submitted a paper just past week by telling that I operated on 80 patients within the so-called voluntary system. And of
54:26
course, you have to preserve some areas within the system, but not all. So you have to imagine the vicarians. You have to imagine the redundancies from one area to another one, from one network
54:43
to another one, from one hemisphere to another one, because you have seen another equation raised, which is very interesting. about the mechanisms on your plasticity in the contralateral misfer or
54:56
not? And the answer is, it depends. But it depends on the same patient. Because as you have seen in the first illustrative cases, you can re-operate a patient and to continue to have very
55:13
regional areas critical for the function during a second or third surgery. And of course, it's not very good to re-operate a patient because you will not push to match the resentment during
55:26
re-operation. Conversely, you can have a perfect compensation by the Conchrolatram inferr, so giving you the opportunity to do a separate authorization during a re-operation while it was not
55:41
possible during the first surgery. In other words, the pattern of reorganization can change in the same patient. from one surgery to another one.
55:55
That means that I spoke during the first talk about in their individual, another functional variability, now I'm speaking about intra-individual and how to move functional variability over yours.
56:10
And how to predict that? Of course, at that time you can use it from right, not because this is not the absolute truth, but to start to see if there was a modification within the meta network
56:23
because the main interest of fMRI is that you can see the full, the wall brain and not just the area exposed by the bone flap conversely to interpretive stimulation. So we have to combine. After a
56:41
second and third surgery, the different methods in order to try to anticipate at the individual level. if it will be possible to re-operate the patient N1.
56:56
And now this is the challenge in the field of committing neuroscience to have a field of predictive neuroscience applied to multiple stage surgical physician in patients with brain tumors.
57:15
This is still in progress, of course Excellent, excellent, excellent.
57:22
But we need to put aside that concept of watch for waiting for low-grade
57:30
gliomas. That wait and see is just wait and see after restricting the tumor and decreasing the volume just to be clear, not initially. When you have less than five to 10cc a procedure and the proof
57:45
that it's not yet a mackling non-tumor. you can apply weight and see, but by doing MRI, every six months, all the life of the patient. Now, I have patients with 28 years or further because you
57:60
need to have an MRI twice a year.
58:05
What he's done is, I was thinking, as he was presenting, he did
58:12
a wonderful job. He was one wonderful job. Great cases with great explanations And when I was watching it, I was reflexly saying, what were we trained to do? And we were trained to remove the
58:25
tumor and make it a gross total removal. But he's telling us it's the word. It's totally the reverse. It's maintain function and remove what is necessary and leave the rest alone and let the brain
58:31
reorganize and come back and do the same And,
58:37
and,
58:47
And I was reflexly saying, well, gee whiz, he's operating on this patient two times his career. Why doesn't he go to get radiotherapy? The answer is, that's not the answer. The answer is come
58:60
back and re-operate. There's a reformation, reconstruction of the brain. There's the plasticity and it changes everything. And the imaging doesn't show that. Anatomy doesn't show that. It's
59:14
function, which is what he's testing. And so, it's a reverse of what we've been trained for years. You agree with that, Estrada? Oh, no, certainly, absolutely.
59:28
There's a whole different way of looking at things. And it's not based on your MRI appearance, it's based on the function. We've been trained for years to look at the imaging, look at the anatomy,
59:44
what was he was saying? is yes, all those things are adjuncts, but the real test is the function. What is the function and what is the interconnected functions?
59:57
Daniela or Horatio, do you have any questions you want to ask? So Daniela had a question about neuroplasticity is it due to change? I think who's the answer is already, is the neuroplasticity due
1:00:09
to changes in the same hemisphere or to the contralateral one? I suspect you will say both.
1:00:18
Hughes? Exactly, but I have to mention that I was, I did not insist enough on the fact that all patients after a surgery, first, second, third, why you want, before to return to an active life,
1:00:34
benefited from a prosperity of a cognitive rehabilitation. You see, the reason why I say that, Thank you so much to your psychologist and speech. therapists, because without you, it would have
1:00:49
been impossible for me to redirect the brain this past 30 years. Exactly. So that means that the brain plasticity is magic, but sometimes you know that you can have negative plasticity. And for
1:01:04
instance, in using negative automatism, preventing you to return to work, or in using seizures and so on and so on. You are there in order to show the way to the brain. To improve the
1:01:20
neuroplasticity. Yes. And maybe so to redirect to the concolateral hemisphere. I don't know, but it's the next feature by using also RTMS. Why not? And then to pushing away the critical mosaic
1:01:40
networks, away from the surgical cavity, In order, once again, to increase the chance to remove more when we will come back, thanks to what you did in the three months after surgery. After that,
1:01:55
behind us, the vast majority of my patients I want to return to an active life. But during three months, I insist before, each surgery and the fact that they will have to perform the best under
1:02:09
the guidance of rehabilitators like you So once again, thank you.
