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SNI, Surgical Neurology International, a 2D Internet Journal,
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and SNI Digital Innovations in Learning, a 3D video journal, interactive with discussion, in association with the Sub-Saharan African Neurosurgeons,
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are pleased to present the Sub-Saharan International Neurosurgery Grand Rounds, held in the first Sunday of each month. This is the fourth Sub-Saharan African
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International Grand Rounds meeting devoted to the topic of global solutions to clinical challenges in neurosurgery.
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The discussants are from Africa, Iraq, France, Persia, USA, and other countries The
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moderator. is a strut of Bernard, who's the head of the program committee, and James Hausmann.
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The first part of this meeting, the talk will be on tele-proctoring in
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neurosurgery is this the future of global medical cooperation, a lecture and discussion lasting 60 minutes.
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It will be given by Samir Hose, a hybrid vascular neurosurgeon from the Neurosurgery Teaching Hospital in Baghdad, Iraq, also a research fellow at the Department of Neurosurgery, University of
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Cincinnati in hybrid neurosurgery.
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The second topic of this meeting is the diagnosis and management of subarachnoid hemorrhage in any environment, an interactive discussion, what we do, when and why
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The discussions are a strata-burnard from the United States. in Liberia, elven doe from Liberia, Samrho is from Iraq in the USA, Saeed al-Kansuri,
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who's from Persia, France in the USA, named Magwambi, from Nigeria, Sam Hregobam from Kenya, multiple attendees from Africa and Europe,
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and students, and young neurosurgeons, and students from multiple countries. And welcome, everyone, to the - this is the fourth conference. And we, as you know, we're having this monthly.
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We're talking about aneurysm management today. Dr. Osman will lead that discussion. And we'll be talking about managing it anyway in the world. But before that, we also have Dr. Harris, Sam
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Hregob, talking about tele-proctoring for.
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and endovascular surgery. So, Samra, would you like to get started? Welcome. Thank you. Thank you, Dr. Frada. Thank you, everybody. Hi, everyone. I'm Sam Earhose. I'm a
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vascular neurosurgeon. Was practicing in Iraq now, doing endovascular fellowship in Cincinnati, Ohio, and US
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And we'll talk about our experience back in Iraq in 2022 and
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later about the tele-proctoring and investment neurosurgery. Can I share my screen? Yes, you should be able to - I will try to just make a focus presentation just to start points for discussion for
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the - after that. So that experience is about tele-proctoring, as we say, in your surgery in general and in your vascular in particular as an example.
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And that's my affiliation, as we already know, and I usually start my presentation with this slide, and that we are not superior to our fathers, and we are shown fully inferior to them if we do
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not advance beyond them. And with the more mentors we have the, the more wealthy scientifically we will be
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So when we are talking about vascular neurosurgery, in general, lines of treatment and being open surgery or in the vascular treatment, sometimes people can do one of them, sometimes they can do
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both of them And I think the future are more towards comprehensive vascular neurosurgery when you can do open and maybe also harmonize if you are treating AVM, or at least some principles on on each
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of them so you can choose the better for your patient. So when we start to do a vascular neurosurgery, we start in ERAC. It was a very primitive experience, starting with the surgical loops first,
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because basically anesthesia all don't trust us. And then with the time getting confidence, having microscope, better and better in quality. And most of the practice was based on the ruptured
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aneurysm So ruptured aneurysm, it's very critical. Patient cannot travel outside to be treated in more established centers. And that's why we can offer this, that we can try to clip this aneurysm
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on the urgent basis. This is an advantage for indication. However, there is a risk
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as well, which is operating acutely or on the hyperacute stage, which is the first day or two of a rupturingeurysm. It's not easy. higher risk of rupture. And with the time you will get
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confidence, yes, but still it's very risky and how to deal with the surgery and complication. So I'm just trying to show some of our
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real
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cases. Basically, those are not the first 20 or 50 cases. Those are more about the later cases when we have a very established recording, maybe two years after starting the process of treating
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subarachnoid homogeneous cases. Before we start that, usually the cases will stay in a neurology world treated conservatively because it's obviously it's not available treatment everywhere. And
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with the time, yeah, more and more skills will be developed. we are more comfortable doing temporary clip. We are doing more procedure with intraoperative monitoring, which is not available at
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the beginning. And also the clips may be not available. Sometimes you will use oversized clip or whatever available clip quality or quantity sometimes. It depends on what's available. So it's not
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the typical practice of vascular neurosurgery, but it's more a modified practice. Definitely, we will try to discuss those cases. Pre-unforced output mentors, mainly online. And then that would
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be very helpful while dealing with more and more difficult cases. This is the last example for open cases when we are operating in a very thick cloth
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cases all of those cases we are just showing are. left become aneurysm rupture. So just to give an example on how different some surgeries for the same lesion on the same setting with the acute
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rupture, sometimes it's very easy. Sometimes the anatomy is very helpful. Sometimes not. And the timing also is an important factor.
