0:01
Okay, we're welcoming you to another in
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the series. This is the second in the series withused to flow about what we think is going to be major changes in operating on the brain. He's already done this for 25 years, but operating on the
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brain and identifying quality of life outcomes. And this is sponsored by SI, which you all know is an Internet Journal on SI Digital, which is what this is. It's a multimedia 21st century
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neurosurgical and medical information resource. It's new. We're all over the world. SI has read in 239 countries, has over 600, 000 views a year. SI Digital is seen by 35, 000 listeners because
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it's on And it's on video and this will come out in probably a day or two on the website and you can access it there. If you want your friends to see it, we had eight over 800 people have seen the
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first video by Dr. Defoe by today, by this morning. And it's free to everybody on the internet.
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And here's the talk and the talk today is on a Wake Functional Guided Surgery, a master class on how I do it. And Dr. Defoe, I'm gonna just say a little bit about him and then Andre, what I want
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you to introduce him. He's from the Guided Show of the Arc Hospital in Montpier, France. And I put down his phone number here in his email and he's been working this area for 25 years. That's a
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little bit about me We developed SNI, SNI Digital. in professor and a number of universities and head of neurosurgery. I couldn't keep a job, that was a problem. And here's a strata for now. My
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colleague was a Duke of former head of neurosurgery in North Carolina, and he's on the board of directors of SNI Digital and so forth. And Mike Chealy is the person who makes this technically
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possible. Mike is our chief technology officer. That's his phone number in the United States. He's the principal and head of GraphTech So Andre, I'd like to introduce you to Andre. Servia,
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Andre's head of neurosurgery. He's a colleague, a great friend. And he heads the neurosurgery section in Fledi, which is a neurology neurosurgery rehab institution in Buenos Aires. It's extremely
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well known. He has an outstanding department. And he worked with Dr. Defoe 20 years ago when he was developing this And Andre, would you just - Introducing to everybody, we have some new people
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here award here before. So thank you.
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Thank you very much, Professor Osman. Maybe many people from all over the world had seen the previous presentation of Professor Dufour. Professor Dufour is very well known for everybody around the
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world. Maybe not only because of his expertise, but for me, one of the most important thing is all over the world, he's joined his results in a very democratic way. He's a person, an excellent
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surgeon, but most of it, he's always with intention to teach, to show the results, to show maybe today it will be, for me, one of the most important of his lecture, how he performed the surgery.
3:48
Because these little details, you can read all the papers, you can see videos, But will you see? Professor DeForo operated on all live. It's the same in the papers, in the book. It's completely
4:03
different when she said, I am doing this in this way or in the other way because really, it's a pleasure to understand the way of thinking because it's a concept, the way of surgery. Maybe it's
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not so complex, specifically speaking about the techniques of the surgery But it's all the necessary things you need to start doing these type of surgeries. And when you start entering this, I mean,
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in this world of the awake surgery, you will never abandon it. It's an excellent surgery. So I would like to thank Professor Dafoe because I repeat, he's a very democratic guy, always sharing his
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thoughts And I think all over the world. we have a great opportunity to see this this class master in the in the video of surgical neurology internationals. Thank you very much, James, and go
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ahead, Professor Defor.
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Okay, thank you, Andrea. Okay, here.
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Thank you so much, once again, for this invitation console for this very
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excellent introduction, but also showing that I am a little bit
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impressed by colleagues. I had the opportunity to meet already 25, 20, 15 years ago, and developing so many good reasons in the meantime. So finally, I'm not sure that I can continue to teach
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you something. Thank you so much, Andres, but nonetheless, for younger people, I will try. First of all, today, to show a movie, 10 minutes movie, approximately how I do it. And finally,
6:01
to try to explain in a few slides before to open the discussion based, of course, on the knowledge of the functionality and the dynamics of network we described during the first
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lecture, but also insisting today on deep and tricks So, of course, I will show a typical case where physicians of the so-called Broca Zeria, an illustration in practice of what I developed at
6:30
conceptually during the first talk. And
6:36
I'm sure that you will be able to listen to the patient also in a real time during surgery, which is absolutely critical because we are speaking about right and the medical doctor, living and still
6:53
active in Sao Paulo, and speaking two languages, namely Portuguese and English, with this tumor revealed by a seizure, being very exceptional, and involving the schooled bastrian gularies, but
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also the left insula. So in practice, you have the habit to use the
7:18
awake sleep, awake procedure, but I will insist about that within
7:24
the in the next slides. I think that the most important, first of all, now is to show that I have no technology in the operating theater, except, of course, awake mapping process, or electrical
7:39
stimulation, and ultrasound. Why? Because This is real time. And you can see very well a grown-up slide with the CBN Fisher, with the opterular port of the
7:50
tumor,
7:52
and the insular port of the tumor. So that means that online you have exactly what you can see, an intra-protive MRI, and it's not expensive. That means that everywhere, I think, that in all
8:06
department of your surgery, we should have ultrasound, not only for you, but also it's very easy to share it from one room to another room. Now the patient is awake because I did, of course, end
8:21
up being under a joint anesthesia. And now what I will do is ask the patient first of all to count and to identify the
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so-called ventral premodal cortex. We detail that during the first lecture. In other words, the natural part of the
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prison trial occurs, whatever the site. In this case, this is a typical - left side tumor, and when I stimulate, then at the level of the ventral prima duct, thanks to the patient, we have a
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Doctor, we don't fear. Are you here? Is that clear? A complete blocking wave of localization, you know that this is the good intensity. And the parameters for me are very simple, between 15 to
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3 milliamps, 60 hertz, and that's it. That means that I did more than 14 hundred awake surgeries by using these parameters And the rate of intraoperative seizures in my experience is less than one
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person. And the rate of aborted awake surgery related to seizures in my experience is zero, because never I will go beyond 3 milliamps. So I have no reason to induce seizures. So that means that I
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use positive mapping in 100 cases by exposing the ventral prima
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Now I will ask for the patient, remember, to do many tasks simultaneously, namely, to name, to move, and to switch from one language to another one, English, to Portuguese. And of course, by
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asking first of all the patient to speak Portuguese because her native language. And then we have a translator into the operating theater in addition to the New York Scientificists in order to adapt
10:32
the interpretation according to the fact that I'm not speaking Portuguese and that I did the surgery in 33-0 different languages from patients coming from 66-0 different countries. And never it has
10:50
been a problem because of course the translator is first of all briefed, trained by the speech therapist before to go to the apartment here.
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I can start the mapping by using exactly the same electrical parameter, which induced initially the positive mapping by blocking the counting and atria. And I will never changed the parameters,
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cortically and subconsciously. And what will happen when I will stimulate the past triangularies? Now of the so-called broker's era, than the partial peculiarities of the so-called Broca's era.
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Nothing
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And when I will stimulate the ventral premodal cortex at the level of the lateral part of a prefrontal jarrus, I will induce blocking. So the inferior frontal jarrus is not involved in speech.
