Intraoperative Ultrasound; Inexpensive, real time, practical, imaging.

SNI, Surgical Neurology International,

and SNI Digital Innovations in Learning.

In association with the Sub-Saharan African neurosurgeons

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.

This Grand Rounds was held on Sunday, July 7th, 2024.

This presentation will be given by Professor Samuel Kaba Akaroya, who is 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 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'll do my best to do it as quick as possible. And just one disclaimer, I'm not actually a radiologist, I'm a neurosaging, but I think this is the future tool

for low resource setup. I don't have so much 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. And why so because most of the time we talk about intraoperative MRI, we talk of intraoperative CT scan and all that, these are quite extensive. And in most countries, in the

developing countries, should we even have to them right now? You got to break down your theater, you need to build a new place to put down. but with the ultrasound you easily go on without having

to make any changes.

Let me see. All right, so there you

go, good. So ultrasound is this machine that uses high frequency sound with

the view inside the body, all right? 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 little history, just to say the term brown and obstetician, AM. Donal, way back in 1956, decided to use the first to use the first prototype. And of course, as gynecologist, they 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 the boom. Now, this is how

the Elliot would. The sounds look very bulky, big. And today, Utra sounds look very, very simple, small, portable. You can even have them on your cell phone and then you get what you want to

do, get it done. And that has changed the perception and the expectation of neuroscience that now is easily being used in neurosurgery for many, many procedures in brain tumors, placements of

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

it's allowed live as well as a suggestion of the structures. And it can be used alone. You don't actually need to have a neural navigator before you use an ultrasound or intra MRI.

You can use it alone and it's a very good navigational two So, typically when we talk of ultrasound, talking about a frequency above human hearing. That is about 20, 000 heads, or you can say 2,

000 mega heads, sorry. And human cannot hear that. So this is how the probe works. I will just write to just quick and simple. We have different modes in which the ultrasound operates. So in

mode A or eight mode, you can see if the blood, is my case being seen?

So if you take this as a tissue, you emit the, you use the transducer. The case, you see the sound goes in and then returns and this will be your mode A and then you get whatever you want to see.

So hand movement is very, very important in dealing with ultrasound. We also got the mode B where you see the brightness. So B for brightness. And this is what on the right hand side or left to

your computers, you can see the brightness and you can see how it will look in the ultrasound. There you have the M mode, which signifies motion, which is movement. So 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 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 It helps to quantify the directional velocity of whatever we're doing. So we do have, sorry, we do have a different type

of Doppler modes. You have the pause mode, you have the continue wave mode and the advantage, I don't know, the advantage of the C mode is that unlike the power mode, if the time is the flow and

the velocity accuracy. Then you have the Doppler display mode and we can see the different modes here, spectrum 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 characterize the blood flow through the hatchin base or cardioporacic legends are more

using that. And there you have the color doppler, which is what we see. Now, in the blue, the blue only 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 helps you to document the presence or absence of blood flow within the pathological lesion.

So when you operate in a chemo and you use the ultrasound, you can actually see the blood flow, you can see the vessels and it helps a lot to determine how much you can resect, where the challenge

is and what to do. With the power doppler is useful to examine low velocity blood flow and it's more sensitive to flow than the color. mode. So other modes and one of the things that neurosurgeons

would enjoy would be the 3D and 4D scanning modes. And this is determined by the probe. The probe is about 74 days, 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 neuro navigation and you use the ultrasound, you can pick up the 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 neuro navigator. So now the ultrasound can correct that 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 that. I will talk a little bit of the line density, which helps to adjust the number of scan lines,

you just have to keep trying to stand. Now as I said the ultrasound actually the most important about it has to do with the proof that you use. You have all these different proofs. We use a lot of,

I'll be talking about the proofs that we use, but you have the line-up probe, you have the sizes also matter, depending on the procedure you're going to do. So the type of scans, we have the 3D,

4D, the color-dope layer, we're already spoken about that. And then the properties of the images, why they form their reflection, refraction, 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 them to go ahead. Now, if you check here ultrasound, when you talk of CT scan, you

talk about

the properties that we look on in ultrasound, we talk about echogenicity. And echogenicity means that there is no echogenicity, that is seen in the

ventricles hypoecogenicity, normal white matter. echogenicity, we see that in Tumor. We also have the homogenicity where you see 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-inflammatory Tumor that we see. So you have echogenicity, normal tissue, isodence that will be

talking in CT scan or iso-intense when you're talking about MRI. So you look at hypericosogenic issues, which is the brighter one you see in the files, the tendurium, correct places. The

hypericogenic will be the brainstem and then the n-ec-code, n-ec will be in the ventricles and the

Bessel systems. So use of ultrasound intraoperative, intra-pretively, we use it for many tests. It could be in the infections, trauma, efficient placement, vascular, tumors, combination with

other neural navigational tools. And now I'm coming to what we do where I work currently. So we have a tenant point. And the tenant point, as I said, projects that I'll be talking about, Dr.

