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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,
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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 Lazarus,
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Emeritus Professor Pediatric Neurosurgery at the UCLA Medical Center in Los Angeles, California.
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Andres Servio, MD, will speak on pediatric brainstem tumors. The third speaker is Juan Bosco G, Torres MD, Pediatric Neurosurgery, Hospitale Bautista, Managua Nicaragua. He is speaking on
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decompression, biopsy and permeabilization surgery for intraventricular craniopharyngeomas, a purely endoscopic transventricular approach. The fourth speaker is Professor Abdul Hadi Khalili, MD
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Mphill, Head of Department of Neurosurgery, Baghdad University, Iraq. He is speaking on A clinical scale for setting sun sign. The fifth speakers are Exsequiel Verde, MD, Cesar Petre, MD,
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Department of Neurosurgery. Children's Hospital Buenospiades Arjentina. They are speaking on AVM of the posterior circulation The sixth speaker is Juan Bosco G. Taurus MD. Pediatric Neurosurgery,
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Hospital Bautista, Managua Nicaragua, speaking on myositis ocifican and hydrocephalus. And the
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final presentation will be given by Ezekiel Verdea, MD, Cesar Petre MD, Department of
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Neurosurgery, Children's Hospital Buenos Beerus, Argentina. They are speaking on Hemisferotomy for Rasmusen Syndrome and Cephalitis Hello, everybody. Nice to have you all here. This is the
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22nd SR surgical neurology international Baghdad meeting. This type of meeting started almost three years ago, started from Baghdad, but the aim to work with the surgical neurology international on
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the international basis, connects people interested in neuroscience around the world. And today we have a special episode focusing on the pediatric neurosurgery with the Latin American flavor,
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let's say. We are
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happy to
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share with you. This is the schedule for today. We have seven presentations. They will be sequential and then will be followed by question and answers, which is something that we are really
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interested in listening to your question. The attendees and also we want to listen to a discussion from the panel. I will I will hand the leadership now to
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Professor Jorge Lazarev and so he can start with the presenter one by one. I forget to introduce myself. I'm Samarhos. I'm Vaskirani Arasirjan from Iraq doing research fellowship now in Pittsburgh,
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Pennsylvania and United States. And yeah,
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nice to see you all, Dr. Lazar. Jorge A Lazaref, MDFAN's Emeritus, Professor of Neurosurgery, Andres Servio MD, Department of Neurosurgery, David Geffen School of Medicine, University of
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California, Los Angeles, USA. He will begin with an introduction. Thank you, Summer. Thank you, everybody. So in honor of at the time, I will just say briefly this that pediatric neurosurgery
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is the Cinderella of neurosurgery. And but it's like the Cinderella has its own personal story. It's a strong story. And
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I am very happy to share with you
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today with our audience of medical students and the physicians. from Iraq, United Arab Emirates, as Pakistan, and all the surrounding countries. They, in three countries, and the beauties, and
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the challenges of pediatric neurosurgery. One of the first challenges I pass now to the Tura Lucila Domet la Plaza,
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and to Dr. Fidel Sosa, are precisely brainstem tumors. So I leave that to you, Estim College The speakers are Lucila Domet la Plaza, MD, Fidel Sosa, MD, Andres Carvio, MD. We'll speak on
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pediatric brainstem tumors. Thank you very much, Dr. Lasarev. Good afternoon, everyone. It's an honor to be here presenting with you today. So my name is Lucila Domet la Plaza. I'm a fifth
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year neurosurgical resident at Fleni in Buenos Aires, Argentina. And together with Dr. Fidel Sosa, with the chief of the pediatric new social department. here in Plenny and his whole team of
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pediatric new surgeons. We wanted to present to you our cases of the sub-temporal approach for the biopsy of the fused brainstem high-creatic leomas. So as an introduction, as we all know, tumors
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of the
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brainstem constitute a very heterogeneous group ranging from what are the low-grade primaries and from nervous systems tumors, such as the pylocytic astrocytoma among others, to what are the
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high-grade tumors. Since the hook classification from 2021, they constitute mostly the H3K27M mutant diffused midline gliomas as well as other H3 wild-type tumors.
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So brainstem diffused tumors represent approximately 10 of all pediatric sensory nervous system tumors. Among them, the
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H3K27M mutant diffused midline gliomas are very rare childhood central nervous system tumors that carry this prognosis, as we all know, with a mean survival time of 12 to 24 months, sometimes even
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less. So tumor biopsies not only helpful for addressing a correct diagnosis, but it's also a very important strategy nowadays for the continuous study of further therapeutic options and specific
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molecular targets in order to find a treatment for this pathology.
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Given their complex location and the lack of effective current treatments, even though there's surgical options that we have cannot guarantee a macroscopic or a gross total or even a near total, a
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subtotal section of these tumors, they do offer the possibility of biopsy in these lesions with the aim of better understanding their behavior and the hope of finding some molecular targets on some
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additional treatment.
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There are multiple surgical approaches described. One of the most commonly used are both a stereotactic biopsy or either a neuro-navigation guided surgery. But however, what we wanted to present is
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our experience with open biopsy, which proves also to be safe and accessible route to properly address pathology.
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So what we like to do is to use the subtemporal approach The subtemporal approach provides an easy and safe approach. It gives a good bleeding control with no need of additional technologies, such
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as are the stereotactic of the neuro-navigation surgeries. It also gives the opportunity of obtaining big and mobile pathological samples, which we all know are extremely important in order to
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obtain all the molecular viologist that the patient needs.
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So these are today's section views. We would like to thank the left one to Dr. Maximilian Eunice who kind of lent it to us for this presentation. It shows the lateral view of the right subtemporal
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approach. And the second one shows the syphallic view, which shows the great corridor that the subtemporal approach provides for accessing the bonds. So our idea now was to present two patients
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that we had at our service and that we operated using this approach as an example of how we do it. So this is the first patient. This patient was a 13-year-old male. He presented with a right third
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cranial nerve, six and seven cranial nerve palsy, as well as some gate disturbance. So he went to an erologist, they ordered an MRI. And what they found was this very expansive lesion will
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approximately five centimeters. in diameter.
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This sequence is a fluoresce sequence. It was
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hyperintense inflammatory tube and it generated all this comprising of the fourth ventricle as well as the adjacent structures. So we talked this patient over with our neuro oncologist or pediatric
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neuro oncologist team and we decided to perform IVopsy. So we did it via the sub-temporal approach. We had good samples, the patient had no vasoparative complications and the result was an H3K27M
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altered diffused dioma. These are some of the pictures of the anatomopathological results. This is the H3 staining and this is the HNE result. The patient, these are his post-operative MRI. This
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is a three-month post-operative MRI when he started the radiation therapy. is the eight-month vasoparative MRI. The patient had no complications due to a surgery or the treatment either, but he
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died a year after the surgery, due unfortunately to ecological progression of the disease. So this is the second patient. It's a very similar patient. It's a 12-year-old female patient that
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presented with a right facial palsy and left brachochuro palsy, which are
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a Miller-Gobler syndrome. So it was very similar. We talked it over with the neuro-oncological team and we decided to form a biopsy and the result was same. It was an H3K27M diffused midline glioma.
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This is the H3 staining and this is the methoxilinarsin result. Even though the patient had no necrosis or
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mitrobascular proliferation, the H-reap positivity result correlated with the H-reap positivity result correlated with the age 3,
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27 kms midline diffuse glioma result. So this is his eight month was operative MRI. The arrow shows the biopsy site. The patient had no complications and is currently undergoing oncological
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treatment, but she's on
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the second line of treatment now due to the prognosis of this pathology So in conclusion, the diffused midline gliomas are rare childhoods and from nervous systems. They carry a very decimal
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prognosis unfortunately. Historically, biopsy for these tumors was only used when the diagnosis was not clear. They used to be treated only by the image, but nowadays with the forthcoming of
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different surgical techniques and mostly with the development of new subtypes of molecular targets, the biopsy seems to be a fundamental step nowadays. So we wanted to present an alternative to
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what's usually used, such as the syntactics of them or the new navigation and surgeries, which is the September approach, a classic approach to the brainstem, but which is an excellent alternative
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to bi-absundic pathology and with no need of additional technology. So while this is the bibliography, and that's all I wanted to thank everyone for the opportunity to be talking with you right now
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and to be on the part of these presentations. So thank you very much. But I am biased for pediatricians is that you grow and you do the extra step. I mean, yes, don't worry, it's a fatal disease,
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but we here will do the best. We will put ourselves on the task to improve the health of your child. Summer holds as they, Summer, you have to say something Yeah, and thank you to Lappla for this
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nice presentation. I really appreciate
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the initiative for and the pushing for alternatives,
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depending on the cases and the ignorance and to be individualized according to patient. Speaking on the bias, Professor Lazarov, I'm biased to the vascular. So my question to the third surplus
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will be more on the doing September for biopsy I can imagine it will be less invasive than the usual September we use what was called base. But
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is there any need to
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consider the vena flabe as an obstacle pre-op planning? Maybe it will affect the site of approach or just to consider one section. So what's your thoughts on that? Yes, it's an excellent question
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So we will. First of all, we see if the patient, well, if it has the age enough to see if he's left or right handed, and we always use the non-dominant side. But besides that, yes, the
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venoflavae, it's crucial for this approach. So we evaluate it with the pre-operative MRI if we are gonna have the enough corridor for use for use of this approach. And if the venoflavae is quite in
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the middle of it, if it's not possible, we don't do it. I don't know if Delcafid also wants to say something else, but it's the main surgeon and the one with the most expertise.
