SNIDigital Innovations in Learning

SNI, Surgical and Rology International, and SNI Digital Innovations and Learning in association with the Sub-Saharan African Neurosurgeons

presenting another in the monthly series of Sub-Saharan Africa International Neurosurgery Grand Rounds

The general topic of the Grand Rounds are global solutions to clinical challenges in neurosurgery. The moderators are Estrada Bernard and James Osmond.

This Grand Rounds was held on Sunday, October 6, 2024. The first talk will be on experience in treating hydrocephalus

using third ventricular fenestration and

choroid plexus coagulation. How I do it? And advances in intrauterine surgery for myelomon ingasil.

It will be given by Sammer Elbaaba, who's the chief of pediatric neurosurgery, and the director of the Leon Pediatric Neuroscience Center of Excellence at the Orlando Health Arnold Palmer Hospital

for Children.

where he's a professor of neurosurgery of the University of Central Florida, College of Medicine in Orlando, Florida.

According, I want to welcome everyone to the SNI Digital Global Solutions to Clinical Challenges in Neurosurgery. We have these monthly grain rounds where we come together and talk about relevant

topics in neurosurgery as can be addressed in Sub-Saharan Africa. I'm looking forward to an excellent program this morning. We have, we'll start with Professor Samra El-Baba, who's Professor of

the University of Central Florida. He will be talking about endoscopic thermatriculostomy and plexectomy And that will be followed by Dr. Ben Matuso, who's at the Kajabi Hospital in Kenya. will be

describing their experience with ETV and Plexectomy. And then we'll have from Nigeria, Professor Bhagubon, group talking about

spinal instrumentation, decision-making in Sub-Saharan Africa. So welcome

to everyone. I want to make special reference to Dr. Elbaba He means a lot to me. We recruited him to be one of our residents and he trained with us at the University of North Carolina. So I'm

very proud of all that he's done and to see the

contribution that he's making. He's, as we were talking about earlier, he's not doing innovative work with ETV, but he's also, as he has an active program with the in utero fetal.

surgery repairing

myelomeningosils.

Dr. Osman, before we get started would you like to make any comments? Oh, welcome to everybody. Let's go on with the program.

Alright, well, Sam, you can share your screen. Welcome again. Thank you so much for agreeing to participate with us.

Thank you. Can you see the screen now? Yes.

Okay, Professor Bernard Strada, greatly honored to be here with you. Professor Osman and this wonderful group of colleagues from around the globe.

Truly privileged to be with you here today and I would love to join you future grand rounds to learn from you all. One of the topics that's close to my heart is taking care of babies and children

with. how to selfless and sponobifida. I'm a pediatric neurosurgeon in Orlando, Florida, and we have busy programs both treating sponobifida as well as innovative work, treatment options for how

to selfless as well. As we all know, pediatric how to selfless is an ongoing global problem, and not only in Africa, but all over the world. And if we look at the science behind treatment options

about what are the outcomes so far, the truth is none of us has a better option to treat than the other. And when the double NSCNS tried for years back to look at true guidelines trying to find out

if shunts or other endoscopic treatment options like ETV or EDCPC, which one is better? The final result was none of them is, the truth is both are equal good options we have to guide the treatment

based on the patient environment, and the outcomes of such programs. When we look at ETV, in

this topic, Theverine to Colostomy, has been historically a great treatment option for patients with obstructive hydrocephalus, and when an optical colony from Toronto and the group of the HCRN

looked at the success score, ETV success score, clearly you can see in the ETV success score that age matters, as well as the etiology, as well as the history of previous shunting, so a child

with aqueductus stenosis, 10-year-old, should have 90 chance for ETV success, and a baby who's a one-month-old with postinfectious hydrocephalus, the

success rate can be really low below 50. Then Professor Ben Worf, with the excellent work he did in Bali and Uganda, and other colleagues in Africa, have looked closely at what about CPC,

choroplexis choriasis. If we add it to the ETV, what does it do for success rate? Well, the first data they came up with almost 20 years ago in 2005, the ETV CPC is more successful than ETV alone

when it's performed an infants under the age of one year. That's the first data we have. Number one, it's safe. Number two, it can add to the ETV success. And number three, it's best when it's

done under the age of one year And how does it work from pathophysiology standpoint? We all believe that we have choroplexis producing CSF in all ventricles, even in the centric canal, the spinal

cord. So the CPC we're actually targeting is primarily in the lateral ventricles, bilateral lateral ventricles. And the body of the ventricle,

the glomus near the atrium, the occipital horn, and the temporal horns We don't go after the coronaplexus in the third ventricle or fourth ventricle.

we can perform a conduit at the floor of the third ventricle and bypass the area of likely blockage near the aqueduct. In addition to the CPC, this can improve the success rate for ETV. Then more

data came out three years later, also from Eastern Africa, from the group,

and Embali and Uganda looked at ETV CPC, not only good for post-infectious or equiductus stenosis, hydrocephalus. Also,

in some pathologies like spandophidae, it can be more durable, actually, than shunts. And they developed their own Cure Children's Hospital, ETV Success Corps, that mostly focused on

post-infectious etiology, looked at

the degree of cauterization, status of the equiduct, and the status of scarring within the pre-pontine cistern People started questioning the outcomes. How about neurocognitive outcomes? Well,

more data started coming out. A year later, after the paper I just showed you, shown that both ETV CPC and SHUNS can have similar neurocognitive outcomes when they looked at intellectual function

related to Bayley's core system and other neurocognitive and neuropsychological testing, they found that actually both groups, SHUNS and ETV CPC have the same outcomes. Well, in North America,

people started questioning those outcomes coming from Israel, Africa, and can we replicate the data? And then the Hatter Selfless Clinical Research Network did a study. They published five years

later, exactly 10 years ago, look at ETV CPC in North America, and they found the early ETV CPC experience demonstrated that this procedure has reasonable safety and we need prospective randomized

data Then, around three years, two years ago,

National Institute in Health invested millions of dollars to start this prospective randomized trial in North America comparing shunts to ETVC-PC in the first two years of life. And there are 16

centers in North America enrolling babies with different etiologies except post hemorrhagic hydrocephalus in this prospective randomized trial to my knowledge so far, 120 babies have been randomized

and here in Orlando, where one of the busy centers contributing to this prospective randomized trial. And we expect to see results in the next two years. People started looking at the technique.