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One of the incidents that will be always in the mind of surgeon is this
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moment with the intraoperative rupture and how you can manage that. Once you are managing more and more intraoperative rupture, you will build some confidence, you and your team. And then all the
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next steps will be just improvement of the quality of service, especially focusing now on more pre-entpose of improvement rather than enthrall. And then the endovascular. Once we tried the
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endovascular for the first time, for this and yours, and for example, is of lack of.
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calmic segment aneurysm. This case, the patient, 26 years male, have up-descent palsy, not rupture. And we try to operate, but the open surgery failed. We couldn't localize the neck of
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aneurysm and the surgery. The shape, intraoperative luar, was not like this. It's more about the aneurysm is like aneurysm sagging around the operative field. We cannot see the carotid with the
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para-clinid carotid. We cannot reach with the section to the neck of the aneurysm and we stopped the procedure because we feel that's too much. We cannot handle that. And also the proximal control
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from the neck was not typical. So we stopped that procedure. And then a few months later, we started this experience I'll do it in the basket procedure. in a private clinic just close to the
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hospital, but still we need some supervision. So that's what we are sharing today. So with the help of online proctor, he's just joining us on Zoom during the procedure and he will
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take us together that what to use, when to use and how to use each step, like step by step, in addition to pre-op planning and then post-op discussion, sorry for it. And a few minutes later,
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this aneurysm is just gone.
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As you can see, it's
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very, very beautiful if you are thinking of the patient as one of your family and his unfortunate to have this giant aneurysm and he's very young. You will, you will be happy to have this treatment
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for him. And it's a, we just apply flow diverter, flow diverter usually take a few months to close the aneurysm and to shift the blood out of the aneurysm But in this case, because it's a off time
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mix segment, sometimes loading flow diverter will close the neck completely. And this is also, we prepare that as a test report and literature review that immediate closure of the giant aneurysm
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after using a flow diversion For us, actually, it's a miracle at that time. Wow. This is the result. It's just gone. And just remember that we already operate the patient and we failed to clip
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that so. Yeah, this is a new extension. So then we start with Dr. Hassan Jani. A big thank you for this human. Actually, he already started to contact us. He is from Saudi Arabia. He has
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training and outside on endovascular and open vascular and neurocritical care. So they call them a triple the train because they have the neurocritical care advantage as well. And he contacted us
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and he said that, I like what you are doing now and I see that you are growing as a team. But if you want some extra support, I'm happy to be available online for any procedure you want. So then
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we start the real work. So we start with the setting. It's just simple setting. It's just a monoplane in the vascular service It's usually used from the cardios.
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And we start to do one of the team, do a zoom meeting with the, with Dr. some journeys. And this is a sample of what we are doing and the idea and the advantage for the new, you're on the
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vascular And that we operate basically on the screen, which is the exercise screen. And if we both have the vision or direct vision for the screen, we can take a combined decision
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And we, as a, as a collective, we end doing seven cases for each case, we will do approximately four sessions, a session to prepare. And then a session to prepare a session to take decision
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first, to operate or not. And what's the best treatment option is it open or in the vascular That session, very important for me as a practice practicing local neurosurgeons, because after
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discussing. with Dr. Hassan, I will go back to the patient and give him the update of the discussion. I will talk to the patient that we have contact and supervision from a professor outside. And
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after discussion, we decide that we should operate you or the best option for you will be through in the vascular, for example. So that's the advantage of first session, which is the decision and
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the initial plan. And the second session, which is, I think, very unique, is that in Iraq, at that time, and I think that will be the example for any, for example, centers in Africa,
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starting soon, will have the same issue, which is we don't have all the devices available. We don't have all the types of coils or sizes. It's not available. So I need to request that from the
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left, from companies before the procedure. This means I need to know what I need exactly. which is not easy for those have
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some contact with the endovascular they will understand it's not easy to prepare yourself. Yeah, I need this size exactly offload diverter and that's it. Usually you will you will prepare a size
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more or less and also you will prepare two or three flow diverter because some cases will require that. Again, that's very helpful because this session which is preparation of the devices is very
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important for me and for the rep to understand and most importantly because this is a private private practice for the vascular only service so I need to approximate the cost and I need to talk with
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the patient about that exact cost Each coil will cost almost1, 500 for us back in Iraq so that's by its own huge number. So I need to know it's not about annual small coiling. Okay, how many coils