Mariela, she's the one you can see the arrow to.

Sorry,

I've gotten some frozen machine a little. So you can see her, she's the one. Prior to her, arrived in our hospital in 2021, we were only doing pre-op ultrasound or post-op. That was being done

either by the pediatricians or the radiologists, but she's a neurosurgent and she is a pediatric neurosurgent with over

25 years of experience and has been using ultrasound for the ADS. I'm happy she's online, so if there is anything she can also talk to it for, talk to it. Sorry.

For some reason, the screen is gone

We can still see you can see my screen. Yes, we can. All right. Okay.

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?

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

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

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 KSI is, you can see us trying here to do post

ultrasound to see the ventricles and to see the intracranial pressure Therefore, something happened dramatically that we recorded our 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 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 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 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 so we've used them in many of these procedures that you've seen

listed and and I'll go through some of them by being. So here you can see in hydrok fellows, we use it. If we did an insurance, we use it daily and we print out everything that we do. So here you

can see in this video,

you can see the 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 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 can put this patient on the inside and 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, went through the midline and then we 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 us together with other equipment that we

use. We use it, as I said, in the intra-parent camera in Murij, especially in CVA.

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,

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

water coming in excellently. Then here, you can see in

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

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 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 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,

and this is intra-dural, intra-parenchymal, you can see them. All right, 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 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 also see in the ultrasound. And then you can see the matoma here and through the ultrasound guidance, we evaporated this and matoma. So this is the part of BW, the red part would be the matoma.

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

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.

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

way. And this is the point here If you go to the MRI, you wouldn't know what to do.

whether the pellets will be MRI sensitive or not, or the 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 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

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

the ultrasound probe. We come in and then with the ultrasound, we are able to perform the surgery.

And then these are some of the pellets removed. As we can see, this is the patient postoperatively walking and without any big challenges

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.

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

everything. And then we get it repaired with our little,

you can see with the stimulation of the naps around the nose.

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. 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 the chamomor and when you put your bipolar and it's

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

helps in visualizing the chemo and the surrounding structures. I just sent to the chemo. When you complete with the navigation system, to me, it's almost like an MRI, because you are seeing

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, too, we use this

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,

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 questions side. So we look at now using the contrast and using

the 3D or 4D pro. 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

places. We move it to ICU, to the war, to the theater Everywhere, emergency. And you can be used alone. And no need to pause during the surgery and say I'm moving the patient to another room,

to do an MRI, or you need to record

everything in 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, then you

can evaluate blood vessels and flow. Neurosigions can easily use it in our setup is with the Niro Sejus. who use it, we don't call it the

radiologist. It's cheaper in the installation. All you need is small gel and the probe and then even with the water, the normal saline, you can enhance the imaging. You don't need nuclear people

to can't satisfy nothing. And of course, it has a learning curve, but the more you do, the more you learn. What are some of the challenges, maybe the artifacts and the learning curve, but the

more you use it, the more you get, 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 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, including visual reality,

using ultrasound to and all that. So my message today is that nothing can get done at all, if he manuated until he could do something so well. that no one can find a fault. 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 we thought could not be possible. So this, the future is bright and I think ultrasound should be

incorporated. We are still learning. As I said, I only have four years in it. My mentor, Dr. Infantee is online, he has eight years. And we are still learning in the country and we never stop

learning I will pause here, but it is a question. I will give to

Prof. James, so that you can moderate. Then I can answer the questions and my colleagues who are online to can answer those with more experience can talk about it. Thank you. Superm, a superb

job with real practical advice. Are there questions for Professor Kaba in the use of his instrument? Thank you, Mr. Zane. Go ahead. Hi, 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 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 he went in with Dr. Osman and Dr. Strada and he decided to talk about it. It's

a beautiful case and we really enjoyed your talk and that presentation.

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

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're talking about the separation of the first

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

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

from Cuba, is she still available to make comment? She's in there. Marielle? All

right, yeah, so she's - 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

lot. And later introduce, they use the ultrasound with the tumor detection

because the baby has the hematoma. We are driving to Ghana. We start to use it

for a way to them atoma with good results, because it's more behold, and

the result is very, very good. The proof that you use the pump, because if you need to see

the flow, you use the plane, but if you use the hydrocephalus, I use the cubes. How can I use? I use the glove, a cherry glove.

Previously, we had the gel, and the rest, I covered with the gloves. It's a cherry, and it's secure We not have the infection after the use of the hydrocephalus. I wonder if you could comment on

how you found it.

The perspective, the interpretive ultrasound is for gauging the extent of tumor resection.

Let me take this before she comes in. Sure. Let me say, Dr. Professor Fante is a pediatric associate professor in neurosurgery and she is in Ghana now in our center as a collaboration between the

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

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 sticks probe. If you look at some of the probes that are presented, they are able to allow you to actually navigate in inside

the ventricles and outside If you use a small, it's easy to use. you can easily evacuate a assist, you can evacuate an abscess, and then the liner probe is good. When you do cranial tummy, you

can see it. Then the probe, besides the probe, it 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 there, when so. And depends on the quality of the machine. You need to actually talk

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 configurate it in a way, you

might 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 purposely for that. We got them to come in and accommodate it

for, or accommodate them for neurosurgery. So we're getting good images. But we hope that with 4D, we should even improve better.