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Unfortunately, we have no problems with La
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Verbein. Always can we do the biopsy?
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Yes, we haven't encountered any problems with it, but yes, it's a very important thing to consider when using a sub-temporal approach.
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Yeah, thank you. Well done.
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Uh, could you go back to the images you had in your presentation and share screen? Yes.
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And where you had a not patient, uh, be a patient. A. Yes, of course.
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Fidelity, you're, you're approaching this. That's very good. You're, you're, there are many ways to approach this. Uh, the traditional way was to approach this, uh, posteriorly, I guess So
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much separately, uh, you chose the subtemporal way because it was easier for the patient, um, easier surgery. Can you talk about that? Yes, it was a very, an easy surgery for us.
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We are, uh, realized a lot of ones. And we prefer this socially because the better we have a better breathing, breathing control, and
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we can take last year, not tomorrow. a collision in samples, and it needs less technology, because in our country, sometimes it's difficult to get some technologies as node and navigate or still
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attack these biopsies.
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Fidel, let's say
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the tumor was located on the floor of the fourth ventricle In other words, superiorly and not laterally, this is diffuse,
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that would make it a longer route to get to that, wouldn't it? If the
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tumor is in the floor of the fourth ventricle, we approach the tumor with a telo-velar approach.
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With
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a telo-velar approach, okay. So you do it posteriorly. So it depends upon the location of the tumor as to what approach you're doing and so further than the.
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on case B, Lucia? Yes, of course, here. It was obviously located more to one side. So how do you choose what area? There's some that
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have eye contrast or hyperdense area. There's some that are lower dense. How do you make a choice on which area to choose?
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Fidel, could you answer that or? We'll show the areas with the, there are more cellularity. Also in
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MRI, we can know which is the, the shown that is most cellularity. This is the,
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the, exactly place to the biopsy. So, so if you look at the image, so that would be the image would be, where you see, where you have the most contrast material. So anywhere, anywhere in that
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image, or would it be in a more in the more cystic area, where you could get at least some decompression? How do you deal with that?
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Sometimes these tumors not take very contrast, contrast, there are without contrast,
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and we treat to take a large, large amount of pathological samples. And we have no problems with the patient, with
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the patient doing well in a few days. And oncologist's scan to begin with the complementary treatment.
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And
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so how do the people do, what are the complications? How do they do it after your surgery?
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We have no complications And maybe in
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Madoma, sometimes, but it's not frequent.
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And
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no complications that you have any cranial policies or any sensory deficit or motor deficit or are they transient or they get over it quickly?
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I don't
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understand the question, please If they have a deficit, a neurologic deficit, Is it just brief or is it not at all for any of them? No, we have known the relational, we've known the
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relational deficit.
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How many biopsies do you take of the brain stem? Do you take multiple or do you take one? No, we take multiple, multiple biopsies
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Sorry, we also do some, we do some frozen biopsy at the time, we have the pathology team waiting for the biopsy so that they can certify that what we have sent is enough, and that we are at target
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for the place of the tumor So we always do it with the pathological team in place for us to be okay with the amount that we are sending. I'm sorry, I interrupted Of
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course, Fidel, sorry, I'm not sure I am. I'm speaking very loud, but Fidel remember that we have also a band in the pathological section to put samples of all of our tumors, not for frozen
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sections to preserve in a frozen condition samples of the tumors for
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the future. Maybe for ventilation, maybe for a foundation one, whatever the patient or the family decide So we have to need more than one biopsy, they'll perform as we are in the adult population,
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we took a lot of biopsy, if it's possible. In those cases, you know, the human is big enough to take out more than one biopsy.
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Sorry for the Thank you. I'm sure there's some people who want to know what kind of an instrument do you use to buy up sit So, I said, do you use a little biopsy for someone?
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What did you use a little needle and do some aspiration? How do you do this? Because other people may want to try this and because of your approach. What do you do? You use biopsy, four steps. A
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biopsy, four steps, you're yours. Yes, yes. Okay. And do you do anything special with the bleeding that you get after you take the sample? Or how do you know how deep to go and so forth? So
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maybe one centimeter and we have no bleeding. And we can, we should this approach, we can control the bleeding.
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Okay, so no deficits and no bleeding. You go about a centimeter in. Yes.
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Okay. Oh, okay. Now, I assume you're, as Andrea said, you're collecting all these, you have a tumor bank. And there's some papers appearing in the literature the genetic changes, and some of
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them are, at least one of them I know I've read, as sensitive to some chemotherapeutic agent. Are you doing anything in this line? Yes, of course. This is the reason why we change our policy. I
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will speak about adult population. I perform surgeries in the adult population. Fidel is the chief of the Peliatrix area unit. But the point is, it's more or less the same until maybe six years
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ago, six, five years ago, the policy of our neuroemphological department was completely different in the adult population. Brenistem tumors, like the first case Lucila showed, maybe our
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oncologist said go to the, to treat the patient with real therapy now because of the advancement in meditations. Our oncologist wants the biopsy and his mandatory to perform biopsy to do regulations,
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we are involved with the Hyderabad group. we are trying to do the methylation in the same way that they are doing. And that the reason why they try to obtain it very clear the most important
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histopathological diagnosis in order to know which way to treat chemotherapy, immunotherapy, you know. In our case, we have our ball tumor, neurosurgeon performed the surgeries, but then our
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oncologist with our very ghettos who they took up the patients and decided the treatment, but they need biopsy. Since the last five years we changed our policy, further maybe she's doing the same
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approach because you know it's more frequent in the in the pediatric population.
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Dr. Alwash here asked what about intraoperative neurophysiology monitoring? Do you do any monitoring in that? Yes, yes. We use You use a monetary always. Yes.
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What do you monitor?
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You know, we're the eighth nerve or the seventh nerve. What do you monitor?
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Yes, we have, we have electromyography of the fifth, sixth, seventh, lower tranial nerves. And then a long, a long, a frat in motor evoke in potential and some of the sensitive motor both
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potentials. And we also have the possibility to have, we are using a specific cannula
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of aspiration with the isolated the team in order to perform stimulation monopolar stimulation if you want in the middle of the brainstem. So when we are trying to check out the biopsy with the
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forces as field search, after doing that, sometimes we put this cannula in order to change. It's not subcortical, but it's intra brainstem, in order to know how.
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how near from the nuclear tranial nerves we are. Excellent, and that's it. So you said immediately elevates the procedure to something that should be in centers like yours that handle that extra
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monitoring equipment and so forth, is that correct?
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Yes No. So
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the next patient that will come to your service, you will do this approach. So the next child with high grade leoma, diffuse segment, brain strength leoma, will have the sub temporal approach and
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you will be collecting data of that. Okay. Wonderful. I think that. Hopefully How many cases a year do you
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see? You're a
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referral center. How many come a year with brain stem nugly brain stem tumors? Yeah, how many do you think, Fidel, that you operate a year? We are using this technique for a lot of years ago.
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We prefer this technique that the
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biopsies or the navigation biopsies. I think we are using this technique almost 20 years And we use, now, we like this approach for dispatology. So I had a question there. How many of these
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tumors do you see here, Andre? How many do you see here? Brings them tumors? Maybe two. No, two.
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It's finished. Is there a reply first in the pediatric population, please? Yes. Yes. Yes. Maybe two or three tumors are near. Okay
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It's not common anymore in the world and when you're a major center. and you get two or three a year or so, it's not something somebody's inexperience should do. Is that correct? Oh, yes. No,
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but also in the moment, there is this popular belief even here in the United States that if the patient has a brainstem leoma, the neurologist usually send us directly to the neuro-oncologist, they
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bypass the neurosurgeon. I feel that if you expand or you present cases you are at the casuistic in publications and in, for instance, more and more that the number, that the culture of avoiding
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surgery for brainstem leomas can naturally change. I would like to, because otherwise, this is the fascinating subject, but we have one or two more, at least, or three or four more fascinating
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subjects. I would like to, yes, don't ask me, I say something. No, no, no, it's fine, I don't want it to.
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I mean, I think the answer is a very important question. Everybody needs to know. I compliment them on trying to get tissue in these tumors. Otherwise, we don't know what we're treating. I think
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you've done a great job. Absolutely. And I have to make a brief note. I am extremely happy to see Dr. Sosa in the command of this. I remember when he was a resident. Anyway, so sorry for that,
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I mean, don't at all
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Okay. Dr. Juan Gonzalez, then Juan, I remember you are ready to share your. Yes, yes, Professor. Yes. Dr. Laplace with your case A number A. Yes. It's already present. So extensive. I
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think the biopsy was a bit late. Patients must have presented with lots of theological problems. The patient was. Yes. three-week history of
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his neuroagical deficit. He went to the neurologist and the neurologist, all the DMRI and due to the MRI, he was not from Buenos Aires. He was from a province that's quite far from here. So the
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medical attention there, it all takes a lot more time. So when they performed the MRI, the patient was then referred to FLENE and when the patient came here, the deficit was quite severe But that
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happens a lot here in Argentina because we have a lot of centralized medicine. So in Buenos Aires, we usually do have, fortunately, quite fast treatment and evaluation of patients. But when you
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go outside of Buenos Aires and mostly to other provinces, it takes a lot of time for patients to be referred to big centers. Yeah, thank you. Very nice, sorry, Lucilla. Thank you so much for
30:48
the
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presentation.