Doesn't matter if we do it with rigid endoscopy or flexive endoscopy. And the reason is the Professor Worf and others focused on the technique of flexive endoscopy is because we think that maximizing

the CPC in the area of the temporal horns we'll use in the flexible endoscopy, will lead to improved outcomes. So after the state of started coming out in Florida, we started doing ETV CPCs with

the rigid endoscope. And then I started feeling that, you know what, we're seeing some good results, but maybe not the results I'm seeing from Africa. So started again, maximizing the use of ETV

CPC with the rigid endoscope here You can see, you look here carefully, you can see that I did good job with the CPC all the way to the atrium, but what's happening in the temporal horn? And

that's what's missing without using the flexor endoscopy. And data started coming out showing comparing flexible, rigid endoscopy, showing that actually flexor endoscopy makes a difference. My

journey took me to Uganda around six years ago, at once, been good time with the amazing group, and Bali, Uganda. Children's Hospital, amazing experience working with colleagues, all of them,

amazing colleagues, well-trained skilled surgeons, all of them worked before with Ben Worf, and learned to use the flexible endoscopy technique from this wonderful group to treat babies in Uganda

with different etiologies for how to selfless. The technique is done using the babies in the lateral position, all of it doing with a fabric, optic digit, and discope. And you can see here one of

the videos from Uganda. You can see the debris. This baby had this at the core of plexus. Now we're looking at the right ventricle crossing the midline. Now this is the left ventricle. And now we

go

this is the left occipital horn We go back to the

now this is the fourth third ventricle. Now looking back at the aqueduct, aqueduct is open. We'll look at the fourth ventricle. Now we go to the floor of the third ventricle, basilar artery,

clivis. The technique is done there without the fogurti balloon, just using the monopolar cottery to do the opening, then going all the way to the pre-pontine cistern. Here we can see more

scarring, and here we can see the sixth nerve all the way down within the pre-pontine cistern. There are two types of flexible endoscopes, paparoptic and digital in North America. We have the

digital one, which I'm using now more in my practice. Both are excellent. Maybe the picture is better with the digital endoscope, but they do both do the job. This is a recent case here in

Florida using the digital flexor endoscope, going through the small frame in a front row, into the third ventricle. This patient has sponobifida. You can see interthalamic adhesions

And then now we're looking at the interthalamic adhesions.

The mammillary bodies, now we're targeting doing the ETV

after they're using the balloon to dilate

the ETV, and now we're looking into the naked basilar artery within the pre-pontine cistern confirming no further pre-pontine adhesions. Now we go back to the ventricle and we start doing the CPC We

start again, we try to avoid any injury to the ependema or to the coroidal dussels feeding the thalami and taking our way down to finish the CPC. Now after we perform the CPC within the glomas,

this is a glomas of the ventricle, now we start targeting the temporal horn by you doing a special manoeuvres to turn the endoscope tip to get us into the temporal horn and maximizing the CPC Again,

the trial, now 16 centres, the criteria are very.

fixed babies under the age of two years old. They have to have symptomatic hydrocephalus and again the babies are placed in the lateral position. This is the right corner of the anterior front and

all this is the CPC entry site and

we now modify the technique. Sometimes we do with the rigid endoscope to pass time. I start with the rigid endoscope with a pedoscope finish the ETV like in this case after the ETV has been done

coming back to the

ventricle and performing the CPC with the rigid endoscope and then once we get to the temporal horns we can switch to

the flexible endoscope to save time. So there are different ways to do it. Now I'm at the temporal horn maximizing the CPC all the way internally within the temporal horn and this is the part the

rigid endoscope will never show us. Switching gears for a few minutes, talk about Spana Bifida.

We know this is similar, it's a random uncontrolled study of a chord plexusectomy, I guess, and what is in the other arm? One arm is to treat, remove the chord plexus from both sides, I assume,

right? Yes, so we do not remove it. We do not do plexectomy, sir. We do coral plexus cauterization, maximal targeting 90 to 95 of the visualized coral plexus in both lateral ventros.

And randomizing one arm of the study is shunned, and the other arm is ETVCPC. And we're looking at neurocognitive outcomes at one, three, and five years, and looking at DTI cryptography, looking

at the impact of the reduction of ventricular size on the white matter tracts. That is coagulation. Why did you choose coagulation rather than removal? The truth is that we're following the

technique

developed. described by Ben Worf, and that technique showed excellent outcomes from the African series that was published. So the same technique is being used. It is safe, it's efficient, it's

quick, and we do not need to do plexectomy. And the second part is technical. Doing plexectomy requires retrieval of the core plexus if you do it,

and you cannot do it through the plexa endoscope. The working channel is extremely tiny, and you have to use much wider opening to get the core plexus out. And there's no scientific evidence behind

doing it. Thank you very much. Okay, go ahead. Thank you, sir. So switching gears about the use of post-natal repair. As we know, the standard of care worldwide for repairing spanabifida is to

perform post-natal repair using for all types of spanabifida. So

When we look at the pathophysiology of

a hydrocephalus in patients with malamininoseal, we know that from the high-end herniation that happens early in pregnancy, we develop the Chiara top two malformation, which leads to the fourth

ventricular after the obstruction and hydrocephalus. After

we talk about ETV, I'm just going to jump and talk about the mom's trial There is a trial, prospective randomized trial, comparing fetal repair,

doing prenatal repair under the gestation age of 26 months compared to the standard of care and the primary outcome was looking at mortality, rates of shunting at the age of one year, and the second

outcome is looking at motor and cognitive outcomes. This trial compared prenatal to postnatal repair came out in 2011 New England Journal of Medicine showing significant reduction in the rates of

shunting from 80 down to 40 between the standard of care posted into repair and prenatal surgery groups. And they found significant reduction of the high-embrane herniation. And the take-home

message from the mom's trial was that performing fetal repair for span Bifida under the age of 26 weeks of pregnancy can reduce the rates of shunting for hydrocephalus

in half. It can significantly reduce the rates of high-embrane herniation, and it can improve motor and cognitive outcomes at the risk of pre-maturity, as 10 of the babies would be delivered under

