0:00
As an eye, surgical neurology international,
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an internet journal with an anti-abstiness that's that are in chief, an SI digital, a new video journal on neurosurgery interactive with discussion with James Osman as it's that are in chief.
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An association with the Sub-Saharan African neurosurgeons are pleased to present another in the series of Sub-Saharan Africa International Neurosurgeon Grand Rounds held on the first end of each month.
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This is the 17th meeting and the meetings are devoted to the topic of global solutions to clinical challenges and neurosurgery everywhere
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in the world. The moderator and organizer is Estrada Bernard, assisted by James Osman to an international audience. Kim Speaker, Ish Chica, and Debussy. who's at the Memphis Hospital in Inugu,
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Nigeria. And he's gonna talk about complex giant seller region tumors, the dilemmas in the surgical approach.
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Dr. Endavusi is a consultant neurosurgeon at Memphis Hospital in Inugu, Nigeria. Four neurosurgery and is acting head of neurosurgery. He's been trained at the Department of Neurosurgery at the
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Shinshu University of School of Medicine in Matsumoto, Japan, where he received a neuroinovascular fellowship. He received multiple prizes and awards, has written two books, and 40 research
1:37
papers.
1:41
A little bit about Nigeria. Nigeria is located in the western coast of Africa. You can see on the map there.
1:50
It has a diverse geography, but it has climates ranging from era to human, because it's in the equatorial region.
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Its most diverse feature is its people who speak hundreds of different languages. Their country has abundant natural resources, large deposits of petroleum and natural gas. It became independent in
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October of 1960 and adopted a constitution, but elected to stay a member of the British Commonwealth. It is a population of 233 million people, of which a half are Muslim and a half are Christian.
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Take a screenshot. These are some of Dr. and Debussy's references for your records. These are two key references that he's listed.
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presentations on public solar vision tomorrow
2:52
and the concerns about approach,
2:57
because in our environment we still see a lot of very advanced giants in the future tomorrow. I know might not
3:05
be the trend in many Western population.
3:11
Apologies first, because I think the Internet is my function and I think we'll cut it just at the right time now.
3:21
However, about a five-year-old woman
3:26
who presented with data on sets progressively was named visual impairment of five-year division.
3:36
And if I got to with working as a result of right everybody we can.
3:45
we're expressing this vision.
3:48
So this has resulted in being a
3:53
wheelchair bound as all the time of presenting to us. The visual impairment was noticed on the left side and at the time she presented, was already MPL on that eye. I would threaten vision on the
4:09
right eye as well The
4:16
right side end weakness also had a fairly well progressed.
4:28
She had also had
4:33
associated headache, aluminum, vomiting, some seizures and personality changes. Because of this visual, she had a primary fertility for more than 10 years. And these are the relevant aspects of
4:39
the history And when this problem started.
4:44
She had many consultations and I'm fortunate I'm fortunate.
4:58
They couldn't really, but along the line, she had an attempt at developing all that remote connections.
5:08
She had a previous trial to run her clinic with another hospital, about four or five years prior. And then before she presented to us, a mobility has made her to be out of work for more than five
5:24
years. So in examination, we saw a middle-aged lady, vital signs, we are within normal range.
5:36
She had impaired memory
5:39
and speech problems
5:43
and the calculation.
5:45
Other high-server functions looked, okay, apart from these ones If you are like you on the right, I was counting finger and on the left, I was. no perception of light.
5:58
She had a facial weakness from a turnaround time and there were no signs of a naked
6:07
combination of meditation
6:14
The human breakdown showed hypotenia on the right side with three internal reflects and right-sided emiparesis with three to four as outlined and there are no synchos or velocines. So these were the
6:31
images acquired at the time of presentation and the corona image very
6:38
well described the extent of this lesion as well as the study time image in the middle and the axial image. So this became a dilemma of what do we do and if you look at the axial image on the left
6:55
side there was already an area of encephalomalesia close to the speech area which also added to surgical concern about how successful this
7:12
surgery would be as well as growth of the tumor particularly.
7:14
almost touching the upper front of your body.
7:37
We'll try to play the image so that it can be more clear to everybody, not just the image of the patient
7:48
So, that was a span of the lesion
7:54
in different sequences. This is the corona image and we can see the erect distribution of vessels, how they were a bit pushed laterally, which
8:07
was one of the
8:10
findings that helped us in deciding which approach to use
8:16
This city and geography also, if you focus on the corona view, try to
8:27
delineate the vessel anatomy a little bit, try to follow the concern on the sides. The MCA circulation pushed out laterally again as we said, this is the
8:44
vasolatry and a bit posterior and all surrounding the tumor, nearly in case.