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Yeah, thank you.
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But Paula Sarif, can I tell you a little comment? Yes, yes, yes, yes, yes. We are, and now I am returning to Argentina from San Pablo from the South America, and
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the North Carolina American Society. It was a Congress today full of people from Europe and the United States, and there is a very big change in the paradigm, like you said. Also in the United
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States, in Europe there were tables, a round table for pediatric patients, and for all those patients. But never on college is getting more and more involved like the director of a team. And I
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think that the whole situation with the neurosurgeon says, OK, I will perform a
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biology and I will set the patient to the radiotherapy. It's not any more. It's not the new paradigm. I think in the future for the younger surgeons, they need to be involved in a team. It's a
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multi-collaborative team with neurobiologists, neurophysiologists, neurobiologists, because it's impossible for the future to know how many change with the methylation, with the diagnosis,
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histological diagnosis, with the improvement in radiotherapy and
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immunotherapy,
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it's not possible for only one month, but for maybe two, three, four biopsies a year to have all these knowledge. So it's important to, of course, it's difficult But this is a change of culture.
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It's a change of culture, yeah. Thank you very much. Thank you, Dr. Savio. Thank you, and congratulations on planning. Yeah. Dr. Juan Gonzalez is the
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head of PE. at the neurosurgery at hospital, both this time Nicaragua. But as I said before, he carries on his shoulder, all PE. at the neurosurgery of Central America. He's the referral point
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for all the cases, and he's a stalwart. This is one of those guys who believes,
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The speaker is Juan Bosco G. Torres MD, Pediatric Neurosurgery, Hospital Bautista, Managua Nicaragua. He is speaking on decompression biopsy and permeabilization surgery for intraventricular
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craniofarin geomas, a purely endoscopic transventricular approach Hello everyone, I'm sorry. It's for me an honor to be here with all of you. I will share with you my little experience regarding
33:29
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 address these tumors, talking about
33:49
the cranial pharyngeal muscles, which will depend on the third location size of these structures involved and radiological characteristics.
33:59
So this approach, speaking of the endoscopic pathway, can be carried out with the VASIC instrument with the
34:11
endoscopic thermobentric law to me is performing and I think it is increasingly common talking about endoscopic. So
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this is my little characteristic,
34:28
12Ks. And
34:32
fortunately without the complication that can occur in another approach, I think because it allows quick and direct access to the tumour and work within the tumour.
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that is already an old information, particularly I started with
34:59
the first passing, know with the intention of addressing the tumor but to perform on ETV. But when I see the tumor,
35:12
I released that view to the characteristic 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
35:32
ESPN meeting in 2016.
35:37
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
35:54
and intraventricular, I think this option is the ideal. This is my third case, and this is the imagines. In the first case, you can see
36:09
this part. It's the sixth part, but the operations depend and the consistency of the liquid You can see the tumor in the actual view is very close to the programming of Monroe.
36:30
This is my second case. It's a tumor
36:38
system predominantly.
36:45
This is my first case I am sorry for the quality of the imagines. You can see the tumor, this
36:56
is the foramming of Monroe.
37:00
The tumor peaking throughout the foramming of Monroe, we started with the ovulation of the surfers, trying to gain space throughout the foramming of Monroe and try to descend to the third ventricle.
37:14
This is achieved with a lot, lot pathians doing ovulation in the surfers,
37:23
shrink in the tumor, gain space, but you can see, I don't use any special attachment. Just in this moment of disorgery, I use
37:39
only ovulator bipolar, trying to shrink the tumor So this is the first step. trying to do this compression,
37:55
after I am sure I have control of bleeding, we can take biopsy. You can see a little membrane between the tumor and the foramhing of Monro, no good idea, try
38:15
to moving the tumor because these other ends are caused many bleeding, so nobody wants bleeding in this moment, in any moment. So another part of
38:36
the surgery
38:38
is inside the tumor This view is inside the tumor You can see the characteristic of the tumors,
38:49
particularly the calcifications.
38:54
We can open the seas, the capsule and aspirate the contents that are commonly dense, oily and work inside the tumor and take fragments of Egypt for biopsies So
39:12
with passing,
39:17
we can continue outside the capsule,
39:24
this is the capsule and this is the silvus aqueduct and in this moment
39:33
we get a good permeabilization of these ventricular systems. So, um,
39:45
trying to populate another part, the vascular part, the tumor,
39:53
avoiding the mobile list, the
39:57
tumor, avoiding the complication with the injuries in the epidemic regions. This is the principal
40:11
vintage of this approach.
40:16
This is the view puzzle of the first case.
40:22
You can see the pre-op
40:28
and you can see the
40:32
calcification part. In particular, I leave this part because it's inactive biological. So,
40:44
This is the axial view.
40:49
You can see the persistence of theilitation of the system ventricular, but in the next week, disappear the ventricular side return to normal.
41:04
So talking about the this approach,
41:10
I have three steps The principle three-strip. The first is
41:18
identifical, the tumor of the characteristic of the tumor, at this compressing and taking biopsies, and thermalization of the ventricular system. We have two options in this sense. You can
41:36
open the aqua to the syllabus,
41:41
trying to shrink the tumor, you can do an endoscopic therapy entry close to me, to option for permeabilization. And finally, you can get more part of tumor avoiding the contact with the
42:07
therapy integral or the
42:10
neighbor parts.
42:14
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. You
42:30
can do it with a basic instrument for ETV or third relief or from neurological condition without complication principle in the Korean and complication. And in another sense, a voidy placement of
42:48
Vipishan or sometime performing ETV. So
42:57
in safe reports, you will find similar conclusion.
43:02
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.
43:15
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,
43:29
does the cys come back or not? What happens to the today? Just in case, just in two case, Professor, just in two case, return the cyst was necessary
43:44
by the same way, but predominantly in another case, and don't return the cyst.
43:51
I see, so you actually say of the, you had 14 cases, no, how many cases you have 14? Well, 12. Well, 12 cases, so of the 12 cases, two cases that the cyst came back, and the other 10 cases
44:04
didn't come back, I mean, amazing, so that portion of the cranioffin, and clinically the patients were doing fine, I mean, didn't have endocrine deficit, added, nothing like that. Yeah, the
44:19
clinical evolution was
44:23
very good, very, very good.
44:28
Okay, very, very, very interesting because we like to, you know, we, the surgeons like to take it all.
44:38
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 Flemies and caution and understanding. You don't need to take it
44:51
all to be a great surgeon. Okay. Good, as I said. Any, any of the questions from the audience, nobody, any, any further comment?
45:03
And Ray or Fidell, do you have any, do you, do you approach this different layer?
45:09
You know,
45:12
I will, no, no, no, it was a question. In our institution, of course, I will give my opinion in it. I always repeat in other populations. In other population, we used to perform a population
45:26
like Dr. LaSareff said, we tried to, we tried 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
45:40
tell you the truth, we remember having had a patient. similar to this, the patient like Dr. Rossello, with too much calcifications in the cellar and supercellular areas, and sometimes it's not
45:53
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 have everything you want to speak. I have a new deficit
46:11
in 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,
46:24
I can say almost all of our patients have some electrolytous abnormalities in the in the sodium in the possibility period. Much, a lot of our patients remain with in seeping dailities but of course
46:33
the
46:43
While it is life,
46:47
I can say that maybe 80 of our patients in the adult population can remain with a very acceptable quality of life. I remember
46:57
two cases, one of them because of some complications, basses, bass, and so on, the patient is dead because of this tumor So, crying for enjomas is still a very big mass. It's a headache, not
47:13
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. In pediatrics, we try to do a radical resection, but
47:28
it's very difficult.
47:31
But the objective is to do a radical resection
47:37
And Dr. Petre, what's your policy in the children's in El Gutierrez?
47:46
You are mute, you are mute, you are mute, you are mute, the moon.
47:55
Yeah
47:59
Excuse me. My English is
48:04
our
48:07
policies. When you have these craniophane Germans, they're very big now
48:17
The pathology extends to the
48:20
middle force, to the frontal,
48:25
when we have the approach for it. When the
48:44
craniophane German is in the cellar, cellar, or in the axis of the cellar, not a lot of the size we made, and now the transcepter. of the natural senile approach with a
49:03
good result.