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That's it. So I will remove now in front of you in real time, broke his array in a patient doing multitasking with time constraint, everything in five seconds The concept of meta network to do many
12:09
things simultaneously, we detail that during the first two. And of course, the posterior 132 boundary,,
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the ventral premodal taster lateral part of the prefrontal jarrus will be my functional boundaries, and I do not care to remove the
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passive percola, this is triangular, this is of the left inferential jarrus in
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the right and the patient because nothing is happening during stimulation and during Resiction. Now I will do a sub-pial decision. I have the habit to take the parameter in the back key. And to do,
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as you can see, an aspiration, that's it. Without any coagulation in the depth, I calculated the cortical surface. And that's it. And now I removed, in front of you, the past three angular
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reason, operular reason. What happened, nothing, because the vision is still a bomb to move, to speak, to switch from one language to another one, to name, and so on and so on. OK, so I will
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continue. Till now the insular - remember, it was, of course, a particular insular log-reg lemma. So I will take my retractor to retract the surface of the insular. You can see the insular focus.
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And then after a sub-pialtization at the level of the operculum, I was into the insular by doing No coagulation never is forbidden. And if you lift up the circular circuits of the insular with all
13:46
the zones, you have no bleeding. And of course, you can do it without microscopes, as you have seen, without FMRI DTI, without your navigation, without microscope, and robot, without, and so
13:60
on and so on. You need nothing just the patient doing, the cognitive monitoring, because you know the functionality of the networks, and you know that, in the depth, you will have now the
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inferior phantoxopedone fasciculus. Then, when
14:16
you will stimulate at the level of the external capsule, you will induce symptom paraphernalia. And of course, you have to stop, according to the functional boundaries.
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And you see, I continue to speak with the patient, and of course, reaching, because I speak in English, and not in Portuguese.
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Now, I reached the ventralisomontic pathway, but not the dorsal pathway. So I will continue to stimulate more posteriorly, because what I want is to continue to remove the brain invaded by your
14:59
two more own sons, as much as I can. So I will stop. When the brain will tell me, stop. The brain is guiding me, remember, is talking to me Now, by stimulating the ventral semantic pathway, I
15:14
induced semantic paraplegia, per-sevaryation, the inferior phantocybinon fasciculons, running laterally to the lontiform nucleus. Okay, we are understood.
15:28
Now I will stimulate more posteriorly, and what will happen? Nothing. So I will continue to remove all the earnings, the ventral prima duct of text, because there There is a darse on Luke.
15:39
On the point, I, the lateral part of the superior longitudinal fasciculus, the articulatory loop, which should induce an achria, not only the cartilage of the face, but the loop itself. And I
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will continue to remove posteriorly as much as I can till I will induce
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articulatory disorders. Not semantics, because this is not the IFAF anymore. The IFAF was more anteriorly located Now I'm running in the posterior part of the tumor. So I will stimulate. And when
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I will use an atria, I will stop.
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You have a patient stopped. OK, I have to stop. Yes, but you can do intraoperative MRI. Maybe there is a residue. Of course, there is a residue. I will not cut a cell of three. Otherwise,
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the patient would be an athlete. This is not a goal. She wants to continue to be a medical doctor. in Sao Paulo, so I have to stop, according to the limitation of male plasticity, the
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connectivity in the deck, as we have seen during the first lecture. Everything is clear, including the fact that I removed Broca's era, which is now the every half speech,
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You use the same intensity, two milliamps,
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you disconnect,
17:28
you will use a complete inertia. Everything is clear, it's not related to the cortex, but the disconnection between different parts of the cortical area forming a network. You have not to change
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the intensity, you do not need any navigation, you do not need the CTI, which is not a function, you need just to know where you are. And the brain is telling you, the patient is telling you.
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So of course I left a small but objective amount of diffusion
18:04
within the iPhone, and I said three. And then the patient returned to an active life. It was 10 years ago. It has been performed during a meeting in real time. And the patient is still a medical
18:18
doctor living normally in South Florida 10 years later without broke his area.
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Okay, so we are stuck now, definitely at the level of the connectivity. I said during the first lecture, but maybe it was not practical for your surgeon, you are under microscope and you have
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seen that I do not use microscope in order to have a holistic view of the connectivity. This is the reason why microscope is dangerous within the brain I would say it again, microscope is dangerous,
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because now you put microscope and you will like to remove a little bit more tumor under that, because you feel the consistency is a little bit different. You have the feeling to remove three more
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millimeters, no, you disconnect two-third of the hemisphere and suddenly the patients are fast and never the patient will return to an active lash, which is because they are living remember 20
19:33
years and what they want is to enjoy perfect life, especially as a medical doctor. So we have to understand and to know in our monthly maturity the function and anatomy of the brain and the
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limitation of your plasticity so the limitation of the compensation within and between networks
19:55
And the goal is definitely not to try to remove the flare. I don't care. The flare is not that this is, it's a diffuse tumor. The goal is to remove as much as you can apart of the brain, they did
20:09
by Jamal Salz and sometimes you can do a super totalization. Sometimes you have to stop a little bit earlier because invasion of the connectivity You adapt to the functional connectome of this
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patient at a time. And by applying this concept, I will resist about that in another lecture. showing the long-term unco-functional reasons. But the first time in the literature, the survival is
20:37
more than 20 years, not yet rich. And the quality of life is almost perfect in 99 of patients. And you understand why? Because I adapt to each brain according to the feedback provided by the
20:52
patient in real time in the operating theater by forgetting totally the atlases and the classical jagram broke out there, Nicky, and so on, which are totally wrong, as demonstrated by this case,
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but also by 1, 000 cases, I operated that. So now, in
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practice, how I'm doing, not only into the operating theater, I want to know the limitation of the neuroplasticity in this vision at the time when we do the diagnosis. So we have to do We have to
21:26
do. and your psychological assessment systematically to say just my patient is well before surgery, it's totally wrong. In more than 50 cases, they have some subtle, but objective deterioration
21:42
before to go to the org. Who you have to know that. Otherwise, how can you adapt at the end of your level? According to the anatomy of Procosirata's not exist. So the anatomy will not give you
21:57
this kind of information. You need a function. But to understand the function in this patient at the time, you have to understand how the brain reorganized before and the limitation so do a
22:09
pre-apartive cognitive assessment. And it's, more or less, never done. Why? I say that for 30 years. I never understood. It's not expensive. And you have so many information about brain
22:24
processing of these patients.
22:28
Second, of course, you have to do the individual mapping. And then we'll say, ah, fMRI, DTI, technology, robot, artificial intelligence is beautiful. No, this is totally wrong. Why?
22:43
Because when you have an activation fMRI, I am
22:48
a scientist with a PhD in function on your imagine. So I can say that You cannot know today in 2026 if the activation means this area is pretty common for function in the other words, if you remove
23:08
it at the end, you will induce a permanent deficit or just involved in the network. In other words, if you remove it, the patient can have transitory disorders like SMS and Rome, for instance,
23:22
but will recover So why to leave it, I never understood. So in other words, you cannot use fMRI to select the indication and to do the pre-planning. And I spent my life to operate patients not
23:37
selected everywhere. Why? Because fMRI said, oh, it's too dangerous. There is an activation within Broca's area. But you do not share.
23:49
Secondly, everyone would like to think that DTI is the function I was invited in the past international meeting of photography by experts in this field, not your surgeons, not your radiologists,
24:08
neuroscientists. And they are the first to acknowledge that protogram contain many more invalid than valid bundles. And that, of course, protogram is not a function But when I simulated the SLF-3,
24:24
I induced anaphria. Twice, I was sure. When I stimulated the IFAF, in this patient, I used semantic paraplegies. I was sure. So, you cannot operate under the guidance of photography, FMRI,
24:42
robot, it's just illusion. And I will speak about that in another tool demonstrating that never any paper using this methodology reported a significant increase of both overall survival and quality
25:00
of life on co-functional balance. The compare that just with if, I use DTI is better, that if I do not use DTI, I do not share, please do awake patient and use no knowledge of the connectivity
25:16
and suddenly your patients will live longer and better. It should compare to our results, it's never done
25:27
So. How I do, it's very easy. I will use the cornegan and the way matrotract mapping in a patient doing a constant.
