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SI, Surgical Neurology International, an Internet Journal with Nancy Epstein, is a Senator-in-Chief, and SI Digital, an editorially selected multimedia information resource, which is new,
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featuring neuroscience innovations, operative videos, expert interviews, and global discussions for the next generation of clinicians, with James Osborn as its editor-in-chief.
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Together with the Latin American neurosurgeons, sponsored the 4th Latin American International Neurosurgery Grand Rounds, held on the last Sunday of each month.
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SI and SI Digital also sponsor the Sub-Saharan African Neurosurgeon International Grand Rounds over in the first Sunday of every month
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The purpose of these international neurosurgery grand rounds is to expose and provide neurosurgeons with information about global solutions to clinical challenges in neurosurgery.
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The Latin American section is organized by Johan Chokev-Ballisquez with
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the help of Estrada Bernard, Jorge Landruff, and James Ellesman, for an international audience
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A second presentation of the Latin American International Neurosurgery Grand Rounds is by Marcel Bartolucci,
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who works of the service of neurosurgery, pediatric division, inflate, and Buenos Aires, Argentina
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And he'll be talking about hemispheric to me, to whom, when and how
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These Latin American meetings are organized by Johan Choki of Velasquez, who is a Peruvian neurosurgeon or a searcher, who is interested and interested in several vascular, skull-based neurosurgery,
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interventional neurobiology, and stereotactic radiosurgery. He is a PhD which he got from the University of Neurosurgery at Helsinki and the Helsinki University Hospital in Finland
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and he's in charge of the unit of neurosurgery in the regional hospital of Cusco and still continues his research on oncology, neurology, and neurosurgery
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Cusco is located in the southern part of
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Peru, as you see in this map.
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Peru is a name that was derived from the Quechua word implying land of abundance and is a reference to the economic wealth produced by the rich and highly organized Inca civilization that ruled the
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region for centuries The country has vast mineral, agricultural, marine resources, and is served as the economic foundation of it. And by the late 20th century added tourism to become a major
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element in its economic development.
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Favorite destinations of international travelers include Machu Piccho, which is located in the city of Cusco, where Dr. Velasquez does his work
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Okay, okay Okay. And then, yeah, good, it's fine. Okay. It's perfect, no? How do you happen with that? We're going to talk about an hour, okay. I'm going to talk about an hour experience
4:02
about an iforectomy. We're talking about echology. Let me make an encephalum, polymagrigidin and anorezibutin syndrome are the most frequency in the group of patients with this kind of echology But
4:04
vascular volition and stool work syndrome are to another kind of echology. What about the
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background of the history about
4:35
an iforectomy? Mackenzie and Creno in the 1938
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or 1950 used an anatomical iforectomy, but this kind of an iforectomy quite a very good result in relationship to See sure, but if you have a very bad. result about the complication, for example,
4:53
a problem with the MOC, the roses. But was used in 1970, performed a functional emifurectomy. This emifurectomy was a temporal lobectomy, the central region resection. And then a total
5:14
callosutomy intraventricular This emifurectomy was very, very useful for a long time. But in the
5:26
'90s, dell'alam described the vertical emifurotomy. I don't use this kind of emifurectomy, but it's very, very common in the Europe. And the lateral periinsular was described in the same time.
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And mother, ran as a bermure, had a lot of patients with
5:45
this kind of technique I don't have any experience about the industry.
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but I know that there are
5:53
several groups working on it.
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What did we learn after 150 procedures? There is no EC surgery. It's very complicated surgery. We have one there for brain edema, and we prefer to have a post-op with more intracranial space in
6:10
the post-op.
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We have too many re-operation. In that moment, we know that there were technical problems We know that there were technical problems. We know that the myths weren't true.
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Because we have a lot of re-operation in our group. We decided to change our technique, and this is a new technique
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Okay, this is the pre-op. I'm alright. This is the approach. This is the Spanish story.
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Can you make it through screen? Yeah, this is a temporal lobe. This is a frontal lobe.
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We have the,
7:04
the first part is the remove of the pergul.
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We let the ventricle. It's exactly the same if you prefer to reach the ventricle in the temporal lobe or the frontal lobe In this specific case, we use or to reach
7:23
the temporal lobe. But it's exactly the same. Usually, I use
7:30
the frontal lobe first.
