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SNI Digital, Innovations and Learning, an association with the Hose Neurosurgery Lab and Baghdad Iraq are pleased to present. The 22nd SNI and SNI Digital Baghdad Neurosurgery Online Meeting held
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on March 23, 2024, the meeting originator and coordinator of Sammer Hose of the Universities of Baghdad and Cincinnati.
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The subject of this meeting is Pediatric Neurosurgery, Global Pediatric Neurosurgery Experience and Cases from Argentina, Iraq and Nicaragua. The meeting organizer and moderator is Jorge Lassruff,
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Emeritus Professor Pediatric
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Neurosurgery at the UCLA Medical Center in Los Angeles, California.
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This talk will be on endoscopic surgery.
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for interventricular cranium for angiomas. It'll be given by Juan Bosco Gonzalez-Torres,
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who is in pediatric neurosurgery, the Children's Hospital, Hospital Bautista, and Menagua Nicaragua. Hello everyone, I'm sorry. It's for me an honor to be here with all of you. I will share
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with you my little experience regarding the transventricular approach via endoscopic and an option that could be useful in properly select passions. So there are many different ways in which we can
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address these tumors talking about the cranial pharyngeal mast,
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which will depend in third location, size of these structures involved and radiological characteristics So, this approach to.
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Speaking of the endoscopic pathway, can be carried out with the basic instrument with the
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endoscopic third ventric loss to me. It's performing, and I think it is increasingly common talking about endoscopic. So
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this is my little characteristic, 12 case. 12 case, and
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fortunately without the complication that can occur in another approaches, I think because it allows quick and direct access to the tumor and war within the
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tumors. About this approach, there is already no information, particularly I started with the first passing.
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know with the intention of addressing the tumor, but to perform on ETV. But when I see the tumor,
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I realize that due to the characteristic of the tumor, I call address it will already introduce you that first surgery.
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This approach was the subject of the presentation at the annual ESPN meeting in 2016.
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Also, there are not many cases that can be collected It is an option that we can have in our arsenal and if the tumor is predominantly cyst and intraventricular, I think this option is the ideal.
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This is my first case. And this is the imagines in the field's case. You can see
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this part is the sixth part, but the operations depend and the consistent of the liquid. You can see the tumor in the actual view is very close to the foraming of Monroe
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This is my second case, it's a tumor
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system predominantly.
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This is my first case. I am sorry for the quality of the imagines. You can see the tumor, this
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is the foraming of Monroe room.
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The tumor peaking throughout the phenomenon of mongrel we started with the ovulation of the surfers, trying to gain the space throughout the fragment of mongrel and try to descend to
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the
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third ventricle. This is achieved with a lot of pathogens, doing ovulation in the surfers,
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shrinking the tumor, gaining space, but as you can see, I don't use any special attachment, just in this moment of
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disorgery, I use only co-later bipolar, trying to shrink the tumor. So this is the first step, trying to this compression
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After I am sure I have control of bleeding, I can take, we can take biopsy. You can see a little membrane between the tumor and the foramming of Monroe. No, no, no, it's a
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good idea to try to moving the tumor because these other ends are caused many bleeding. So nobody wants bleeding in these moments in any moment. So the another part of the surgery is inside
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the tumor. This view is inside the tumor. You can see the characteristic of the tumors, particularly the calcifications.
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We can open the C's, the capsule, and aspirate.
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the contents that are commonly dense, oily, and work inside the tumor, and take fragments of edit for biopsies. So,
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with passing,
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we can continue outside the capsule.
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This is the capsule, and this is the Silvius Aquaduct, and in this moment, we get a good permeabilization of these ventricular systems.
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Try to populate another part, the vascular part, the tumor,
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avoiding the mobile list, the
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tumor, avoiding the complication with the injuries in the epidemic regions This is the principal
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vintage of this approach.
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This is the view puzzle of the first case
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You can see the pre-op
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and you can see the
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calcification part,
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particularly I leave this part because it's an inactive biological.
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This is the axial view.
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You can see the persistence of the mutation of the system ventricular, but in the next week, disappear the ventricular side return to normal.
