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SNI, Surgical Neurology International,
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and SNI Digital Innovations in Learning.
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In association with the Sub-Saharan African neurosurgeons
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are pleased to present the second monthly Sub-Saharan Africa International Neurosurgery Grand Rounds on the topic of global solutions to clinical challenges in neurosurgery.
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This Grand Rounds was held on Sunday, July 7th, 2024.
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There are two presentations in this Grand Rounds
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The first is Cysticercosis, a review given by Professor Katanga, DU, Merci.
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Cabullo, head of Jason Sendre, General Hospital, and the Coptic Provincial Hospital. He is also on the staff of the University of Zimbabwe and the University of Lumbam-Bashi, in
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the Democratic Republic of the Congo
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The second presentation in this program is by Professor Samuel Kaba Akaroya, who is the Director of Institutional Care, Institutional Care Division, and the Ghana Health Services in Ghana. And his
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talk will be on the use of intraoperative ultrasound in neurosurgery. This talk will be presented by Professor Katanga, Do you? Merci kabula?
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head of the Jason Senway General Hospital,
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and also at the Coptic Provincial Hospital. He's also on the staff at the University of Zimbabwe, and the University of Lubumbashi in the Democratic Republic of the Congo. The talk is on
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sister-circosis, a review.
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Let's get started. Thank you, everyone, for joining This is the second SI
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Digital Global International Conference, but it's up to Heron Africa. We have a forum where we can learn about what's happening in neurosurgery around Sub-Saharan Africa. The first conference was a
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success, and we're building on that. I think we've had some glitches along the way
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mind, and so we will continue to build.
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We have a
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couple of presenters.
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Dr. Kaba will be talking about intraoperative ultrasound in neurosurgery. Followed by Dr. Kebullo talking about neurosurgical treatment. And Dr. Futten, then the third will be a guest speaker,
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Dr Cameron Host, talking about tele capturing in the vascular ultrasound in neurosurgery. And for the sake of time, I'll turn it over to Jim Rossman, who's head honcho for SI
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and SI digital. And then we'll, after Jim talks, we'll turn it over to Professor Kaba. Well, I think I don't have much to say except welcome. Nice to see everybody. And let's try to thank you
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for all the work you put in on this. And let's hear from Professor Kaba. about intraoperative ultrasound. And in the case of where you are, we are seeing as professors and colleagues.
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And I'm Cabullo. I'm going to talk about the neurosis psychosis. I'm a consultant neurosogen trained in Zimbabwe. Right now practicing in the fashion democratic logic of
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Congo.
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This topic, I'm going to make it very, very easy Because I know that even residents are following us. So I'm going to start with the basic things and I will share one case money. And I will tell
4:37
you about our experience. So these are worms in the brain So,
4:47
parasites, organisms that exist by exploiting a host by opening nutrients from it. We have different types of. parasite with protozoa, airmen, and ectoparasides.
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And a number of these parasites can invade the central nervous system, despite the protection provided by the blood brain barrier. And the CCCosis is the most common parasitic infection involving
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the central nervous system. And in some low income countries, it's the most common cause of acquired epilepsy in adult
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It is caused by the CCCosis Cellulosa. This is a lava stage of the tapewem tinnia soya, which has marked predulation for neutrophils. You can go into the lava stage, and you can see its head's
5:43
cold connects. It had different parts. It has four suckers, and it has also two rows of open on the house. Excuse Dr. Cabell, let me just interrupt. a second if I could have everybody mute the
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microphone because we're getting quite a bit of background noise,
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okay,
6:08
otherwise, and you can just remove yourself, okay, please go ahead. Thank you so much, thank you for seeing me in some countries, like in Africa, in South America, Southern Asian countries,
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you see on the table, on the picture show the area in red, it is showing where the disease is endemic and the incidence of neurosis psychosis may reach 4 in some areas and the issue is very long,
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sometimes it can go up to more than a decade for you to see symptoms from the the moment you, you are infected.
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The rate of universities across this are variable ranging from
6:59
12 people for every 100, 000 in countries like India.
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The neurosis psychosis are variable due to differences in the diagnosis
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capabilities and other causes related to the resources available. I especially in a low and middle income countries, the diagnosis poses a very big problem Let me go into a background, an
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historical background, from the time of ancient cultures intestinal parasites were identified as well. And the lava stage of the postion tapewem, Tylia cold, Tylia sodium, it has been recognized
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in P for more than 2 million Our ancestors, Hippocra, Aristotle, and Frastas, they denominated them as flat ones. Initially, I think probably from Aristotle's Historia animal animal.
8:11
due to their resemblance to a temp or to a band that why they were calling them flat band. Then, shows us and plenty and colleagues, they called them Luongricas lattas, which means white one. And
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the dialects are some species of temp or M was described initially by Villa Montpani with a temp that reflected their equivocal idea that one individual could only carry one of these parasites. And
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later on in 1683,
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Thaison described the head of Thaison, like I mentioned before. After he saw the picture of the scallops
8:57
of the parasite, then he described those suckers, as you can see. I mentioned that you can see four suckers and two rows of hooklets Dana in 1855.
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Kuch and Maestar identified the relationship between the ingestion of the Sissi Saka and the development of tinesis.
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Then, other people described the Siss in the Copa Scallosa, as well
9:25
as Mr. Waton, who identified multiple cysts in adipose tissue and muscle, thinking they were glands, though they were not glands, they were cysts of Sissi Saka's And the evidence of this endemic
9:41
life and its interaction with specific communities was clearly established in Dixon's study, where he found infestation of British soldiers five years after they stayed in India. And currently, the
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International Consensus defines the niacis as the
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infestation in the
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intestines and this is a process. like the infestation in other organs, like the brain, like the muscle. The life cycle of tiny solar and the natural issue is more complex, because usually people
10:24
confuse how we get infested, it goes into three stages, the lava, the embryo, and the adult women. So what is happening? Human gets infected by two ways, the first way is when we eat under
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cooked pork meat. So where they are, the
10:48
worm, which is consistent in the meat. So when you eat it, it will go into the intestines and grow as an adult worm, then you get the niacis. But the second way of doing it is by eating,
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that by drinking water, which is infested, by eating, uh, like, uh. food which is not washed well washed. So when you eat the eggs which are because the worm is it has several parts those parts
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called probabilites they get eggs. When you eat the eggs the eggs will go into the stomach then from the stomach they shall get milk then the labs are liberated then they can go into the
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circulation then from there they can join the brain they can join the muscles they can join different organs like the heart the eye and so on. So these are organs which can be infested by the the
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love like muscle you see this which were described last time like all glands but it was
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it was the system of the the then into the heart, into the muscle, into the eye, and also into the brain, you can find those lavas. So it goes into stages. These stages, they are like evolution
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of the disease. So when you get even into on the CT scan, you get different stages. The vesicular stage, this picture on the left shows the vesicular stage which correspond to the cysts that have
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achieved immense tolerance This is a very world-defined cyst, which contains a dot inside. It's the head of the lava or the disk collapse. And at this stage, you have mild. You might or not have
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edema, perilisional edema. Then the second stage is the colloidal stage, which correspond to the beginning of initial host response. When you get the host response, then you start to get the
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perilisional edema.