49:06
It's possible
49:09
to damage the floor of the third ventricle now
49:29
The abetos incipido is 90 near one week. It's possible that
49:37
the patient has a lot of
49:42
endocrinological
49:44
disturbance now The abnormal separation of
49:54
hormonal antideratica
49:56
It's very complex,
50:03
although
50:06
sometimes we have a total rejection, but in contrast, there are procedures, procedures, procedures, procedures, procedures. I would say for Dr. Petres, he slipped into Spanish with his
50:38
passion. But the thing is that, yes, he was saying that in spite of
50:46
the, that you believe, you may believe that the tumor, that you remove the tumor completely, but it usually, there is an allocation when the tumor comes back. I'm saying to one of the questions
50:58
by
50:60
Abdullah Siz, Alayaf, he says, What's the recurrence of those tumors? Yes, if you really remove it completely, the recurrence is zero, but as Dr. Patrick said, if it comes back, it means
51:13
that you didn't remove it completely, you know? The interesting point with Dr. Gonzalez is that if you leave something and disturb, at least in some cases, they don't return. I mean,
51:29
some cases with
51:35
the solid component remains, no, a lot of time when we take only control by
51:46
DC or IRMA-I, but
51:51
although the total removal Halle.
51:55
it's possible to
51:59
live
52:01
in my experience before going to Dr. Halil now, in order to keep on moving, in my experience
52:08
is the the some of those at the kind of an enjoyment that I removed possibly evidence completely was the a tumor that was willing to come out, you know, more than the surgeon because and I, and as
52:23
I said to the at the residence, if you are struggling for more than three hours with a granular pharyngeoma, stop it, don't don't let it continue, you know, there is one moment that the kind of
52:34
an enjoyment when you find that the plane with the hypothalamus and that the capsule, the the tumor says, okay, I give up, I'm coming out, I'm look at the comes out, you know, and each tumor
52:47
has its own personality, but I think that the beauty
52:55
Gonzalez think is that within resources that are not perfect, but not limited, but I mean, he works in a very good hospital, hospital about Eastern Managua.
53:09
There are still innovative approaches that diminish the
53:14
clinical consequences for the patient. So no further comment, we can go to that. I'm going to say, I'm going to say five things. First of all, one, that was
53:29
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. And the
53:41
thing I liked about it is what Jorge said, you knew when to stop.
53:47
You knew when to stop. I think this is probably one of the most difficult tumors in neurosurgery. I used to call it the suckers tumor because what it does is it makes you think that you're being
53:58
able to take it out and as you progress, you get into deep trouble. And what Jorge said is exactly right. He probably should quit over there, but here's a case where Dunbeats perfect. We're all
54:11
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 known to
54:25
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 brainstem tumor. So I'm not sure
54:37
with all the technology we have and Dr. Shillito, 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 invading
54:48
the brain tissue It's not 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,
55:01
Jorge, and to leave the 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
55:16
think a discussion was very reasonable. I know that if we talk about papillary cranial friends, young ones, there's some molecular treatments now that are highly successful, but maybe we'll get
55:26
into that, okay? Andres, do you have any thoughts about that?
55:32
No, I completely agree. And the point is nature is very unfair, because you know, Cranifen in German is a tumor from the pediatric population. And we in the adult population, we have less
55:43
incidence, but we have the possibility of the biorath mutation So sometimes we can leave. On purpose, some portion of the tumor will perform subtotal resection in order to preserve quality of life.
55:54
And then our neurocologists can do something because of the mutation. But in the pediatric population, there is, of course, you have beta-catenin mutation, but it's
56:05
completely different. There is no still clear indication of medication for this patient. It's, like you said, it's a very complicated tumor for pediatric patients. That is one of the questions
56:17
for Dr. Gonzalez from Dr. Alwash. He says, what is the site of the tiber hold to put it in, right side, left side, pre coronavirus, post coronavirus?
56:31
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.
56:44
The right side, pre coronavirus is the same.
56:48
Okay, and you aspirate the assist before trying the reception, you eliminate the water issues, yeah. It's sadly not the question. Yeah, okay. So now we go to the dean of the Iraqi neurosurgery,
57:02
Dr. Al Khalili, who I was asking exactly how to pronounce your name, is Al Khalili. Yes, absolutely. When I write letters to him, I say, Dear HK, because I don't know exactly where the age
57:15
goes and the eye rose, but Dr. Al Khalili is an honor for us. I mean, we have learned a lot from you in past presentations. Please go ahead with your smart and intelligent assessment of the
57:31
Pareno sign. Very valuable for pediatricians. The
57:34
speaker is Professor Abdul Hadi Khalili, MD-MPhil, Head of Department of Neurosurgery, Baghdad University, Iraq. He is speaking on a clinical scale for setting sun signs.
57:48
So this is the clinical scale for setting sunshine, which was developed over the years when we used to see so many cases of hydrocephalus in our country.
58:00
And the clinical measure measurement scales provide quantitative,
58:06
excuse me, sorry.
58:12
A quantitative means of evaluation the patient status, it's very important to evaluate the current status of the patient in many diseases, and also it will monitor the progress during treatment.
58:25
And as you know very well, we have the coma scale of Glasgow,
58:32
and we have the Carnavus key scale, and we have the Rankin scale for cerebrovascular diseases, and then we have recently not published by personal communication assessing with the scale for the
58:48
thyroid exophthalmos.
58:51
But nothing for the assessment and the grading of the setting sun sign in the case of
59:00
agrocephalus. Why the name of this? Because it comes from the setting sun, gradually it goes down So this represents the iris as it goes down. Normally, the upper lid, as you know, very well,
59:14
covers the upper part of the iris, and no stick layer as showing above the iris. This is in Che children and adult.
59:25
But in settings and signs, vertical gaze paralysis and the retraction of the upper lid was clear as showing above the iris.
59:35
Setting some sign is seen in hydrocephalus, which is the common expose, which we see, and perinosis syndrome and kernichtrus, some normal infants, they have it until the age of eight months or
59:45
maybe one year, and then disappears, pineal tumors, midibri and vascular lesions, metabolic disease like anemicic and encephalitis. Grading for setting sunshine was improved, which improvised,
59:57
which is simple, applied and dependable And this scale is important in evaluating the current status settings on sign and monitoring and follow-up. So the matricular system in hydrocephalus will
1:00:18
expand the aqueducts of mantra and then produces this vertical paralysis by the distension and affecting the vertical gaze of an aberration, which is the medial malpassiculus and interstitial nucleus
1:00:34
at the posterior convolution So this is the aqueductorch in here, of course. And then these are the centers which are controlling the up gaze. The scale is a five grades, grade 1, 2, 3, 4, 5.
1:00:52
And then grade 1 is the lower part of the iris is covered with the lid. So something like that, it's not the upper lid covering the upper third, it is the lower lid covering the lower third
1:01:07
and then grade two, the lower lid of the The edge of the lower lid is touching the lower edge of the pupil.
1:01:16
So it's getting worse at this clear eyes showing more on the top. And then grade three, half of the iris is covered, maybe more than half or less slightly, less than half is showing like this baby
1:01:29
here.
1:01:31
And grade four, only the tip of the higher of the pupil is showing
1:01:37
So that's even worse than the
1:01:40
previous one, grade three. And then in grade five, you have only the tip of the iris is showing.
1:01:48
So with this, you can really assess in the progress of the patient with hydrocephalus and then it will help you in grading, evaluating the degree, monitoring and also sometimes it helps you when
1:02:03
the shunt is blocked. And that's the beginning of the setting inside will get worse. And thank you so much.
1:02:11
Thank you. Thank you very much.
1:02:15
This is an interesting research subject, particularly for, I mean, we are used to work in
1:02:26
settings with all the possible
1:02:31
technology like CAT scan immediately, patient scans with a suppose, I don't say follows one CAT scan called neurosurgeon, fight with the anesthesiologist and get the, get the room and boom and,
1:02:44
and goes with that. But often happens that many of our patients, particularly when there is tuberculous meningitis, there
1:02:52
is a high increase of either esophilus in the world in that band of sub-Saharan Africa, expanding to our Latin America and touching the bottom of Erisia, where either esophilus is not caused only by.
1:03:10
on genital metaman formation, but particularly by tuberculous meningitis. And that's why there are so many pediatric neurosurgeons going in the past two, 18, you know, because of the high
1:03:21
incidence of tuberculous meningitis there. And that can give you a sense of
1:03:31
urgency, how urgent you just have to be. And of course, this is a prospective work. Now, if you have a great one, okay,
1:03:40
you can wait if you have a grade three of the Pareno sign, you need to really stop doing what you're doing and put an external ventricular drain. So the simplicity of your presentation can be
1:03:54
extremely useful for those working in less
1:04:00
easy conditions to work, you know? Yeah, so thank you I don't know if anybody has
1:04:09
any other questions.
1:04:12
Can I ask a question? Oh, please. So I wanted to know if you have found a correlation between the grading of the setting sun sign of the and the amount of hydrocephalus that the patient had in your
1:04:26
experience with your patients. Yes, it is related, yeah. The worse the hydrocephalus, the more increased the track pressure is the worse of
1:04:35
the setting sun sign, yeah. And it always correlates, or usually, I mean, I don't know, we can't talk about always in medicine, but - Can't say. Always is.
1:04:46
Almost, always, yeah. Almost, that's right, and I, Cassie.
1:04:52
Cassie's here, but almost always. Which is
1:04:57
what it is in itself, okay. So, we'll, yeah. No more questions, Dr. Osmano. I think Heidi did, that's a very interesting analysis, Heidi, I think is very useful.