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for coils is totally different from eight coils for each patient. So I need to know exactly how many devices I need for this case. And also we will modify a lot of steps just to make the cost as
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reasonable as possible for the patient, because it's already costy. We don't have insurance system
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So the first session is the decision, second session is the plan exactly the devices and I know the cost for each step and third session will be the intro operative, which is when he joined us
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during the procedure. And the fourth session is reflective session after we finish the procedure, we will discuss what we did right what we did wrong how to improve That's basically provide like
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around 28 session in total. for this case, as we say, is different to step. I think this is unique. We don't have this full idea before starting the experience, but with the time we develop more
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based on the need. And this is exactly how we will do that. Like one of the surgeon, or let's say the local team, they start to do the endovascular. One of the team usually medical students told
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the Zoom meeting with Dr. Hassan and showing him exactly step by step And Dr. Hassan will be online. He's really happy at the end of the procedure because he have the same citrus. And we published
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that on a paper, I think, in the SI. And part of the paper saying the perspective of the proctor as well, like the supervisor, because he have his type of citrus. And also his concerns is
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different from the pro like the local surgeon. So yeah, as we said, how we will do the cases. It's not easy, sometimes complex AVM. And then at the end, you are very thankful for him. I think
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our patients also very thankful for this experience. And it's much different, very cost effective as an alternative to travel outside and much
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safer as compared to non-supervised procedures. In the vascular, the procedure will be much technically easy as compared to the open vascular. However, complications have a huge impact in the
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vascular. So you need people with huge experience to supervise most of the first few years of practice. Yeah, so a lot of advantages. I don't think that we need to go through each of those, but
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just to list what will be expectation of advantages and also.
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There is a challenge, there are challenges. From the advantage is radiation exposure because the proctor is outside and
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the room with us. Also, of course, reduction, we said, avoid scheduling delay at any time we can do that is easier. And no, but no, I don't know many proctors and supervisors are ready to
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visit back that Iraq at any moment because sometimes it's stable, sometimes it's not, sometimes it's risky, sometimes it's not. So that will be just overcome by this online proctoring. And the
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other concerns are like the challenges, how to improve that, it depends on how to, how image quality, we will just simple 4G connection
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from the mobile phone, and that's it, I think we can improve that. But I don't think we need to complicate the steps because keeping those. Some people will be more and more effective to have more
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sessions. That's a summary of all the cases that we are doing through the online proctoring, the coiling of the timing on the embolization of AVM,
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coiling, aneurysm, and
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embolization of a feeder for a tumor flow diversion session, which is failed, failed, which means we didn't deploy flow diversion at the end, because of difficult anatomy, but that's very
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important. I will show you as a final example before ending this talk, and then different type of sessions, and this is, for example, a case AVM, we try to do a pressure cooker technique, which
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means using coil to block the high flow vessel, and then deploy the ONEX and through the cooling process. one of the coil just migrated outside going into the one of the branches, the stair
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branches of ACA, at that moment, me as an operator, I have no experience with that complication. And the presence of the proctor online, very helpful. He, he take me through the steps, how to
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do a trial. We try three different techniques. And at the end, we decide, no, it will not work We just push the coil distally in the branch. And there is no signs of stroke on the patient.
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There is no change in blood pressure. There is no change in vitals. And we, this is the only thing that we can do at that moment. And we continue the process of embolization. And at the end, it
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went uneventful, asymptomatic. There is a sign of local ischemia from that coil, which is a migrated coil, but that's I cannot imagine how I will do with that complication without that online
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proctoring. I don't know how to do all the techniques, how to try to fold that. So after all the trial is done, then we feel that, okay, we tried all our best under supervision and that's the
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only thing that we can do right now. Yeah, so it can be tough at any moment and the moment we agree with the proctor that no more intervention is required, that's very helpful, also very helpful
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for the family when they understand that. We just discussed this. Another tricks like how to mark the screen to understand where is the embolizing material, just very simple basic tricks that will
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be very effective in dealing with real cases This is the view from his. and how he will see the images with us. This is me operating. And another example, just some
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fistula, which is of tarmac fistula and post closure with just one simple coil, but very long because we need to reduce the cost. It's not typical treatment always, but this will be very modified
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to maintain the standard we want to do. Again, it's very clear as compared from like, if you say that, oh, you are using phone and just regular internet, yeah. And it's okay, it's doable.