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So talking about the this approach,
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I have three steps The principle three-strip, the first is
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identifical the tumor of the characteristic of the tumor, this compressing and taking biopsies and permeabilization of the ventricular system. We have two options in this sense. You can
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open the aqua to the syllabus
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trying to shrink the tumor
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you can do an endoscopic therapy intercourse to me, to option for permeabilization. And finally, you can get more part of tumor avoiding the contact with the
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therapy integral or the
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neighbor parts.
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And in conclusion, it is a sad and an effective technique avoid complication common with other technique. So it's very simple because no, it's necessary, a special instrumental or attachments.
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You can do it with a basic instrument for ETV or third relief or from neurological condition
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without complication, principal endocrine
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And in another sense, a voidy placement of whippishone or some time performing ETV. So
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in save reports, you will find similar conclusion.
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Thank you. Thank you very much. Thank you, very good. So Dr. Bosch, I understand correctly, you leave that calcified part of the tumor. You don't touch it, right? Yeah. You just take care.
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I mean, it's not just. You take care of the cystic portion or the walls of the cystic portion. And what happens to what the follow-up, I mean, a year after doing this procedure in your 12 cases,
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does the cysts come back or not, or what happens to the today? Just into the case, just in two case, Professor, just in two case, return the cyst was necessary
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by
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the same way, but permanently in another case, and don't return the cyst.
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I see, so you actually say of the, you had 14 cases, no, how many cases, you have 14? Well, 12. What, 12 cases, so of the 12 cases, two cases that the cyst came back, and the other 10
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cases didn't come back, I mean, amazing, so that portion of the crime, and clinically, the patients were doing fine I mean, they didn't have endocrine deficit, added, nothing like that. Yeah,
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the clinical evolution was
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very good, very, very good.
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Okay, very, very, very interesting, because we like to, you know, we at the surgeons like to take it all.
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I just took it all, it was a huge tumor and I took it out, But the so you are you are showing us the same as our colleagues from the Flesnians and caution and understanding. You don't need to take
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it all to be a great surgeon. Okay, good, as I said. Any questions from the audience? Nobody? Any further comments?
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And Ray or Fidell, do you have any, do you approach this differently or?
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You know,
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I will. No, no, no, it was a question. In our institution, of course, I will give my opinion in need. I always repeat in other populations. In other populations, we used to perform a
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population like Dr. Lazareff said, we try
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to remove everything little by little. We, since the last five years, we started to do surgery by endoscopic extended approach from the nose. And tell you the truth. Remember, having had a
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patient. similar to this, the patient like Dr. Rossello, with too much calcifications in the
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cellar and supercellular areas, and sometimes it's not so easy to remove this calcification through the nose with the endoscopic approach. In our case, we have in the other population, we have I
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have everything you want to speak. I have new deficits in
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the optic systems, we have sometimes, I remember one patient with the severe affectation of the hypothalamus with the sign, the positive sign of the hypothalamus. Of course,
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I can say almost all of our patients have some
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electrolytous abnormalities in the in the sodium in the possibility period. Much, a lot of our patients remain with in seeping diarrhetes but of course the
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While it is life,
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I can say that maybe 80 of our patients in the adult population can remain with a very acceptable quality of life. I remember
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two cases, one of them because of some complications, basses, bass, and so on, the patient is dead because of this tumor So, currently, in
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Jomas, it's still a very big mass. It's a headache, not only for the patient, also for the neurosurgeon. But maybe if he is here and he can play, give his opinion about the pediatric population.
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In pediatrics, we try to do a radical resection, but it's very difficult.
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But the objective is to do a radical resection
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And Dr. Petre, what's your policy in the children's in El Gutierrez?
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You are mute, you are mute, you are mute, you are mute, the moon
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Yeah
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Excuse me. My English is
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our
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policies. When you have this kind of enjoyment that's very big now,
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the pathology extends to the
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middle force, to the frontal,
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when we have
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the approach
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before, it will be a delta. When the
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cranial phoenician
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is in the cellar or in the axis of the cellar, not the lateral decides, we may
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know that it's a transcepter.
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a natural senile approach with a
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good result.
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It's possible
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to damage the floor of the third ventricle
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now The abetos incipido is 90
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near one week. It's possible that the patient has a lot of
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endocrinological
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disturbance now This is the
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abnormal separation of hormonal antideratica.
