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SNI Digital, Innovations and Learning, an association with the Hose Neurosurgery Lab and Baghdad Iraq are pleased to present. The 22nd SNI and SNI Digital Baghdad Neurosurgery Online Meeting held
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on March 23, 2024, the meeting originator and coordinator of Sammer Hose of the Universities of Baghdad and Cincinnati.
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The subject of this meeting is Pediatric Neurosurgery, Global Pediatric Neurosurgery Experience and Cases from Argentina, Iraq and Nicaragua. The meeting organizer and moderator is
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Jorge Lassruff, Emeritus Professor Pediatric Neurosurgery at the UCLA Medical Center in Los Angeles, California
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This talk is on an approach to the mesial inferior. Post-year temporal AVM supplied by the post-year circulation. How we did it? It'll be given by Ezekiel Verde and Cesar Petre of the Department of
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Neurosurgery and the Children's Hospital of Buenos Aires in Argentina. And we're in the medial surface of the occipital lobe So we presume that this was a covenant malformation or
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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
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extubated Non-neurological deficit was assumed Uh.
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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 we closed the EVD for 48 hours, so we
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could withdraw it,
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acknowledging that there was no hydrocephalus. We could also see there is an image on the medial occipital lobe, showing there is still a disease to be treated. So we did an MRI. So you can see
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the pictures here. So there's no problem on the ventricles, but we still see this MRASH on the left atrium that involves also a dilatation of the bane of gallant system Ahh.
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In the ion choram, we can see that there is some feeders getting into the
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deletion. So we could acknowledge that this is an AVM.
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So we did an ion choram. So you can see that this is like a plexiform AVM of the posterior circulation, which involves feeders from the postural lateral arterial arteries and the p4 assignment of
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the cerebral posterior artery. And in the venous window of the ion choram, we can see that there is a delayed vein of gallium, aneurysm. And if
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can I play this video, you can acknowledge that there is only one draining And then, Ben, if.
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for the AVM to the complex of garden. So the challenges of these cases is that it's a raptor AVM at the left etune, involving the medial portion of the occipital love, involving the it's moods,
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whereas the calcaling sulcus has shown the
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peritoxipital sulcus, so it's a deep
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AVM with only one vein of drainage into the complex of gallon, that's make it difficult in there to operate.
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The other thing that is very important here is to think what approach to do. Of course, we agreed that these patients should go or underwent both endovascular and surgical treatment. So as we did,
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We performed first pre-op embolization of the AMEM, especially the gallium part of the AMEM. The patient tolerated very well this procedure. And then we start to thinking about what is the best
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approach. There are two options here. Of course, the best way to get to this AMEM was from a posterior inter-emophoric approach But the discussion here was to
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do it epsilateral deletion or contralateral deletion as was described by a loton. So in this pattern martin scale,
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we can see this is a grade four AMEM. And we plan a
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torque color craniotomy. And the discussion doing it epsilateral or contralateral, I think it's more on the insertion experience. I've, we've never done, and in my experience, I never done a
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contralateral approach for the occipital medial region. And our concern was to, for
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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 a feeders from the posterior lateral choroid arteries.
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And at that part of the AVM, at the lateral part of the AVM, there was the bane of gallon complex. So in an epsilateral approach, all that is going to be difficult to view and we would need more
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retraction of the occipital law.
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Otherwise, on the contralateral approach, That was a scribe a lot on. you can approach the AVM from medial to lateral. And as you start
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accumulating the feeders 360 degrees from the AVM, you can have 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
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protect, of course, in the atrium of the ventricle, the posterior part of the talamence and the posterior part of the forearms. But well, this is the
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post embolization pre-surgical MRI and we can see that this plexiform MBM is still alive. So we perform
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a posterior interferripap approach.
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from theipsilateral because of our experience on this approach, and we placed the patient in a park bench position,
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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
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of the approach So as we 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 a ballast clinic. It's under
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the splenic of the corpus cachosum and we could remove all the AVM, preserving the vein of gallant that was embolized previously to a surgery. And the patient did really well without any
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neurological motor or visual deficit. 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 occipital love. This
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is a much better picture of the post-op And I will show you the video of the Instagram
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post-op and post-embolization. We can see that it's no AVM and there is still the cast of the previous embolization of the
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ban of
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gallant aneurysm. These are the pictures comparing the pre and post-surgical results.