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And like a last example, maybe this is, we have a stroke case, we called him and we have this anatomy, which is common carotid, R3, left common carotid,
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internal carotid, non-internal carotid, and then intracranial, we can see the internal carotid, again, giving me the cerebral. So this is called occlusion of the internal carotid adenic with the
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reconstitution through the internal auxiliary branches of the internal carotid intracranial. At that time, we don't know how to do with this. Is it stroke or not? Should we treat this occlusion or
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not? And then we end with, this is not a acute occlusion. And this is not the anatomy should be treated with stroke and should be defined as intracranial or reconstitution through the internal
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auxiliary artery branches. Again, that's the variation that you may not know, but having a proctor with good experience would be very helpful. Yeah, I just want to remember this for all of us.
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Because this is the point, if you can deliver this treatment to your patients, your local patients, that's a huge. And that's a thanks again to Dr. Hassan for this. I think it's an example for
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others to follow. And we are happy with this collaboration. And we are happy to maintain that. Thanks for the team. And thank you for listening.
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Okay, why don't we stop sharing screen for a minute? Yeah, that's great. So we're almost at 40 people already. So first of all, people have some questions for Sam.
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Yes, I have one question. Dr. Hasen, did you try first to use the temporary clip before you put the final one? Because that's one of the trend that I see in our neurosurgery group. They put the
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temporary to wear a better dissection. Then they put the permanent clip. Did you do that on your
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practice over there?
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Yeah, basically. It depends. In general, we will try to avoid temporary clipping in general because there is a risk of injury or vessel or a perforator on the backside. But if we deem that it's
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important or if it's the rupture case with very adherent structure or folds to the aneurysmal drone, yeah, temporary clip can be safely applied. So do we use temporary clips? Yes. Do we use it
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for all? No, I think for only percent of the equipping we will use that because the temporary clip has some risk by its own, especially in the early experience for experienced surgeons, it will be
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just easy step. But for the early experience, there is a huge potential for complication from the temporary clipping, especially with old age patient atherosclerotic disease, you can, you can
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cause trouble with that temporary if you are not using that for the
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Correct indication. Second question I have for the patient that you showed that there was a blockage of the internal carotid artery. Do they do external cranial ECIC bypass in your in Iraq, or they
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don't have the facility because that's another option when they have this Obstruction, they can come in, make the ECIC bypass
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extracurricular intercaronial and it works in many cases. And I don't know if they have that experience. in Iraq and because it is a facility.
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Yeah, I think you are totally correct, sir. Yeah, that's one of the options
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if they decrease vascularity or dynamic fluid and try crannially, one of the options is to do ECR, IC bypass, actually we did that bypass, high flow bypass, for a few patients, we will use more
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indirect bypass, like EDAS or EDAMs for Moya Moya cases, we have like more than 25
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Moya cases treated with EDAS EDAMs and. So it depends on the type of anestomosis, but both of them
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is ECIC bypass. I think the high flow bypassed are technically more difficult,
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but it's doable. Once you have the basic micro instrument, can do it but we will definitely do that. without the ICG without the Doppler. It's not always available. Because typically, as you
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know, most people will use ICG or Doppler address to confirm the pay tensi of anestomosis. We will not use the app. We will use direct visions that's available. And definitely, we have
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intraoperative monitoring that will be also very helpful in the bypass to show pay tensi
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Okay, any other questions? I noticed Sam Al-Brahmani, who is, are you in Azerbaijan, Sama? Are you back in Baghdad?
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Samma was in Iraq and then went to Ashu Bajan to receive training and is she back in
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English? I think the other student is
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the other Bajan student. I think Samma is still in Baghdad, Iraq. She's just graduated, but she give the classification lecture. Okay. Good. Yeah. Oh, she did the classification lecture I'm
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confused with the other one, yes. Yeah, yeah. And the approaches to the Petrus Ridge, right? Exactly. Yeah, Samma, it was okay, great. Well, if I have a question for you, Samma, my
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understanding is that in the session two, you say there were four sessions of the process. In session two, you reviewed the process and try to predict the materials that you would need. Correct.
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How well were you able to do that prediction of the materials needed?
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That's very important session because with the first session, with the decision, the family will agree on the treatment in general and then I will prepare a session to agree on the, what's the cost
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to and do they accept that or not. So that session will be going through all the potential steps and try to eliminate one by one. For example, we are using a re-sterilized instrument which is not
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usual. So for diagnostic, we will use one kit for patients for diagnostic cerebral angiography, just to reduce their cost. So we already will ask for each device do we have all
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gone, can we use that for like variation?
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And this is definitely off label because most of the company will say, no, this should be one use, but at the end, I cannot use a lot of
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optional devices. Yeah, you should have this in case you need it. Yeah, I will keep that restaralysed just in case needed because it's very costly I can say
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that for the one flow diverter, the cost may be15, 000. And without
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insurance and the patient paying that directly, this will create a total cost of surgery around20, 000, at least without any fees from the surgeon And this, this is, I can say, it's never heard
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of and Baghdad Iraq.