30 weeks of gestation. Late Professor Tolopan from Vanderbilt came out in 2016 before he passed away with a paper looking at the status of severe ventricular megalic prior to fetal surgery and found

that the rates of that the severity.

of hydrocephalus in fetuses before the fetus surgery under 26 weeks can impact the outcomes of shunting and all of them will end up with shunts. We developed a program in St. Louis and now in

Florida. We follow the same criteria from the mom's trial, criteria for fetus surgery, the

lesions have to be between T1 and S1 There has to be evidence of high membrane herniation as well as the gestation age has to be under 26 weeks. We do fetal MRI. We can see here the high membrane

herniation and the malamininucile. So far, we have performed over 120 cases between both programs. After the uterus is expanded, here you can see the spum bifida ex-smilamininucile is

shown through the ampehstoratomy defect, we perform micronair surgical closure for all from three-layer repair doing re-neralation or re-tibularization of the plaque hood followed by approximated the

dura and the skin. Initially we started doing two-layer closure then we started doing microsurgical three-layer closure. Here we're doing re-tibularization of the flat plaque hood by re-tibularizing

it followed by closing the dura followed by closing the skin. Babies are born 90 of them the heels are woke at the backs are well healed and most interestingly when we do MRI at 32 weeks of pregnancy

after the fetal repair we see the reversal of the key arm malformation because there's no more CSF leak at the spum bifida side. Then we started looking at what do we do about those babies after

birth. As you know in the mom's trial I mentioned earlier they only looked at shunts for those patients. What we started looking at our group in St. Louis and now Orlando is look at ETV and now ETV.

CPC for this group of patients who have fetal repair for spinal bifida. Like in this patient has minimal Chiari and had fetal surgery before. We do the ETV, after the ETV is done, we do the CPC,

we monitor the ventricles coming down, three years later we can see the ETV remains open and we monitor them with cognitive outcomes as well And those patients, as you know, respond differently,

they can have

unusual, unfavorable anatomy of the fourth or third ventricle from the intracellanic adhesions. But still, we're doing ETVs in all of them and we're successful in getting the ETV done by using,

you know, both a combination of frigid and flexoendoscopy. We have very low threshold to put shuns in this group, obviously, if they have progressive macrocrania or worsening ventricular sites.

And now, if we look at the mom's trial, the mom's trial Chumpting rate was 40 in St. Louis. We are at 27, and now in Orlando, we're in the range 25. We publish our data. Look at our first 60

feet of surgery cases. Look at ETV outcomes. And when

we compared ourselves to the ETV success score, as well as the data from telepan paper I shared earlier, we found that if we do the feet of surgery over four months of age, and the babies did not

have feet of ventricular megalea more than 15 millimeters, which is the severe hetero-selfless, those patients have better chance for success. Recent data also came out looking at ETV CPC for this

group and showing that ETV CPC has higher success than ETV alone in meta-analysis studies. Should we do it for everyone? The answer is no, we should look for favorable anatomy This patient is a

favorable anatomy, this one does not,

hearings. Great respect for Ben Worf and the amazing group and different groups in

Kijabi, Kenya and Bali, Uganda. I remain a loyal student continuing to learn from those amazing people. Greatly honored to recently join the efforts of New York Kids, which is a global initiative

now, to trying to expand ETV CPC-Flexa Indoscopy Education worldwide. I know that more than 10 countries have been served by New York Kids over the last two years. I had the honor to be involved in

training, setting up new programs when New York Kids in the last two years. We did Jordan last year, and I just got back from Armenia recently, and I know many programs in Africa now are moving

that direction. And I will conclude by saying thank you Professor Abunard, Professor Osman for the

to be with you here today and I'm ready to listen for my colleague from Kenya and to have a discussion. Thank you. Thank you, excellent presentation. Excellent works, and I really appreciate that.

Thank you, sir. One quick question. So you defined complete cauterization. I assume, how do you define that? Does that, just by definition, means you entering to address the coral complexes in

the temporal home? So the key is to maximize the CPC, or let me call it safe maximal caverization, which means the

goal is to maximize the cauterization of the visualized coral plexus and bilateral ventricles without interfering

with a third ventricle or fourth ventricular coral plexus So typically, we started the framing of Monroe. cauterize gently in that area given the proximity to the septal vein and thalamstrae vein,

moving backward, cauterizing the body, the curoplexus of the body of the ventricle, being careful not to interrupt or cauterizing the curodo vessels feeding the thalami. Then once you get to the

atrium, you become more aggressive and maximizing the cauterization for the glomus and the curoplexus in the atrium Then at turning the endoscope clockwise and upward and getting into the temporal

horns, and that's the value of flexible endoscopy to maximize everything that's in the temporal horns. Then crossing to the other line with or without septostomy depending on the status of the

septum and doing the same technique on the other side. The goal from reading all the papers and looking at all the data, the goal is 90 to

95 so that you can make a difference. And to reach the 95, FLEX Windoscopy is key. Yeah, yeah. Thank you, Sam. Does the

Cori PLEXis regrow or repopulate after coagulation? I'm not familiar with this area. So can you explain that to our viewers? No, sir. When we go back for redo cases and we visualize the areas we

perform CPC before, almost always you're looking at a naked ependema with our Cori PLEXis, especially if you hit the feeding coroidal vessels at the region of the glomus. Once you cauterize, Cori

PLEXis, the correct technique, when you come back, it's dead and it's absent, actually, and you look at a naked ependema. Interesting What's the, just enjoying the standard? CPC procedure,

chord, plexus, coagulation. What's the morbidity mortality for that? So the mortality in RCR so far is 0. There's obviously small risk of mortality published by the amazing groups in Africa.