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The stage is the granular nodular stage, which represent feather damage to the cyst, where the fluid content within the cyst are no longer disabled on imaging. So this stage, you see
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inside, you won't see the collects, and the fluid inside start to finish. And the last stage is the calcific stage, where you are only seeing calcifications in the brain on imaging And it's better
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to see it on a on a CT scan, because classification sometimes on a MRI scan you won't see it properly. So the type of neurologic involvement, you can get spinal cord involvement, you can also get
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giant cyst within the brain, which can go up to more than 50 millimeters millimeters. And those systems which are being developed in the brain, they are of two types. The first one is called the
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cysticic celluloside.
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You see the regular ranging from two to three to 20 millimeters and they are round or over. They tend to form in the
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parenchima and in the narrow Sabarachnoid space, they contain these colleagues instead of the other cyst which is called cysthesecas racemosas which are very large
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and they grow actively in the
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buzz of arachnoid and they produce inflammation. So in this type of cyst you won't see the lava inside the cyst. We can we find them. We have different locations, meningia where you can get in the
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docile lateral Sabarachnoid space Usually if the CCC is a conciliency, you can get them in the buzz or Sabarachnoid space. You can get them into the parenchyma in tightly to 63.
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They can go also into the ventricle, especially when they're in the ventricle, they block the CSF flow, and you might get hydrocephalus, or you can get the mixed lesions, and also the spinal
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lesions, which are very, very rare, and sometimes they don't respond to treatment The clinical presentations depend on the number of lesions, depend on number of the location of the deceased, and
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like I said, the incubation period can go up to 30 years for you to develop symptoms And the group presenting symptoms is
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seizures, you get patient, adult onset seizure, with signs of elevated intracranial pressure, sometimes you get neurological deficit when the deceased is big, and causing mass effect, and
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sometimes out at mental status.
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when the cysts are in the baza in the arachnoid space causing baza arachnoiditis, and sometimes in the subcutaneous tissue, you might get other cysts. So the diversity of this manifestation,
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depending mainly on the size, like I said, the number, the location of parasite, and focal signs are frequently due to local irritation or mass effect In terms of clinical topographical
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presentation, when they are in the parenchyma, you will get seizures. When they are in the meninges, you might get chemical meningitis into the ventricle, you can get hydrocephalus, and so on.
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So what is happening when you are sending now the simple to the laboratory? Sometimes you get, in the blood smell, you get
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pephalosine or filia. Sometimes CSF are normal. collect and you send to the lab, they say it's normal. Proteins might be elevated or sometimes normal. And glucose levels, sometimes they are
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normal.
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But what
17:23
you have to request is to look for over into this tool and the way you might get them in 33 So the
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usual finding is the mononuclear pleocytosis, with sometimes another age of 300 cells by cubic millimeters. Serology, unfortunately, sometimes in our center, like when you go in rural area, you
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won't get this. You do enzyme-linked immunoelectrotransfered blood And AIBT,
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which is -
18:08
effectively supersede elisa and the whetata is considered significantly at 164 in serum and 18 in CSF. So, first negative result can also be found. What else we do? Redographic, you do x-ray of
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muscles. You can do x-ray of ties. Then you will see calcification into the muscles. You can do skull x-ray, which is going to show you calcifications into the brain from the x-ray. And on CT
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scan, like I mentioned, there are different stages, physical stage, nodular stage, nodular glandular stage, and the calcific stage. On MRI, like I mentioned, you see the cysts with
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perilisional edema, which is high pain tens on
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T2 Calcifications sometimes are very difficult to see on MRI because calcifications are
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IO intense on T1 and IO intense on T2. On
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spectroscopy, you might see a peak of lactate, acetate, alanine
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and succinate. But the presence of strong succinate with a smaller acetate peak may help to differentiate neurosis psychosis from pyogenic brain abscess. And also, if you check you are doing your
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spectroscopy, you go into the cyst, you might not find coline and
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acetate aspartid But it can help you to differentiate an acrotic area of a brain abscess from neurosis psychosis when you are doing a spectroscopy. Because when you get a tumor with an acrotic area,
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you get a peak of lactate and lipid, which are not seen in neurosis psychosis. According to the agnostic criteria, in some developing countries,
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people are,
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Ah Yeah Oh confusing this with the tuberculosis, because sometimes imaging can be the same, but now the best way to understand the clinical spectrum of neurosis psychosis has been true diagnostic
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criteria, which are based on four elements, epidemiological data, immunological, radiological and clinical. There are these two associations, American Society of Tropical Medicine and I gene,
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and infectious diseases, Society of America, which gives us these criteria to diagnose neurosis psychosis. They are absolute criteria, major criteria, minor criteria and epidemiologic criteria.
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What we have to do if it's definitive neurosis psychosis, you get one absolute criteria or two major criteria or one major and two minor plus one epidemiologic If you get the combination of those.
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you can think about the neurosystemosis.
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Then we might differentiate it from tuberculosis, from brain abscess, cystic tumors with
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the inside the brain and sometimes to idiotic cysts. What are the treatment, what we are doing, what we are using locally here in our country? We give anti-meltic medication, anti-epileptics
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drugs, steroid and surgery. And this surgery, you might do surgery section of the deceased or the lesion, or you can do a CSF diversion. Siroi, they are very, very important because when you
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are about to start medical treatment, you have to give steroid first, to reduce the amount of edema otherwise the patient will deteriorate while you are giving anti-meltic drug. And in our setting,
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what we are doing within Siroi, we start with dexamethasone, eight milligrams,
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Then on day three, we decrease the dose to four milligrams, eight hourly, and on day six, we change now, dexamethasone to prednisolone. And at that moment, we introduce now our anti-apoleptic
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drugs. So anti-apoleptic, they respond very well. Usually it's one only, you won't even go to
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two drugs, you give one, and usually they respond well And the risk for seizures is when you get classified brain lesions, when the patient is presenting with multiple seizures, and when you get
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multiple brain cysts
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How are you? Do you want to
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introduce you to the weeks from Mexico? What did you say briefly, Dr. Arredondo has been introduced to us as one of the shining and bright figures in Mexican neurosurgery. He's in Guadalajara and
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with that introduction, I mean, he came highly recommended by all my senior colleagues from the country. So Dr. Arredondo, you
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continue with your opinions about this
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subject of sister causes on this engineering system. Thank
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you
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very much, Dr. Lasereve. Can you hear me, everyone, can you hear me? Yes. Yes, perfect Thank you for the kind
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introduction. Sister cases in Mexico are in many other development countries. It's a major problem and still is a health services of public problem. And we have a major incidence of this disease
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in the last five years, which has been decreased
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from the first years of the 90s. We have in 1996, for example,
24:16
about
24:19
1600 cases per year. And in the last register in 2022,
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we have 225 cases. So we are seeing a diminished in the cases
24:37
in our country. And the major problem is, of course, the
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lack of preventive measures
24:49
in the preparation of the food and the prevalence of the street food in Mexico. So you noticed a decrease in the incidence? What do you attribute that to? I think there is a Um.
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major information and more education among the population and I think it's because people are preparing best their foods and they are aware of being in risk
25:35
of being with the disease if
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they don't have the measures to take care of the food.
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By the way, how do these people present to neurosurgery with seizures or mass effect?