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Mm-hmm
7:51
You can see now the ventricle here,
7:57
the temporal heart of the ventricle.
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We never have any problem to correlate
8:06
the vein in this part.
8:09
In the first cases, we have some
8:14
problem with this, this correlation, but really what they never have any problem with this situation.
8:22
You can see the ventricle again
8:27
And we draw the ventricle shape there
8:41
The bantigal again,
8:44
mm-hmm
8:50
Why there is no CSF coming? Did you put a drain before? I don't know why. I promise the CSF is there, yeah
9:11
And then,
9:13
if you want to remove the paraculum, you need to cut the seed and the archery
9:22
We use the coronavirus plexus to limit for the resection of the paraculum.
9:55
In the last cases, this correlation is first, knowing in the final of the intersection.
10:14
When you remove the percolum, all the ventricle surface is easy to see,
10:22
okay? You can see the ventricle, yeah?
10:31
This is the hypo-campus, cornix,
10:35
and then
10:37
we are going to disconnect the anterior part of the hypo-campus and the temporal lung. You can see the iron noise, you can see the
10:49
pre-age of the taintorium, third part,
10:56
and Then,
10:59
They are going to find their pericallosal artery,
11:05
they are the pericallosal artery and you know that all below to the pericallosal artery is the corpus callosis
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This is in 17th school or corpus callosum, touch or corpus callosumum
11:50
We
11:52
have to disconnect the 30 and the posterior part of the hippocampus under the plexus corallus over there.
12:06
And you have to join this part with the posterior colossal to be. Okay. You can see the ironoid there
12:19
Basal Daim
12:38
And you have to join the posterior part of the temporal lap with the posterior part of the corpus callosis. And then we need to remove or disconnect the anterior part of the corpus callosis. This is
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anterior part of the temporal
12:55
The rest of the Perkulun or the Talams?
13:15
Mm-hmm. Okay.
13:23
Okay. This is in our new technique.
13:27
It's similar than the technique that you described maybe 10 years ago. It's similar.
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Who would be the ideal patient? The patient with focal epilepsy, unilateral EEG finding, unilateral amorrhizum, non-dominant emitreal, hemiparesis and amionopia, preserved anatomy, even better
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ventricular megalae and more than 10 kilos. This is the ideal patient because they have a very big elation in the right emifere. This one is another patient similar, but this patient is really
14:08
different. This
14:15
is a very bad hemimagalencephaly with no anatomy. It's a very, very difficult patient to operate. And this patient is similar with no ventricle frontal harm in this. in this case. Okay, this is
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one of the ideal patients. You have a very, you have a, you can see the
14:31
left hemiferus atrophy, and this is the video EEG. You can see the focal epilepsy with very
14:42
clear left side abnormalities in the EEG.
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Okay, I'm going to show you some patient with an unusual patient. This is Eric. Eric is 12 years old boys, no prior history, answered at eight seats with focal seizure, no motor deficits, the
15:06
patient does not have motor deficits. VEG finally spigons, sharp frontocentric and right occipital wave This is the EEG, you can see clear
15:20
right frontal temporal immunity, the
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other one, the other one. And this is the
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image, this is the MRI, this patient was one of the first patients who have a very big mistake, I know that it's very, very common in
15:46
this moment but 10 years ago this patient was in our first patient.
15:56
with unusual presentation of a distribution syndrome. This is the patient we performed temporal lobectomy in this patient because they're having any specific lesion in the temporal lobe. But three
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months later, the patient continued with seizure and this is the video EEG.
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You can see this movement is
16:16
a
16:18
typical continuous partial
16:22
seizure is very, very common in the respiration syndrome. And you can see the right emipheral abnormalities.
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Okay, summary, I think this is not prior to history, answer that eight six with focal season, no matter deficit, easy with a spike sharp weight from the central and right occipital, MRI was
16:53
right temporal and usual lesion, we performed a temporal lobectomy with a big mistake because this patient, today I know that, but in that patient with all that this patient have a temporal lesion.
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The patient to continue with seizure after temporal lobectomy, the patient had progressive, hemiparesis, continuous partial seizure and
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the aggressive wall of the musin syndrome. We performed a peri-insular epiphyrectomy without seizure or cognitive impairment at the moment. This is the MRI,
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opeletive MRI, the van gimmede. Prostivusive encephalitis does not always appear in the classic form with progressive anti-paracies, have a metrophic, continuous partial seizure and dynamic lesion.