It's very low. It's in the range less than 1. And it's typically related to mortality from other causes. But the typical morbidity is seizures. Transient seizures can happen. One of the published

groups looked at one out of four babies. After ETVCPC

they may have

transient mild seizures in the first 24 to 48 hours. We typically do prophylaxis with Kepra and some

people do not do prophylaxis. And it has to do with the amount of irrigation as well as the amount

of pneumocephalus. You have a lot of air bubbles and eventful and some. colleagues, claim decisions can be related to heating the CSF. That's why the right technique is that you do CPC three,

four, five minutes, stop due irrigation to cool down the CSF. The other morbidity obviously related to CSF leak, which is typically an indication this is not working and you have to go in the

direction of a shunt, there's also a

small risk of interventricular hemorrhage while you're doing the CPC. And I would like to emphasize on the importance of the learning curve. If you're a new surgeon doing ECV CPC with the flexor

endoscope, there is a learning curve. And in my hands and hands of many colleagues I worked with, it's around 10 to 20 cases. It's very different from rigid endoscopy and requires learning,

learning it in the lab or work assistant colleagues doing it. It takes around 10 to 20 cases to figure out the anatomy with the flexor endoscopy. based on the technique. Excellent, with a sequence

matter, ETV and CPC. I mean, I do believe it matters because remember, the key of this procedure as far as the ETV, as CPC is I think on the cake. We believe CPC adds 10 to 10 to 15. The worst

thing we can do, we start with the CPC, we cause a hemorrhage, then you cannot do a safe ETV So ETV first, always.

Okay, well, thank you very much. We could, are there any burning questions now? If not, we'll have Dr. Ituso go ahead and talk about the experience at Kajabi Hospital, and then we can pose

questions to both of them. So Ali, you have your hand raised, go ahead. Yes, thank you very much for such a nice talk You mentioned about autonomic adhesion in most of these cases. As far as I

know, the adult people very rarely we see this on the anatomy lab. And is it more frequent dynamic atation in the pediatric group or in the prenatal group, in comparison to the adult or they

separate later, because I'm not familiar with this. I appreciate you comment on. Thank you. Thank you, sir In general, patients with sponobifida or open Europe to defect, the anatomy of the

ventricular system, a third ventricle is typically associated with either a very large mass intermediate, which we all know, as well as into thalamic adhesions. And typically they do not have any

clinical implications, but with you try to do ETV, typically the into thalamic adhesions, if they're in the posterior half of the third ventricle, they're irrelevant. If they're the anterior half,

they're two options. Some colleagues advocate to, you know, retract them to do the ETV. I'll cut them, I heard no clinical implications. I've never done that and I'm not planning to doing it.

But in general, by doing careful hydro day section, you put the tip of the endoscope near the floor of the third ventricle and tear it to the mammillary bodies with irrigation, this intercalamic

adhesion. You'll be able to push it so you can get your ETV done. In the adult population, as you know, we don't do usually a lot of ETVs for adult patients with spongrifidad. But in my

experience, the cases I've done in the adult side or teenagers, they have similar

anatomical variations in the third ventricle, but not the same degree in pediatric. To answer your question, probably as we get older, we remodel the anatomy of third ventricle and those

interthalamic adhesions become more embedded within the thalami and not becoming a real anatomical entity and young babies. you very much. I really appreciate it.

It's strategy and muted.

Dr. Osman was asking how long you give prophylactic antibiotics?

Prophylactic antibiotics, we only do 24 hours and prophylactic, cat prophylaxis, we do it for three days. There's no science behind it Okay, thank you.

Thank you. Thank you. Thank you so much, Samra. Excellent presentation. Let's move ahead with the. The second talk and discussion will be given on the endoscopic treatment of hydrocephalus in

Kenya, the Kajabi Mission Hospital experience This talk will be given by Ben Monteso, who's at the University of Nairobi in the Department of Neurosurgery in Nairobi, Kenya.

And I think he is located at the Kajabi Mission Hospital in Kajabi, Kenya.

Dr. Matuso, welcome. Thank you so much for sharing your experience at the Kajabi Hospital in Kenya. I think there's this combination with Dr. Elbaba and then you explaining your experience is

very helpful. Please. Thank you, thank you very much for the introduction.

I hope you can hear me. Yes. I'm a neurosurgeon working in Kenya. I currently work in the military hospital. I've had my short stint in Kijanapi where I've managed a lot of patients with

hydrocephalus

and predominantly, this has been the pediatric population. So I'm going to be sharing my experiences with you and some of the things that you have learned

So, I'll start by a short

overview of hydrocephalus in

Kenya, and we see about, based on studies that have been done before by

WAF and senior colleagues here, it is estimated that we see about 2, 200 new cases of hydrocephalus in Kenya.

And by and large, the leading causes of deontric hydrocephalus

here are congenital, and this is from a study that I did in 2022 in Kenaton National Hospital, which is a largest referral hospital in Kenya. But

from the studies by wife in

2010, most of what he found was post infectious. So it does seem that the years go by we are seeing fewer and fewer. infection care

and more of the congenital causes of

hydrocephalus. I wanted to just have this light to highlight

what are the key differences between hydrocephalus in our setup and probably what you'd see in a developed country.

And what is that we have a higher incidence, the incidence

is emitted to be of 148,

but 100, 000 bats compared to developed countries which is about 79

And that actually puts the largest burden of hydrocephalus in the low and middle income countries where 80 of

the burden is. And because of various Thanks for watching.

barriers to access of care,

we seem to see the patients quite late. And therefore, they present with extreme macro sufferings.