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Most of them present with seizures but some cases are present with mass lesions and the
26:07
form of sister coaches is the parenthesis, these are coaches. And we have seen
26:16
every day
26:19
less cases of hydrocephalus associated with this disease. Hello, professor. I'm sorry my network was bad. Can you hear me? Yes, come here. We were just hearing from Louise about his experience
26:33
in Mexico And actually, your slides at the right time, because I was going to ask Louise, and now that you're back, Cabullo, what are
26:44
the drugs you used to treat them, and how successful are they?
26:50
I'm almost at the end. Please, can I proceed? OK, sir. OK, thank you so much. So I think we used Rosaconta, 50 millibrams per kg and we divide it into three doses. The most used is
27:06
albendazole, 15 milligrams per kg per day. Then we divide into two to three days. But we have to start first with the
27:17
steroid first before we introduce this one. Then how do we prevent them? It measures sanitary education, which is the most important strategy to control this disease And hand washing, also
27:35
installation of latrins or other hygienic measures for disposal of human waste. And in
27:44
the surgery, surgery may be used to establish the diagnosis. You can do the biopsy, to get the definition of the diagnosis. You can use the rotactic biopsy, which is well suited for small lesions
27:59
And CSF, the invasion. You do ventricular peritoneal shunt to treat hydrocephalus. Sager also might be indicated for spinal cyst,
28:11
intraventricular cyst, which may be less responsible to medical therapy. When you get intraventricular, that's why people sometimes they do it endoscopically to go and remove the cyst into the
28:18
ventricular, otherwise you get hydrocephalus. And the spinal cyst, once it grows, it will compress, you
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get the
28:31
neurological deficit related to that And surgery may also be used for giant cysts, when intratina, eye potential does not respond to steroid. But though every case you are operating, you have to
28:42
continue after the surgery, you have to continue with anti-elimetic drugs to complete the treatment. And follow up, we always do CT scan every six months until the lesions disappear completely into
28:43
the brain. I will show you a 46 year old male
29:06
was diagnosed with neuropsychosis and he went at the local facility. You see the picture here, this is the vesicular stage. You can see the lesions with a white dot inside. This is the sconex.
29:20
This patient went somewhere and he received
29:24
albendozo without giving steroid. The patient deteriorated. The Glasgow Comaskill dropped up to nine on 15. So he could not walk. He could not talk for two years. Then this patient was referred
29:39
to us. The moment the patient came to us, we did the city scan control. This was the city scan. It was now the calcified stage. You see only calcifications you can see into the brainpower and
29:52
chima with active hydrocephalus. Then we shunted this patient after something a month later the patient could walk and could pronounce few words. Today we are almost four months post-CSM division
30:07
and we are planning to do a CT scan. Though it's a very poor patient who could not even do a CT scan control soon after the, the, the, the, the, the, the, the,
30:21
I think we just lost him again, but it was a very, very good talk,
30:27
Professor Cabolo. Luis, any more comments?
30:33
What you just saw? I have a question for Dr. I don't remember the name.
30:42
Cabolo, Dr. Cabolo, excuse me. I'll be connected. I think he got disconnected. Yeah Okay. I was wondering how many Sean failures they have in their practice. Or
30:57
because the failure of the shunt in my country is very high
31:05
because of this disease. So we need to do a revision of the shunt failure than two
31:16
or three times because of sister psychosis, I don't know. What is the amount of revision of the shunt in this country? Is that because of protein in the sun, shunt?
31:30
That's the main cause of the protein in the CSF. And it's not related mainly to the technique, but it's related, yes, to the protein content.
31:43
Are these shunt's, commercial shunt's, or do you have shunt's in Mexico that you make in Mexico that you use, or are they straight to
31:51
oops? No, most of the
31:56
shunt's come from South America. We don't have
32:02
shunt's made in our country. In the past years, we have
32:10
shunt's made in Mexico, but it's no more available, those shunt's
32:17
which with President Quinto and our Bend as well. What's the expectation for the reduction of the CSF protein content?
32:29
We need to expect at least
32:34
one or two weeks to the proteins to decrease in the CSF, but sometimes we need to put a shunt very early and we have a very high index of failure in the shunt. Right. Thank you.
32:53
Well, we just got the hand of Dr. Kabbalah. It was a wonderful presentation,
33:01
Dr. Kabbalah. So as a neurosurgeon, do you see hydrocephalus is the most common? Do you see a large cyst is the most common? Do you see what your experience in Mexico and then Kabbalah can tell
33:17
us And what do you see in the Democratic Republic of the Congo?
33:22
The perincomal presentation is must come on. We personally, I have not made a surgery in the past one year related to neurocystic psychosis, which
33:38
resembles the degrees of the incidence of the disease. But
33:48
mostly of the presentation, which is our perincomal. And fortunately, not related to hydrocephalus, because the
33:59
percentage of failure insurance is very high.
34:04
There's a question in the chat about the option of external ventricular drainage before placing in a permanent shunt. Yes, we use that. Yes. Yeah.
34:19
That's right, Alvin wanted to ask you a question. Alvin has your, Alvin, please go ahead. You have your hand raised. Thank you, thank you, professors. So, Dr. Cabolo, thanks for that
34:30
beautiful presentation. But I just want to know what is the rationale of changing the steroids. You started with dexamethasone, and then you say after, I think after some of the two hours, and
34:37
then you gave pregnancy lung Is there any - I don't know. I just need to know what is the rationale. Why can't I also continue with just one? You know dexamethasone? Why should it be changed to
34:37
another steroids? Thank you so much for your presentation. Anybody answer the question about changing steroids? It's from a high dose to a low dose I guess what I got out of
34:40
that, but.
35:18
Anybody in the audience have experience with that? I think Dr. Gabula, I think Dr. Doug was indicating that there was a change of the steroid type. It looked to me like they wanted to prevent
35:35
steroid dependence
35:38
but Jorge, do you know anything about that? No, no, I would imagine that
35:43
the patient dictates the dose and the opportunity, you know? But I don't know, but I don't have any any deep knowledge about that, no, but I don't know. I think it may be because the
35:57
prednisolone of prednisone in our countries is more, more available in oral presentation and dexamethasone is intravenous presentation. I think that's the origin of the change Yes,
36:14
you have any experience.
36:17
in Cameroon with us or Sam and go ahead Ignatius, yeah.
36:24
Thank you, Dr. Cabullo. That was a very excellent presentation. I actually work in the northern part of Cameroon and is majority Muslims. So for the past four years, I've just had two cases
36:38
of neurostate cystic fibrosis. And we actually even wrote a case report about a lady who was initially a Christian She used to eat pork, and then later converted to become a Muslim. But when we
36:49
found a new study in neurostate cystic fibrosis, in this case, we're a bit embarrassed, you know? So we don't have much experience with that. I've just had two cases of our four years. And this
36:57
way, this way, in Trapper and Carmel cases, the patient presented with seizures, in bandages, seizures, and then we had meaty drugs and the patient recovered without any problems.
37:10
Sam, do you see this in Nigeria?
37:14
Thank you very much, Andrew.