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This better to travel outside. That's the standard. So that's that's the issue.
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And is it, am I, did I understand it correctly? So you, you have someone recording the monitor with an iPhone and that's transmitted to the Proctor
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It's not recording. It's a direct zoom call like the one we are doing right now. It's a direct zoom call. So we can have a full interactive discussion. Okay. So how is the Proctor seeing the
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monitor? Yeah, because if you open the zoom from your phone, you can put the on your camera or on the front Oh, okay. Good. Okay. Okay. Thank you.
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So let's, let's take our case examples, Sam, or somebody comes in the hospital. and they have, let's say we're going to go through that in the next lecture, but let's say you've identified they
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have an aneurysm, and
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if it's ruptured, if you've done any acute ruptures, or are they mostly patients who are unwraptured or ruptured and stable?
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So for ruptured, we have only one option, which is the open surgery, because the patient is a critical, because it's a free service, and because the neurocritical care is a free and the public
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hospital. So, and you know, the acute rupture, you cannot predict the course of the patient. So those emergency settings will be only treated in the public hospital, pre-off charge, and the
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only available treatment will be open surgery, open clipping Have the patient to present an R rupture or like. any other lesion that can't be considered elective case, then we can offer both open
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surgery versus endovascular. It's similar to the standards in general. So have you done an open acute ruptured aneurysm but this technique or it's mostly, it has time, you have to schedule it,
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you have to do some other things. So it's mostly unwraptured or stable, which we've done in a setting there. Yeah, with the proctoring, we will do like, not only like endovascular treatment for
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acute aneurysm rupture, we don't. Well, I mean, what I'm driving at is we're talking to people
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and there's a billion people in
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sub-Saharan Africa And we've just heard from a number of people that are limited neurosurgeons. And we know from Alvin, he's the only one in Liberia. So the question is, if somebody comes in with
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an aneurysm and they are
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stable, would there be a way to interact with a proctor to help guide somebody, clip the aneurysm because coiling in those situations is probably too expensive, it's not reasonable. And so you're
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dealing with surgery. Have you had that experience or is that something we ought to look into?
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Actually, we have a similar experience. Now while we are dealing with,
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I'm outside the country, they are inside and we can communicate directly within the team. Yeah, we are trying to do that But
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yeah, I think this is something to look like.
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forward in the future because you will need that during the procedure, definitely, at specific moment. I think you're sorry, you already have a huge experience in the vascular that once you
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dissect the
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aneurysm and before reaching the neck, you need some discussion with somebody if there is like, I have this on this coil only. Is that enough? Should I quit? Should I continue? Something like
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that. Sometimes just weird anatomy that's not that's not available
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in the pre-op planning, that would be very helpful to have someone online. And this experience will add the visual part, which is you can't call somebody for consult, yeah. But this visual part,
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because you cannot describe the second aneurysm that I present, The pre-op image, which is three days,
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CTA pre-ops, three days, is showing a small aneurysm picon. And intra-operatively, there are, there, this aneurysm just changed the shape into a three bulges with, with very thin wall. So it's,
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it's just an, uh, something, um, uh, unexpected. If we have something online through zone with consult from anywhere in the world, that's the advantage of this type of,
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uh, supervision will be definitely helpful. So, so I'm trying to get this for everybody and maybe I'm the only one who doesn't understand, but so you identify a case, it has to be a case that you
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have some time to prepare for, right? So you'd have to connect to the proctor, you'd have to show him the films, uh, talk about the patient, and then you think about, you talk to the.
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obviously the patient and it says you can go ahead and do this procedure and then you have some planning sessions where you go through the various steps of the procedure that you're going to do if
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it's surgery or it's intervention and then you have the actual live conduct of the procedures, is that correct?
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Yes, with the man focusing on the endovascular, that's no, I understand that, I understand that, but that's what we're driving at because if to have endovascular then you have to have other
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facilities too, you have to have coiling, you have to have the imaging, you have to have all these other things which many people don't have, but the question I have is I'm let's say I'm Alvin and
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I'm in Liberia and somebody comes in with a Separatite hemorrhage, I don't have any help, Oh. We'll come to that in the second lecture, but practically, is this a system that can be used in
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Africa for other kinds of cases other than interventional?