Seeing

complete to

that point. Then to find them when they are quite that far

I did a study also in 2022 in Canadian National Hospital and found that 20 of the children that we see with hydrocephalus also have spina bifida. So this is also

higher compared to the developed countries. And again, we have a higher prevalence of post infectious hydrocephalus compared to the developed countries So our kind of hydrocephalus is sort of

different and is not exactly what you'd find in a developed country.

Our treatment is that most of the children we see and adults we see will end up with the VP shant. So most of the patients in this country is still undergo VP shanting and the scope of treatment is

not widely practiced in Kenya.

to be one of them. There are a few hospitals that

are there and also the techniques that are needed are probably not widespread among the practitioners. So, most of our patients will undergo them, but we patients as we know them

are prone to complete and we've done studies here and we found that a huge chunk of washens block and we

have a myriad of other complications such as infection. As shown in these cities, this is a patient I was seeing last week and you can see these huge brain abscesses just around the tip of the shunt.

We have shunt migrations, we have shunt excursions, this is a patient I also saw just a while back with an animal Bye.

but

very young black or shunt extrusions and oral shunt extrusions and so on and so forth. So shuns are actually prone to lots of complications and for us

we would

shunt avoidance should be the goal where you can to avoid all the problems.

Once that we see, then we would know that Shants will be revised quite often, and from studies we did way back in 2010, we found that the average shunt survival in Kenya is

about 18 months, about one and a half years, a child will need to get the shunt revised. And of course, like we said before, shunt blockage is leading course of failure

I will repeat some of the

highlights of the previous speaker, but so the

thought process of how then we adopt ETV and CPC is we should try to see the feed in our setup and our kind of hydrocephalus that we see And some of the questions that we should ask is that one, is

it safer than VP Shanti and

from studies done in India, Africa.

we have an operative mortality of less than 1 and pre-operative infection.

Is it an option for infants less than six months, which is where we are seeing most of our patients. Remember, we said a lot of the hydrocephalus we see is congenital. Is it an option for children

less than six months? And we have studies from North America with success rates of 67. We have studies from Asia with success rates of 76 in infants less than six months and studies from Mali in

Africa with success rates of up to 54. So it does look like we should

Not what is traditionally believed to be an option only for children greater than six months of age

The thing is that

I also have spinal bifida, so then you would be asking yourself then is itavian CPC an option in these children with spinal bifida.

Studies were done by Raf again in 2008 and

if you found that itavian CPC in children's spinal bifida gives a more durable treatment than the patients, and up to 78 of these patients will achieve shunt it, so this statistics are looking quite

attractive.

Again, we ask ourselves is it a durable treatment than VP shunt,

and we look at the shunt survival, which we've already alluded to before In

shunt, 85 of them will have filmed by five years, and 85 of your TPs will be functional at five years. So,

It deviance would be, would be quite an attractive options for children with hydrocephalus because like we have highlighted that it is safe, it is more durable, it can be done with children with

spinal bifida and it does work in children in less than six months. So this is, this is how we do it. We,

we position the patient's spine, they had we put it in the neutral position and slightly elevated, maybe 15 to 20 degrees elevated.

We make our skin markings. And our typical entry point is a pre-coronal tool.

In children, this would probably be a lot for the edge of the frontal lobe.

Really easier to access with the chalinea.

I want to, away from the int, this might help with CSF using,

um, uh, uh, we,

we, uh, mentioned with the head one, uh, like, like one of the, uh, like the previous speaker demonstrated. Um, I would say that we use both, uh, I'm comfortable to, to do in, in either

positions and in the event That I won't, I need to convert to a shunt, then I just turn the head, uh, slightly. Um, and I put it in the lateral position and I, and I can convert to

a VP shunt. Um,

so this is a, so this is a, is a short video to show once Uh, sorry,

to show um,,

a video of what we typically would see once we. We introduced the, you see the coral plexus there. And again, you see the vein and the

abdomen of Monroe. And as we advance the scope, you see the two mammillary bodies there and the tuba scenario, the area where we would probably be doing our hit TV later. At this point, you see

the interthalamic adhesion on this side

We try to look behind to see whether we could see the equator, but this was a weak scope. So we're lucky to find out. We will later on be putting the flexible scope to look around. As we look

until early, you see the

infinipilum, that area there. And then you see the docensella would be here and our ATV

would ideally be placed in the air. between the docemcella here and where we estimate the bacilla would be. So that would be where we would be making our storm. So

we use via instruments to make the storma. Sometimes we use the

bovey. Sometimes we use the rigid endoscope itself if the floor is quite thin

This is a video to show that

in this one, we use the endoscope to operate the floor. And you can see that we're already within the bocilla and cistern. This is the bacilla actually. And these are the profraitors that are

going into the brains.

See some of that as we go down into the front main magnum. And

really, this is what you want to be seen you wanted to see the naked basila and

And you want to expose the preponderance system. And after you do this, then you should get a nicely pulsating trauma to show that your ETV has been successful So, um,

Bye

You need to check is that the membrane of the liquid is a common thing that you encounter within the preponderance system and as you can see it in this particular,

you can see the membrane of the liquid, so this is a soma that you've just made and as I introduced the endoscope into the soma to look into the preponderance space, you see a lot of arachnoid

membrane

and really you don't see, you don't see the basilar or any of the perforators, all you see are arachnoid webs and as we look around to try and see what is obscuring the free flow of CSF, then we

notice that there are all these arachnoid webs, this is the membrane of the liquids that we need to operate and see the naked the basilar for us to get a completely

stoma in the connection between the

peoponta and cispen and the fat and from the arachnoid completely and as we wiggle the scope around

we see we see the pothritas again there they are covered

and very soon now you will see that we will be able to get to get to see the basilar and here now you see the naked basilar and this is essentially what you want to see once you see this then you know

that you have met a good connection between the

pothritas and the phataventrico you see the phatnav there and even as you as you look father you you could even look beyond beyond and see the ventral aspect of the brainstem the vertebral latches and

even the lower cranial now is the exit

So, really, the naked basilar should be the goal, and in the absence of this, your ATV then is unlikely to be successful.