37:17
Nigeria, strangely enough, we eat a lot of pork in Nigeria. And this is quite, it's not a common in Nigeria, but I have not encountered one neurosurgical case over the so many years of practice
37:31
in Nigeria. It's a bit strange. Maybe we're a musician. We have got the diagnostic tools to be able to make a diagnosis, but I can't recall that we have treated it in my center
37:44
Okay, Dr. Osmat, did you mind if I add that? If we're hearing our neurosurgery conference at UCLA from time to time, that the patients who had the cystic psychosis, we had last year one from the
37:58
spinal cord, they removed it completely without a rupture. And also we see, personally, I see many patients who migrated from Mexico to Los Angeles They come with seizures and you're on the
38:13
anti-epileptic, because of the cystic psychosis. Unfortunately, this is the topic that is very insisted on neurosurgery and they try to teach it, especially the medication the doctor presented is
38:30
the one that she's used and also it was a beautiful, beautiful presentation of this because this is the topic I used to teach with Dr. Jorge Lazarov in the class for the students just to make them
38:45
aware and your talk was excellent and really I appreciate and we see that in Los Angeles we see it, especially the county hospital, we have the cases from time to time and they know it very well and
38:60
they handle it beautifully because of the cases that we see. Thank you very much Mariela from Cuba, did you do you see this in Cuba at all, Mariela?
39:13
No, in Cuba it's very impregnative. I've never seen after you'll be formed. I never didn't give you the knowledge. Okay, but it looks like Ignatius or our name or
39:32
Professor Cabullo that it's concentrated in different areas of Africa. Is that true?
39:41
Yes, as I mentioned before, I work in the majority Muslim community. When I was Cabullo was in Loomumbashi and I think it's a mixed community with the majority of Christians. So Christians, it's
39:53
pork, but mostly don't. So for example, during my training, I was in Cairo, I didn't, over 70 years, I didn't say kids on neuro-centrifices, and Cabullo, I've seen too. So I think that's
40:04
experienced why Cabullo maybe has seen so many cases as well as we have seen very few.
40:20
Yeah, Dr. Kimo, please do. Yeah, Dr. Kimo couldn't make it.
40:25
Dr. Kimo couldn't make it. He's our neuropathologist, but we rarely see neurocystic psychosis in Kenya. Of all the years I've worked, we haven't done a, I never did a single surgery. Dr. Kibwe,
40:39
I think is on this call. If Dr. Kibwe is now working at Ganesha National Hospital, or it could give us his comments, but.
40:50
Yeah, Dr. Kibwe.
40:52
All right, thank you, thank you so much, yeah. It's true, we don't see a lot of
40:59
patients with sclerosis in our set up, but that was a very good presentation. Really showcasing what we have. What we see in our country is more of a high that exists. The high that is common in a
41:13
notable part of our country And the professor, you are very much aware about our identity system.
41:22
but that very good presentation and thank you very much. Okay. Thank you. Yeah.
41:30
I could comment. I mean, it was a, it was a wonderful presentation and very, very informative because I really don't know when a fast, last revised neurocystic psychosis was a, as I said, we
41:45
rarely really see it. Hydrated disease is very common in our, in our setup. Now, in our population, we have a, although the Muslim population is about 10
41:57
majority is Christians, but still we don't see neurocystic psychosis. I have discussed this with our physicians as to whether maybe they treat the condition, but even the physicians and
42:09
neurophysicians, they told me they don't, they don't see it. So I think this is one area we really would like to do, to go a step forward. up this with my colleagues in DRC to find out how come
42:23
they see these cases and we don't see them. What's the epidemiological factor? What is the reason, you know, we like because they hygienic factors, the exposure factors at the same. So if that
42:35
was there, we should be seeing these cases. So I really don't know why we don't see them. And this is why I wanted our neuropathologists to come and give me these views. But we do see cystisacosis.
42:48
We see cystisacosis. It's a common problem in our country, but we don't see a neural cystisacosis. Thanks. Dr. Restarata, if you're talking is right in the hand. I mean, yeah, yeah, we have
42:60
a we have a race and we should we should probably go on to Dr. Kava's presentation. But let's let's hear from Dr. King, who has a who has his hands raised. And there are questions in the chat.
43:13
So if people can answer in the chat, that would be great. Go ahead, Paul.
43:20
your mute.
43:24
You can hear me now? Yes. Yeah, I just had a comment. One that Dr. Kabuda's talk was just was outstanding. And I out of times that I've tried with Africa, I've not seen since the psychosis,
43:39
but in America, I've treated about 10 patients with cysticicosis. And I think that we got to be aware and our residents have to be aware of this problem because we have so many immigrants. And we
43:54
can't forget about cysticosis because it's alive and well. And so I think that we have to keep that in our differential when treating patients, express the immigrants from all over the world.
44:09
Excellent Paul, Said.
44:12
Yes, I wanted to mention that in South of Iran, which is a Muslim country, we have a lot of And as everybody knows, the animal involved is the dog, is the warmth, the present grows in the
44:27
intestine of the dog. And because of their excrement in the area, the people who get contaminated, and it goes, then the treatment is totally different. And we had some talks from the, our
44:42
colleague from Iraq who had a lot of case like that. So it's a contrast, those who are in the Muslim world If the dogs are in contaminated, hydrolysis is very prevalent. And sometimes it's very
44:54
deadly. And those we have the work using cystic circuses. And in the talk we had at UCLA, they have never seen hydrolysis, at least at UCLA, as up to now. Because the animals or the quarantine
45:11
before coming to US and Canada. But there have been some cases from East Europe who have immigrated. in Canada, four cases they were contaminated with the hydro thesis. Thank you. Thank you,
45:25
Alia. Dr. Cabolo, you raised your hand and then we had to move on, I guess. But first of all, it's just a wonderful talk, very nicely done, very informative. You wanna make some comments?
45:39
Thank you so much, Professor. I'm very sorry about my network, very sorry for that. I wanted to answer the question about changing theory When we give dexamethasone its injection, then imagine
45:53
someone who comes with neuropsychosis, with no surgical indication. And you can't keep the patient for 10 days in the hospital while you're receiving steroid. Imagine dexamethasone, the tablets
46:06
here, they are 05 milligrams. If you want to give eight milligrams, it means the patient has to take 16 or more than that tablets at once. So if you go to dexamethasone to prednisolone to be few
46:22
tablets, then you discharge your patient. The patient continues the medication at home with the arbendazone instead of keeping the patient with dexamethasone for long and injection and long period
46:35
for oral or for injection of dexamethasone only in the hospital. That's the reason why we change We change it because with brednisolone you take less pews than dexamethasone. Thank you so much.
46:49
Yeah, thanks. Thanks for that clarification. Excellent. Kabbalah, one other question. Why do you see it more commonly in your country as opposed to others? Do you know?
47:02
Yes, we see neurosis and those we are operating, they are less than those we are treating medically. Even recently, we gave tablets to one of our colleagues.
47:18
who had the neurosis psychosis, but with no hydrocephalus. He came already in the pacified stage and we gave a tablet and everything went well. So we see more of these cases. Like I can say, for
47:36
four years, I have more
47:42
than 30 cases of neurosis psychosis. So the presentation I would guess to neurosurgeons is perincomal from seizures, maybe acutely from hydrocephalus and the
47:51
drug treatments, are they very successful or not?