1:05:24
And there are extra questions you might take, Rob, serve Lazaro? No, I don't see any, no, no, no, no other extra questions in here. I want to emphasize not for the pediatric neurosurgeons who
1:05:30
are here,
1:05:33
but for the young, well, Dr. Tomek is young too, but she's inclined already into pediatric neurosurgery. He said the fascinating field, and Dr. Osman wrote many, many years ago in surgical
1:05:48
neurology that
1:05:50
the paper journal, remember that blue journal, we used to have journal neurosurgery, the red red journal, and the blue journal. Blue journal was said he developed Osman. He wrote that what the
1:06:00
world needs are pediatric neurosurgeons, and even there is a great educator in the United States, Jonathan Kozol.
1:06:14
And he also wrote a long editorial
1:06:18
of education about Haiti, and he says what Haiti means are pediatric neurosurgeons. And there was an editorial in the New York Times, six or seven years ago, which was called Desperit in Kabul,
1:06:34
Kabul being
1:06:37
the capital of Afghanistan And the message was, We need pediatric neurosurgeons. So for those of you that are considering that the carreling neurosurgery and neurosciences strongly consider
1:06:53
pediatric neurosurgery, and there is a clear example. Excellent. So we will jump the next presentation of Dr. Gonzalez, we are ready. And we'll also, we know one EC, one, one, I mean, one,
1:07:06
one, three, four or one, less We go to Dr. Essekyl Patrisio Verde, who will
1:07:13
to us about the case of the arterial venous malformation of the posterior circulation. Dr. Vadier is a staff physician at the Children's Hospital in Buenos Aires and he works together with Dr.
1:07:29
Petre. Exquial Vadier, MD, Cesar Petre MD, Department of Neurosurgery, Children's Hospital Buenosperis, Argentina. They are speaking on AVM of the posterior circulation So, let me know if
1:07:41
everybody can see the slide. Okay, so this is a case
1:07:50
of a complicated AVM for the posterior circulation in a pediatric patient that we treated in our institution, in the Pitalgut LRS, it's a Children's Hospital in Buenos Aires, Argentina. So, this
1:08:02
is a case of a Nainia Lorger that presented with an intense headache Followed by seizures, an active level of consciousness. It was admitted to another institution where she was intubated and
1:08:15
referred to our hospital. When she arrived to our hospital, we performed a CT scan that showed interventricular hemorrhage while in the fourth ventricle and in the lateral ventricles. And we can
1:08:32
see in this CT scan that it's the results of a clot or
1:08:37
hemorrhage in the medial surface of
1:08:41
the occipital lobe. So we presume that this was a cavernous malformation
1:08:50
or AVM. So as she was in a delicate situation, he was admitted to the PQ and we placed an EBD to drain CSF and the blood. Unfortunately, the patient did very well So after 40 hours, she could be
1:09:08
extubated.
1:09:14
a
1:09:18
non-neurological deficit was assumed. We did a CT scan several days after the EVD was placed to acknowledge that there was no blood on the ventricles and the size of the ventricles were normal. So
1:09:31
we closed the EVD for 48 hours, so we could withdraw it,
1:09:38
acknowledging that there was no hydrocephalus. We could also
1:09:42
see there is an image on the medial occipital lobe showing this, there is still a disease to be treated. So we did an MRI, so you can see the pictures here. So there's no problem on the ventricles,
1:10:01
but we still see this MRI on the left atrium that involves also, a dilatation of the bane of gallant system.
1:10:14
In the ion chagrin, we can see that there is some feeders getting into the
1:10:22
deletion. So we could acknowledge that this is an
1:10:31
AVM. So we did an ion chagrin. So you can see that this is like a plexiform AVM
1:10:40
of the posterior circulation, which involves feeders from the postural lateral colloidal arteries and the p4 assignment of the
1:10:49
cerebral posterior artery. And in the venous window of the ion chagrin, we can see that there is a delayed vein of gallium, aneurysm, and if can I put it in the vein of gallium,
1:11:04
play this video, you can acknowledge that there is only one, only one training ban for the AVM to the complex of guidance. So the challenges of these cases is that it's a rapture AVM at the left
1:11:25
atrium, involving the medial portion of the occipital love, involving the it's moods, where is the Calcany sulkus showing the
1:11:41
pallet occipital sulkus. So it's a deep
1:11:44
AVM with only one ban of drainage into the complex of gallon that's make it difficult in there to operate. And the other thing that it's very important here is to think what approach to do. Of
1:12:02
course, we agreed that these patients should go or underwent both endovascular and surgical treatment. So, as we did, we performed first pre-op embolization of the AEM, especially the gallium
1:12:20
part of the AEM. The patient tolerated very well this procedure and then we start to thinking about what is the best approach. There are two options here. Of course, the best way to get to this
1:12:37
AEM was from a posterior inter-emiphoric approach, but the discussion here was to
1:12:47
do anipsilateral deletion or contralateral deletion as was described by a loton. So, in this pattern Martin scale we can see this this is
1:12:57
a grade 4 AEM and we plan a circular cronyotomy.
1:13:03
And the discussion, doing it epsilateral or contralateral, I think it's more on the social experience. I've, we've never done, and in my experience, I never done a contralateral approach for the
1:13:18
occipital medial region. And our concern was to, for
1:13:25
two reasons, what concerns us for surgery in this patient The first was that the more lateral aspect of the AVM wasn't embolized because it was feeders from the posterior lateral choroid arteries.
1:13:42
And at that part of the AVM, at the lateral part of the AVM, there was the bane of gallium complex. So in an epsilateral approach, all that is going to be difficult to view and we would need more
1:13:59
retraction of the occipital law.
1:14:04
Otherwise, on the contralateral approach, it was described a lot on, you can approach the AVM from medial to lateral, and as you start equagulating the
1:14:19
feeders 360 degrees from the AVM, you can have a better view of the postural lateral arteries or feeders from the AVM And, I mean, you can be more secure to correlate them, as to protect, of
1:14:38
course, in the atrium of the ventricle, the posterior part of the
1:14:54
talamus, and the posterior part of the forensics. But, well, this is the post-embolization pre-surgical MRI, and we can see that this plexiform MBM It's still alive. So we. perform a posterior
1:15:05
enderempathetic approach, we went from theipsilateral because of our experience on this approach, and we placed the patient in a park bench position,
1:15:17
letting the gravity do the space for the corridor on the position to gain access to this AVM Unfortunately, we don't have the video of the surgery, but we have this photo of the approach, so as we
1:15:35
can see, we have exposure of the left occipital love, and as to get into the AVM, we have to go interemifuric and deep. As you know, this is about a splenic, it's under the splenic of the corpus
1:15:54
kashosun, and we could remove all the AVM, preserving the vein of gallant that was embolized previously to a surgery, the patient did really well without any neurological motor or visual deficit.
1:16:15
This is the MRI of the post-surgery, which can show that there's no evidence of the AVM, and this preservation of the visual area and the citadel of. This is a much better picture of the post-op,
1:16:35
and I will show you the video of the Anishigram
1:16:43
post-op and post-embolization. We can see there is no AVM, and there is still the cast of the previous embolization of the
1:16:56
Bane of Galen, uh, aneurysm.
1:17:01
These are the pictures comparing the pre and post-surgical results
1:17:07
of this patient.
1:17:12
And as I said, there was no motor or visual deficit posterior to
1:17:21
the surgery. There is still minor occasional headaches that the patients say that she has
1:17:28
After the surgery for the first two weeks, she had a translatory color blindness that recovered at the interim. And as you saw before, there's post-op digital algebra, where there's no evidence of
1:17:42
residual AVM, and there's the vein of gutting that is embolized. So to conclude, we can assure that posterior circulation AVM are challenging cases that combine endovascular and surgical treatment
1:17:57
are an effective option. There is a discussion between to
1:18:04
do anipsilateral or contralateral approach, immediate occipital LABMs that extend to duration of the atrium are suited for contralateral strategy. But in our case that we don't have experience on a
1:18:15
contralateral approach, we prefer theipsilateral approach that brings
1:18:21
the AVM closer to the assertion view, protects the involved hemisphere, but requires more retraction to reach the lateral border or the lateral aspect of the feeders for the AVM.
1:18:37
Thank you. Thank you.
1:18:41
Well, I leave to Dr. Hose and Dr. Osman, who are the biased vascular surgeons who are the most vulnerable. You want to say any who vote? Yeah.
1:18:57
I just want to say, congratulations. It's a very nice restorative case. It's not easy at this position, obviously. And yeah, I think it's challenging from different perspective. And the
1:19:12
vascular may be not easy option to attack a significant part of the AVM and also from the surgical part, it's challenging. Congratulation for this outcome And my only question is that, what's the
1:19:28
type of collaboration with the endovascular treatment? Is it in the radiology department? It's in the same department, how this decision is made. I would be interested. Fortunately, we at the
1:19:43
general hospital, we have a staff member of the team that is in the vascular surgeon So, actually it's.