25:41
Can we stop here for a minute? There's some people that have some questions. And I wonder if you'd be willing to answer them now before they forget them, okay? I think you're at a very good point.
25:52
I guess if you're going to go into that. No, maybe I will answer this question in my talk You sure, you do not want to be in the end? I'll show it, I'll ask you a question here. She'll ask if
26:03
you want to. I'm okay waiting and seeing if it comes up later. I'm fine holding it. I wrote it in the comments just so I wouldn't forget, but it doesn't need to be addressed now necessarily.
26:17
Okay, but I think it's better to explain what I did in movies and then in the end because I will not speak too much today about the conceptual issues, but to detail what I did in front of you, and
26:31
after that we will discuss. Okay, let's go on and then
26:37
people can hold a question Your question could be, okay, how you selected the task, particularly, especially for neuropsychologist, it's very easy, you have to ask the patient. What do you want
26:51
to continue to do? And it's totally different if you are a driver, a medical doctor, a mathematician, a musician, an artist, and so on and so on So you have, first of all, to adapt the mapping,
27:06
but in a patient doing tasks to the definition by the human being in front of you before to go to the door.
27:18
of Israel's quality of life. So Job, Hobie, Habits, Leisure's, Lifestyle, and so on. Typically, we ask to this patient to switch from Portuguese to English because she was the one to speak two
27:29
languages. I will not ask to French people speaking French and German to speak English Portuguese. We adapt.
27:42
And it's never done in the literature because we have to do the counting, the naming, and that's it. And eventually, the moving. But never simultaneously, never in full sequence, never by
27:55
switching from combination of tasks to combination or the combination of tasks. And first of all, to adapt, remember, to the preoperative cognitive assessment if the psychologist told you, you
28:10
know, this patient started to have some problems with executive functions. Of course, you will take care about that into the world a little bit more because the brain told you before, Sanjayi, be
28:22
careful. I started to have some limitation in some cognitive domains. But we have to adapt also to the environment. In India, in France, you cannot drive. I'm sure it's true in the US for
28:38
medical issues. But in many countries, it's not forbidden so that means that I will not radically change the quality of life of the patient in North Africa if despite India, they can continue to
28:54
drive and in the vast majority of cases to work. Why, if you cannot drive in France, in 90 cases, you cannot work and the patient is not a vasectomy, but you destroyed his life. So you have to
29:09
take into consideration this criteria But speaking on so how I do it.
29:19
the post-operative cognitive rehabilitation. You know, better than me, that in the US, it's not reimbursed. In France, it's reimbursed. So that means that you have not to take into
29:27
consideration the fact that if the patient would like to stop to work for three months and to be rehabilitated, it would be paid for that.
29:39
I do not understand your assumptions because I showed you a case of left humor. And of course, the vast majority of them today will not select for surgery because of workers area. But in the right,
29:52
a misfer, they will do this kind of surgery under general anesthesia. But they continue to think that the right a misfer is not critical for cognition, especially social cognition, special
30:04
cognition to drive semantics have
30:10
not to speak if you cannot understand that. you will not be connected to the environment. Executive functions, to do many things simultaneously. The colleague told me, I hope I will not forget my
30:22
question in a few minutes. This is typically executive functions. This is what we are doing every day. But when the patient is doing that, after surgery, 99 of your surgeons in the world, I know
30:37
how happy with that
30:40
You ensure that your patient will be able to return to work, but also to family, normal life, if you've changed behavior and the personality. So we have to adapt according to the wishes of the
30:57
patient in front of you. Typically, I did surgery many times. We will see that in the next talk. And this week, for instance, I operated on a nurse I did surgery 10 years ago.
31:14
In the meantime, she enjoyed her new life. No chemotherapy in the right of her piece or small breakthroughs, and I used mechanism for your plasticity to re-operate her. Everything was perfect.
31:24
But I did not use exactly the same tasks. Then, 10 years? Why, because now she retired. And she told me, finally, I do not need to have a so high level of cognitive demand regarding the
31:41
executive functions, because I will not continue to work as a nurse. And what I want is to see my grandchildren growing. So if you would like to push a little bit more now, without considering
31:54
executive functions, and just avoiding a phrase, I may pledge a and buy back. Preserving personality, I would be happy with that. Why, 10 years ago, it was impossible for me, because I would
32:06
like to return to work So I changed, she changed, her brain changed. it was not the same subject. This is the reason why. Never I will use any technology in my operating theater because how do
32:23
you want to explain what I told you just now to the robot? And the best results objectively if we're reporting in the literature of the having both instances about that survival and quality of life
32:37
have been taint without technology. This is different tricks How I do it, forget technology.
32:46
So I will not resist about the fact that you have to ask it to the patient to do many things simultaneously, okay? But to switch also, we have seen that, okay? But to switch, if you would like
32:60
to increase, not only the cognitive demand, but the behavioral demand. For instance, to ask it to the patient to do a semantic association text.
33:13
the pyramid with the unpree. Okay, you have to move. Everything in five seconds. You stimulate, you identify, the cortex, the connectivity. You use the same parameters of electrical
33:27
stimulation, not monophasic, biophasic. I will change the ring, the surgery. That is too complex for me. I never did that. And I obtained positive mapping in 100 of my patients without seizures
33:43
But now the patient told me I would like to preserve also emotion. So I have to speak about empathy, especially in the so-called rhyme number, the misfer, so to check if the patient is still able
33:57
to recognize the emotion expressed in front of him or, and to self-evaluate. This is, for instance, here, irritation, okay? One to six, one, I don't know. probably use stimulated and they
34:14
say something totally wrong, random, six, I'm sure. And if the patient gave a right answer by telling six, six, that means that he, she has a problem of meta-cognition, knowing of knowing. So
34:31
you cannot in general my life if you made a mistake and you cannot act on an aged act. And suddenly you switch again to the semantic association task, movement, naming. So you increase the
34:44
cognitive demand. That's too much difficult. No, it's exactly what we are doing in the real life. Suddenly someone behind me can ask me something much more emotionally. So I will change in my
34:59
mind the meta-network to answer her equation by becoming maybe more effectively involved And now I will again continue my lecture cognitively. we are doing that all day long. So please do it in 3D
35:17
operating theater. And now, how I do it again, illustrative case showing the full picture, 32-year-old right-handed patient, seizures, slight language disturbances. The naming is not optimal
35:35
just before surgery. You will understand why because of voluminous, temporal glioma in the
35:43
so-called left temporal lobe. But also, as you can see at the junction between the temporal and occipitinal area, but also with a start of involvement of the optic tract. I will not show you
35:59
tractography because you should see that in your mental matrix. When you have a consultation in front of a patient, during the first meeting, you should think, I will have to say to the bishop, I
36:13
will use visual field deficits, and you have to accept that, or if you cannot accept, then I will leave approximately three CC. And you can say that to the patient in order to give him or the
36:29
choice. It's too complex if you know, they know better than you, if they can accept a visual field deficit or not.