47:57
Yes, many of them they come with seizures. Adult onset seizure, when you do CT scan, you get
48:07
the diagnosis
48:10
This presentation will be given by Professor
48:15
Samuel Kaba Agaroya. who's the Director of Institutional Care Division of Ghana Health Services in Ghana. His talk will be on the use of intraoperative ultrasound and neurosurgery. All right, can
48:32
you hear me? Yes, we can. All right, so thank you so very much for this great opportunity and to all colleagues who are online. I'm gonna be talking about intraoperative ultrasound and I would do
48:43
my best to do it as quick as possible And just one disclaimer, I'm not actually a radiologist, I'm a neuros agent, but I think this is the future tool for low resource setup. I don't have so much
48:57
experience. This is my fourth year of experience in ultrasound, transoperative, I don't think that is a lot of experience, but I just believe that is the future. Now why so because most of the
49:11
time we talk about intraoperative MRI, we talk of interpretive, citizen, and all that. quite extensive. And in most countries, in the developing countries, should we even have to do them right
49:22
now? You got to break down your theater. You need to build a new place to put there. But with the ultrasound, you easily go on without having to
49:32
make any changes
49:35
Let me
49:41
see. All right. So, ultrasound is this machine that uses high frequency sound with
49:49
the view inside the body. So without the image, images are captured in real time. And that is a good thing because you see everything you're doing, including the blood flow. And now, just a
49:59
little history, just to say that Tom Brown and of the session, he and Donald, way back in 1956, decided to use the way the first to use the first prototype. And of course, as gynecologist, they
50:12
use it for the diameter of the head of the fetus. And Later on, teodor and Frederick, they attempted the ultrasound to diagnose brain tumors. And then in the 70s, we just have a boom. Now, this
50:25
is how the Elliot ultrasound looks, very bulky, big. And today, ultrasound looks very, very simple, small, portable, you can even have them on your cell phone, and then you get what you want
50:37
to do, get it done. And that has changed the perception and the expectation of neuroscience that now it's easily being used in neurosurgery for many, many procedures in brain tumors, placements of
50:51
EVD shams. And it can also help you to actually determine how much volume of tumor you've removed and where your catheter is placed or not. And as I said before, the beauty of ultrasound is that
51:05
it's allowed live as well as just know the structures. And it can be used alone. You don't actually need to have a neural navigator before you use an ultra sound or an intra. intra of MRI, you can
51:18
use it alone and it's a very good navigational to to. So, typically when we talk of ultrasound, we're talking about a frequency above human hearing, that is about 20, 000 heads or you can say 2,
51:32
000 mega, 2 mega heads, sorry. And human cannot hear that. So this is how the probe works. I will just write to the ask quick and simple. We have different modes in which the ultrasound operates.
51:45
So in mode A or eight mode, you can see if the black is my case of being seen.
51:53
So if you take this as a tissue, you emit the, you use the transducer. The case of the, you see the sound goes in and then retains and this will be your mode A and then you get whatever you want
52:06
to see. So hand movement is very, very important in dealing with ultrasound We also got the mode B, the mode B where you see the brightness, so B for brightness. and this is what on the
52:18
right-hand side or left to your computers, you can see the brightness and you can see how it will look in the ultrasound. Then you have the M mode, which signifies motion, which is movement. So
52:31
thanks to this mode, you can actually see movement of blood and the tissues and X, Y, and Z. Then we also got the Doppler mode. And in the Doppler mode, I'm being very quick because I think I
52:42
just have 20 minutes to do this. And the Doppler mode is one of the modes that generally we like to see and they look nice because you have them in colors and all that. But it helps to quantify the
52:54
directional velocity of whatever we're doing. So we do have, sorry, we do have a different type of Doppler modes. You have the post mode, you have the continue wave mode and the advantage, I
53:08
don't know, the advantage of the C mode is that unlike the power mode, if the 10 is the flow accuracy. Then you have the Doppler display mode, and we can see the different modes here, spectral
53:23
mode, and which we are actually not going to talk about it, but it's just to show that in the Doppler mode, we have different type of modes. And the spectral mode is simply a typical use for to
53:36
characterize the blood flow through the hatchin base, so cadio thoracic legends are more using that. And then you have the color doppler, which is what we see Now, in the blue, the blue only
53:46
shows that the data is going away from your transducer, and the red shows that the data is coming to your transducer, as we can see in the pictures. Now, the color doppler is so good because it
53:60
helps you to document the presence or absence of blood flow within the pathological lesions. So when you operate in a chemo and you use the ultrasound, you can actually see the blood flow, you can
54:10
see the vessels, and it helps a lot to determine how much you can reflect where the challenge is. what to do. With the power droplet is useful to examine low velocity blood flow and it's more
54:22
sensitive to flow than the color mode. So other modes and one of the things that neurosurgeons would enjoy will be the 3D and 4D scanning modes and this is determined by the probe. The probe is
54:37
about 7, 4D is about 7500 and then one property we do have has to do with the elasto graphene which has to do with when you're using neuros navigation and you use the ultrasound you can pick up the
54:51
difference. In our experience we've seen one centimeter difference when you open the you do the cranial tummy as to if you were just from the neuron navigator. So now the ultrasound can correct that
55:04
brain shift once you do your cranial tummy. So what kind of things can affect the image quality, the environment, the tridusa and then the system you use will not go too much into little bit of the
55:16
line density, which helps to adjust the number of scan lines. You just have to keep trying to scan. Now, as I said, the ultrasound, actually, the most important thing about it has to do with
55:26
the probe that you use. You have all these different probes. We use a lot of, I'll be talking about the probes that we use, but you have the liner probe, you have the sizes also matter,
55:37
depending on the procedure you're going to do. So, the type of scans, we have the 3D, 4D, the colored oplet, we're already talking about that. And then, the properties of the images, why they
55:49
form the reflection, reflection, absorption, and scattering. Because this is not a cause, but just to give a talk and let us understand what we use it for, I'm talking about this, mentioning
56:00
them to go ahead. Now, if you check here, you ultrasound, when you talk
56:09
of CT scan, you talk about the properties that we look on in ultrasound, we talk about eco-genicity. And an echo-genicity means that there is no echo-genicity that is seen in the ventricles,
56:22
hypo-ecogenicity, normal, white matter, hyper-ecogenicity, we see that in Tummo. We also have the homogenicity where you see
56:33
low-grade gliomas and heterogeneous, heterogeneous in high-grade gliomas. And there you have this issue of demarcation that has to do with infiltrative versus non-infiltration tumors that we see.
56:42
So you have echo-genicity, normal tissue, isodence that
56:45
we'll be talking in CTSCAM, or iso-intense, when you're talking about MRI. So you look at
56:52
hypericosogenic issues, which is the brighter one you see in the files, the tendurium, correct places. The hypogenic will be the brainstem, and then the
57:02
enoch-genic will be in the ventricles and the base-out systems. So use of ultrasound intraoperative We
57:11
use it for many things to be in the infections. from a efficient placement, vascular tumors combination with other neuro-navigational tools. And now I'm coming to what we do in the Rich Hospital
57:26
where I work currently. So we have a 10-in-point. And the 10-in-point, as I said, Projems that I'll be talking about Dr. Mariela. She is the one you can see the arrow too.