In our series of patients, we have really found different types of anatomy of the flow of adventical,

and it's not always constant, it's not the same for different patients, it's not, you'll always find a different type, but the anatomy is almost constant with a few variations, but really your

prayer and hope is that you find something that looks like this, and friend flow that is bowing downwards, and it shows you that the terminal branches of the bacilla you see, the

p-segment of the PC is, and all the branches, and a very flow there that bows down and this would be an easy flow to deal with. Again this is this is also another flow another kind of flow that you

will find not so transparent and sometimes this can be quite fibrous and as you operate it you really have to be careful not to damage the vessels around it and again and especially in patients with

post-infectious hydrocephalus and some patients

also with with post hemorrhagic hydrocephalus you find that the visibility within the flow is very difficult so you see the momentary body is here but then you can hardly pick where the pacillatries

you can't see the docemcella all you see is so it's just this

this quite

low

And you could get into trouble with the bacilalia before you see it, but this is an example of what we see in

our daily practice

We also do see this, as has been described before,

from the, we start CPC, just as has been described before, we started from the front end of Monroe and go backwards along the body of the lateral ventrico and turn into the lateral ventrico. And

through that single bahole, single pre-coronal bahole, we are able to do a septostomy and go to the control lateral ventrico

and coagulate the PC also in the entire body of the lateral ventrico and turn into the lateral ventrico. into the temporal horn, or the contralateral ventrico. As an example of us just got rising

this, the chord

around the veins there, and taking into the epen rhyme, or to dig into the vessels there. And really what you want to see in the end is that you want your chord flexes

to appear this way And this shows that this is quite structured. And the vessels would just be the only thing that sticks out. And that really would be a sign

that you have done, most of

that you've eliminated most of the chord flexes

With the spinal bifida, in some of the challenges we encounter with children with

spinal bifida as we do, and those ETVs is one is that they have a large mass of intermediate, this is a child I was also managing, and once I introduced the endoscope, this is what you get from

the Thank you

And you don't see the dose of cella and this makes your, makes your, you know, such a

request difficult and if this is large enough, this could stop you from, from doing an ETV in these patients Secondly, again, you find that there are quite a number of them, we love small foramen

of Monroe, like in these other patients that I also managed. And you see that

it is not only small, but the position is such that for you to introduce a scope here and be able to see the flow of the

flat ventricle might end up with some damage to the phonics around and to the veins here which would obviously not be a great thing to get here. So these are some of the challenges you would

encounter with children with spina bifida and then in an arm

to convert to VP shans. And

then the other thing that you commonly find in children with spina bifida and especially those that have had infection from contamination of the SAC and the sending infection with ventriculitis is

that you find a lot of skin of the preponderance system. Once you get scaring of the preponderance system, then that also becomes a challenge. Your ETV then is unlikely to work. And like I've also

put a

post infectious hydrocephalus,

you find look related hydrocephalus, a lot of times you have to finish straight. These slow cues, these extensive scaring of the preponderance system. This is a short video to show the endoscope

within the quantum system. This is the patient I recently obtained. And you find a lot of starting within the preponderance system, and really you can hardly get beyond

all these scars within the preponderance system. And once

you find this, then it's advice that you convert to a ventricular period on your shunt, because your ETV is unlikely to work with you You see a

lot of patients like this. This is also another patient, I saw, with

purulent material around in the preponderance system. You see all this that is stuck on the pacula, this is the pacula artery, and all this purulent material within the preponderance, again making

the chances of success quite slow

Yeah, so thank you very much Because, um. that was my presentation. This is the endoscope that we use, the flexible endoscope which we use for the CPC. We sometimes use it for the for the ATV as

well. Yeah, and this was a generous donation from your kids

very much.

Thank you. Excellent. Thank you so much for describing all of the technical details and talking about your experience at the Kajabi Hospital. I think it really complements the previous presentation.

Are there any other questions? Actually, I have one question for you. And I think I think you alluded to some of this when you talked about the challenges, but it sounds like you're prepared to

convert to a shunt procedure when you do these And I wondered if, uh, if that is more the case with spina bifida versus patients, which is hydrocephalus without spina bifida. And if you had a

sense of how frequently that may occur with or without spina bifida, how frequently do you have to convert to a VP shunt?

Yeah, we always prepare for VP shunt so whenever we are doing ETV or

CPC, even the prepping of the patient is such that we can converge to a shunt anytime. And this is more common in children with spina bifida because of the anatomical challenges that we've that are

highlighted before. And also the chance that this, there could have been in fact one before and when we are likely to find a lot of scarring in the content system And so, an average I would say

maybe about one in 10 Maybe about one in 10. we would convert to a shunt that's a rough estimate. We are still collecting data and trying to at least come up with the

figures, but that would be the rough estimate.

Thank you. Well, Sam, I don't know if you've traveled to Kenya, any comment?

Excellent talk, but my colleague, Ben Throul enjoyed his talk. I do believe the technique used by Kijabi and Kenya and Bali Uganda is very similar in many ways. And the criteria for treatment and

indications and post-operative outcomes are very comparable. I personally did not have the privilege to go to Kijabi, I've only visited Nairobi. But I congratulate my colleague and the excellent

working and colleagues are doing Kijabi and continuing to advancing this field. Thank you Any other questions or comments? Could I ask you a name? Could I ask you a name, go ahead. Okay, thank

you very much. Very excellent presentation from both Professor Elibaba and Dr. Ben Moutisso. My comments, the unit where Dr. Moutisso is working was set up

by Professor Leyland Albright and he worked there for about five to six years In the same period,

the duration as Ben Walf was working in Uganda and just as Ben Walf was very instrumental in setting up

the unit there at Tambale, Professor Leyland Robert was

very instrumental in setting up this unit at Kijab Emission Hospital. And after he left, then Dr. Ben Moutisso really has been doing voluntary work there are two donut in this time.

you know, managing these cases as he works at forces Memorial Hospital. And he has had very good support from these international organizations which have helped him to carry out this very good work.