8:48
But not as bad as one would have imagined.
8:56
MRI. A
8:59
lot of phone dial investigations, I see the hypo-coastalemia, of course, and the implant target function test. That took almost two months to correct.
9:11
That was just marginally increased at a full-acting level. Many of that investigations needed to be bad for surgery came out relatively normal, including cardiology check, doffler standard blooms,
9:24
and the protein profile and other imaging investigations. So, it was optimized for surgery, and eventually scheduled.
9:34
So, rapid consent was obtained based on the complexity of this lesion, and
9:42
it was clear that it might be difficult take this as a single procedure. And so the team discussed options that not including a trans-sevian approach. But the dilemma with this was that it was a
9:58
dominant hemisphere predominant lesion. So, and the previous surgery on that side. So the risk of mobility was going to be very high. We also contemplated the same for the temporary or
10:13
trans-particle approach But again, because I've already threatened the
10:24
encephalomylicia on that side. We were a bit careful about the permanent speech problem. And already the patient came with
10:32
expressing dysphobia. So eventually we opted
10:39
for anti-ventrionic atmospheric trans-calusala approach Which was what we eventually settled for.
10:49
So all the clearances we are obtained and protocols we observed.
10:54
So in trouble, we had a general anesthesia with arterial lines, central line and advanced part, multiple momentum. The patient was positioned to find for the until-end time is very tough, which
11:09
was slight flexion of the neck And secured on May 3th at turn. Standard protocols for positioning and safety's control, we observed. We used an anterior-reliant incision. And then a parameleon,
11:27
left parameleon from 2 paraterminipunitomy, as part of standard for anterior trans-colossal approach. Can I ask you a question? I'm sure I'll find this where
11:41
I'm swelling at the time of bone work,
11:45
was expected because of the size of the tumor, and this made
11:51
access a bit challenging initially. And that also
11:59
was also denied the post-operative edema following
12:07
a surgery, which we believe were due to the challenges of dyslexia. The tumor
12:13
was encapsulated, break-a-lot, soft, or suckable, which also gave advantage for more extensive work to be done, occupying a blood ventricle, no bond, and left side. The top ventricle was
12:30
closed, and eventually a gross total excision was obtained with good personalization, meticulous morbidity Okay, so after the Antoine Casa Tony, we really wanted to leave it to you.
12:47
That was expected, based on the, I'm not talking about the issue, but look at it. It's
12:55
like it's a suckable tumor and he's able to work from his minimal incision there and remove a bunch of the tumors, what it looks like to me, anybody, what do you think that's drawn to Eric?
13:12
You know, I wanted to ask Eric, because the concern about this case was about the surgical approach and I wondered if Eric, you thought,
13:27
yeah, you're in and out.
13:32
Okay, so that was, I still,
13:36
we posted that with the continuation of the tumor removal Film was accurate. That was the post-op image.
13:47
Am I on the go now? Yes. That was a post-op image
13:54
with the post-op.
13:60
Even though there was a lot of intraoperative hemorrhage, but the tumor
14:06
bed was fairly well, most disease was fairly well
14:13
achieved
14:17
So, first of all, I stand in ICU for three days,
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and the
14:26
total duration of Master's Day was for 20 days, and we had a post-operative time,
14:36
like
14:39
this, typically with time and actually we reached out, period, and then some weekly data was observed, some days post surgery.
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But by the time
14:53
of this chart, patients had improved the neurology
14:59
back to 5, 6, 6, it was V-tray pre-op, and then still had some data, and get through to
15:12
the trays and my parishes
15:21
Well that's a good case again.
15:24
I mean, this time I made 54-year-old
15:30
and this is a salary job called SAN.
15:37
It had progress in the Washington Regional Department. Actually, it was initially 10-3 years before the surgery, 2019, in 2020, it was a decline in surgery. And then I
16:03
became a factor. So it had to come back. It was a tremendous opportunity on the right eye and left I was a 20 of a hundred very advanced
16:19
left eye vision impairment with temporal field deficits.
16:25
Did you have more to deficit or any other systemic or some? Um.
16:35
This was the same amount.
16:42
Sorry, wouldn't play.