1:20:02
she's a girl. She does all our endovascular patients. And of course, we discuss with the whole team about doing combined strategies for this patient. If they're going to underwent endovascular
1:20:17
treatment, we have to assure that the surgery is going to be
1:20:22
no more than two, three weeks ahead from that treatment, because of the risk of a rupture of the AVM after that embolization. So everything is discussed in our meetings. The
1:20:35
surgeon that does is a neurosurgeon. That's the endovascular part Myself, Dr. Petra, did the
1:20:48
surgical approach.
1:20:50
Yeah, well done. Thank you.
1:20:55
Alayaf is asking, what's the mortality rate or the severe complication of the surgical approach that you have?
1:21:05
Well, actually we don't have mortality, but of course these are very difficult approaches, even for epilepsy surgery, what it's described to remove the posterior part of the hippocampus and
1:21:19
forensics So complications, in these cases, are related to the AVM. If the AVM, it's very fit to the AVM with a
1:21:34
very complex of gallon involved in the
1:21:42
AVM. Of course, the rates of mortality are higher, but that's what we did an endovascular treatment before And then the vascular treatment before. because we were concerned about the gallant
1:21:55
aneurysm. I want to do a question to secure. Yes.
1:22:01
Do you operate this
1:22:04
AVM without road tour? Just with headaches?
1:22:10
If we have the patient, yes.
1:22:16
Yes. At least we offer the patient the treatment.
1:22:23
It's a safe approach. The only problem is to identify if the AVM is, it has
1:22:34
a lot of draining veins through the complex of gallium In this case, it was only one draining
1:22:44
vein, so that makes the case.
1:22:50
I mean, not easier, but if you preserve that draining drain through all the tertiary, there's not going to be greater complications.
1:23:01
I can make some comments if you want to worry Thank you, thank you. That's an excellent presentation, a work-up of a case, very nice imaging. You define the lesion well.
1:23:16
The question you ask is, and the procedure you use, we wrote up about 40 years ago, called the 34 pro and operated side down procedure to the pineal region, you probably know about it. Where you
1:23:29
look at the hemisphere, you operate on essentially fall away by itself. And what that means is it opens up a corridor so you can see into the posterior, except at all temporal region, you can see
1:23:43
in the pineal region
1:23:46
And you have immediate access to the posterior cerebral artery, which is what you want to go to, to stop the feeders to the lesion, and you get around the lesion, and then you'll get the other
1:23:57
feeding vessels from the choroplexist later as you go around the lesion and get to it. So I think it's a very good approach. You have very good vision. I don't agree with the approach going, just
1:24:11
to help you a little bit. I don't agree with the approach.
1:24:15
from the opposite hemisphere and making a hole in the in the folks. To me, that makes no sense. There's a principle in surgery and that is that you don't operate on both sides of the brain at the
1:24:26
same time. Yeah, yeah. But you know, it's a new, I don't know,
1:24:33
I don't know how to say, but it's like something that it's gaining more and more attention through young neuroscience to go through the opposite side, even in the anterior internal metabolic
1:24:47
approach for lesions deep in the talamus. My father always told me you don't have to jump off a bridge to know what it's like.
1:24:59
And so if you just take a skull and you turn it and you look at it, what you find out is exactly what you did. And you don't need to go to the other side. It makes no sense. You had perfect
1:25:10
visualization. In fact, more than you're going to have. by retracting the other occipital lobe and going through a cut in the faults, which is gonna be bloody. And then working through that small
1:25:20
hole to get to the AVM makes no sense. So I think if people think about it ahead of time, they can do that. If they wanna have something to publicize, something different they're doing, they can
1:25:32
do that. But I don't think in the end, the patient will benefit. And you're right, the experience is that these people basically have no mortality because you're not really doing an awful lot to
1:25:45
them, except to taking out the AVM, and they do very well post-operatively. So I think you did a very nice job for a lesion in this area. And you got a very good result, which you should have
1:25:59
expected to get. Yeah, thank you, thank you, good and good, very much. Excellent, congratulations. Here we are, the pediatricians, the raffling feathers good.
1:26:12
And now we have two more at the presentations and we hopefully will be in time. One is Dr. Gonzales going back to a taste, went back to Nicaragua and he will share his screen with us and then in
1:26:30
the closing where we Dr. Verriel and Petri talking about a case of epilepsy surgery and we had, I think, a nice landscape of what pediatric neurosurgery is about, the challenges of brains and two
1:26:47
or more either cephalos, craniophonic giomas, ABMs and functional surgery. Dr. Bosco, you are the man now. The speaker is Juan Bosco G. Torres MD, pediatric neurosurgery, hospital boutista,
1:27:01
menagua nicaragua. Going back to
1:27:04
speaking on myositis, ocificin and hydrocephalus Thank you, Professor, and thank you all of you for your passing with me. for your time and talking about my
1:27:19
oceficance. Idrocefalo is a very strange
1:27:28
relationship. I did not find many information about this topic, this relationship. This case was a real challenge for me. This reason I bring all of you and share my experience.
1:27:43
Okay, this is a 13 years old female passing with an economic model and Portuguese father, and when she, she had seven years of age, was made the diagnosis of
1:28:02
myocytics, ossificans probabilistic. And this was a consequence of a trauma in the shoulder, the right shoulder After this injury, the passing can move this arm. So the meositics ossificans has a
1:28:18
very low incidence, a very low prevalence, is very, very strange. So in Nicaragua, it's not so, it's common, this pathology. But 10 years and 100 years ago, was made the first classification
1:28:37
about the meosit ossificans. But actually, I think the most useful specification is this. The third type, the one type is first time is the prerequisite or synonymus fiber of the plasios or
1:28:55
significance prerequisite. The second time is the post-traumatic and the third is the aftermath type. So the genetic has show it the way for the training So actually the training, you know, is
1:29:15
a curet. It's just an alternative palliative for a stop the globe in the calcification parts. Talking about this case, this passing in 2022,
1:29:26
suddenly after a mild trauma
1:29:31
present headache for three days growing as a shadow with vomiting was the emergency room in 10 point of Glasgow Common Scale. So the first CT scan was made, showing an obstructive either cephalous.
1:29:54
I talk about the patterns about the risk with the
1:29:60
two option bibhishan or ETV. We decide for ETV for many reasons So the clinical resolution was excellent. The person returned to home in five points, Glasgow Common Scale. So to class everything
1:30:17
was okay, but she returned three months later to the emergency room again with the intracranial hypertension. So a new CT scan show an active either cephalous I thought Dios to me.
1:30:38
very, very fast. So, for this reason, I decided to put a BPHM. I told with the parents, everything agreed. So, but, um, Oh.
1:30:60
After two days, after placement, the vision, the person say I have pain in abdominal area.
1:31:12
I decided to review going to operation room to check this area, but I saw the
1:31:22
liquid was contained in the abdominal area So the vision though is doesn't work, I take it a sample of this liquid and german grow. For this reason, I put an external system, but she received
1:31:46
training with antibiotic for two weeks The revolution was good, the CBC
1:31:54
was good. And I decided to close the external drain and make a new
1:32:04
ETP bed. But when I closed for two or three days, the external drain, the passing improved. And
1:32:13
I did a new CT scan. The CT scan was good. So I observed for
1:32:22
a few days in the hospital And she was this shared to home, but she returned later, four months later, again
1:32:37
with the intracranial importation. So in this case, I decided to do the new CTV, the
1:32:49
second ETV So
1:32:53
you can see,
1:32:56
the new membrane under the pre-mambular membrane, like close, close the, the first ostomy. But in this second ETV,
1:33:11
no, no,
1:33:14
no. Everything was good, relatively easy. Just the particularly, as you can see the, this new membrane, but
1:33:29
the second ETV was working. This is a view to the final second ETV was opened. And actually, this passion has maybe 16 months after the second ETV and now she's okay. So in conclusion,
1:33:57
This pathology showed a rejection to the BP shown so in my opinion it's very hard to try to get a good conclusion. But in my experience with
1:34:14
this case, the first option will be the ETV.
1:34:22
Thank you Thank you.
1:34:25
One of your colleagues, Dr. Salado Perez, is asking whether the adosifos was secondary to an obstruction on the level of the bone obstruction on the level of the skull base, you know But, because,
1:34:42
but you can ask answering directly about that, no?
1:34:49
It's an interesting case. And again, so why do you agree with the. a failure of the first ETV
1:34:59
failure of the option? Yeah, I think
1:35:04
there is a relationship between the
1:35:09
myosites with the new membrane in the pre-mammular area, because it was very fast, the closer, the first ETV. I think this is the problem in this passing with the myosites, because they have a
1:35:26
capacity of game calcification in many areas. I think this was the reason.
1:35:36
Let me see. And how long since the last - since the last century? How many months? Sixteenths.
1:35:44
I was going to be my question, Jorge. What's the relationship between hydrocephalus and myositis, myositis, osseficans? And the
1:35:53
one of you - you're suggesting there's some coagulation or some collagen disorder with this or something?