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Yeah, I think if we decide that we will start with whatever available, I mean type of cases, the more most frequent just to establish a system, and then you can take that system to the more and
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more acute setting, that would be just reasonable. Absolutely, it would take a little organization a little time to do the name, Professor Nim, is this something you think would be, you have a
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number of neurosurgeons in Kenya, would this be a value in communicating with others? Well, currently, they're. We do coiling at Agacan University Hospital. They have a center which they've set
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up, which they're doing that. And in our teaching hospital, not yet, in the private hospitals, I think some neurosagions are
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attempting it. The problem is the cost, you know, in developing countries. It turns out to be very, very expensive And this is why up now we really emphasize on clipping, you know, because
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that's quite affordable. Remember that in our country, the patients have to buy the clips. So even in public hospitals, the patients have to buy the clips. So the cost element becomes quite high,
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even in a public hospital, because the clips are quite expensive But when we now look at the calling aspect, it becomes quite, quite. enormous. But in the private hospital, I know there are
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neurosurgeons who have set up that aspect. And because it needs a lot of backup, we must have a center which has the type of facilities for that to be done. Now, this teleproctoring is
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very interesting and is there one question is, does the patient know that he's being subjected to that type of treatment? Is the patient aware that and what are the medical legal aspects if
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something went wrong? So who takes the responsibility?
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Yeah, so I think this is a very interesting question, but I think very important. So basically, it's my patient and I'm the surgeon and I will take the responsibility and that option of
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will be an additional level of standardization that I want to do in my cases. This is the way that we present that to the patient that I will do the case. In addition, I will invite some professor
42:15
from outside through zone to be with me throughout the process So I have also another layer of supervision just to improve the standards So we will present that to the patient, the patient will be
42:33
informed on all the steps. And I think based on real practice, that was very helpful. Like at the end of a few, remember, we present that a failed flow diversion At the end of that procedure, I
42:48
will say to the patient that we try all our best, and to deploy that flow diverter but you to difficult enough anatomy is not a problem. And that is not only my experience that's confirmed by the
43:02
proctor who's online with us throughout the procedure. So it makes sense. Go
43:10
ahead, go ahead
43:13
That's it. So now the other question would be, this can be applied on the other areas of neurosagerie therefore. Exactly. It's coming to them. Yes. Because, and if this can be applied to the
43:29
other areas of neurosagerie, it can also be applied in the training of,
43:35
of neurosagerie locally You know, I mean, it's a, if, if, for example, it's an emergency and then Rosage, my resident has to do a case as an emergency. You know, I could take him through that,
43:49
because then that would be quite applicable and it's, it's quite, it's very interesting. I mean, I would like to discuss it with. So some of my other colleagues would like to try it. But as I've
43:59
said, that the big issue here would be the medical legal. We are very little just in my country. And if you make a small mistake, the lawyers will be after you. So that's what worries us. That's
44:10
what
44:12
would worry me, frankly. Thank you. Okay, I'm sorry to add his hand raised. Dr. Senator and Dr. Osman, if you permit me two minutes, I tell you a story which has happened to share with our
44:26
young colleagues. Two weeks before the September 11th happens in New York with the bombardment of the twin tower. Two weeks before that, the French telecommunication arranged for this type of
44:40
surgery. The surgeon was in the twin tower and the patient was in the stress book. And he did the callist's take to me through the internet with some people in the stress book to put the endoscope
44:54
inside the abdomen. And he did the colesistectomy from New York when the patient was in the stress work. Until the communication of France, close 1, 000 channel of internet, not to have a
45:11
interruption of the surgery. That is one of the point that having the good communication, because even here in the US, sometimes the internet is suddenly disconnected because of the problem with
45:25
the electricity or no. And this was the case happened almost 20, 24 years ago. And unfortunately, when the twin tower came down, they tried not to bring this issue up because of the damage with
45:41
what's happened. But the correct internet that is exactly that we have to be careful and thank you for Dr. Haus and all those who are involved with this But that was the first case, as far as I
45:55
know. They did it for the general surgery from New York with the patient in Westeros book. That's what I wanted to share with all of our colleagues. Thank you very much. I'd like to ask Sam and
46:09
Nigeria, are you there, Sam?
46:16
Yes, I'm enjoying the discussion. Sam, yes, yes,
46:23
yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes,
46:27
yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes,
46:30
yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes,
46:33
yes, yes,
46:43
yes, yes That's good. Because of the problems already highlighted. Internet instability, cost of the process, etc. The more importantly for aneurysms of vascular problems, I was hoping that
47:00
after your presentation that we can discuss holistically about aneurysm management as it impacts the subs are in Africa. But really the hard problem is volume. volume, volume, volume, as we have
47:17
drawn attention in several publications, the volumes of aneurysm cases in South Africa are not very encouraging at the moment. So whether we are missing them or what, we don't know. But my center
47:32
is one of the high volume centers in Nigeria. But I know that in a year, the number of
47:42
aneurysm you see are quite few compared to other parts of the world that are trending. So how do you advance this technology if you have a low volume? I think, let's discuss this later. But every
47:52
technology is worth developing. But how far is affordable because of volume that we can address later? Thank you. We'll come to that in the second talk. And I think those are good points.