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It's very complex,
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although
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sometimes we have a total rejection, but in contrast, there are procedures, procedures, procedures, procedures. I would say for Dr. Petres, he swept into Spanish with his passion, but the
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thing is that, yes, he was saying that in spite of them,
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you may believe that the tumor, that you remove the tumor completely, but it usually, there are occasions when the tumor comes back, no? I'm saying to one of the questions by Abdullah Siz,
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Alayaf, he says, what's the recurrence of those tumors? Yes, if you really remove completely, the
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recurrence is zero,
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but as Dr. Petri said, if it comes back, it means that you didn't remove it completely, you know, and the interesting point with Dr. Gonzalez is that if you leave something and disturb, at
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least in some cases, they don't return,
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I mean, it's a, it's a, it's a. Some cases, some cases with the
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solid component remains, no, a lot of time when we take only control by the CRM,
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I, but although the total removal but although the total removal Halle.
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it's possible to live
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in my experience before going to Dr. Halil now in order to keep on moving in my experience
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is the the some of those at the kind of an enjoyment that I removed possibly evidence completely was the tumor that was willing to come out, you know, more than the surgeon because and I, and as I
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said to the at the residence, if you are struggling for more than three hours with a granular pharyngeal stop it don't don't let the continue, you know, there is one moment that the kind of
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pharyngeal when you find that the plane with the hypothalamus and that the capsule, the tumor says, okay, I give up, I'm coming out, I'm good, it comes out, no? And each tumor has its own
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personality in the persona, but I think that the beauty of Gonzalez think is that within resources that are not perfect, but not limited, but I mean, he works in a very good hospital hospital
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about this time, manago. There are still innovative approaches that diminish the clinical consequences for the
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patient. So no further comment, we can go to the doctor. First of all, one, that was
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a very nice presentation in a very selected series of cases. Obviously, there are different kinds of cranial fringe illness, and I know you do this differently, but this is a very nice thing. The
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thing I liked about it is what Jorge said, you knew when to stop.
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You knew when to stop. This is, I think this is probably one of the most difficult tumors of neurosurgery. I used to call it the suckers tumor because what it does is it makes you think that you're
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being able to take it out and as you progress, you get into deep trouble and what Jorge said, it's exactly right. He probably should quit over there, but here's a case where Dunbeats perfect.
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We're all perfectionists, but I've seen this for 60 years. People would put isotopes in the cyst and they would do very well. I've seen you had a site of a paper there from New York where he was
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known to aggressively take the whole tumor out and it was devastating for the patient. And Andres has mentioned that and it's a quality of life and you mentioned that in the brain September. So I'm
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not sure with all the technology we have and Dr. Shilato who used to work with Dr. Matson did it a very nice study. I'm sure you remember this or where he shows the cranial pharyngeal nerve
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invading the brain tissue It's not
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necessarily all outside. and that's where you get into trouble in the third venture goal. So I think you have to know when to stop and I think you're absolutely right, Jorge, and to leave the
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patient with being functional. I know there's a great debate in pediatrics about this, but I think what you presented was very reasonable for those kinds of tumors. And I think a discussion was
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very reasonable. I know that if we talk about papillary cranial fringe young ones, there's some molecular treatments now that are highly successful, but maybe we'll get into that, okay? Andres,
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do you have any thoughts about that?
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No, I completely agree. And the point is nature is very unfair, because you know, clinical in German is a tumor from the pediatric population, and we in the adult population, we have less
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incidence, but we have the possibility of the a bit rough mutation, so sometimes we can leave. On purpose, some portion of the tumor will perform subtotal resection in order to preserve quality of
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life. And then our neurocologists can do something because of the mutation. But in the pediatric population, there is, of course, you have better caffeine in mutation, but it's completely
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different. There is no still clear indication of medication for this patient. It's,
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like you said, it's a very complicated tumor for pediatric patients. That is one of the questions for Dr. Gonzalez from Dr. Alwash. He says, what is the side of the tiber hold to put it in,
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right side, left side, pre-coronal, post-coronal.
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Beautiful. Yes, professor, yes. Yes, the axis is the same if you seem to do an endoscopic therapeutic close to me. It's the same. It's exactly the same.
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The right side, pre-coronal is the same.
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Okay, and you aspirate there at the ceased before trying to the recession, you eliminate the water disease. Yeah,
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we hope you enjoyed these presentations.
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