57:40
Sorry
57:44
I've gotten some frozen machine a little. So you can see her. She's the one. Prior to her arrival in our hospital in 2021, we were only doing pre-op ultrasound or post-op. And that was being done
57:59
either by the pediatricians or the radiologists. But she's a neurosogen and she's a pediatric neurosogen with over 25 years of experience and has been using ultrasound for over 80 years. I'm happy
58:12
she is online so if there is anything she can also.
58:18
Talk to eat for, talk to eat, sorry I'm sorry.
58:31
For some reason, the screen is gone
58:39
We can still see you can see my screen. Yes, we can. All right. Okay.
58:49
So did you have many more slides after this or not? Yeah, sure, I do. I'm now going to talk about how we use it. Oh, okay. In our setup, but for some reason, good. Is it back? Is this it?
59:02
We have a loss that we can see is good. All right, so in our department, we started using the transfer printer ultrasound in 2021 with the arrival of Dr. Infante. And as I said, she has a lot of
59:14
experience with this. And then prior to that, we used to borrow our equipment. This is our first ultrasound. Let me see if the video can show. This was one of those things we're doing with
59:28
evaporation of intraprene camera and we're using from the machine from our new metal department. On the other side, you can see on this image where my case I is, you can see us trying here to do
59:39
post ultrasound, to see the ventricles and to see the intracranial pressure Then something happened dramatically that we recorded our
59:48
for joint twins and with that we approach the government and we're able to get our first ultrasound and this is now the ultrasounds that we have in our setup and this is our typical setup with the
59:59
navigation and then we try to couple the ultrasound you can see with the neural navigation system with the cruiser and with all the things that we do the indoor scope and we try them we keep trying to
1:00:12
land. Then we went ahead to try to measure the probes and see with our bayholes if you have a probe how the probe can go depending on the barehole you use if you place in the shunt you know this is
1:00:24
the diameter and then this is the kind of ultrasound you might want to use. Now we have not received a 4D yet but the probe yet but we are working towards achieving one our acquirer one very soon.
1:00:38
So we've used them in many of these procedures that you've seen listed and and I'll go through some of them need by being. So here you can see in hydrok fellows, we use it. If we did an insurance,
1:00:51
we use it daily and we print out everything that we do. So here you can see in this video, you can see the
1:01:00
ventricles and how we apply after that. You can see on your right side, where the KSI is, you can see our tools in there. In literature review, seeing that there are a lot of catatam displacement
1:01:14
and malfunction and refiction but with the ultrasound, you have the opportunity to get in once and the revision rate is low. Here is the case, a patient who came with a stab wound. Obviously, you
1:01:26
can't put this patient on the inside an MRI because you don't know what will happen to the knife. And in CT scan, you get artifacts as we see. And with ultrasound guided, we did the operation,
1:01:39
went through the midline and then removed the knife without any challenges. And as you can see, and push up, this is the patient walking when he came after the stop move. So ultrasound has helped
1:01:57
us together with other equipment that we use. We use it, as I said, in the intra-parent camera in Murij, especially in CVA.
1:02:07
And then with the navigation system, we're able to aim everything. And then we come, we don't have to actually save the ladies But they spend a lot of money doing their hair cut. We get this,
1:02:19
measure the hole. And then we can see here, as we put washing the clot, where you see the water come in. We can see the water. Let me see here again. As you clean the clot, you can see the
1:02:34
water coming in excellently. Then here, you can see in
1:02:40
the Let me see, you can see the water you see the water coming out, or as it comes, then you can see the grade of washing that you're doing in the metroma, and then you are done. Of course, we
1:02:52
can see, we can use it to measure the pressure, as I said, and this is for the young ones, I mean, this is the future of neurosurgery when it comes to needle monitoring. Then, as I said, you
1:03:05
can continue on bedside, if you're not satisfied, or you can, it's a procedure with the ultrasound, you can do bedside, and this is the patient when he came two days after the surgery, you can
1:03:15
see the difference This case just happened yesterday and was operated on. This is a fracture, you can see multiple bilateral elements here, this is epidural,
1:03:28
and this is intra-dural, intra-parenchymal, you can see them. So, in one side, you do your cranial tummy, you remove the matoma, and the other side, you go the matomas in there, and you can
1:03:38
do another cranial tummy. With the ultrasound, you come in, you can see, if you look at the CT scan, you see a cystic part of the Matoma and you can see the part of the matoma, which you can
1:03:49
also see in the ultrasound. And then you can see the matoma here and through the ultrasound guidance, we evacuated this and matoma. So this is the part of BW, the red part would be the matoma.
1:04:02
And then let me trade this with you. As you put, you don't need to do y-cranium tummy. So you see this line is removal of the matoma in one side and then decide the washing of the
1:04:19
matoma here. So we can see the ultrasonic component. You can see how it's being washed. So this patient, we don't have the pulse of the head because it was yesterday. We're now doing the scan.
1:04:30
But after that, you can see the parameters here, the BPA everything normalized. And we hope it does well. We also use it in gunshots. And this is a patient who came with all these bullets in this
1:04:41
way. And this is the point here If you go to the MRI, you wouldn't know what to do.
1:04:48
whether the pellets will be MRI sensitive or not, they'll be magnetic sensors or not. And if you do see this, can you get a lot of artifacts? We use the ultrasound, with the ultrasound from the
1:04:58
skin, you can actually count, you can see the pellets, and you can actually count all of them, and you can measure the distance and everything. And this is a fluoroscopy, you can see some of the
1:05:09
pellets actually moving inside the patient. Let me see, towards the end, you see, they are moving And in cities kind of MRI, you don't see that. Ultrasound helps. During the surgery, this is
1:05:21
the ultrasound probe. We come in and then with the ultrasound, we are able to perform the surgery.
1:05:29
And then these are some of the pellets removed. As we can see, this is the patient postoperatively walking and without any big challenges
1:05:43
We do a lot of awake surgery in my center and we use the ultrasound to do the nerve blockage as we can see. And this helps to keep the patient without pain. And this is brachia plexus that we repair.
1:05:55
You can see the entry point of the night. You can see where the patient is having the challenges. This is the MRI. This is the ultrasound version. When we did, you can see the vessels and
1:06:06
everything. And then we get it repaired with our little,
1:06:11
you can see with the stimulation of the nerves around the nose.
1:06:17
You get all that. Tomorrow's section, we use it every day, every single day. And the good thing is that you locate your tumor, you do your tractography, spectroscopy, you do your registration.
1:06:30
We use the ultrasound immediately, we do the cranial tummy. So you do it before you open the dura. Then after opening of the dura, it guides you. And you can actually see your tools You can see
1:06:40
the chamomor and when you put your bipolar and it's
1:06:45
In meeting the heat, you can actually see your bipolar. You can see all the tools moving. And you can do your doppler. You can see the vessels, the blood flow, and everything. So it really
1:06:56
helps in visualizing the chemo and the surrounding structures. I just sent to the chemo. When you complete with an navigation system, to me, it's almost like an MRI, because you are seeing
1:07:07
everything, and if you use a 3D probe, it's better Now, maybe those who have used ultrasound a lot on this platform can talk to this, because in our setup, we use this
1:07:20
to enhance the tumor visualization, but we've not used yet the contrast in the ultrasound. And we've been checking to see if there will be any contraindication or any reaction. So those who might -
1:07:39
Yeah, so I'll be talking about that. So we do that. Sorry, a message came and I was trying to read and I'll talk about that in the question side. So we look at now using the contrast and using
1:07:53
the 3D or 4D proof. This is our patient after a section of the tumor. So why ultra sound, why am I interested for the younger generation? Because it's relatively cheap. It's easy to take too many
1:08:05
places. We move it to ICU, to the war, to the theater, every way, emergency. And you can be used alone. And no need to pause during surgery and say I'm moving the patient to another room to do
1:08:14
an MRI, or you need to
1:08:19
record everything's life. The surgical tools can be seen. You can combine with other navigation. You correct the brain shift. It improves the, once we improve the image quality with training,
1:08:29
then you can evaluate blood vessels and flow. Neurosigions can easily use it in our set up is with the nearest agents who use it.