48:11
I'd like to follow up on what NIMM said at NIMM. I was saying, well, can this be used? Let's see, somebody has a tumor or some complicated tumor or somebody's doing a pediatric case with
48:24
myelomeningocele or something. These may be common, but we have some people in the talk are going to country that has one or two neurosurgeons. And the question I have, is this going to be
48:40
practically helpful? And Nim, if you would answer that, and Jill Bear, and maybe some of the other people, is it not just for vascular, would it be helpful for other things?
48:55
Yes, I think it would be helpful, but as Herbalam has said, the problem is connectivity.
49:03
Our internet is very, very unreliable. So if it breaks down, then that's a challenge which one would face. Now, as I said, you know, we, it would, it's worth trying And I think, I think I'll,
49:21
I'll get the nitty-gritty's from Samira and see whether it's applicable. What I would
49:30
like to comment is And
49:36
we're really small bleeds. In the alias, we were also not getting as many, but nowadays we get a lot, we get a lot of.
49:45
And we're really small bleeds and we get a lot, a lot of patients with vascular anniversums, which will undergo. undergoing surgery. And this aspect of training, of our training has improved a
50:02
lot and quite a number of our residents, when they finish, then they go through a process where they do some fellowships in vascular work. And unfortunately, one of our senior chap couldn't join
50:15
us, but he would have given you the comments on how we are handling this. And therefore, we do get these types of problems. And it's part of our training. And in the AAAS,
50:28
we used to say to think it's not common, but no, no, it's quite common nowadays. And I really don't think there's any difference between what you see and what is seen in the Western world,
50:36
because the lifestyle has changed, completely changed. I'm getting young young people getting struck at the age of 40 now in Arabic. And therefore, The lifestyle has changed, and our population
50:50
is very young.
50:52
72 to 80 percent of our population is below the age of 45 and therefore these problems now we're seeing them quite quite quite quite often and therefore we have to teach our residents how to handle
51:03
them also have to teach our medical students how to manage and raise small blades. Okay Alvin you had a question I saw you had your hand up did you have something you wanted to ask Calvin. Thank you
51:18
professor for recognizing me and I want to use this time to extend appreciation to Dr. Hors for that brilliant presentation and actually it had me thinking because it just reminded me of a
51:37
collaboration that my hospital was about to enter into with a company regarding the surgical glasses wherein there will be a mentor in another country while doing surgeries and he will be seeing what
51:52
I'm doing and we'll be doing them together. But I think with what Dr. Horz presented, I think in my country, Liberia, I think the challenges here are huge. And number one, a stable electricity
52:11
that you need.
52:14
Number two, internet connectivity. And then I think we could work with it, but I don't think it will be in those
52:24
conversations by taking other cases, like most relative cases that are going to be planned. For example, if
52:34
you have some complex fine cases and you need a mentor to guide you to the process, I think with that, that will be much easier, especially if it is scheduled. But for emergency, I think it will
52:45
be a huge challenge for my hospital.
52:51
Okay, Elman, I think that's right. We probably ought to go on to part two because it's almost a continuation of this, but so you want to do that? Yeah, let's go ahead. We almost had an hour,
53:05
so please proceed, Jen.
53:09
The second topic of this meeting is the diagnosis and management of subarachnoid hemorrhage in any environment An interactive discussion, what we do, when and why.
53:24
The discussions are Estrada Bernard from the United States and Liberia, Elvin Do from Liberia, Samor Hose from Iraq and the USA, Saeed Al-Consory, who's from Persia, France and the USA, named
53:37
Magwambi from Nigeria, Samohegobam from Kenya,
53:49
multiple attendees from Africa and Europe,
53:56
and students, and young neurosurgeons, and students from multiple countries. Well, you're looking, while you're getting that set up, I'll just say, I think an important point that Dr. Haas
54:09
made was that
54:12
it, it optimally, it's optimally set up with an elective process, process, and then once you develop the infrastructure and a protocol, then you could move on to doing more urgent cases. Anyway,
54:30
Jim, it looks like you've set, you wanna get started? Sure, I think everybody, can everybody see this? Yes. Okay.
54:41
Well, anyway, this is actually a complimentary talk to what Shammer gave.