I wonder if Ignatius is still here because I can't see it on my screen. Ignatius, are you still here?

There you are. Yes, sir.

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 started during my training, but I wouldn't use it. Is it too

expensive, a device to get in Cameroon?

No, no. Okay, so it's a matter of convenience, I guess.

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.

So the government bought ultrasound for primary health care, so we went into the Ministry and we got one. And then the other one that we we got. That was from GE,

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,

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,

which your cell phone, they are going for almost5, 000, even you can get them for3, 000. So it depends on

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,

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

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 a

neurosurgeon who spends 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 Dr. Infante. I'm still learning from the 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 CVS, you should be able to look into

this. You should be able to look into 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 tumor and the adjacent structure. So in a week, every neurosogen should be able to use it for simple procedures. On that side, in the day.

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

had an emergency procedure. So anyway, it looks like it's very valuable that you mentioned something, Professor Kaba. I remember when we

were using the very expensive interoperative neuro navigation systems. Oftentimes, by one out of three times it didn't work or 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 think

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

ultrasound, which one do you use or do you use both?

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

the navigation because once the navigation you don't have life

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

you're removing, how much blood you are evacuating, how much does you have, you see every little change

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

questions. Up at Professor Montballi Professor Mombali.

Do you have some comments?

Oh, so a.

Well, I mean, well, side had his hand raised. Yes. Go ahead. Okay. I just wanted to mention about the author from Doppler that our previous chair, Dr. Neil Martin. We used to do a lot of

vascular anastomosis ECIC bypass. He used the Doppler for verification of the The potential of the artery and after the anastomosis, he used that one. And I think it's something for the vascular

surgeon to recall it. Remember that Doppler operation is very effective to verification of the. Patency of the anastomosis and the choice of the artery you are using to do the anastomosis. You may

need a different size probe, but it's a very good That's what in David he when he used to do it, sir. 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 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 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 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 about it at something

that seems very practical and can solve a lot of problems with personnel Yeah. John, do you have any other thoughts or comments? I thought the two presentations were outstanding. 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 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 the probe? So

usually we use the same ciata gun that we used to, we just put the cable in and then

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

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

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

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

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

agree with Professor Seid. Whenever you do the doppler mode, you can actually see the vascularization

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 were afraid now, and

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

it on the brain and you just operating and you see how much tomorrow you remove it. Thank you. Thank you. Thank you, Luis. You're still here from Mexico. I see you're you're still there. Any

comments on the, do you use intraoperative ultrasound? Any comments, any experience? Yes, we use both. We use neuro navigation and ultrasound interpretive and it's a 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 neuro navigation? Both, we use both.

You use them at the same time? Both, yes. Okay, in receptors tumors we use both.

Okay, anybody else have any questions?

Okay, well, Strada, I think, Gilbert, yes, Gilbert, yes, please. No, no, just to say some words and the congratulations and good presentations, very, very impressive, very interesting

and very informative. So, we are waiting for the

next courses, maybe one month 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 first Sunday at the same time as this.

So, the program committee will meet in about a week to determine the agenda, but, but this is going to be a recurrence form every every week of the month.

Okay. Well, I want to thank

both Professor Kaba, and, and, and, and, and Cabullo for their presentations and Luis for commenting and joining us and everyone else for coming. We hope you've enjoyed it. I'll try to any last

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

Oh, okay. Thank you. Thank you very much, everybody.

We hope you enjoyed this presentation.

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It is a 2D internet journal. It's editor-in-chief is Nancy Epstein. And

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SNI Digital Innovations in Learning is a new 3D video journal, interactive with discussion.

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Surgical Neurology International is read in 239 countries and territories. It's the third largest neurosurgery journal in readership since 2010.

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This program is supported by the James I and Carolyn R. Osman Educational Foundation,

Thank you very much for watching.

The value using Intraoperative ultrasound; Simple, Useful in many areas of the brain and body;

SNI Digital®, the Global, Interactive, Peer-reviewed, New Video Journal of Neurosurgery and Neuroscience-2024 Edition; "Innovations in Learning" for the 21st century

VIDEO EDITORIAL

NEW SNI Digital® Version 4.2

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The value using Intraoperative ultrasound; Simple, Useful in many areas of the brain and body;

SNI Digital®, the Global, Interactive, Peer-reviewed, New Video Journal of Neurosurgery and Neuroscience-2024 Edition; "Innovations in Learning" for the 21st century VIDEO EDITORIAL

NEW SNI Digital® Version 4.2

SNI Digital®, the Global, Interactive, Peer-reviewed, New Video Journal of Neurosurgery and Neuroscience-2024 Edition; "Innovations in Learning" for the 21st century

VIDEO EDITORIAL