1:36:02
I'm sorry, Professor? I was trying, it's a case of a relationship of hydrocephalus with another disease that's an myocytus-specifican, which is genetic disease. And does the myocytus have
1:36:21
anything to do with the hydrocephalus or could it have occurred incidentally? Yeah, the person has had a little trauma, a little head trauma playing in the garden. I think Okay, how are you,
1:36:35
understand my point is
1:36:46
this? What's the relationship to this genetic disease? I'm not sure that's clear to me Yeah, I mean, the question again, upon is. Correlation and it a causation is there is there is the cause of
1:36:59
I don't say for those related to the my city's Ocificantis or just inside the coincidence that she had anything and she had this sabbal Island hemorrhage I I I wonder if that so called failure of the
1:37:15
first it to be whether has something to do with the old Pathology of the of the patient no
1:37:23
Yeah
1:37:28
Yeah Sir once yeah, he had the correlation in quality like the cows are they like oh was the was the cause of the of the correlation between the one disease and the other It's very
1:37:44
hard to say there is a relationship in between in to the of two diseases. It's very hard to say. there is a relationship, maybe was a coincidence, because the passing has a little frown, but it's
1:38:05
very hard to say. Okay, is there any literature where they report my acificans and it is associated with hydrocephalus in the literature, I don't, I've never seen a case. No, I never seen a case
1:38:20
either Yeah, yeah, me too, I never, I never find many information about this relationship was very hard to find information.
1:38:33
I would say how many of your cases of
1:38:37
external of ETV, of endoscopic third ventricular stomach are you need to go back again in such a small time? I just wondering if the so-called failure of the first and the need for the second may
1:38:52
have been related to the. pathology of the child. I mean, what's your success rate with your
1:39:02
ETVs, 90 percent one?
1:39:05
And in another case, with
1:39:10
ETV, it's enough, just one.
1:39:15
That's, that's what I'm saying. Maybe the association that, that you, an experienced agency in ETVs, you don't have a return. Maybe somehow is related to your, to the Oceficantis, you know.
1:39:31
Anyway, it's a, it's a subject that I will start inquiring now as we are. Absolutely. And thank you very much, one, and then say congratulations. And now to close the day, close the day in,
1:39:45
in two hours or so, or
1:39:48
sort as we have again, the, the team
1:39:54
hospital, Gutierrez, Dr. Petre, and
1:39:57
Dr. Verier to talk about a case of surgery for epilepsy. And again, I keep on saying, from the brainstem tumor to epilepsy to AVM to cranial pharyngeoma shows you the wonderful complexity and
1:40:15
questions that the specialty has So I encourage all our 11 now that are still more in the audience than presenters, which is very good. And they to strongly consider pediatric neurosurgery has such
1:40:33
a phenomenal subject. Dr. Verier, go ahead, is your - you have the podium. Exiquiel Verdeer, MD, Cesar Patre MD, Department of Neurosurgery, Children's
1:40:46
Hospital Buenospiras, Argentina. They are speaking on hemispherotomy for Rasmus in syndrome encephalitis.
1:40:53
Well, this is a patient of Dr. Betray. He is one of the neurosurgeon Argentina has most experience in epilepsy surgery. This
1:41:06
is, we're going to present a case of a rusty music encephalitis, which is
1:41:14
a case of a two year old child had a history of cognitive decline and left armed weaknesses He began with seizures
1:41:26
at first decision world obsolescence, and then were followed by a tonic and then tonic oblonic seizure, focused always on the left hemibary.
1:41:38
He, this patient had a frequency at last of 40 seizures per day.
1:41:47
I'm going to show you this,
1:41:51
this this first video where you can see this focal seizure on
1:41:58
the ME phase.
1:42:03
And then this, sorry, this other seizure that is a drop attack, the kid is playing and then it falls, it doesn't fall because he was jumping, it falls because he had a drop attack, you can see
1:42:21
the face of the kid having this seizure. So
1:42:28
we started to study this patient, we did an MRI that demonstrate that there is a cortical atrophy on the right hemisphere, then in the flare sequences, we can see that there is an upper intensity
1:42:47
on the gray and white matter of just one which is something characteristic of raspous encephalitis. And in the
1:42:58
spectroscopy, we can see there is a pattern of loss of neurons on the
1:43:09
right side of the brain.
1:43:14
In the EEG shows there is emifocal paroxies on the right hemisphere that diffuse to the left, but there is no independent focus on the left side. This is the characteristic that the patient had that
1:43:32
drops at that, that the seizure started on the
1:43:37
right hemisphere and diffuses to the left. So because of the EEGs and the clinic of the patient, We assume that this was a resume using Cephalitis and we offer the family to do functional lemme
1:43:58
ferotomy. That is surgical treatment and it's a good option in this patient, especially at the young age, because the kid already had a left-unwitness We know that this pathology is progressive.
1:44:15
The trophy is going to be more marked over the years and the patient is, if there is no treatment for the patient, there is going to
1:44:30
be with a hemiparesis. So, surgery
1:44:37
gives the patients this
1:44:40
weakness on the left side of the body, but with the potential of recovery. So, in incredible seizures without treatment, we know that it's going to cause that the patient, it never get better.
1:44:56
So, in this surgery, we perform a
1:45:03
functional epitome, putting the patient in this position, doing this big approach to expose the whole hemisphere, is like a big pen-filled approach. These are some pictures of the surgery. We can
1:45:21
see that this hemisphere is with a trophy and it's not normal. We
1:45:32
started doing the disconnection to try to improve the quality of life of this patient. To achieve the disconnections here, we have to do a complete disconnection Well in different steps. So there's
1:45:48
the connection of the corticotelamic tract. Then there's the connection of the temporal structure. And there is a total corpus chosotomy that have to be performed, and this connection of the orbit
1:46:02
of frontal hypotelamic tract that would disrupt the frontal horizontal fibers.
1:46:09
So we start doing an upper window We enter the ventricle, and we start performing the
1:46:19
corpus chosotomy at the
1:46:22
first identifying all the interventricular structure. Then we take advantage of this ventricular dilatation, and we go from the
1:46:34
frontal part of the ventricle through the atom, and then we perform all the paracetal cashews of Tommy until we reach the archery. Then we go through the affinoidal prolongation of the ventricle,
1:46:51
and we carefully respect the vein of the gallon. And we start in the inferior window, which you can see here in the picture. And there is a picture of a drawing of the functional emiphelotomy. And
1:47:05
we go through the superior temporal circles and try to
1:47:13
try to do the temporal polyctomy. And I'm in a lot of hyponchopectomy. And then we connect this inferior window through the superior window. And we finally do the disconnection of the frontal basal
1:47:30
along the middle and anterior cellular artery. The temporal parietal disconnection try to respect, of course, the posterior cellular artery on the front of the tutorial level, limited by the
1:47:42
Perimeters and Sephalyx system. So with this surgery, we disconnect the frontal part, the temporal part and
1:47:54
the parietal part. So while this is the last image of the surgery,
1:47:58
and we are going to show the results of the surgery in this MRI. So we can see there is an amygdala hypochatectomy, a
1:48:10
temporal polyctomy, and then in the societal picture, we can see the hashosotomy that was performed in the surgery.
1:48:22
We're going to show a video of a patient several months after surgery that he has the weakness, but he can work independent all by herself, and you can see that
1:48:39
as he's playing football, which is a very
1:48:43
popular sport here in my country. He has a very good quality of life
1:48:53
We control the seizures with the surgery so to conclude we can say that cerebral hemiphytic disconnection surgery is a well-established treatment for intratubile epilepsy, of course secondary to
1:49:07
advanced mucin encephalitis, which is a unilateral empathetic disease. The main goal of this patient is
1:49:17
not to improve the weakness of the hemibody, but to improve reduce or cut out all the seizures. Of course, these patients needs a lot of rehabilitation. It may provide remarkable results in terms
1:49:33
of seizures, of course, and this will improve quality of life. Otherwise, these patients are designated to miss a level of life. A lot of them, if they are not treated, and in a PQ with an
1:49:50
intubated
1:49:52
and still having seizures.
1:49:58
Thank you. Thank you. I think that, I don't know if Dr. Patrick is listening, if they are, if
1:50:09
they want to say something.
1:50:13
I think it was, to me, it was not an abortion surgeon You both, Cesar and Ezekiel did an outstanding job there, outstanding surgery and a wonderful result and a nice evaluation, just a terrific
1:50:28
job. And just a terrific job. One last thing I have to say, I mean, you did an MR spectroscopy, but basically to obtain this good result, you need MRI,
1:50:45
anesthesia, surgery, microstroke, and of course experience, no? knowledge of anatomy now. So if anybody wants to reproduce your results in another environment, no,
1:51:02
less, yes, it's still possible. Similarly, as Dr. Sosa and Dr. Dominic MRI work the because And? no, equipment tremendous need don't We. equipment reasonable with possible were approaches
1:51:10
surgical both or techniques surgical both,
1:51:25
spectroscopy is fantastic, I mean, it adds another level of. Yes, but the STAN-S spectroscopy doesn't mark any issue here in breast musin and sephality. We did it because we had the chance, but
1:51:38
the only thing that shows the spectroscopy is the loss of neurons, which is
1:51:45
not specific for racemones So if you don't have any suggestions, it's just a job, yeah. I agree, I don't know, the more information we actually have about the disease, the better is our
1:51:57
understanding, you know? So, et cetera, et cetera. Is it gonna be done, as you said, anywhere. I think we discuss a lot of this patient with Dr.