1:08:40
in the radiologist. It's cheaper in the installation. All you need is a small gel and they probe and then even with the water the normal saline you can
1:08:55
enhance the imaging. You don't need nuclear people to constertify nothing and they of course it has a learning curve but the more you do the more you learn. What are some of the challenges maybe the
1:08:60
artifacts and the learning curve but the more you use it the more you get a well vest with it and then you can do more. So in our setup we use the ultrasound we use all the pros available and then we
1:09:15
also do some few 3D printing which we're trying to see how we can combine that with the ultrasound and see how those can go. This ultrasound together with what we do has helped us do a lot of things
1:09:27
including visual reality using ultrasound to learn all that. So my message today is that nothing can get done at all if it manuated until he could do something so well that no one can
1:09:39
just let's start doing what we can, it's more small little by little, we do what is possible and suddenly we're doing what this we thought could not be possible. So this, the future is bright and
1:09:51
I think ultrasound should be incorporated, we are still learning. As I said, I only have four years in it, my mental health and fantasy online as eight years, and we are still learning in the
1:10:02
country and we never stop learning
1:10:06
I will pause here, but it is a question I will give to prove games so that you can moderate, then I can answer the questions and my colleagues who are online to can answer those with more experience
1:10:17
can talk about it. Thank you. Superm superb job with real practical advice. Are there questions for Professor Kaba in the use of his instrument Hi,
1:10:31
Dr. Sorry, it was excellent. and I really, and I'm sure everybody enjoyed it. But I have one quick question about the conjoint twin that he showed on the exam. Dr. Lazareff did the first
1:10:45
conjoint separation at UCLA in the US. If you can one time talk about it so he can share his experience because that's a topic for the next generation of the neurosurgeon. And when he was Dr. Osman
1:11:00
and Dr. Strada decided to talk about it, it's a beautiful case and we really enjoyed your talk and that presentation.
1:11:10
Thank you, Ali. Anybody have questions from Professor Kaba? Yeah, so I would say to my colleague, Daddy S, thank you so very much. And sorry for the internet issues that the slides move back
1:11:23
and forth. I just have to try to fix it to make the presentation. Maybe in the next round, when we get the opportunity, we'll be talking about the separation the first conjoined twin thing guys.
1:11:33
And so I reserve that. And for when the rounds get back to us, we'll be talking about it. It's very important. And I think it's extremely wonderful experience any neurosurgeon can ever experience
1:11:45
once in your lifetime. So we'll be talking about that. Thank you. Excellent, excellent presentation. Thank you. And excellent case for the practicality. I wonder if the Dr. Professor Marielle
1:11:59
from Cuba, is she still available to make comment? She's in there. Marielle? All
1:12:09
right, yeah, so she - Yeah, thank you. Uh-huh. We start to use the most of sound with the child, because I working with the child with 20 years, for 20 years, and it's time we try to save a
1:12:22
lot. And later introduce, they use the ultrasound with the tumor detection
1:12:29
because the baby has the hematoma. We are driving to Ghana. We start to use
1:12:37
it for a way to them atoma with good results, because it's more behold, and
1:12:48
the result is very, very good. The proof that you use the pump, because if you
1:12:56
need to see
1:12:59
the flow, you use the plane, but if you use the hydrocephalus, I use the cues. How can I use? I use the glove, a cherry glove.
1:13:11
Previously, we had the gel, and
1:13:16
the rest, I covered with the gloves. It's a cherry, and it's secure We not have the infection after the use of
1:13:28
the hydrocephalus. Excellent. I wonder if you could comment on how you feel. The perspective, the intraoperative ultrasound is for gauging the extent of tumor resection.
1:13:43
Let me take this before she comes in. Sure. Let me say, Dr, the professor is a pediatric associate professor in neurosurgery and she is in Ghana now in our center as a collaboration between the
1:13:57
Ghana government and the Cuban government so she is on a mission temporarily And we've actually benefited a lot. This is an example of what we have benefited from. And a lot of questions also came
1:14:10
in as to the probe. The best probe depends on what you're going to do. If you're going to do just a bare hole and the drainage of the trauma, you just need a small probe We've evolved to the hockey
1:14:21
sticks probe. If you look at some of the probes that are presented, they are able to allow you to actually navigate in inside
1:14:31
the ventricles and outside. If you use a small, it's easy. you can easily evacuate a assist, you can evacuate an upstairs, and then the liner probe is good, when you do cranial tummy you can see
1:14:42
it. Then the probe, besides the probe, depends on the type of machine you have. Some of the machines that you might have, we have one from G, very excellent, and then the other one that you see
1:14:53
there when so. And depends on the quality of the machine. You need to actually talk
1:15:00
to the vendor that you're going to use it for neurosurgery. Then they can actually accommodate it and put the apps for you to be for neurosurgery, or as they might configure it in a way you might
1:15:12
not be getting good images. And because we are just using them for neurosurgery, we got the EGE guys to come in. We bought it personally for that. We got them to come in and accommodate it for or
1:15:23
accommodate them for neurosurgery. So we're getting good images. But we hope now with 4D, we should even improve better. Thank you.
1:15:32
I wonder if Ignatius is still here because I can't see it on my screen. Ignatius, are you still here?
1:15:39
There you are. Yes, yes, sir. Do you have any experience? Is this practical for you and the camera owner? Do you use it or what's your experience? No, no. I don't have any experience. I only
1:15:51
started during my training, but I wouldn't use it. Is it too expensive, a device to get in camera room?
1:16:00
No, no. Okay, so it's a matter of convenience, I guess.
1:16:08
Professor Kaba, how expensive is it to get the proper ultrasound machine that you can use intraoperatively? All right, so in Ghana, in my facility is a public facility, it's a government hospital.
1:16:23
So the government bought ultrasounds for primary health care, so we went into the ministry and we got one. And then the I don't want that we got. That was from GE,
1:16:37
the one that we can use the 4D probe. And usually the procurement is done by the ministry. So we can't say how much it is, but it ranges between20, 000 to30, 000, or you can get as much as50,
1:16:50
000. However, the simplest ultrasound machines, you can get them for10, 000, even5, 000. Those that they're using for primary health care that you can actually cooperate with your cell phone,
1:17:04
which your cell phone, they are going for almost5, 000, even you can get them for3, 000. So it depends on
1:17:12
the quality of the ultrasound you need. And the most important thing now will be the probes, because for some reason, they sell with some standardized probes, and then when you want more probes,
1:17:24
then they give you different prices for the probes So for instance, the 4D problem getting is going forward. 7, 500 US dollars. What's the learning curve? Is it take how many patients 10, 20
1:17:38
patients to become comfortable with it? Or how do you, how do you establish experience? All right. So in my personal experience, depending on the kind of procedures you'll be doing, but any of
1:17:51
the people who spend the more you do, the more you know. And as I said, I only have four years. I'm still learning. I'm still learning from the doctor in front there. I'm still learning from the
1:18:00
Internet. I'm learning from other conferences, but the more you scan, the more you get better. And in a week, if you do this in a week, you should be able to look into CVA's, you should be able
1:18:14
to look into cyst, you should be able to look into
1:18:23
the common, common diseases. But then you need more time to go into the vascular diseases, you need more time to go into the tumors and be able to differentiate between the tumors and the other
1:18:29
structures.