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It was, this was our first patient with an unusual presentation of the
17:53
distribution syndrome. We,
17:57
this is a paper who wrote 10 years ago, when 25 of our patients had a typical presentation the resolution syndrome. This is another patient, it's Maria Luz, it's 11 years old woman. CBR, CBR,
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headage and photophobia, trying to connect to any seizure with parastations in the right lower extremity, one seizure per week, not neuro-cognitive impairment, no hemiparesis or fascia. And the
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patient presented with this
18:35
in the
18:40
left occipital lab. This is the, sorry,
18:44
this is the EEG, this is our side, this organizes and symmetrical EEG, brief and irregular generalized parasyphin of sharp, slow wave focusing the left temporal occipital relation. You can see
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here was the original lesion. Yes, this is the progression. You can see the EEG with generalized set bars of this long wave with prefrontal predominance, brief and moderate frequency. Very good
19:14
changes in the
19:17
electrical parades compared to the previous study. Yeah, you can see the atrophic here
19:24
in the place where was the first lesion. The patient is referred to my hospital with this EEG, this
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disorganization, symmetrical, globally slow EEG with the delta range,
19:40
with bactam, bilateral, rapid and pseudo-alpha-remes, predominantly natural areas with high frequencies, with diffuse voltage attenuation, the spike in the left postural area and bilateral, with
19:54
moderate frequency of degrees. The patient is a mechanical respiratory assistant in our hospital, opening and closing the eyes to the boys. It's according unreacted populace of a simple motor
20:07
common, no perecia, no a fascia in the dominant
20:12
emifero. Confused later is an hallucinization of continued partial tissue, but the patient in mechanical rapid Australian assistant with very, very bad prognosis. Okay, summary, no prehistory,
20:25
onset of age 11 with focal seizure, easy focal analysis, acute deterioration with hallucination, lethargy that would be left to go with the pileptic encephalopathy. Continuous partial seizure, no
20:39
motor deficit or
20:42
a fascia with the left emifure. We did the hypnosis of raspousin syndrome. We performed emiferectomy. The patient is seizure-free and a clear recovery. This is the patient I don't know it's
20:57
possible to hear
21:03
it That'd be good. He has a bad speech problem,
21:07
but the patient was in the status epileptical, but another mid-surgeon is possible without emiparesis or
21:18
a fascia. When we have
21:22
a hyperactive raspousin syndrome, epileptive and self alabatic, of preventing the natural cause of the disease This is another patient, it's Samira, 72 or
21:32
all. isolates micron focal motor seizure of the left upper extremity, similar seizure per day, EEG findings with paroxysum of sharp waves with isolated spike in the left temporal occipital region,
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the patient too with status epilepticus, mechanical respiratory system with medication, original MRI was performed normally in another hospital, referring to our hospital at four months. This is
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the
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EEG. You can see the activity in the posterior quadrant of the left side.
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You can see here the side of the baby. Really, really? Oh my god.
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I don't know. Sorry
22:29
Three-pussles.
22:36
Okay, can you see
22:42
it? Okay, okay, we can guess. Okay, this is the MRI of the patient. You can see
22:49
the posterior quadrant abnormality. The
22:56
patient didn't have a parisia. And we decided to perform And
23:02
posterior quadrant discrimination with temporal lobectomy. Five kilos of whey, no hemiparesis. One week later, the patient with similar seizures, and we performed hemiparactomy. No seizure,
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this same surgery. The bangin myth. Not only can patients weigh in less than 10 kilos undergoes surgery, but they can also undergo re-operation When severe hemiparactomyencephally epileptic
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encephalabartic, again preventing the inaugural course of the
23:34
disease. Okay, what about the result? You put all the patients together, the rate of seizure-free is 73, but it is dependent on the theology. And the amygdala clearly is worse. Rasputin or
23:50
vascular lesion are better. Is the patient have bilateral lesion, a bilateral EEG finding? The result is worse than another kind of patient
24:03
What is the patient continue with seizure? They are just two options. Is the control lateral seizure onset or incomplete
24:17
disconnection? Unfortunately,
24:29
the most common situation is incomplete disconnection, no, control lateral seizure onset. When we decide to re-operate the dispassion always, we operate dispassion always. As said, for a clear,
24:32
independent control lateral seizure onset Okay. If you see in our first series, we have a very high re-operation rate,
24:44
23 of the patient need a second surgery. But you can see that the group here, with the re-operation, we have 83 of patients become angle one, because in this group, on this theory, we have
25:03
serious surgical technical problem. In the last 54th patient with a particular reception, only three patients under one re-operation. Clearly, we have a learning curve of this kind of patient.