And what the message here is that with good support from international organizations, we can actually, you know, get more and more such centers, you know, do this type of work because there are

also neurosagulans who are placed in other areas who can get that support and do this type of work. My other comment is that

Vipishan still remains the cornerstone of management of patients with that receptionist in our setup. For two reasons. One is the setup which is required. for ETV and the associated challenges is

not available during the training. So we train our residents to basically just manage our cases through the ventricle peritonis shunt. And then I would like comments from my senior colleagues or my

other colleagues on the challenges of ETV

versus VP shunt Because when I read the literature, it seems as though most centers, you know, when children have hydrocephalus, you know, the primary treatment is VP shunt. And only some cases

are channeled towards ETV. So I want those comments. You know, in our centers, you know, the children we do, we do VP shunt as really because we are constrained. Not because we don't have, you

know, we just don't have the facilities. but we get very, very good results. But at the same time, we do find colleagues of them, each of these and where these failure and distills in the

children for the patients. And the failure rates, as we have said, with the patients is high, but by a large, it's still a time tested treatment, you know, with very, very good results. And I

really don't think this is something we can ignore. Thank you.

Thank you, Professor Naim. Thank you. Professor Naim. Linda has a hand up, a strata. Well, yes, please, Linda. You have a question, go ahead.

Linda. Yes, I do. Good evening from this end. I really like to thank the speakers for truly, truly interesting and wonderful presentation I practice in the southern part of Nigeria. For us here,

like the previous speaker has said, we do have a lot of these cases coming late and most of them are post-infective. And so Vipishon still for us remains

the modality of treatment for most of them. So ETVS, of course, for those to be favorable anatomy. So I do appreciate the speakers. My question for Dr. Elbaba is, do you have cases when you

have to go for redo, redo surgeries? And for these redo surgeries, how often? What is your incidence like? And what is the main etiology for your redo surgeries? Thank you.

Excellent question. The

indications for redoing ETV CPC is typically not for the CPC part but for the ETV part.

The initial surgery was done at a very young age for a high risk for failure group, let's say, under the age of four months. And imaging, especially if we do MRI, if it's available, shows that

the third or the fourth event of penetration closed and the parent of the baby is willing to try. I always say, if we don't try, we will never know. I do believe based on our data, the success

rate for

redo ETV is in the range of 50. And I can tell you, when I tell parents about a treatment option that has a success rate of 50, I'm becoming surprised how many parents or most of them are willing

to try 'cause they don't want to live with a lifetime commitment for a shunt. And I want to emphasize the excellent comment from professor, a number of the about

the shunt shunt save lives, shunt save lives. many generations and we continue to believe in that. But if we can avoid them in patients who have, if based on the local environment, the culture,

the perception of the parents, if we don't try, we will never know. And if parents are willing to try, we should give it a shot. But the redo indications obviously are worsening ventricular size,

worsening hit circumference, symptomatic hydrocephalus with radiographic evidence of ETV closure. Thank you.

I'm going to ask two questions quickly before Sam. Go ahead. What percentage of the, we've got 50 countries roughly in sub-Saharan Africa? Can somebody name or somebody give me an estimate of how

many, and how many of these countries is endoscopic,

choroplexis, coagulation, and endoscopic, third ventricular, and lost to me available? 25, 50, 75, just a while, guess? I think we could, well, if I could comment, I can only comment for

my country. You know, as I always mentioned, that geopolitical Africa is so different. Each country is so independent with its own data, and highly is this data interchangeable, but we have

colleagues here from Nigeria who can give their views, but from my country, probably in about two or three centers. Are we able to perform this? And when I talk about two or three centers,

neurosurgical centers, I'm talking of a situation where we probably now have about 10

centers, neurosurgical centers. So, and three are referral centers. Three are referral centers. So the feasibility of having this done as a routine is really minimal, it's minimal and it's only

in some sectors. That's what I wanted to know. And this is primarily done below the age of six months, Samara for infectious post-infectious or equiductal stenosis or something else. So the

truth is that historically we used to avoid ETVs under the age of one year. This is how I was taught 20 years ago 10 years ago, we cut it down six months, five years ago. pushing the limits around

the age of four months. I can tell you the ETV CPC prospective randomized trial, now the ST trial that I discussed earlier, there's no age limit. We're randomizing babies as early as few days of

life if they have favorable anatomy and if the equipoise panel assigned by the trial sees that the patient has a favorable anatomy for safety for either ETV CPC or a shunt So I think this trial is

going to give us a lot of information about age, but I can tell you the comfort level, sir, is the comfort level with young ages is dropping year after year. And again, I go back and say it's all

about the anatomy, it's all about the parents if they're willing to try.

The same problem exists in our country is in your country and Africa. And that is the availability The procedure is dependent upon who can do it and may be limited. And so the goal is to get it more

acceptable. What's the cost of an industry in Africa? Just a last question and then we got to go understand.

Anybody know? 5,

000, 2, 000? It's about 5 million Kenya shillings. So 5 million Kenya shillings divided by 130. That's for about 4, 000, 5, 000, 5,

000 I know that because we had one bought by our university and it cost about that much, about 5 million Kenya shillings. Okay, I think we should go on. Somebody asked a question, but do you want

to do that or go on? We should probably go ahead for the second time. Oh, Sam, it looks like you, but we have several questions. Thank you very much. I just wanted to make a little comment on

this problem.

Many years ago, my friend was very enthusiastic about this procedure, and we invested on it, in fact, invested on storage and the scope. Unfortunately, we didn't quite sustain it. Still there,

we do use it for other interventions,

and we use it for the interventions, but we don't routinely, we prefer Vipricant. Oh, no, that's okay. Okay, that's a perspective I wanted to hear, and practically. I don't know whether you

hear me, that's a bit of a worry, whether in a place, it's very bad, and we have. Okay, you're coming in and out, but

if.