1:18:31
So in a week, every neurosogen should be able to use it for simple procedures. On that side, in the day.
1:18:41
We were going to have Professor Monty from Iraq, Baghdad. He uses it extensively in tumor surgery, has had excellent results. He didn't, he's not here, he probably tied up as his Sam or hose who
1:18:59
had an emergency procedure. So anyway, it looks like it's very valuable that the,
1:19:08
you mentioned something, Professor Kaba. I remember when we were using the, the very expensive interoperative neuro navigation systems. Oftentimes, by one out of three times it didn't work or
1:19:24
people didn't know how to use it. The ultrasound is just what you said in your talk, practical that's easy to use. inexpensive, it's simple, and you can get a great deal of information. So I
1:19:37
think
1:19:39
don't be enamored by all the companies wanting you to spend expensive, lots of money on something that you might find this is very helpful for. Now, you have both, you have neuro-navigation and
1:19:52
ultrasound, which one do you use or do you use both?
1:19:58
We combine them, we combine them, we've actually calibrated to combine them, but for emergency cases we use, this time we use only the ultrasound and I'm tending to like the ultrasound more than
1:20:09
the navigation because once the navigation you don't have life
1:20:15
surgery, I mean after you open the brain and you even resect the tumor you still see in the same, but the ultrasound you see in life and you are actually operating and you're seeing how much tumor
1:20:26
you're removing, how much blood you are evacuating, how much does you have, you see every little change
1:20:33
How much saline you are pumping in? So I tend to like the ultrasound this day even more than the neural navigation. And I think it is the future for neurosensors. Thank you. I think we have two
1:20:43
questions up. Professor Mombali.
1:20:52
Do you have some comments?
1:20:55
Oh, so a.
1:20:58
Well, I mean, well, side had his hand raised. Yes. Go ahead. Okay. I just wanted to mention about the author of on Doppler that our previous chair, Dr. Neil Martin, we used to do a lot of
1:21:09
vascular. Anastomosi ECIC bypass. He used the Doppler for verification of the Patency of the artery and after the anastomosi's, he used that one. And I think it's something for the vascular
1:21:24
surgeon to recall. Remember that the author is very effective to verification of the. Patency of the anastomosi and the choice of the artery you are using to do the anastomosi's. You may need a
1:21:39
different size probe, but it's a very good That's what in David he when he used to do it, sir.
1:21:46
I strata. It's nine thirty. We started about five minutes after. or eight. And I think Sam or I'll just give you a short summary. Sam or was going to talk to us in it. We'll have him come back
1:21:60
the next time about think of something going to be of interest to everybody. And that is using a smartphone. And he's he's a hybrid vascular neurosurgery. He does interventional neurosurgery and
1:22:15
and standard neurosurgery. And they were using an interventionalist in Saudi Arabia and helping guide people in Baghdad and other places using the smartphone to educate people beforehand to go
1:22:31
through the needs you have beforehand. And during the actual procedure to guide them through it, as in 29 cases, they've been very successful with it. So we're going to have him come and talk
1:22:42
about it at something that seems very practical and can solve a lot of problems with personnel. John, do you have any other thoughts or comments? I thought the two presentations were outstanding.
1:22:55
Well, I thought they were excellent. I think we were establishing a good foundation to build on. There was one question that might be, my others may have in the chat about whether a craniotomy or
1:23:11
a burr hole is needed for doing the ultrasound. If Dr. Kaba could briefly comment on that and I think we can focus. Yeah, so actually there are two there. How do you maintain a sepsis while using
1:23:24
the probe? So usually we use the same ciata gun that we used to, we just put the cable in and then
1:23:35
we put the glove, as you can see in the images and then it's completely accepted. So there's no problem with that. Now there are two ways When we face yes, you have to do cranial tummy. And then
1:23:49
immediately you do the cranial tummy. The best moment is to do the ultrasound before you open the doer. It helps you to locate yourself. It helps you to mark everything. And it even helps you to
1:23:59
also get the image and the surrounding structures. By then, if you were using only the narrow navigation, there would have been brain shifts and you wouldn't be able to actually be in the same
1:24:11
position, but the ultrasound will help you to see that very well. Now, we also, there are moments, for instance, when we do push-up, when we are in the ICU, sometimes we can use the ultrasound
1:24:22
to measure the flow of the middle cerebras artery. You just put the ultrasound there that you don't need cranial tummy. Put it right there and you can see the flow. You can do the doppler and I
1:24:32
agree with Professor Seid. Whenever you do the doppler mode, you can actually see the vascularization
1:24:40
and how the blood flow is. So yes, during chemo surgery, do cranial tummy, do ultrasound, open dura, you can do ultrasound. again. Before we used to hold it, twice we will pray. Now, and
1:24:53
then you come in and out. But now, you can actually have some system where you adapted to the brain and you're operating, you don't need to be removing it back and forth, back and forth. You have
1:25:02
it on the brain and you just operating and you see how much tomorrow you remove it. Thank you. Thank you. Thank you. Thank you. Thank you. Luis, you're still here from Mexico. I see you're
1:25:11
still there. Any comments on the, and do you use intraoperative ultrasound, any comments, any experience? Yes, we use both. We use neural navigation and an ultrasound interpretive and it's a
1:25:24
very remarkable tool for surgery and we've been sitting in cases of tumors and hydrocephalus as well as the doctor presented the cases. Do you use ultrasound more frequently than you use neural
1:25:39
navigation? Both. We use both Do you use another same tool? Yes. Okay. In receptors tumors, we use both.
1:25:49
Okay, anybody else have any questions?
1:25:54
Okay, well, Strada, I think, Gilbert, yes, Gilbert, yes please. No, no, just to say some words and congratulations and good presentations, very, very impressive, very interesting and very
1:26:11
informative. So we are waiting for the next courses, maybe one or two months, I don't know exactly when. Thank you very much. So along those lines, we're planning a regular recurrence on the
1:26:25
first Sunday at the same time as this. So the program committee will meet in about a week to determine the agenda, but this is gonna be a recurrence form every first Sunday of the month.
1:26:39
Okay, well, I wanna thank
1:26:43
both Professor Kaba And, and, and, and. and Kabula for their presentations and Luis for commenting and joining us and everyone else for coming. We hope you've enjoyed it. Astrada, any last
1:27:02
comments? No, excellent presentations and I appreciate the very active participation. And I think we'll end it now and look forward to the forum in a month, the first Sunday
1:27:19
Okay. Thank you. Thank you very much, everybody.
1:27:26
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