25:17
Okay, what about the complication? Turn on the penance technique. All the technique are good. They are no different between the different techniques. And the complication is the volume right of
25:31
blood love.
25:34
This is the patient who has a coagulation problem after surgery.
25:41
This patient was, we have just one patient that, this is the patient because we have a V enough for post-coagulation, the hydrocephalus is one of the complications. We have the right of the
25:58
hydrocephalus in our patient is more or less 10
26:03
The cranial deformity is another kind of complication. You can see how the healthy emifers go to the other side and you can see in the score rate, the deformity. And the fever is a very, very
26:20
complicated problem because we have a fever in 100 of the patient after this kind of surgery. And it's very, very difficult to convince the pediatrician that is no efficacy. infection in this
26:35
patient. And the fever is the big problem, it's not the infection problem, it's the inflammatory problem.
26:47
This paper is very interesting because the group of use the kids
26:55
in patient database and include 552 hospital.
27:02
They can see the admission increase in the last 10 years, and the mortality was more or less 1 during the specialization, but the most important thing is this that, is hospital volume fever than
27:20
two, emiferectomy per year, have an increased risk of complication. You have a lot of emiferectomy, You have less complications.
27:32
What about the functional aspect? This is the paper from Cleveland Clinic. The group of patients was 115 patients. 83 work independently. 87 work with a system. 8 can not work. 70 are able to
27:48
speak. 42 patients of those over six years also can reach a TIF activity. 27 have behavioral problems 6 are trained at a school regularly, but this last part is
28:05
the most important.
28:07
21 of those over 18 all have paid employment. All these patients, the majority of these patients will need familiar government assistance in the future.
28:21
What about the cognitive aspect? This is a paper from China You can see the, I will write your prayer practice IQ.
28:32
two over 23 patients with normal IQ. This is the average possibility. With 13 patients, over 22 patients with normal IQ, and with one, are the positive predictor of possibility of IQ changes. I
28:49
believe it answered after one, there is good, sorry. No contralateral possibility, this chair is good. T-shirt free is good And less than five years of preoperative C-shirt duration. What about
29:03
the functional aspect? The one of the most important functional aspect is the motor aspect. The motor aspect decreased immediately after surgery, improved at six months and returned to preoperative
29:17
state after one year, more or less, except for the ham. The ham never improved The ham
29:29
never go again go again. like that before.
29:34
And the gross motor function classification scale is simply improved and periodic evaluation of the stability inventory in this bar by more than 20 points of the scale. Recommendation, many
29:49
techniques, non-is-wearer, all are good. Choose one and stick with it because
29:56
the learning group is very, very important My, I know that it's preferred to start with friendly anatomy, even with ventricular megalae. Do you need a spirit of the good team, the anesthesiology
30:11
and the therapies is very, very important and job delay is the time is brain. This is now our routine in the Opital Garochand monocides. We need a lot of people to work in the epilepsy surgery
30:30
program. and really we need all of them. Thank you. Thank you very much. Thank you, very good. Very good, very, very interesting experience. One, the question, what was the incidence of, I
30:45
mean, what's the incidence of a shunt, of needing shunt when you open on the tavenge call? Do you need to put a shunt? Is a large number of patients that you need to put a cyst of peritoneal shunt?
