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SNI Digital, Innovations and Learning, an association with the Hose Neurosurgery Lab and Baghdad Iraq are pleased to present. The 22nd SNI and SNI Digital Baghdad Neurosurgery Online Meeting held
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on March 23, 2024, the meeting originator and coordinator of Sammer Hose of the Universities of Baghdad and Cincinnati.
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The subject of this meeting is Pediatric Neurosurgery, Global Pediatric Neurosurgery Experience and Cases from Argentina, Iraq and Nicaragua. The meeting organizer and moderator is Jorge Lassruff,
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Emeritus Professor Pediatric
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Neurosurgery at the UCLA Medical Center in Los Angeles, California
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This presentation will be on hemispheric to
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me for rasmasins and sevelitis with intractable seizures. How we do it? By Ezekiel Verdeé and Cesar Petre of the Department of Neurosurgery Children's Hospital of Buenos Aires in Argentina. Welcome
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to the 22nd SNI and SNI Digital Baghdad Neurosurgery Online Meeting. March 23rd, 2024. The meeting originator and coordinator is Sammer Hawes, University of Baghdad and Pittsburgh.
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Well, this is a patient of Dr. Petre. He is one of the neurosurgeon Argentina had had most experience in epilepsy surgery. This is,
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we're going to present a case of
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rastomyosin encephalitis, which is
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a case of a two-year-old child that has a history of cognitive decline and left armed weaknesses. He began with seizures at first the seizure world, abscesses and then were followed by a tonic and
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then tonic of glonic seizure focused always on the left hemibary.
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he, this patient, had a frequency at last of 40 seizures per day.
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I'm going to show you
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this first video where you can see this focal seizure on the ME phase
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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
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the face of the kid having this seizure So
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we started to study this patient, we did an MRI that demonstrated that there is cortical atrophy on the right hemisphere. Then in the flare sequences we can see that there is an upper intensity on
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the gray and white matter of just one hemisphere which is something characteristic of rasp mucin and cephalitis. And in the
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spectroscopy we can see there is a pattern of loss of neurons on the right side of the brain. In the EHE shows there is
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emifocal paroxys 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 drops at that that the
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tissue started on there.
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on the right hemisphere and diffuses to the left. So because of the issues, the images and the clinic of the patient, we assume that this was resumes in Cephalitis and we offer the family to do
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functional lemme 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-arm weakness. We know that this
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pathology is progressive, 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
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be with a hemiparesis So, surgery Uh.
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gives the patients this
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weakness on the left side of the body, but with the potential of recovery. So, in intradable seizures without treatment, we know that it's going to cause that the patient, it never gets better So,
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in this surgery, we perform
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a functional emphylogomy, putting the patient in this position, doing this big approach to expose the whole hemifyr
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It's like a big pen-filled approach. These are some pictures of the surgery. We can see that this hemifyr is with a trophy and it's not normal. We
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started doing the disconnection.
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to try to improve the quality of life of this patient. To achieve the disconnections here, we have to do a complete disconnection
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in different steps. So there's the connection of the corticotelamic tract, then there's the connection of the temporal structure and there is a total corpus cashosotomy that have
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to be performed and disconnection of the orbit of frontal hypotelamic tract that will disrupt the frontal horizontal fibers.
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So we start doing an upper window, we enter the ventricle and we start performing the corpus cashosotomy at the first identifying all
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the interventricular structure. Then we take advantage of this ventricular dilatation And we go from two to
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two. from the frontal part of the ventricle through the atrium. And then we perform all the paracetylchital casosotomi until we reach the atrium. Then we go through the epiphenoidal elongation of
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the ventricle 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
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emifero tummy. And we go through the superior temporal circles and try to
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try to do the
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temporal polyctomy and amiglala hip ponha pectomy. And then we connect this inferior window through the superior window. And we finally do the disconnection of the frontal basal along the middle and
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until your cellular activity. The temporal parietal disconnection tried to respect, of course, the posterior cerebral artery and the frontal-tentoria level limited by the perimetersencephalic
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system. So with this surgery, we disconnect the frontal part, the temporal part and the parietal part. So, well, this
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is the last image of the surgery.
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And we are going to show the results of the surgery in this MRI. We can see there is
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an amygdala hypohatectomy and temporal polyctomy. And then in
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the sagittal picture, we can see the hashosotomy that was performed in the surgery.
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We're going to show a video of a patient several months after surgery that he has the weakness, but he can work independent. always herself and you can see that
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as he's playing football, which is a very popular sport here in my country, he has a
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very good quality of life.
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We control the seizures with the surgery. So to conclude, we can say that cellular hemiphytic disconnection surgery is a well-established treatment for intratubile epilepsy. Of course, secondary
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to advanced mucin and sephylate, which is a unilateral empathetic disease. The main goal of this patient is
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not to improve the weakness of the hemibody, but to reduce or cut out all the seizures. Of course, these patients needs a lot of rehabilitation. It may provide remarkable results in terms of
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seizures of course, and this will improve quality of life. Otherwise, these patients are designated to miss a lot of life and a lot of them, if they're not treated, hence, in a PQ with an
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integrated.
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still having such seizures.
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Thank you.
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I think that I don't know if Dr. Patrick is listening, if they are, if
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they want to say something.
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I think it was to me, it was not an abortion surgeon. You both say there and Ezekiel did an outstanding job there, outstanding surgery and a wonderful result and nice evaluation, just a terrific
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job and just a terrific job. One last thing I have to say, I mean, you did an MR spectroscopy, but basically, basically to obtain this good result you need MRI, anesthesia, surgery,
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microstroke and, of course, experience, no, and. a knowledge of anatomy, no? So if anybody wants to reproduce your results in another environment, no? Yes. Less? Yes. It's still possible.