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of this patient.
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As I said, there was no motor or visual deficit posterior to the surgery. There is still minor occasional headaches that the patients say that she has.
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After the surgery, for the first two weeks, she had a translatory color blindness that recovered at the interim, and
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as you saw before, there's post-op digital algebra, where there's no evidence of residual AVM, and there's the vein of gutting that is embolized. So to conclude, we can assure that posterior
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circulation AVM are challenging cases that combine endovascular
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and surgical treatment at an effective option There's a discussion between theipsilateral,
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contralateral approach, immediate occipital AVMs that extend to duration of the atrium. are suited for contractors strategy. But in our case, that we don't have experience on the control lateral
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approach, we prefer the IPSI lateral approach that brings
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the AVM closer to the insertion view, protects the involved emifure, but requires more retraction to reach the lateral border or the lateral aspect of the feeders for the AVM.
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Thank you Well, I leave to Dr. Hose and Dr. Osman, who are the biased vascular surgeons here. Well, Sam, do you
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want to say anything about it? Um, yeah, I just want to
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say, uh, congratulations. It's a very nice, uh, restorative case. Uh, it's not easy at this position, obviously. And, um, yeah, I think, I think It's challenging from different
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perspective. And the vascular may be not easy option to attack a significant part of the AVM and also from the surgical part, it's challenging. Congratulations for this outcome. And my only
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question is that, what's the type of collaboration with the endovascular treatment? Is it in radiology department? It's in the same department, how this decision is made. I would be interested to
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- Fortunately, fortunately, we at the general hospital, we have
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a staff member of the team that is
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endovascular surgeon. So actually, it's a she, she's a
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girl.
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She does all our endovascular patient And of course, we discuss with the whole team. about doing combined strategies for this patient. If they're going to underwent endovascular treatment, we have
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to assure that the surgery is going to be
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no more than two, three weeks ahead from that treatment because of the risk of a rupture of
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the AVM after that embolization. So everything is discussed in our meetings The
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surgeon
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that does, it's a neurosurgeon, that's the endovascular part. Myself and Dr. Petre did the surgical approach.
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Yeah, well done, thank you. Dr. Adaiaf is asking, what's the mortality rate or the severe complication of the surgical approach that you have?
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Well, actually we don't have mortality, But of course, this. These are very difficult approaches, even for epilepsy surgery, what it's described to remove the posterior part of the hippocampus
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and forensics. So complications, in these cases, are related to the AVM. If the AVM, it's very fit to the AVM with a, I
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mean, with a very complex of
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gallium I am involved in the AVM. Of course, the rights of mortality are higher, but I mean, that's what we did. And then the
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vascular treatment before, because we were concerned about the gallium
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aneurysm. I want to do a question to a secure. Yes.
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Do you operate this AVM without road tour? just with headaches,
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if we have the patient, yes.
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Yes. At least we offer the patient the treatment.
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It's a safe approach. The only problem is to identify if
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the AVM has a lot of draining veins through the complex of gallium. In this case, it was only one draining
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vein, so that makes the case.
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I mean, not easier, but if you preserve that vein and drain through all the tertiary, there's not going to be greater complications.
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I can make some comments if you
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want to worryThank you. That's an excellent presentation, a work-up of a case, very nice imaging. You define the lesion well. The question you ask is, and the procedure you use, we wrote up
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about 40 years ago, called the three-quarter prone operated side-down procedure to the pineal region, you probably know about it. Where you look at the hemisphere, you operate on essentially fall
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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 in the pineal region And you have immediate access to the
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posterior cerebral artery, which is what you want to go to, to stop the feeders to the lesion, and you can get around the lesion, and then you'll get the other feeding vessels from the
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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 to help you a little bit.
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I don't agree with the approach.
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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
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same time. Yeah, yeah. But you know, it's it's a new, I don't know,
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I don't know how to say, but it's like something that it's gaining more and more attention through young neuroscience to to go through the opposite side, even in the anterior internal medical
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approach for lesions deep to in the thalamus. My father always told me you don't have to jump off a bridge to know what it's like. Yeah.
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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 a perfect
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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
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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
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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
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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
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expected to get. Yeah, thank you, thank you, good and good, very much. Excellent, congratulations. Here we are, the pediatricians, the raffling feathers. Good.
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