16:45
Sorry. It's okay. So the question was also optimized for surgery as per standard protocol. And this time around as well.
16:56
One option was whether to use a photo-temporal, right photo-temporal transcemia approach But because it's too much, we don't know if it was doing it vertically. Again, into the thought and
17:14
lateral ventricle. I bought in on the copus callosum as
17:22
well. So the decision was to go right from time until and time is fake After the
17:32
extensive reviews. Under the same positioning protocol
17:41
the same finding
17:45
was noted,
17:47
and then did our best with the excision. Sorry, we could all load microscope images for this because the internet was not allowing us to attach.
18:04
And this one still had a major problem it had post-op was severe hyponatremia
18:12
that happened on the, uh, let a part of the first week of surgery, um, with some suspected hypotallamic syndrome, um,
18:23
which by the time of his discharge data then had largely, uh, improved. Um,
18:33
and um, he also had one or two seizure events post-surge. By the time of discharge,
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um, he had no mapper and limbs and then was a fully conscious with no deficit.
18:52
Thank you very much. Okay, thank you. Thank you for sharing those, those two cases and you're presented it in terms of the dilemma regarding surgical approaches. And I can see why you did the
19:12
transcolosal approach given the intraventricular extension. But I wanted to ask Dr. Nussbaum if he thought that there might be any advantages of some skull base approach, like an orbital's
19:27
psychomatic approach or something like that As we didn't see as many images of the second case, but certainly with that first case, Eric, what are your thoughts? I mean, I think the limitation on
19:45
the first case - first of all, congratulations. They're tough cases and well-operated. The first case, I was impressed by the fact that the patient had a previous terraonal craniotomy on that left
19:54
side And that, I think, makes it much harder. to go, but I agree with the decision not to use a trans-silvian approach on a redo with that much tumor. And I'm not sure that adding an orbit is
20:10
like a medic in the setting of the prior surgery adds that much. Sure. That was a tough, that was a tough case. It was interesting to me, if you look at the images on that first case that, you
20:24
know, it ends up being in the midline, but it almost looked like it had pushed the ventricle a little bit laterally to the right.
20:34
But I mean fundamentally, I think it was the right intracranial, right, right to go transcranially. I don't think you could have taken that tumor out from below.
20:45
I, you know, at our center, the patient probably would have had some type of transnasal procedure first, just to get a sense of how soft and see how much you could get out and how much you could
21:00
decompress from below, but I think would have also had a trans cranial approach. It's
21:08
interesting at the group at Emory, Dr. Osmond probably would remember this. The group at Emory for a while, we're doing simultaneous combined trans cranial, transnasal approaches where they would
21:22
work from above and below and push the tumor down from above I don't have experience with it, but I also don't have experience with the tumor quite this large. I remember one tumor that maybe
21:34
rivaled this in size, it was a prolactinoma and so we just treated the patient with medicine and the tumor really shrunk down and has never needed surgery. The second case, I think it's really more
21:46
of a choice. I think could have been done through a variety of approaches and it's a matter of what the center's most comfortable with and that's what probably should be done. We didn't see as many
21:57
images. I think there's a possibility that a really experienced pituitary surgeon could have done a fair bit of that from below, but I'm not sure. And I certainly am not critical of the approach
22:07
that was chosen and what sounds like a very good result, so.
22:12
Yeah, congratulations, professor. Great, great presentation, great resection on those two lesions. Ali, do you have a comment question? I need a question What was the pathology of these two
22:26
patients? I didn't get it, maybe I missed it if you can tell the pathology of the results
22:44
All right, so I'm going to take you to Did you say, what did you say, what did you say, add a normal?
22:60
I'll be interested in knowing what was the pathology of the fast case because from their presentation, those upper motor neuron paralysis of the seventh nerve and upper motor neuron paralysis of the
23:09
seventh nerve
23:15
in barrier breaks means that this was an invasive tumor and
23:23
therefore what everyone would want to do is it's already invaded and the seventh nerve is involved. Well, I think my thing is that it was an upper motor neuron lesion and the patient had expressive
23:37
phages. So in the absence of a scheme, I was assuming it was due to mass effect. So what was the pathology? That's why I was interested in knowing the pathology of the fast case
23:53
and like it. It was Ahwad, Peter Theradnoma and
23:60
would he probably have considered it to be a malignant
24:05
type of lesion since it's a very invasive, it's invasive, if
24:09
it resulted in an autoimmune or fish or not.