1:02:16
Well, there's these minutes of our question here. So if you make a judgment that a patient does not seem very motivated to do the work, to enhance their plasticity and enhance their brain work, to
1:02:35
drive plasticity, could that influence your decision for surgical resection?
1:02:43
at least for re-operation, certainly. Because if the patient did not induce enough plasticity in the meantime, I have a risk to re-operate the patient more or less for nothing. I mean, finally,
1:02:58
to stop prematurely, to benefit from updated extomerular analysis, but not to perform at least a subtletor removal. It's exactly as if you ask to try it as cool If he's not motivated, is it
1:03:14
possible for him to learn enough to become a neurosurgeon? And the answer is, of course not, because we have, first of all, to be motivated in order to work hard and then, finally, to have a
1:03:28
chance to classify our brain accordingly. It's true for a child, it's true for a patient. So in these cases, when I can feel them reluctant also, I would prefer to refer them to the young
1:03:44
colleges, not to be irradiated, but to use chemotherapy.
1:03:50
Interesting. Sayid, do you have any thoughts or questions?
1:03:57
It's a very fantastic topic. And I hope for future neurosurgery training, we have to have more talks from Dr. Dofu for training the future neurosurgeons, because this is very important This is a
1:04:11
problem with the training or generation. And there has to be a change on the treatment of the brain tumor. And really, it's a fantastic ideas that he's bringing out. And really, we have to bring
1:04:27
this to the curriculum of the neurosurgical training. Unfortunately, many centers don't follow this because of the tradition and just don't do something new. but really I congratulate you to bring
1:04:42
all the aspects of the neuropsychology and the plasticity in the treatment of the brain tumor. I really appreciate it. Congratulations to what you have done. Thank
1:04:55
you, but this is the reason why the next talk will be dedicated to the objective, long-term, functional and oncological outcomes, because I can say something totally not adapted to the reality,
1:05:12
but what I want is to be harmful for my patients. So if I can demonstrate to you that they are living longer and better, which is the truth now, I would ask to the vast majority of neurosurgeons
1:05:25
still applying the traditional concept, what is the survival and the quality of life of your patients. And if they are better than mine, then I will change my view. because my goal is to
1:05:39
contribute to my plastic.
1:05:43
Thank you very much, really. It's very encouraging and very promising for future of neurosurgery, because the field has been stagnated with few ideas, especially in some countries that they have
1:05:56
commercialization, just give new medicine, new thing, new thing, without having any objective. But your point is very well taken, and I'm really thankful to learn from you, and I congratulate
1:06:09
you to make the pioneer in changing this.
1:06:13
Dr. Gwen, that you can apply this concept everywhere in the world by doing that with a fork and a knife, but a good team, of course, a good neuropsychologist, a motivated patient, good
1:06:25
anesthesiologist, you do not need billions of dollars to buy in cooperative MRI. This is the point. Thank you, sir. Thank you, exactly. Appreciate your point. I'm glad you mentioned that. It
1:06:39
was because you wrote a paper on this, and I was going to ask Elba. So Liam was in Syria.
1:06:47
I think the message you want to say is he could do this under
1:06:53
stressful conditions. Obviously, they have challenging conditions in Syria, but the same concept you're applying can be used everywhere in the world, not just in certain centers, isn't that right?
1:07:09
Definitely, I confirmed because I did this kind of surgery, even in Sierra before the war with a folk and knife, but also in North Africa, in so many countries with just the motivation of the team.
1:07:26
And the reasons are exactly the same. I organized recently an international meeting in Montpellier with 300 people coming from five continents, and I was so happy to see now the feedback of people
1:07:42
coming even from Africa with 20 years of failure, because I trained them 20 years ago and reproducing exactly the same results, like I'm sure in
1:07:57
South America, because I know that you are many in Mexico, Argentina, and so on, but also in Syria So definitely. Please think about the brain, not about the tumor, and you will see that
1:08:11
suddenly everything becomes possible. The brain is magic, more intelligent than us. That's an outstanding, outstanding summary there. Think about the brain and not about the tumor. Think about
1:08:29
the brain, that's exactly what we've done. You're totally reversed by the way of thinking Daniela and Horatio, any other comments at this point?