30:58
More or less 10 in our cereal. But in the last 50 patients, we used the external drains for all the people for three or four dates, more or less. This helped to the puzzle overall for the fever
31:15
because we need CNF sample in the majority of this patient. That's right, on the blood itself. Yeah. You had a percent Yeah, it's a
31:28
good point that you say. 20 of the patient roughly, 20 or 22 have an independent life, that means 78 of the patient still requires some support, you know, that's at
31:47
the figure that we have to work around as the surgeons, you know, I mean, as the surgeons, we don't have to think post-operatically either or infection or death or whatever, we have to think as
32:01
pediatric. They are big different between the different of of etiology. The ME. ME. ME. and
32:08
Cefalee, all this patient with ME. ME. ME. and Cefalee, the program is it's really really bad. But the rest of us in order the Basquale Alicia is is is is together. Yeah. It's better. Yeah So
32:21
you are you given steroids perioperatively? And does that seem to have any impact on the fever? Thank you. Sorry. No, no, it's no problem. So yeah, and
32:36
again, how's the conversation with the family? Of course, in your cases, and Cesar Petros as well, you have patient that is seizing, it's a physical deficit, not that leads with the family to
32:52
accept the surgical procedure per se, no? But yes, I am starting with that number Even if he's 40 that have an independent life, still have 60 that don't have an independent life, no? Anyway,
33:09
that's it.
33:11
I leave that too, to the rest of the people. But despite that, certainly I improved compared to the
33:19
preoperative state correctly. Oh, yes, absolutely, no, no, I'm saying this as a new challenge as a surgeon.
33:26
Our challenge is not to reduce infection, because it has been menial, reduced complications, and nothing like that. I mean, our challenge is how to do surgical procedure at this connection that
33:39
will minimize the cognitive effect of the patient. How to control it, how to cut the wire that goes to the seizure, and how to keep those that go to the prefrontal cortex or something like that,
33:51
no? Yes, for Fernando has his hands raised, Dr. Palacio? Yes, I have a question, please, Dr. Vartilucci. There is a limit of age for
34:05
do this surgery or a better prognosis. So the last patient was maybe 45 days old It's all today that the
34:20
age is not
34:23
the limit for us, no, no, no No, no. If we have a patient with an amygdala encephalae or a lot of teacher, we decide to operate very, very fast, very fast. Now, when neurologists are
34:38
convinced about that this is the best way to improve this patient. Otherwise, it's very, very important, the support of the neurologist. Because the decision is not just the neurosurgeon, it's
34:51
the neurologist, tooMm-hmm. Your point, yeah. Maybe 10 years ago, the resolution and Cephalitis did not operate this patient
35:05
without hemiparasis. And
35:13
this group of patients will be operated 10 years later without with the eparasis and serious
35:22
neurocognitive environment in Korea. In this moment, we operate very, very fast of this patient.
35:31
So, on the flip side, when you see, when you evaluate these patients, are there certain criteria that would lead you not to operate?
35:42
Mmm.
36:04
We need to work together with the neurology because the first step is maybe medication, some drug about, I don't know, corticulitis or
36:19
immunoglobulin, but when the patient is
36:25
no improved with this kind of treatment, the surgery is very, very important and very fast because the result when the patient is operated
36:40
fast is better than the patient was wait for a long time now.
36:48
So you invariably operate on someone presenting with status epilepticus? Sorry? Someone presenting with status epilepticus? Yeah, sure. So I suspect you wouldn't delay, you would proceed. Yeah.
37:05
We have maybe 10 patients were operated in the status epilepticus? Yeah
37:17
We never wave with this patient. We operate very fast in this group of patients, yeah.
37:26
Any other questions, comments? Jim, do you have any comments? No, it's an extensive experience that they've accumulated that's
37:38
probably not matched
37:42
by other centers, it's just extensive experience
37:47
And the issue with the experience is the same with any surgery. Marcello showed that the hospitals who do two cases a year have poorer outcomes than other hospitals. But in order to have six cases a
38:03
year, at some moment you need to have two cases a year, you know. I mean, there's no way that you can all of a sudden So, one moment you have to start, right? And that, yeah. And, and, and
38:15
burn the brand or that. And that happens with, with any specialty, you know, rascal and surgery, or particularly, you know.
38:25
I wonder if
38:28
Dr. Patrick has any comments you want to make?
38:34
Dr. Patrick, you have comments in there, you are the epilepsy guy on the other side.
38:41
No, you are mute, you are mute, unmute
38:48
I am mute, unmute, unmute, unmute, unmute. Hi,
39:01
I am Kuchar. We have a small experience with respect to the series of Marcelo But in three cases that we operate on, we do go pomata many years ago. First, we said the resection of the central
39:25
cortex now. And there were two kids, and
39:33
one year of life, one year old. And there were hypo-balamic shock And then, with the
39:48
bile mode technique, it's best for this patient, for this,
40:07
we put very interest in the blood of lots No, uh,
40:17
for a better, uh, overall. And if it's necessary, we make it in two steps, the surgery. But
40:32
the same that said, Marcelo.