24:19
We tend to link
24:22
the fish on the
24:26
ground, this fish. Probably the cause there was already an sapphire on the
24:36
left side. So it might be possible that there is a spillover of the, because it had a previous transcereium surgery, and this tomorrow I guess was quite big then. So
24:49
we don't know that this is part of the picture The added to the clinical
24:57
situation at the time she presented to us. So, it might not be related manifestation alone. But for them to have gone through that, that transceiver means, I've been issued that tomorrow was
24:59
already by us to
25:14
the left side. Some other comments, these are difficult
25:19
These are difficult shumas. I mean, the
25:24
way they handled them was really
25:27
expertly. But, again, my other comment was, it depends on, you know, unfortunately, for
25:36
one year, it's comfortable. You know, with experience, we'll find that different resurgence, we'll go for the approaches which they feel comfortable with And, uh, the
25:48
sanctions will follow another type of approach. they used to was very good and they got very good results. Thank you. Absolutely right. Dr. H or I see your
26:03
ollie, you wanted to say something? Yes, Dr. I let me share something with the residents and other colleagues in Africa. There was a book named Micron Resurgery by Robert Rand from UCLA.
26:16
The third edition, it has a chapter by a famous
26:22
Russian Resurgent who presented all these enormous huge PTSD tumor that he operated in Russia because that was the time that they didn't have so many facilities and we don't see this type of tumor
26:39
these days, not everywhere And it's a very good chapter by this person, Professor
26:48
Kana Varov, from for this gun institute from Moscow. It's a great chapter. I'm sure in the library they have with micro neurosurgery by Robert Avenue Ryan, the third edition. It has a great
27:01
chapter on this huge P2 theory at the normal. It's gonna be a very good experience, although they didn't have all the facilities we have these days for P2 theory surgery, but it's a good background
27:15
for you And also, Dr. Osman has a chapter on that. But if I was gonna set a theory in that book, too, it's
27:29
1984, Why Mozbein? I would pose a question. I'm not sure if it was in the second case, but certainly in the first case, at least one of those cases, the carotid arteries were encircled. And so
27:41
it brings up the question of, What measures can you use to try to predict if there's been a. there's invasion of the karate arteries pre-operatively.
27:56
Well, it's a careful study of a proactive image and we'll routinely do
28:07
a geography pre-op to study vessel anatomy and we usually do these reviews as a team that helps to
28:21
have a good view of what is going on pre-operative. And intra-op will have intra-op image availability to guide surgery from time to time.
28:38
The pack system helps us to have you get safely.
28:45
And also haven't burned that in mind. And it seems it's a soft demo. It's a good operating microscope and a gentle
28:59
Not aggressive, two more remover, one can carefully navigate around these structures without significant changes.
29:13
I can ask a question, Israna. Sure. Eric, or maybe others, you mentioned going, going endoscopically, transphenoidally, I think, initially to decompress the tumor.
29:33
How much do you
29:37
think you could get out? I'm sure people would worry about the carotid arteries and the optic nerves. You may not see it. What's your thoughts about that?
29:48
I mean, I think it's really what Professor Nim said. You know, that it's a matter of what people become comfortable with. I saw Yasergil once gave a talk about his experience with pituitary tumors
30:01
and cranial fringeomas and not surprisingly, he did them all from a adrenal preniotomy transylvian and
30:11
managed to get these amazing resections that - and I use the terraonal - the terraonal and trans-celvian is probably like my most comfortable operation.
30:24
And I couldn't do what he did. Now, I couldn't come close to what he did with some of those tumors. I just now, you know, Estrada talked about adding an orbiter zygomatic osteotomy. I think that
30:37
helps with some of the very high aspect With a softer tumor, sometimes it comes down and delivers itself with a more firmer tumor, it doesn't. But, you know, I was just commenting on the fact
30:47
that, you know, I think we, I don't do actually the trans nasal endoscopic, but I'm always amazed by how much our, my colleagues who do that can get out. And we probably would have had them
31:02
start with that just to see how much they could get out. But I think the first case for sure needed transcranial approach of some sort.