36:37
The patient only know Now, so in practice, lateral position, I have not a very good multimetry. So I have just two positions since 30 years, right, left. But through the skin, through the skin
36:55
in the morning, I can see the pathways six centimeters in the depth in my multimetry. Snowman, I am a brain surgeon. I spend my life to learn the functional anatomy And it's very good for
37:11
anesthesiologists too.
37:16
to put a laryngeal mask because this is the safety lateral position, right, left. And it's good for the team since 30 years, nurses and so on and so on because right, left. And that's it. Now,
37:29
the patient is sleeping with a laryngeal mask, a proper full remin frontenile. You have the habit not to shave. I can put, of course, on the field. So that means that if you want to add your
37:39
navigation, you can My philosophy is to be reductionist regarding the technology, but if you want to add, it's not incompatible. It's just useless.
37:53
I will do a more big bun flap than the two-marred fluff in order to have a positive mapping. I disagree with Mitch Berger, who's telling a negative mapping protecting you. No, especially when
38:10
you're young. you have to know exactly where are the critical areas in order to remove the brain up to the critical areas. And then you have no seizures because with the positive mapping, as you
38:25
have seen, you will not increase the intensity of stimulation. Why if your bone flap is too small? So many young guys will increase the intensity and finally seizures, right? And I will
38:37
exaggerate is dangerous. No, you are dangerous.
38:43
Now, the patient is awake. So as you understood, the tasks have been elaborated with the patient and then your psychological and the lego bed is deep before surgery. And now we are switching, et
38:58
cetera, et cetera. 60 hertz, one to two to three milliamps and you have a positive mapping. So now I will use, of course, the coagulation at the level of the cortex, but just because it's a
39:14
true negative mapping, till
39:18
the sulcus very, very near the cortical positive area. And then I will just do a sub-pial decision without any coagulation. I will say it again, I never coagulate in the brain except the cortical
39:36
surface And the rate of ematoma I had in 30 years, one.
39:45
So now the most important is the connectivity in the depth. So the inferior fontoxibular fasciculus. And of course, in this case, the optic tract. Because the patient told me, I do not want to
39:58
have a vision field deficit, okay? I like it, it decided, it's not my life. It's not my evaluation of quality of life So, I have to ask to the patient.
40:12
to have naming of two pictures in front of him, cat dog, three hours while you're gone. And suddenly the patient is just naming one. So it's not a language deficit. It's a vision field deficit.
40:26
Why? Because I stimulated the optic track. So I start.
40:31
Before you would not leave tumor, while it's possible to remove more and to reach super totalization according to your own definition, just for a man up here. Of course, I will stop. The vision
40:45
doesn't want a man up here. I will not judge for him. It told me that, so I will stop.
40:53
So I will preserve the tracks.
40:57
But also I will preserve the visuals. Never I will calculate. I will say it again. Never I calculated any visual, within the brain in my life You can see the veins, you can see it and so on and
41:10
so on.
41:13
So in the end, you have no margin around the cavity. Everywhere when you stimulate it, you used vision field deficit, semantic paraphernalia, anomia and so on and so on. So I cannot remove more.
41:29
Even if I know that there is a residue at the level of the optic crack because I saw that when I was in consultation, when I met the patient for the first time and he decided to preserve that So to
41:42
have a small but objective residue, it's exactly what happened. Except the fact that, of course, thanks to this removal and the tumor was big, 108 CCC, language improved very quickly. And of
41:57
course we adapted post-operative rehabilitation because we had friends and the patient has not to pay. But it could be also from New York. And if the patient decided to pay for the rehabilitation,
42:09
Everything will help him. by being pre-planned before surgery to recover more quickly. And this is the reason why I have 94 of patients with return to work, which is unique in the literature. And
42:26
of course, you can see the postpartum MRI. And of course, there is voluntarily 3CC
42:32
left at the living under a tick tract. And of course, this patient can back 15 years later by saying, now, I'm still alive, but you more grew again. And of course, the level of the occipital
42:47
lung. I do not need to drive anymore because I am 60, and I will stop to work. I would like to continue to live. Please do the occipital lobectomy now. And I am understood that I will have an
42:59
amen up here, but now I did not share why 15 years later before it was not acceptable for me So this is Alacat, but not just Alacaton now, but by anticipating. What should happen in this patient,
43:15
five, 10, 15 years later, we harnessed 2025. It's a little bit complex nonetheless, at least for me, but within the next 10 to 15 years, we stop really to be able. Why? Because I have this at
43:29
last. The sole, I had to move function on at last in the literature because not based on DTI, which is not the function, but based on intraoperative electro-constimination in thousands of patients.
43:44
And of course, you have to anticipate before to go to the world how the brain will compensate, especially by the contralateral hemisphere or the more they look analyzed network in the same
44:01
hemisphere or both. But we have seen that in the previous talk and you see that everything is linked. Because I really insist on the fact that brain processing is based on the brain. a better
44:12
picture, successive new equilibrium straits resulting in adaptive behavior. What means that in the operating theater, and I will show you that next time, you can see reorganization just in one
44:26
hour of the cortical mapping, but not the way matter tracks the limitation of neuroplasticity. So before to discuss, I would like to tell you how I do it Served by your decision with no coagulation,
44:43
especially in the deck. I have seen so many neurosurgeons in my life under microscope and so happy in the end to coagulate the one matter track by telling you, see, now I have a beautiful amount of
44:56
stasis, but you will, but the fact that you disconnected when found at the hemisphere by doing that.
45:04
Even if cortical mapping is important, Why matter track napping is much more. critical because the limitation of neuroplasticity. This is the reason why when you have a stroke at the level of the
45:18
internal capsule, when you are, just aren't, you are me pledging and you do not recover. That's about just one cc of stroke in the depth. Why sometimes if you have a very big stroke at the level
45:32
of the coty-consular phase and what happens? Nothing because the patient can recover three months later thanks to stroke
45:41
rehabilitation is so clear. Even if stimulation mapping is important, the most important is the cognitive monitoring based on the good selection of tasks and their switch into the important theater
45:58
based on the definition of quality of life by the patient himself. And during the awake period, The main goal is not to remove the tumor mask. which does not exist, we are speaking about diffused
46:11
humor. But to disconnect the loops invaded by the glioma, especially when the glioma is very big, I published a paper about Luke Ray glioma with more than
46:27
10100, I'm sorry, CC, the sole paper in the literature, only more than
46:34
100 CC. And so many colleagues told me that it's not possible because the patient is too tired because you need time to remove the tumor. But I do not remove the tumor. I'm not removing the tumor
46:46
from inside to outside. Otherwise, that means that you're afraid by the brain. My goal is to run directly to the limits and to disconnect the loops and you need more than one hour. And after that,
47:03
you can finish under general anesthesia Remember, a sleep awake, a sleep. by putting a tube under generalization, because you do not need the help of the patient anymore, because you disconnected.
47:16
Especially the temporal lobe, for instance, so many colleagues told me I'd sometimes spend full. What is spend full? The school base, but I do not reject him to the contact of the school base,
47:28
because I disconnected before I can do it. Finally, don't tell your temporal lobectomy under generalization and the end, because the lobe is disconnected Why to induce pain to the patients? You
47:39
have to change radically the strategy of surgery based on the knowledge of the functional anatomy, and never technology will give you this knowledge. Go to the brain, forget the tumor,
47:54
interrupting, mapping, and cognitive monitoring are more sensitive, reliable than you'll imagine, which are beautiful for didactic and research purposes. but never in the operating theater.