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Similarly, as Dr. Sosa and Dr. Dominic MRI the because And? no, equipment tremendous need don't We equipment reasonable with possible were approaches spectroscopy surgical both or techniques
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surgical both, no, work is fantastic, I mean, it adds another level of - Yes, but the SPC spectroscopy doesn't mark any issue here in the rest of the
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museum's authority. We did it because we had the chance, but the only thing that shows the spectroscopy is the loss of neurons, which is
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not specific for racemuses. So if you don't have - No, any surgery or copy? That's the job, yeah. Yeah, I agree, I don't know. The more information we actually have about the disease, the
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better is our understanding, you know? So, et cetera, et cetera, et cetera. It can be done, as you said, anywhere. And I think we discuss a lot of this patient with Dr. Patreon,
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the thing that it's under the table here is that you have a kid that have 40 seizures per day and it doesn't have a good quality of life. It's getting worse and worse over the month and the years.
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It's getting witnesses of the deaf, heavy battery. So
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if we do, if we don't offer the family treatment, we know the patient is going to, it's not going to do well. If we offer a treatment, which is this MFA,
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we know that First, it's not going to be well because he's going to have a heavy paralysis, but as being a kid, it has a neural plasticity, and they improve, and as you saw in the video, they
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can work independent and have a good quality of life without seizures. Of course, this
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is technically not 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
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don't know how it's like a deficit that I have to pay to stop the seizures. Even though at the future, the seizures can come back.
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And another, Ola? Yes, yes, right.
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secondary in the other atmosphere, no, to avoid, no,
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in the, in the ideal EEG, we, we try to, to operate the patient when the, the pathology, but
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an anatomy for the image is, and it, and electrically,
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in one size, only on one size And
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I'm very, very, very interesting case.
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Ahoy, you had a presentation today from three continents, from South America, from Central America, and from in Baghdad, and it just shows that, And it just shows that. 85 of the world's
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population lives in low to 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
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seen that here, just 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
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he developed an 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,
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congratulations and 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
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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,
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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
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to be there,
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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 craniopharyngeoma, whether all
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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
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in the world. So I am extremely grateful for your collaboration. And if I do, there are two, two chats in question, I think, but most of our congratulations to us in here, to you, to you all
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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
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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
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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 because.
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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,
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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 in too much already. Thank
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you 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
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where 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
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poderma whatever we're seeing now is everywhere.
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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
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help them and discuss it together. Thank you for inviting me. Yeah, no, no, you're part of this. And it seems like between, for the
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and Cesar and
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Seqir, 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 hierarchical. We are an
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horizontal, horizontal project, no? We are - Thank you very much for the invitation, Jorge. Thank you, thank you guys for all of you All right, there's a question in the chat, which is a
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general question, maybe you want to - spend a minute working at that. Let me see if I can, can find it. I mean, what
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did, thank you, Dr. No, for the piano, Senator, the part of the day, what are the most significant challenges and rewards specific to working in this field?
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Felipe Cesar, which was the most significant reward and challenge of working in pediatric neurosurgery
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Uh, I think the most significant, the future of the treatment of the, uh, cellular, uh, tumors. For me, this is the, the future. Uh,
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I think that we can improve a lot in this field.
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Yeah. Yeah. Yeah. And also in, uh, in our part of the world, most of the population is in that age group.
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40 of the population are that pediatric group. So, that of course.
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I think, I think for example,
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complication of
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shans, infection, depression, over-drain, because there are a lot of patients, more than half
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of surgery releasing in a
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series of neurosurgery is related with your cephalos. And I think that this is, well, there are patients that, That, yeah.
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will survive, it's difficult, sometimes it's very difficult to manage these complications A tumor, a tumor
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is so a way, a wrong pathology,
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it's impossible to make a lot of therapy But if you can manage, have a good manage, this child has a long time and a long life, and some time, no? I don't know, but I'm not sure.
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But I think that the problem is that the problem is that it's not a key problem. I don't know how to repeat this. But the question is, in enthusiasm, he goes and for net conference, everybody
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will learn Spanish. But the thing is, I fully agree with Dr. Petrie, with Cesar, is that sometimes the level of the complications, and we feel the responsibility of the complications. But just
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to enthuse Dr. Lucila Domingo, who is going to be the new leader in the neurosurgery in the country, is after a secure rentiles, of course, is that now in May, on the second weekend of May, I'm
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going through San Diego to the wedding of one of my oldest human patients And she won these validations. She said, every time we went to the CU, you said, See you in your wedding. Well, that day
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has arrived. And I, of course, start to scramble in my mind, who is this patient, no? But yeah, and then I found, so those are the beautiful things of pediatric neurosurgery, you actually see
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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 or getting better. Unfortunately, the brainstem
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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 on growing. So to answer the question, the major
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challenge is the patients that should have survived the eyes and the benefit as those patients that you see them growing, you know? You'll see them going to school to wear things or something like
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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 problem that was exactly the same when I started,
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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. And Juan today presented a case just like that
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Well, a very complicated case of recurring hydrocephalus, I said, is extremely troubling. And the second thing, Cesar and everyone, this broadcast can be translated into 10 languages. So you
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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 intelligence. So we're trying to make that
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good for you. So thank you Regarding hydrocephalus, I recall the time of the sanction, which we had in Iraq. in the 90s. We used to take, we have no shunt at all. So we used to take the blocked
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shunt and we clear it and then very celerize it and put it back again.
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I think that's amazing and in the United States people would say you can't do that but obviously you can.
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Thank you very much all of you. Thank you, thank you
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Thank you, and I will see you in a second, right me, and tell me how can we get better and fun as well. Thank you. Yeah, thank you. Bye. Bye. Bye. Bye. Thank you.
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