40:37
Yeah, the thing is that, and I do remember, when I was in at the Cape Town, I assisted Peacock in his second hemispheric domain. And it was the whole thing, no? I mean, the variation of the
40:49
corpus callosum, your commissure, everything now, no?
40:55
And I have seen, because, well, I didn't know, because UCLA was a pioneer in that thing of the limited, Ms. Ferret-Thomas and working with Gary Mathan, as a such. And then the
41:13
point is being again, that the blood loss and the teeth less than 10 kilos.
41:21
It's not that the blood loss in partial, you know, I mean, you have to be extremely careful that the 10 kilos a nine kilos kit has a volume much less than at the teenager, of course, we all know
41:32
that. And then it's actually what Cesar is saying, and it's Marcelo mentioned that as well, and then he'll do it maybe in stage way You at the can do it as a such, but that's a very cool area for
41:49
us was very, very helpful to the pop up.
42:02
The patient are really better with this kind of surgery if you compare with just interventricular disconnection. Because the space is better for this patient, the pop operative is very, very good
42:10
And we could see in your video that the blood loss was minimal if any. It was a
42:17
very, very good blood video.
42:19
Like the majority of the people, I show the best cases. I don't know, we have a lot of cases with different, I mean, megal is really, sometimes it's very complicated to find the ventricular, to
42:34
find the landmark, the anatomical landmark, when you have ventricular megalae, it's easier to
42:41
operate this kind of patient, yeah. Yeah, yeah Will Julianna do you have any comments to make about this?
43:03
I don't know, I guess maybe she's not there. Or Savi, do you have any questions, Dr. Argoa? Thank you so much for this presentation. It was definitely very eye-opening to see your progression.
43:07
I know you mentioned multiple different techniques on how your program has approached this. And of course, since there is such a large learning curve, I was wondering if you saw any changes and how
43:18
many cases were needed to, like develop, like lower complications, or if that changed at all as you were switching techniques.
43:30
When
43:39
you compare the vertical technique with the lateral techniques, the solar are rather in the vertical technique, but I know on shore that in this group of patients,
43:54
they are few aminegal encephalae. This is the problem, the aminegal encephalae, because it's very difficult to find a landmark. It's very difficult to use the
44:08
classic technique, surgical technique. Sometimes you have to improve,
44:14
improvise these different techniques. Sometimes I need to remove the frontal lobe
44:22
because it's impossible to reach the mid-line. I
44:30
believe that you have to choice one technique, I figured it, because it's very, very important. The learning group is very, very, very important. Yeah. Thank you very much. I'm going to learn
44:30
it every day. Mm-hmm, a good point, Marcelo That is the good point, steep to one technique. No, I mean, just.
44:54
They are not chasing.
44:58
The techniques are all similar. The result is exactly the same. Yeah.
45:06
Okay.
45:10
Well, I think, I think we have two excellent talks. Thank you. Thank you very much Thank you. Yeah. I don't think if there are no
45:20
more comments or questions, we'll plan to sign off and resume in a month. And thank you for here. Thank you,
45:30
the guys. Marcello Julian and Cesar came to the podium. What a pleasure to be here Yeah,
45:38
thank you. Thank you. Thank you. Thank you. Okay. Okay. We'll see you next month. See you next month. Bye. Bye. Bye. We hope you enjoyed this presentation.
45:51
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SI digital innovations in learning
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is seen in 158 countries in the last 24 months. It's an all video publication with 24, 000 viewers and 15, 000 on podcasts who are listeners each year. It's web addresses SI digitalorg, web
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addresses surgical neurology is SIglobal. Both are free to everyone everywhere where there's an internet 247, 365, and it is the goal of the foundation supporting these information resources to
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help people throughout the world
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SI is now offering this program. and all of this program on podcasts, on Apple, Amazon, and Spotify look for us and I digital.
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And the foundation supporting these programs also has a medical news network, which is dedicated to bringing truthful medical and science news to the world. It's medical news should have been depend
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upon all of these programs are copyrighted by the James I. and Carolyn or Allison educational foundational rights are reserved. Contact Dr. Osmond is email listed on the slide. And we thank you
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for watching the video and hope it's been helpful.