48:12
Technical aspect and not an issue in brain surgery. I do not need to be very skilled. I have to understand what I do and to adapt to each patient. So concept is stronger than technology because the
48:29
vast majority of young your surgeon, now I know in the world, are addict and without your navigator, they are lost in the brain. It's pathetic.
48:41
Because never they will preserve the quality of life of the patient, otherwise they will do just a big biopsy. So the patient will not live 20 years. So quality of life should be the first endpoint
48:53
because I will demonstrate to you in next took that if you feel better and if objectively, the scores are better and if you return to work you live longer. Everything is linked. There is no
49:09
reconfunctional dilemma.
49:12
This is the reverse. It's a non-confunctional potentiation, except if you continue to believe in
49:21
localizationism and if you say, we cannot pray the patient, I showed you during the first movie because she's a medical doctor and she doesn't want to be a fascic and this is in progress area. Okay,
49:36
so that means that you cannot pray in brain tumors.
49:41
Now, I am ready of laboring to answer your patients because I would like to cover this topic regarding the concept a little bit, the technique, but first of all, the understanding of the
49:55
functionality in all cases, this is critical, the first step, otherwise you cannot pray the brain.
50:10
Very good. Thank you.
50:16
There's some questions in the audience that you'd like to ask. This is wonderful.
50:21
There must be a lot of questions in the audience.
50:27
Well, people are thinking about that question as used. Thank you very much. This is excellent. And as I mentioned after your first, during your first lecture, this is a paradigm shift. The
50:40
question I have for you is, at what point did you develop the confidence about the reliability of your recording before resecting the brokers area, for example, in the patient with the tumor. How
50:59
to walk us through how you develop that confidence about the reliability. I know that because definitely I really continue to ask the patient perform the tasks in real life, regard the restriction.
51:01
So that means that, of course, especially when I was younger, I stimulated the
51:20
wrong trial prima local text positively and broke the rail, nothing happened. Perfect. Are you sure it's your question? that you can't remove it without any problem. But when I started to
51:31
calculate voluntarily, the patient continued to speak to move to switch and so on. When I started to remove, by doing a supply of decision, the patient continued so that every four seconds, you
51:44
have to answer to your question. And this is the reason why it's systematically on the fact that the cognitive monitoring online is much more important than stimulation per se Because if the patient
51:59
is moving, speaking, you have to answer. And of course, I spend my life to hear the not only translator feedback, not only the speech drop is feedback, but the patient by myself. And this is
52:13
the reason why I hate to operate patients in another language when I cannot do the analysis by myself, namely not in French, not in English, because I'm never completely sure. I published a paper
52:27
by that by telling Find the Lydia one, but the price of pay was that I left 5 more impatience when I cannot analyze by myself and I need only the translator back because I was a little bit afraid and
52:45
I decreased my level of confidence so I left 5 more tumor
52:53
Excellent. Excellent. I assume that you use the ultrasound when you're at the cortical surface level, but once you get into the subcortical space, you're completely guided by the functional
53:08
response. Is that correct?
53:12
Exactly. If I stimulate, nothing happens, I will continue. You will tell me maybe it's a false negative. Definitely, I do not care because the patient continues to do the task. If now I
53:24
stimulate and I induce a complete enough here for instance as you have seen in the movie, then I know I have to stop. How are you sure before? Because I will stimulate again many times and each
53:36
time I will use the same transitory deficit. At that time, I will really recommend you to stop. So ultrasound, imagine I do not care at the time, to be honest finally, why I use ultrasound at
53:51
the level of the surface, because I never did any surgery these past 20 years without visitors in my operating field. And just to demonstrate to them that in two minutes, you had exactly the same
54:04
imagined and intraoperative MRI for more or less nothing. I mean, it's not very expensive. And that's it. So it's a didactic tool. Today, I can do it without ultrasound.
54:17
Dr. Heathen has a question. Dr. Heathen, please proceed I have so many questions, but I will limit it to one win. the surgery is progressing and there's a longer duration where you may have
54:34
evidence of focal acute edema at the surgical site. When deficits, you know, you don't think there would be. Okay, so what I grapple with is when the impairment is not black or white, it's not a
54:54
pathinemonic arrest. It is a more variable or fluctuating level of functioning that I see as a decline and concerning. But the neurosurgeon I'm working with, we're trying to figure out what's going
55:11
on and is at the time to stop because we're seeing an evidence of change or is that more transient and will resolve postoperatively
55:24
I'm sorry, it's not now even if I understand. of course, because it happened to me about 25 years ago, when I was too slow, when I was afraid by the connectivity. And finally, I removed from
55:37
inside to outside, and I wasted time. And after 40 to 60 minutes, the patient started to decline, and the second hardware was on nightmare for them, so for us. But now, I go very quickly to
55:53
warn the limits. Since the beginning, I'm not afraid by the alpha by the arcuate, I want to find the limits. And definitely, so frequently for the insular, for instance, I removed the part of
56:06
the insular, very close to the arteries and their generalized seizure after the discontinuity, if I can say, in the depth. And finally, my patients have no time to be tired because never I need
56:21
more than one hour to disconnect even in very bit humor. So that means that when they start to have a problem, it's related to my stimulation. So this is the answer to the patient because I will
56:35
stop, they will recover, I will stimulate again, I will induce exactly the same symptoms. So you have the answer. So now I have the habit to say to minus this geologist, put the tube please.
56:46
Now I have, I don't know, 30 to 40 more minutes of resection on their general anesthesia before closure Yeah, the outside in that that is transformative and I can see why that would make a big
57:02
difference because that is what I wonder I'm encountering in the later portions is fatigue, stress, attention, pain, all those confounds for cognition.
57:16
And sometimes, nonetheless,
57:19
it could be related to the fact that you, not speaking about pain or the fact that the patient cannot help you anymore, but attention, you say. It could be related to the fact that you started to
57:32
disconnect not one network, but in fractions between network. This is something else. This is the concept of meta-network And at the time, I started to say, maybe it's related to me because an
57:46
increase of reaction time because difficulties to do multitasking. So I would stop. And so many visitors are surprised, but just because an increase of ration time more than five seconds will stop,
58:00
yes, because I know this is related to the fact that I'm very close to the interactions of the track underneath the dorsolyteral prefrontal cortex, for instance So I have the N-4, I have the SF-2,
58:15
and I have more visually. the deployment network. It's exactly what I looked for. So because this guy will not return to an active life, I have to stop. But it's not a problem. It's exactly what
58:28
I looked for.
58:33
I'm also seeing differences in picture naming versus auditory naming that are making a big difference in when we're making adjustments or stopping, where we're getting no findings with the picture
58:48
naming, flip to the auditory, and I assume because of connectivity tracks with temporal lobe, we're starting to pick up deficits earlier.
58:59
Yes, but to be honest, I have no problem during the naming. Even I mean during the call even mapping. I will increase the cognitive demand since the beginning, but asking for instance to do the
59:12
semantic association task with naming andor switch as As I said, in order to identify something positive, we've fallen already. And then I will use something more complex in order to have a
59:24
positive mapping, not just to avoid a failure, I mean pleasure, but to give the opportunity, the patient return to a real, normal, family, social, professional, eventually supportive,
59:39
artistic life, and I will develop this kind of results in the next lecture But in fact, the secret is that, if I have something negative, say no, it's not sensitive enough
59:54
Well, thank you. There's another question from Sherry. How do you decide which series of tasks to perform for each patient? How different? is it a test complex cognitive functions example,
1:00:07
memory retrieval, etc.