1:08:45
I think you're muted,
1:08:48
I think you're muted,
1:08:52
I don't think they're, I mean, okay. Let me, I'm going to ask you a question, so with your first case, there was a between the two initial operations, there was a five-year interval. For the
1:09:07
second case, there was an eight-year interval So what is the, as you balance recurrence and neuroplasticity, what could be the smallest interval of time in which one would do a re-resection? How
1:09:26
are you guided? Are you guided? If you see imaging changes, are you
1:09:36
impaled to proceed or are you first trying to determine that there's been sufficient.
1:10:44
brain tumor with a small volume. You are not her rate to reapprate, except if the patient has seizures. And then once again, see the brain because the brain will tell you, okay, the oncological,
1:11:01
the tumor is under control according to an oncological point of view. But I do not feel well, so I'm doing many seizures per week, for instance, then it could be a good argument to really operate
1:11:18
if the tumor is growing faster, if the volume is more tensile if
1:11:23
the patient starts or to have seizures. But also finally, according to the wishes of the patient because sometimes to be honest, I postponed by explaining everything to the patients who knows very
1:11:37
well that this is, but telling me this year It's really complex because I would like to finish something from I don't know, a family, a life, a professional life. You think it's possible and you
1:11:52
thought to postpone the re-operation, I haven't understood the concept, I agree, but next year. And by doing at that time, memorize every three months in order to avoid to miss the action and
1:12:06
maybe an acceleration of the tumor, I try to say yes Because you can't re-motivate the patient to go to the door a second or fifth time if the patient is in good condition. And it should absolutely
1:12:24
be sure that not only this is the good strategy to adopt, but also the good timing. So an answer to your question, you have to anticipate that with the patient More or less, it look great, glaier,
1:12:40
man. six to 12 year months in advance. Okay, excellent, thank you, thank you. That was very clear. I think when you showed one of the cases and you talked about this where the patient had a
1:12:55
change in the pathology from grade two to grade three. To me, the reflex answer, the reflex answer would be, oh my God, I lost the battle here. I need to send them to radiotherapy and
1:13:08
chemotherapy Your answer
1:13:11
was the absolute opposite. You need to do more resection, at least to maintain function.
1:13:20
Yes, to maintain function. And I will show another slide during the next talk. Trying to explain, I published that in your surgery, not in the tumor. If you had some hotspots just in the center
1:13:38
of the tumor, And if you did at least a subtlet or removal, of course you have not to give a German treatment because my first reflex seen 25 to 30 years is to ask to my neuropathologist what about
1:13:55
the periphery of the tumor? And I have the habit to do samples at this level or if possible to do a monobrook. And if the answer is how it was horrible in the middle, but the full periphery is
1:14:10
still a low-grade lemma, that means that you can wait. Of course, the price to pay is maybe to do in a MRI every two months initially, I'm not totally crazy and not every year or every six months.
1:14:23
And to say to the patient very honestly, the current protocol would recommend you to benefit from adjourned treatment now because according to the current classification you have a high-grade lemma
1:14:37
in comparison wait for first time, but. because they removed the tumor according to the post-party flare MRI and because they were only some fusci in the middle we can also try to wait and see and
1:14:56
to delay the MRI's after one year and by telling finally we will continue to keep the chemo and radio therapy in reserve because one day you will have a insurance and i read in system the fact that i
1:15:11
am the first proposed they are not benefit from the radio therapy but two and years later so my goal is definitely to give them the opportunity to leave 25 to 30 years and i'm sure that now it's not
1:15:24
she wants to fix you i will succeed
1:15:28
okay outstanding outstanding um on that uh you go on that you're just gonna do you have any uh where are you from on that
1:15:40
You're muted.
1:15:44
Yeah, where are you from? I'm from Germany. Oh, Germany, do you have any, are you a neurosurgeon there? Yes, I'm neurosurgeon, but we do not do awake surgery.
1:15:57
And you have any questions you wanna ask professor or a default? No, no, no, I don't have a question right now because I just came in, though I did not get the whole lecture Okay, well, thank
1:16:11
you very much. You'll be able to access the whole lecture later on SNI digital, it will be, it's recorded and it will be made available. All right. Thank you. Alex, you're just finishing your
1:16:22
residency. Do you have any questions you'd like to ask for Professor DePaul?