31:12
And I have no problem with what was chosen. The second case, harder to tell, I think we only saw one image. It depends how lateral it extended. If it extended a fair bit lateral, then I think it
31:26
would definitely also need a transcranial. If it was more just straight up and down, it's amazing what can be done sometimes from below. And typically the optic nerves in those cases are gonna be
31:37
split out. They're not gonna be way over the top in a tumor that high and they're not gonna be running through the center of the tumor. So you're gonna leave some capsule, you're gonna leave a
31:48
little bit of tumor on the sides when you do that operation. But I think you can do a surprising amount from below when it's a softer tumor. But I take no credit for it because I actually don't do
31:60
those. I have colleagues who do those. Okay, well, Estrada, we're coming up to two hours here. Anybody else have any common, Just incredible cases, we saw.
32:13
Yeah, this has been a fascinating discussion. And just to add to what Dr. Nesbong just said, I think I've had some experience with endoscopic resections of pituitary tumors, but it's amazing what
32:32
the people who are experts with the endoscopic approach can do with scope-based tumors, especially tumors that are soft as this one I mean, they can really
32:45
get very good visualization of the critical structures and can do considerable resection with the endoscopic approach. And I get some comment from Dr. Soiter. Soiter, Dr. Soiter is on the call.
33:13
because they handled a lot of these cases. So that's why I wanted them to sort of comment. We see this almost routinely in my area. Is Dr. Sweta in Kenya professor here? Well, not contact, was
33:26
there any question or address to us? Oh, oh, sorry, sorry, we did, I did address a question to Dr. Chica, Professor Chica. The, my first question of my, my first comment was, of course on
33:41
the, what was the histopathology? That was my first comment. Then my second comment was the investiveness of these tumors, that was my second comment, which I had wanted to make. And then my
33:54
third comment would be, what has already been commented about, about the, I did make the comment that, Daniel Sergeant follows the route, which he feels more comfortable with and you'll find with
34:09
experience, you'll be. Many neurosagens can tackle these tumors in which ever route they may choose to tackle them depending on the experience. But the addition here now, as far as myself I see
34:25
the issues nowadays is the endo-nezzle approach, the role of the endo-nezzle approach, and this is where the endo-nezzle approach now to decide which route to follow, whether to go endo-nezzle
34:40
route to go transcranially. And the first case, I think there was really no route at all for endo-nezzle approach in the first case. But in the second case, quite an above my colleagues would
34:51
actually say that they could remove this tumor endo-nezzle and the ones with the experience of doing that would go ahead and do that So that would have been my comment. And again, to ask my
35:05
colleague professor from Nigeria, did they consider that endo-nezzle approach?
35:14
for the second test. Oh, you didn't consider the regular approach in this place, because the, if you look at the MRI, those I didn't play for the two images. You know, there was a lot of
35:27
extension, superiorly,
35:33
and laterally. Those are the image, the second
35:35
image did not play.
35:38
So that's detected the need for a trans-preneur approach for these two procedures. From our experience here, I don't think, 'cause we see a lot of very big tumors, you know. We're feeling more
35:55
comfortable now, for those very giant tumors heading very high way up. We're feeling more comfortable going straight and trans-preneur because the extent of resection is always superior. You know,
36:09
the solution is in control of the anatomy.
36:13
And for eventual, this is not a soft tumor. When the nasal surgery may not do
36:21
very much
36:24
for the surgeon, we tend to have more
36:29
soft tissue resections but tumors are both per centimeter,
36:35
heading up. I don't know if it's experienced with many other centers
36:42
And in Africa, people don't have the love drop by in
36:49
stage surgeries. So one tries to do what could be safely done. I mean, when I'm in Africa, I don't mean every part of Africa. What could be safely done in one sitting because most patients are
37:03
paying out of pocket and cost of surgeries eventually bi in on the eventual outcome.
37:13
That's good, I can just add one more comment, if I could. In my country, we have neurosagulans who have been trained in skull-based surgery and transcranial surgery, and
37:28
they are quite good in that. And they would, probably most of these cases, involve a recession of the anti-acranial fossa and creating more room for removal of the tumors and nowadays, we tend to
37:43
give them most of these complex cases for them to handle.
37:48
Okay, well, thank you. I think we've had a very, an excellent discussion. I appreciate, again, Dr. Nosebaum, from the National Aneurysm and Tumor Center in Minneapolis for his excellent
38:02
presentation. And I appreciate Professor Nen Dubuzzi from the Memphis Hospital in Nugu, Nigeria. Thank you, everyone, for your active participation. I think, Jim, do you have any further
38:17
comments before we close out? Nothing, I just understanding presentations of incredible lesions. Yeah, very complex problems and very well handled.
38:32
Thank you both, and thank you everyone for participating. See you in a month.
38:38
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