1:00:11
Definitely based on the decision by the patient himself of what means quality of life. And because during the first talk we described the functionality based on the interaction between networks, I
1:00:26
started to have some insight into a motion complex movement We spoke about connection, not just an image you just know. Executive functions, to be able to do many things simultaneously as I said.
1:00:43
But also semantics, verbal, non-verbal. But also vision field and eventually visual speaker cognition. For instance, to use remember the line by section task in order to avoid induced any neglect
1:01:01
and so on and so on in other world. that the answer is the first talk, and this is the reason why I wouldn't like to speak about the understanding of the dynamics within and between networks during
1:01:14
the first lecture in order to answer to this question today, and now everything is clear.
1:01:25
You may be addressing this in a subsequent lecture, but you mentioned leaving residual tumor based on the functional assessment. Now, in the follow-up years or so later, describe the decision
1:01:44
about winter return, balancing tumor recurrence versus plasticity.
1:01:53
It will be in the next lecture, because I speak about. Oh, you might say that. Okay, that's okay. We can wait mid-stage surgical resistance and the heart. Now to select the good patient and the
1:02:05
good timing in order to re-operate by using mechanisms from neuroplasticity occurring after the first or the second or the third surgery in order to continue to preserve the quality of life according
1:02:16
to the definition by the patient, but also by reducing again the volume and preventing backlink non-transformation in order to give these 20 years of median survival So I will answer much more in
1:02:31
detail in the next talk. Okay, thank you. Shall Ram Bakui? Yes, yes. Can you hear me? Yes. Okay, so can you hear you? Hi, thank you. How about using
1:02:48
5ALA, just to see the more extended infiltration which then can be mapped and if, you know, functionally stable and resect, what about that idea?
1:03:04
Why? Because I will continue to remove the brain in the functional boundaries. So if it's green or yellow, what do you want? And if I stimulate, I induce an achlea, I will not cut the SLF3 and
1:03:19
de-reverse. If you remove the green, blue, what do you want? You happy? But you have not reached the functional network. I will continue to remove more because I know that you have your own
1:03:31
sounds So move on
1:03:49
you. Yes. Any other, well said, any other questions? Are there functions that you've been unable to map that you think would be important for quality of life that you haven't figured out a way to
1:03:56
map it?
1:04:00
Yes, no. I mean that I see. I've taught it at the end of my career or must not to explain to you, of course, the mechanism of reorganization within the brain, because the brain is magic, as I
1:04:14
said during the first lecture. But I know the
1:04:17
limitation, and my problem is really the limitation, which are based on the fact that if you cut a pathway, because you know that you will recover, you need to use indirect pathway And we had the
1:04:34
discussion with Jim just one hour ago, by telling this is like a subway map, for instance. If you close one station, you will find another way in order to go home. But what will be
1:04:50
the price to pay to answer your question? You will arrive to whom, later So, the patient will have an increase of reaction time, so we will have to focus a little bit more. more, because
1:05:05
normally it should be automatic, but which is true, very, very frequently before surgery. For instance, if you apply the working memory and back concept, the vast majority of patients who seem
1:05:19
to have no one life when they have the first zero, in fact, have a problem of three back, and they have only the possibility to do two back When they are telling you, I am tired, and I can
1:05:34
understand. And finally, they will be tired after surgery, and this is the reason why I will not really stop according to this criteria, because this is the limitation of neuroplasticity, because
1:05:46
this is not normal to have a brain tumor and to do the bactony So we can cover more or less everything except tiredness.
1:06:06
in neuroscience, you know, Argentina, you're a neuropsychologist. Did you have any other questions you want to ask? Yeah, but it's a silly question, but you know, Professor DeTho, I can, I
1:06:17
can assume your, your answer, but there are many colleagues in all over the world, suggesting that the stimulation in the subcortical area is better than by monopolar stimulator, but I know you
1:06:30
have a great experience using bipolar in the cortical area, also in the subcortical region. Do you have any comment about this?
1:06:39
This is exactly if you ask me, are you right-handed or left-handed? And in my movies, I use. No, but I mean, you use what you want. If the concept is understood, the tools you adapt, I do not
1:06:57
care. And each piano player can prefer a playel. a presenter for our stanway. This is in fact your equation. So I do not share because this is the style. But if you haven't understood the concept
1:07:15
of this metallic work and limitation of neuroplasticity, and you can use it if you want the finger by pushing the way metal tract, I do not share.
1:07:29
Michael, do you have a question, Michael Levy?
1:07:39
Andre, could you answer this question? You've worked on this now for 20 years. Uh, is it, was it, have you applied this, these techniques to other farms, other, poor, other neurosurgery that
1:07:54
you do?
1:07:57
No, no, no, of course, everything we, we are dying, we are doing in the, in the week surgery, we learned from Professor Dufour. The only difference may be because we have a very huge
1:08:11
neurological department, our neurophysiologists, they want to change between the
1:08:18
cortical and the subcortical area between the bipolar stimulator ocement and then to change to the five-strain mono-polar stimulator in the subcortical area, but maybe this is only a technical
1:08:31
different view. The
1:08:34
point is the stimulation is the same, the patient in the wake fashion and the task. Of course, you can choose whatever you want, it depends on the localization of the do one, of course.
1:08:48
Have you used this in this approach in taking out AVMs or as huge as done in cavernomas or in other kinds of surgery?
1:09:03
Maybe Professor Dufault, we are only using a weak surgery for gliomas, not for post-class surgery. In fact, I will cover this topic in the last talk, because just two weeks ago, I did a
1:09:18
cavernoma within illoquent areas and finally this patient, because very young and because in so-calledvernical area, was not selected for surgery in another department. And what I said is, of
1:09:32
course, I will ask you just to do an awake surgery. I will turn around. I will try to take a margin around because you increase the chance not to have any seizures after surgery.
1:10:42
let's see what comes in the next lectures okay no don't don't be timid you can you can ask whatever you want and uh no question is a stupid question no so okay here's for the young nerd for the young
1:10:58
neurosurgeon in training you know probably at one point you indicated that even before you began this but the procedure you visualize where the optic track was. For the young neurosurgeon in training,
1:11:11
what's your advice to them about learning the anatomy to the extent that it can be proficient at this process?
1:11:25
To do a PhD of neuroscience in parallel with their residency is exactly what I did And I built and he breathed brain since the beginning by understanding positive feedback but also limitation of
1:11:44
functional imagine. by building my multi-metry thanks to dissection, but also a pictography, but also when I return to the operating theater by making the link between your psychology, your
1:11:59
physiology, anatomy, and function. And suddenly everything became clear. And each time I had colleagues coming with a high level of motivation to my hospital and ask to address, then they start
1:12:19
to build that in their mental imagery. The problem is that today we are teaching in the wrong way by telling you have to use technology. So never they will be able to learn because they will become
1:12:37
addict. And definitely if they are not, the new navigation, they are afraid they are lost, so. they will never be able to reproduce these results, even if they are doing 10, 000 brain surgeries
1:12:54
in their life.