1:16:30
Thank you for the lecture as always. Very, very fascinating and thought-provoking.
1:16:38
The thing that I always think about What I'm hearing these talks is, I wonder how to set something like this up in another country, like in the United States, where it's not common practice to have
1:16:51
like a neuropsychologist before and after these surgeries.
1:16:56
If that makes sense. Yes, it makes sense and I was an excellent question. Please, how would you answer all? Things are changing. I was in
1:17:07
San Antonio recently two weeks ago for the double NS. meeting. And we organized an international course of brain mapping with Ms. Berger. But also there was for the first time in this brain
1:17:19
mapping course, David Cevich from initially MD Anderson, and now in the Mayo Clinic. And he gave very exciting tools, demonstrating that more and more neuropsychology should be part of.
1:17:40
neurosurgery in US and I asked this question in front of him and he said that more and more is true because he developed your paper tool, we published that in journal neurosurgery with MD Anderson
1:17:56
recently just one month ago, was used if I ever understood it in approximately 10 to 15 departments of neurosurgery in US, so showing that more and more, not only awake mapping finally is at the
1:18:12
standard or is becoming the standard after 30 years but also if a neuropsychologist before during and after a surgery is speaking about the post-parative cognitive rehabilitation, so I would like to
1:18:25
say that even if US, I'm sorry about that but as 20 years of delay, I would
1:18:37
be. I would like to think that I could be enthusiastic at the end of my career.
1:18:44
Dr. Dufou, one of the
1:18:49
neuro oncologist, the neurosurgeon, he's planning to come and visit you from UCLA because we talked about your talk, but he's very interested to come personally over there to Monfoli, that's his
1:19:00
friend, Dr. Richard Jefferson, he may come, he was trained in also MD Anderson for oncology Thank you very much for this.
1:19:12
Okay, pleasure, definitely. And my operating theater is open since 30 years. I welcomed approximately 1, 000 new surgeons coming from 60 countries from five continents. And in all cases, they
1:19:28
were able to see that what I'm telling in my talks is really what I apply in my operating theater. If you can see that, you know that you should be able to reproduce with a good theme. But also
1:19:45
with a good knowledge and the message is still the same of the dynamics of the functionality of the brain. So you should be, first of all, for the younger people, younger and your surgeon,
1:19:59
younger and your psychologist, neuro-oncologist, neuro-anesthesiologist, neuro-scientist
1:20:07
You should do a PhD in cognitive neuroscience. Just two to three years in your life, and
1:20:13
then you will spend 30 years in the brain of human beings. How do you want to do it if you have understood almost nothing about the brain? Never the technology will compensate your lack of knowledge.
1:20:26
And this is the reason why I continue to be invited everywhere, including US, because they cannot reproduce exactly my results in all cases, why? Because I think about the sometime nervous system.
1:20:43
Absolutely, thank you very much, thank you very much. Jim, I think that's a good note to end on, I mean, I think he makes the point that our advanced technology will never replace the individual
1:20:56
knowledge of the brain anatomy. I think that's the bottom line, and that's the key to Professor Dufour's success Outstanding, you're right, absolutely right, Astrana. Thank you, Hughes, very
1:21:09
much. Just a wonderful job, terrific case examples.
1:21:15
Okay, Astrana, you wanna close up? Thank you for doing all this. Yes, well, again, Professor Hughes, thank you so much. This was excellent, it brought a lot of, I had a lot of questions
1:21:27
before it, but I didn't ask them afterwards because you answered them during your talk So thank you very much. Excellent presentation. Thank you, I
1:21:39
thought about your equation when I prepared this talk because I promised to you to answer this question and it was not really, I did not forget that. So I'm happy to see that finally I succeeded to
1:21:54
explain the concept which is not very complex. We have just to be humble in front of the brain and to study largely to deny the modification of the central nervous system in our patients but also in
1:22:08
ourself. This is the concept of metacognition. I will develop that later. Thank you so much for your patience and your support. Thank you. Okay, thank you. The next lecture in the series is
1:22:24
long-term on co-functional results, connect home and I got it out of my screen here. The connect home based surgical resection, that's what he talked about. And one more on the redefining quality
1:22:39
of life. And then he gets into the final four lectures. Thank you very much, just, Aaron, thank you everybody. And nice to see you all. And look forward to see you in about a month, okay?
1:22:50
Okay. Thank you very much. Bye-bye. Bye-bye. Thanks. Thank you. Bye-bye. We hope you enjoyed this presentation
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