1:52:13
Petrian. The thing that it's under the table here is that you have a kid that have 40 seizures per day. It doesn't have a good quality
1:52:23
of life. It's getting worse and worse over the month and the years. It's getting witnesses of the deaf, heavy battery.
1:52:36
So, if we don't offer the family treatment, we know the patient is not going to do what We offer a treatment, which is this MFATommy.
1:52:49
We know that the patient, at first, is not going to be well because he's going to have a hemiparasies, but as being a kid, it has a neural plasticity and they improve and as you saw in the video,
1:53:03
they can work independent and have a good quality of life without seizures. Of course, this is technically not
1:53:12
a difficult surgery It has some key points that have to be in mind, but the main issue here is to have a good recovery team. So the kid can recover from this, I don't know how it's like a deficit
1:53:31
that have to pay to stop the seizures, even though at the future, the seizures can come back
1:53:39
And, and, and another, Ola.
1:53:49
of Henness is secondary in the other, in the sphere, no, to avoid, no.
1:53:58
In the, in the idea of EEG, we, we try to operate the patient when the, the pathology made an anatomy for the image and it, and electrically in one size, all the
1:54:20
on one size, and
1:54:26
I'm very, very, very interesting case.
1:54:31
Ahoy, you had a presentation today from three continents from South America, from Central America, and from in Baghdad, and it just shows that Yeah. 85 of the world's population lives in low to
1:54:50
middle income countries. That leaves 15 of the high income countries. It is ridiculous to believe that these 85 are gonna have to go to the 15 for treatment. And we've seen that here, just
1:55:03
outstanding treatment in different centers. And you can develop those centers, just like Hadi did in Baghdad by working on it and developing people who are expert in things And he developed an
1:55:16
orbital center that's the only one in the world. So you can do that. And I think just an excellent set of presentations from people who've done a great job. Absolutely, congratulations and
1:55:28
grateful to all of you. And again, I mean, what you see, I mean, what I say, I used to stay here to the rest of the students, what's the incidence of
1:55:40
glioblastoma multiforme in the United States compared to Tanzania is the same. And it's the same incidence, right? The incidence of epilepsy in Germany is similar to the incidence, of course,
1:55:58
according to the population as the incidence in Costa Rica or Nicaragua. This is sort of the brain or universal. And our contribution from our corners of the world, although I am here, but I used
1:56:11
to be there,
1:56:13
it's relevant, it's significant Your outcomes, right, whether in the brain symptom or whether in either Los Angeles with my Pacific countries, whether you do the cranny of foreign German, whether
1:56:27
all those things that you do, and they are read by other people and other people and you're expanding not only for your local population, for your compatriots, shall I say, applicable to everybody
1:56:44
in the world. So I am extremely grateful for your collaboration. And if I think there are two, two chats in question, I think, but most of our congratulations to us in here, to you, to you all
1:56:59
rise. So with that, we go for the next one. I mean, and also remember, surgical neurology, this is not part of the presentation, but surgical neurology international is a fantastic resource for
1:57:16
publishing. It's a fantastic resource for letting people know, for actually sharing. And it's a fantastic resource for learning, as well as the digital version of the general, which will be
1:57:30
distributed to all of you. Once I get the email, not from the speakers, but from the other presenters as well. We have to let people know what we do
1:57:44
by doing so, by sharing your experience. And for instance, you're in Epilepsy, in Avia, I mean, granular pharyngeoma, in the Pareno sign. You are sharing that with the Germans, Finns, Swedes,
1:57:56
Spaniards, Canadians, right? They all face the same problem. And that you see the light in here, doesn't mean that it doesn't shine over there, no? Anyway, I spoke too much already. Thank you
1:58:10
very much For him, I wonder if we could ask the participants here, and I know we've lost a few people. If this is the kind of meeting you would enjoy in the future, we repeated that. And where
1:58:24
people from different countries, not only present the cases they've done, but cases that they might be very troubled with. I got a case this week from Iran, which is probably the largest
1:58:38
poderma whatever we're seeing now is everywhere.
1:58:41
And the question is, what do you do about it? And so maybe if that would be helpful, we can, on some regular basis, get people together from all over the world as you've done and see if we can
1:58:53
help them and discuss it together. Thank you for inviting me. Yeah, no, no, you're part of this. And incidentally, between for
1:59:09
the and secure, right me, your promise, how we can improve this, right? How this can be improved? And absolutely that the next one can be run by any of you. This is not a year article. We are
1:59:25
an horizontal, horizontal project, no? We are - Thank you very much for the invitation, Jorge. Thank you, thank you guys for all of you Jorge, there's a question in the chat, which is a
1:59:38
general question, maybe you want to - spend a minute working at that. Let me see if I can, can find it. I mean, what did.
1:59:51
Thank you, Dr. Noh, for the piano, Senator, the part of the day, what are the most significant challenges and rewards specific to working in this field?
2:00:02
Felipe Cesar, which was the most significant reward and challenge of working in pediatric neurosurgery
2:00:13
I think the most significant, the future of the treatment of the
2:00:19
cellular tumors, for me, this is the future. I think that we can improve a lot in this field
2:00:33
And also in our parts of the world, most of the population is in that age group.
2:00:43
40 of the population are that pediatric group. So, that, of course.
2:00:52
I think, I think, for example,
2:00:58
complication
2:01:03
of shans, infection, depression, over-drain, because there are a lot of patients, more than half of surgery in
2:01:23
a series of neurosurgery, is related with your cephalos. And I think that this is, there are patients that Yeah,
2:01:36
yeah, yeah, yeah, yeah, yeah, yeah.
2:01:41
will survive. It's difficult, very difficult. Sometimes it's very difficult to manage these complications. A tumor, a tumor
2:01:59
is so wrong pathology.
2:02:05
It's impossible to make a lot of of
2:02:13
therapy. If you can manage to have a good manage,
2:02:20
this child has a long time and a long life, you know, and sometimes, you know,
2:02:32
that's a long life.
2:02:56
I think it's a little bit different, but I think it's a little bit different, but I think it's a little bit different, but I think it's a little bit different. But the question is, in enthusiasm,
2:03:02
he goes and for net conference, everybody will learn Spanish But the thing is, I fully agree with Dr. Petri with Cesar, is that sometimes the level of the complications, and we feel the
2:03:05
responsibility of the complications But just to enthuse Dr. Lucila Domingo, who is going to be the new leader in the neurosurgery in the country, is after a secure ventilis, of course, is that
2:03:23
now in May, on the second weekend of May, I'm going through San Diego to the wedding of one of my oldest human patients And she wrote these invitations, and. She said, every time we went to the
2:03:38
CU, you said, See you in your wedding. Well, that day has arrived. And I, of course, have to scramble in my mind, who is this patient? But yeah, and then I found, so those are the beautiful
2:03:54
things of pediatric neurosurgery, you actually see the progression. You saw at the child with the complex seizures Okay, you actually see those, those who take kids graduating or going to school
2:04:10
or getting better. Unfortunately, the brainstem tumors was, Dr. Petri says, I'm off. Both patients that you did such a fantastic job, they didn't survive, but that's fine, that you just keep
2:04:24
on growing. So to answer the question, the major challenge is the patient that should have survived the eyes and the benefit as those patients that you see them growing, you know? You'll see them
2:04:38
going to school, do weddings, or something like that, and they remember you. So that's very nice. I think Caesar is absolutely right about hydrocephalus. I've seen this for 60 years. It's a
2:04:50
problem that was exactly the same when I started, it's still the same. I think it's one of the most difficult problems in neurosurgery. A lot of minds have worked on it. We still haven't solved it.
2:05:00
And Juan today presented a case just like that Well, a very complicated case of recurring hydrocephalus, I said, is extremely troubling. And the second thing, Cesar and everyone, this broadcast
2:05:15
can be translated into 10 languages. So you don't have to worry about Spanish. And we can translate your whatever Spanish or whatever English you have into whatever language there is with artificial
2:05:27
intelligence. So we're trying to make that good for you. So thank you Regarding hydrocephalus, I recall the time of the sunshine which we had in Iraq in the 90s. We used to take, we have no shunt
2:05:41
at all. So we used to take the blocked shunt and we clear it and then very celerize it and put it back again.
2:05:49
I think that's amazing in the United States, people would say, you can't do that, but obviously you can. Yeah, I did it.
2:06:01
Thank you very much, all of you. Thank you, thank you
2:06:07
and tell me how can we get better and fun as well. Thank you. Yeah, thank you. Thank you.
2:06:22
We hope you enjoyed these presentations.
2:06:26
The material provided in this program is for informational purposes and is not intended
2:06:34
for use as a diagnosis treatment. of a health problem or as a substitute for consulting a licensed medical professional.
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This recorded session is available free on SNIDigitalorg. Send your questions or comments to
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osmondSNIDigitalorg
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This program is supported by the James I and Carol and R. Osmond Educational Foundation, owner of SNI and SNIDigital, and by the Waymaster Corporation, producers of the leading Gen Television
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Series, silent majority speaks, and role models, and the Medical News Network
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Thank you.
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