1:12:57
That's a key point here is that the optimum technology is the patient. That's what you're saying. The patient has all the answers, not the technology. Isn't that right? Of course, because if you
1:13:12
go to the meeting of neuroscience, I am a neuroscientist. I ever love neuroscience since 20 years. I am invited in this kind of meeting. I know that they are the first to say, but we hope that
1:13:26
your surgeons are not using tractrography in order to make a pre-planning. They know that this is not the truth. Yes, I would like to explain to them, but they do not want to acknowledge that. So
1:13:39
that means that we have the feeling because you use beautiful tool that they are relying on. But we do not want to acknowledge that they are wrong because so many technical limitations. And never so,
1:13:56
the technology today will be able to explain the complexity of the reorganization of the brain in real time. Otherwise, they would have no surprise by Italy. We have understood the equation of the
1:14:09
brain, but in your science meetings they are telling It's so complex today that we need more, muddling, and to put everything all together, longitudinally, to tend to work a start of explanation.
1:14:29
I think the companies are interested in having you buy the equipment and the problem is, the imaging that you talk about is not accurate because a brain shift or swelling or something else, and all
1:14:42
of these things have some some policies that are not exactly what you're seeing at surgery, real time, operate, isn't that right?
1:14:56
Real time, adoption of the brain. The brain is magic. Even magnetoencephalography is not a bond to capture, not maybe just one network, but not everything altogether So, actually, you imagine,
1:15:12
try to graph, try to graph where you want to perform. I don't know. Today's before surgery, for instance, and we are crazy to think that when we will go to the UR. Thanks to neuroendovigation
1:15:25
because beautiful colors, we will be able to reproduce these results. But I'm still waiting these kind of results by using technology. They do not exist in the literature. I thought that the goal
1:15:41
for medical doctors and especially in your surgeons was to improve the survival and quality of life for patients. But in meetings, I never heard since many years any results changing the world.
1:15:56
They are just telling me that technology is better than another one. I do not care. I do not need technology. The brain is giving me the answer.
1:16:08
What's exactly right, right?
1:16:12
Can students from Lithuania, do you have any questions? She'd like to ask Dr. DeVolt.
1:16:21
Thank you, Professor, for a good presentation. I'm very impressed.
1:16:27
I would like to ask a question from Patrick at our point of view.
1:16:33
How are you achieving chemostasis? Do you use some surgery cells or the brain surface or other chemostatic agents, for example,
1:16:47
pibering blues after the finishing of the removal of tumor, or it's a bit dangerous for brain.
1:16:57
So, by the intersection, your G-cell. Since 30 euros, definitely a head, only matter of my life, that's it. So what I'm telling today, whatever the questions, is that what I'm doing can be
1:17:13
reproduced everywhere in the world without any technology, without any money, just a good team So it's a stimulator, knowledge, good team. That's it. So your point is that you can do this in
1:17:33
high-income countries, you can do it in the low-income countries. Isn't that right?
1:17:39
That did this kind of surgery in North Africa, in Middle East, in so many countries, with nothing around me except a good anesthesiologist and a good psychologist. And that's it.
1:17:56
Shuram, you had a
1:17:59
question? Yes, I was
1:18:03
wondering. When Professor, first of all, this is a great talk and I have your book, by the way. I can show you,
1:18:14
I don't know if you can see you guys or not. Oh, which we said, okay, great. They connect them analysis. So basically my question was when you are deep in the cavity, you know, in the
1:18:26
subcortical region and you continue the testing, electrical testing to see if you get any positive results. Obviously, in your deep in the cavity, you have to be doing the correct tests in regards
1:18:43
to the relation to the area that you are because if you're doing the wrong test and you will see no deficit, then you get the confidence that you can, keep going. And that that is a key in my mind
1:18:59
that you need to know exactly what functions to be testing, you know, which would be in relation to the area, the cavity that you are, you know, and not everyone has that. And that's why I was
1:19:16
wondering if you have the ability to have tractography or additional technology as an approximation, you know, the gold standard, it is the testing, weight mapping, but why would that be a bad
1:19:31
thing, you know?
1:19:34
I hate approximation. For initial approach.
1:19:41
See for initial approach. And then you get the initial approach is to do a PhD in neuroscience. And then you can publish in nature by explaining what you are telling. I know where I am in the brain.
1:19:58
My question is in fact to you and to many of your surgeons. Is it reasonable to operate the brain if you don't know the function?
1:20:08
No. That is the key question, right? Right. But you see, when you are deep in a white, resected white matter cavity. You need to think of what you mean white matter tract in front of you. I
1:20:24
published that more than 10 years ago to explain that even to neuroscientists. So I know the different functions and because of course I cannot tell you just one simulation, one function, I
1:20:36
insisted today, how do I do it? Please ask the patient to do many tasks simultaneously.
1:20:45
So, for example, how much do you resect, you're deep in the white metacavity, and you know that, you know, superior aspect has one function, carries one function posterior aspect of the cavity,
1:20:56
is going to be related to different function inferior part of the cavity is going to be related to different tracks and function. So how much do you take like three, four millimeters around and then
1:21:07
stop and then ask all these functions and test all these functions and then go another two or three millimeter this section and then go ask all these functions again. How do you do that? That's not
1:21:19
really the
1:21:21
question. The question is related to the fact that I use remember very low intensity to avoid any seizure. So you know the rules of course will change nothing, one millimeter, one milliamp.
1:21:33
Because I use between one to three milliamps without a train of five on a lower bipolar and so on, you have the answer. In the vast majority of cases, I know I am more or less too. two to three
1:21:46
millimeters away the pathways. So at that time, I can try to take one more millimeter tangentially by asking, of course, to the patient to continue to do all tasks simultaneously. And at that
1:22:05
time, sometimes you have just an increase of reaction time. We discussed about that just before. It's enough for me. I understood interaction between networks, two millimeters,
1:22:19
I will stop because the patient told me I want to enjoy perfect normal life as a human being. And yes, I can know that two millimeters away from the critical pathways I described 11 years ago,
1:22:37
speaking about their function
1:22:40
The very good question, Sharonda, what is.
1:22:44
What he's really saying, if there's tumor left, and it's invading the tracks, you'll wait. And let the
1:22:55
brain develop new connections and come back later. Is that correct, yours?
1:23:02
Not in the depth. The limitation of neuroplasticity, so we'll speak about that in another talk. I mean, to combine surgeries and adjuvant treatment, I am the first in tumor board to say, there
1:23:15
is an invasion of the junction, the crossing fibers between
1:23:28
the dorsal and ventral pathway, no way to see reorganization. Please do chemotherapy now. And of course, avoid radiotherapy, otherwise you will burn the connectivity of the ventral and some of
1:23:35
the pathway, so the patient will have a gang of cognitive functions So please do chemotherapy to stabilize what I will never be. bone to remove because if you've got this connectivity the patient
1:23:49
will not return to the whole life. It's absolutely sure 100.
1:23:56
Do you like to do radio, radio therapy?
1:24:01
Of course I will demonstrate in another talk that not only patients are not well. We've long-term for that. We are speaking about logarithmic with 20 years of quality of life. But I will
1:24:13
demonstrate to you thanks to another recent publication not from Montpellier that if you irradiate earlier the median survival is shorter.
1:24:28
It's demonstrated.
1:24:31
So we should be crazy to radiate or look regularly on us since the beginning.
1:24:39
Michelle, are you having a question?