My main comment really is that we, I personally better appeal to, particularly North American specialists who help Africans in this field of surgery. They were more interested in going to East

Africa,

And on several locations, I appeal to them. Why is West Africa not on focal? Why are they not interested in helping us in West Africa? But I never got the response. I noticed that most of their

assistants. If he were professor, El Baba here, he can hear your concerns and maybe he'll be able to address that. And that's something that we can continue offline. When we go to Sam's

presentation, I think Yes, well, Sam seems to be frozen. Is there anybody from Sam's team who is ready to present on the topic that we have for discussion? The spinal instrumentation,

decision-making in Sub-Saharan Africa. We'll wait until Sam gets back.

Professor El Baba, any comments about the inroads into West Africa as expressed by the professor. Can you hear me? Yes. Yeah. I do believe

to comment a second go about the cost. One of the things we should remember is whatever the cost for the Flexware Indiscope, which is by the way, to my knowledge, is in the range of5, 000. In

many countries, each Flexware Indiscope, the value of it is similar to almost 20 or 30 shunts. So if you think about

the cost of Flexware Indiscope compared to the cost of shunts and shunt valves in many countries, it is worth investing in Flexware Indiscopes. In regards to it, Sir Africa, I'm aware that many

organizations like New Yorkets started partnering with colleagues in Nigeria. And the last year, I know recently there was a program and others, excellent work in South Africa and Kenya and Uganda.

So I do believe the momentum is progressing well. I'm personally interested in any way, shape or form to support colleagues in Western Africa and to continue the conversations and potentially help

setting up programs in new units as well. Thank you, thank you. I know Dr. Alvin Na in Liberia has indicated that they have been formulating a connection with neurokits. Dr. Morgan, you had

your hand raised earlier. Would you, do you have any questions CSF the into opening the of part a just years of couple a been there's like seems It. designers the for question a have just I. me

hear can you hope, presentation great, Yes? comments or

space

And it seems like

a section of partition in the pre-found team system. One times there's also

in the community, and have you made inroads in that infrastructure to build and destroy the community? I don't know, I don't know, I don't know. Could you restate that question? I have trouble

hearing you, Jay. Yeah. Can you repeat the question? We had trouble hearing you. Can you help me now? Yes. It's muted, we can hear you,

but it's muted.

It is resection of the scar tissue and the creep on team sister and something that will make surgeon kick off to means more viable

than the future. Yes, so I think, I think Jay's Dr. Morgan's question is, I think it's in reference to comments made by Dr. Matusa about, have you seen my hearing that you're, assuring that

you're

breaking down the arachnoid in your creep on teams this turn and he wants to know if, That is essential for the success in the future. Dr. Mitsu so.

Thank you for this question.

I think if we could find a way to break down the arachnid webs and the scarring within the preponderance system, then that would essentially make the ETV work. But I think technically speaking,

this would be not just difficult but dangerous as well because

you find that the pufferators from the basilar into the brainstem would be embedded within this scar tissue and attempt to break it

would, might also put this very crucial vessels at risk. So

I don't know what El Baba would say but yeah, that would be my take about it. When I find extensive scarring in the

preponderance system, I usually convert to a VP shunt.

the data from the interim. Sam, are you still involved with the fetal myelom and ningazil repair? Yes, sir.

We started seven years ago, the first, and that's still the only program, the state of Florida. So we receive weekly referrals from all around the Southeast of the US, including Puerto Rico, all

the way to Hawaii. We have a very busy program. We do around two to three fetal in utero myelom and ningazil repairs per month, in addition to our standard post-net to repair for cases who do not

qualify or they do not elect to continue with the prenatal repair. And are you continuing to see the reduced need for shunting after those end-uteral repairs. Absolutely. One of the things that

I'll touch up with you on my talk about the combo effect

reduce the combination of FITA surgery for spina bifida and it for the ones who develop had their selfless rather than shunting them if we explore the options of ETV, CPC, if they have the favorable

anatomy, we're reducing the shunt rates for this spina bifida group to range at 30 per cent right now.

Yeah, that's very good. How many programs Sam are doing fetal surgery? I thought there were only a few. In North America right now around 12, the ones who are active,

that the volumes can be different, but the programs that are actually busy are around five to six programs in North America right now.

If you're doing two to three a month, that's a consistent volume. That's pretty good. Yeah, it has been good so far. I started in St. Louis. We did 60 cases in St. Louis in Orlando now. We

just did our case number 52. We have another case coming this week. And we have around 15 cases internationally. So the overall experience now around 120 cases or more So it's good the momentum

keeps coming, more programs. Globally, our getting interested in starting has been a pleasure to work with many international groups together, programs started. This is an exciting time to treat

this disease. And I think the momentum is very good. We have - I would guess we probably have many, many countries now in Sub-Saharan Africa We're looking at SI digital. We're over in over 130

countries now. our projected viewership will be over 20, 000 a year. So I think we're doing things that people like. So I just wanted to put that note in. We hope everybody's enjoyed the meeting

today. I did, I thought I learned a lot. And Stroud, do you wanna say anything here at this point? I think we can wrap it up. I want to remind everybody that this conference meets on the first

Sunday of each month. So our next session is on November 3rd. And we have an interesting lineup. And that will include the remaining presentation from Sam's group. With that, I think we can

conclude. Thank you all for your active participation. I think this is gaining very good momentum. Please write us out your comments and how we can do this better. and we really appreciate that.

Thank you very much, Anastrada. Thank you for organizing and arranging all this. We're okay. We'll see you next month. We hope you enjoyed this presentation.

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Pediatric Neurosurgery; Endoscopic Third Ventriculostomy (ETV) with Choroid Plexus Coagulation (CPC)

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