1:24:43
Yes, my question is related to identification of candidates for awake mapping in our experience at the University of Florida over about the past 10 years The vast majority of patients are good
1:24:58
candidates. There's very few situations that they aren't a good candidate. And I think we have a pretty good screening method. The one that I feel like we've struggled to get a good handle on are
1:25:12
those few patients that are not a good candidate for hard to identify psychological reasons. And I have two in mind that we did awake mapping what they had in common is they were young men who were
1:25:29
stoic, everything's fine. I'll be fine, I've got this. And then they didn't, they decompensated, they had a sort of a panic reaction at some point during mapping. And I wonder into what your
1:25:45
experience was with your team, with candidacy. I accept, I understand of course, except if your patient has already a deficit before surgery, I mean, sure. Those are the ones that I feel like
1:25:58
are easy to find. Yeah, yeah. Yeah, those ones are easy to eliminate if they if they don't have like baseline adequate function for mapping. Yeah.
1:26:10
You're just being really careful about psychiatric patients. I mean, not you cannot talk to them because they will understand nothing. Of course, you cannot. But for love
1:26:24
in psychiatric institute under treatment. because they are seen, and they don't show two cases in my life, the compensation. And finally, not so much during surgery because we were able to do the
1:26:40
job, because the patient was really focused at that time. So we used the cognition just for, to be honest, 40 minutes, very quickly. I understood that I had to be very fast But they
1:26:54
decompensated extra surgery, and it was a nightmare for them to do the postpartum rehabilitation, because
1:27:04
it was mandatory for them to go to the psychiatric hospital for many months. And now I have understood that I was not a bone by myself to select these patients who are too borderline before, and my
1:27:20
habit is just to ask to the psychiatrists following them before surgery, at least to meet them, and to prepare a possible decompression.
1:27:31
And then, by knowing that, sometimes we had some transitory problem, but finally, it was not so impressive, like SMS and Room, for instance, so for two weeks, you will have a modification of
1:27:45
the behavior, but because we prepared that, it was smooth after surgery. But we have, first of all, to know it, to ask to the psychiatrist to explain to the patient, and the patient, and most
1:27:58
of whom, to the family.
1:28:02
Excellent. So I hear, do you have any questions you wanted to ask? Thank you. It's so interesting. I have a lot of points, but I don't want to take the time of the professor Dofo and the the
1:28:15
others, because I know it's a long thing, but I will call you and talk to you, then we can discuss it, maybe in the future talk. But thank you very much, professor. It's just great here to hear
1:28:27
you and also very nice discussion. Thank you.
1:28:32
Okay, Daniela, you and and and Professor Andrew, how do you any questions either of you have Daniela is a neuropsychologist also
1:28:47
I want
1:28:51
to know if you try to do free conversation with the patient during the resection of the tumor and monitoring the errors of the patient at that moment, and if it is this possible.
1:29:05
No, because to me it's not reliable enough, just in four seconds, as I said. So I need something very reliable. On the other hand, sometimes I'm doing that. When the patient starts to have
1:29:19
problems with the combination of tasks, because of perseveration. And sometimes I induced perseveration when I was into the contact of the Alpha, but also the striatal and create the head of the
1:29:34
cadet. And to my opinion, but it was just a feeling at that time, I thought it was too early and I was finally, it was biased to have perseveration, preventing you to continue the restriction.
1:29:49
And then I asked to my neuropsychologist to do free conversation, speech and so on, for a few minutes just for the vision to think about something else, and in the first majority of cases, if you
1:30:05
start to gain the tasks five to 10 minutes later, then the peer separation disappeared. And then it has been possible for me to finish the recession up to functional boundaries. This is the sole
1:30:20
indication to my opinion, otherwise it's a little bit subjective into the apartment here. And
1:30:27
if I was a so rigid when I gave my answer is because what we are doing is really mathematics.
1:30:41
Okay, anybody have any questions at the end or should we close this try? I think we're done. I think
1:30:48
it was an excellent session, great insight. Thank you again, here's another very excellent, very, very well-received discussion. Looking forward to continuing the series. Thank you very much,
1:31:03
it was absolutely phenomenal.
1:31:06
Thank you, here's just an outstanding job You're introducing very radical concepts to people who have been trained and learned differently, and it's the hardest thing for you is to have people
1:31:20
change. But you're doing a wonderful job. Andre, thank you very much for coming and
1:31:28
helping out and telling your experience and your work with
1:31:36
Hughes And Australia, just thank you very much for - who are producing us with us. And Shuram, we'll see you hopefully again and we can, you may have some good questions and thank you for coming.
1:31:49
And the boss, we'll see you in another month. We'll give you messages. Michael, we got to know you better and we need to have you all fill out some forms we're gonna send to you that are gonna ask
1:32:02
you what your experiences are like today so we can keep improving what we do. Isn't that what we have to do, Hughes? We have to do better every time, right?
1:32:13
Yes. Every time, thanks to you. So, I'm pushing me, so please continue. I like that, it's good for my own brain plasticity.
1:32:23
Thank you. Thank you. Okay. Okay. Very good. Hi everybody. Hi, thank you, bye bye. Oh, thank you. Thank you. Oh, thank you very much. Thank you very much. Thank you. Hi,
1:32:38
Kister, it is nice to know you're nice to see you.
1:32:43
Thank you very much, Professor Houseman. Bye-bye. See you next month. Okay, nice to see you in your husband again. Thank you. Bye-bye. Thank you.
1:32:55
Michael, where are you located?
1:32:59
In Israel. Oh, terrific. What do you do? You're a neurosurgeon there? Yes, actually, yes. And yeah, it was amazing. I met Euge in Mupaliya a few years ago. And I really like you his know,
1:33:18
this And. approach approach
1:33:20
of friendering things more simple and
1:33:28
more anatomically-based than technologically-based, which is very frustrating because
1:33:36
you see a lot of neurosurgeon and neuroscientists that are
1:33:40
They are not thinking anymore
1:33:44
of all the existing literature, that it's always very dependent on technology, which does not exist in many places in the world. And it prevents people to operate and to think even, and it's
1:33:56
illogical. We agree with you totally It's absolutely correct. Okay. Look forward to seeing you. I have
1:34:12
many friends there and and Shlomo Konstantini and and and Dr. Kane, many, many people. So thank you for coming and we look forward to seeing you again. Thank you very much.
1:34:27
Shalom. Bye. Take care. All right. Bye. Bye Abbas. I'm glad to see you
1:34:37
and I look forward to seeing you next month. Okay.
1:35:34
Professor Dufault is giving a series of nine lectures. The first was on cerebral plasticity. Neuromated networks are necessary to operate on the brain. The second one you are about to hear. The
1:35:51
third is multi-stage surgical resections applying basic neurosciences to diffuse glioma. Fourth is long-term unco-functional results Connect home-based surgical resection.
1:36:06
Fifth is redefining quality of life considering cognition, emotion, and behavior. The sixth is insulin, low-grade gliomas, specialized awake surgery techniques. The seventh is operating on the
1:36:20
corpus callosum and gliomas,
1:36:23
navigating complex involvement. The eighth is neuroimaging pitfalls, limitation of imaging and technology. in the operating room theater, and the last is beyond low-grade glioma, awake surgery
1:36:38
for high-grade glioma, cavernoma, and epilepsy.
1:36:44
We hope you enjoyed this presentation. Legal disclaimer says that these views and opinions expressed in this program are those of the author and interviewee, and do not necessarily reflect on the
1:36:56
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