54:49
and Samir and and Popsie perhaps. I eat and the members of the audience can participate. It's a interactive discussion. This is some things that that Joe Barrett has talked about. Let me give you
55:04
a case and see. Let's see what you do. Hey, here's the first case. And this is a case for anybody everywhere and we're going to ask. I can't see the audience here. So you may have to ask some
55:15
people who try to. But this is a 35-year-old male and it could, Elvin could see this case. It comes in with a sudden headache. He collapses.
55:28
He's in the ER. If he's hours away, he may not make it. He may die. And so you may never see him. But this is a case where it comes to the ER. He moves all of his extremities, but he's not very
55:41
responsive. He's got a stiff neck His right pupil is larger than his left, his blood pressure is elevated. is pulses regular. So what I want the audience to do, the people in the audience to do,
55:55
and I think you may have to ask people, Estrada, is what do you think the diagnosis, what do you, you've got some differential diagnosis you've come to at this point, what do you think? What's
56:05
the cause? Anybody have some suggestions? What are the causes?
56:12
Dr. Dr. Regis. Dr. Regis
56:16
Okay, we have some residents here. Yes, good, well, well, then maybe you can - You can ask them to provide the residents and ask them to wait. Yes, Dr. Rashid, Dr. Rashid, are you on the
56:29
call? Are we? Yes, yes, I am. Okay, I'm following, yes. Okay, fine. I think Dr. Rashid can guide you with the other residents who are here. He's finally a neurosager resident, so you
56:44
could communicate with Professor Osman. Okay, Rashi, what's the differential diagnosis here? What are the causes of this? This is what you see, this is the patient. That's your exam, that's
56:57
the history, it's very limited. The family brings them, that's all they know. What are you thinking about? What are you gonna think about other causes? Okay, so since there's a sudden history
57:10
of head deck and a collapse and signs of women in this mass with this stiff neck and on his forehead the right people being larger than the left or be thinking highest on the list would be a
57:23
subarachnoid hemorrhage probably due to a spontaneous rupture of an aneurysm. Though the
57:29
age of the patient is not typical of an, not quite typical of an aneurysm and then you have the right people being larger than the left. So probably a thinking about a sympathetic system to the
57:45
pupil. is affected with the cranial number three and then we have a lab at BP's of 160-90, so top of the differential would be a ruptured aneurysm.
57:60
Let's say when I always do my differential diagnosis, I always pick my first choice and then I say let's say it's not that. What else could it be?
58:11
Okay, amongst the vascular ones, you would have an AVM to do venous malformation.
58:20
I was vasculitis as well.
58:24
Okay, any other thoughts? Do you have some your colleagues there who want to jump in and do this? There's no there's no wrong answer, so don't worry about it. Okay, everything you said I think
58:35
we'd agree with, okay.
58:38
Does anything about the pupil being dilated on the right side? Does it suggest anything to you?
58:47
Yes,
58:49
that the training level number three might have been compressed. So it could help in localizing the location of the lesion. And you think of a posterior communicating aneurysm or something? Yes, I
59:06
agree with you. Okay, so let's look at the next slide. This is a differential diagnosis. We agree with you. It's an aneurysm all-suburrog night hemorrhage could be. Could be an AVM, couldn't it?
59:19
Yes. And or an interest several hematoma, it would have to be in a silent area because he didn't, he's moving all of his extremities, right?
59:30
Yes. Could be a carotid occlusion was falling in that hemisphere, isn't that possible?
59:37
It is possible, yes. Is there, you have a bleeding disorder, you have a sickle cell anemia in Africa, and I'm sure you have clues. could be related to some bleeding or occlusion. Is that
59:51
possible? That's very possible, yes. How about a tumor? Could it be a tumor? Yeah, especially a hemorrhagic tumor, yes. Yes, hemorrhagic tumor. Or something else that's very disturbing would
1:00:04
be a herniation opposed to your fascia syndrome. Would that be possible? Yes, definitely. And what about a midline lesions? You see people coming with colloid cysts or third ventricular lesions,
1:00:18
something like that, they bleed into it and they get a sudden occlusion and they can have a sudden collapse. Would that be possible? Yes, yes, I agree. Okay, so now here you've got your
1:00:30
differential. Anybody else want to add some other ideas to this list? We may not be complete. Anybody else have any thoughts?
1:00:39
And please, if there are other residents there, please don't be embarrassed. Just this is an interactive discussion. We're all colleagues. Anybody else have any ideas? No? Nim, do you see
1:00:54
anybody who could help us with some more ideas or any other ideas?
1:00:59
All right, well, let's go on to the next one. Okay, now he comes into the place and that's the problem with us in the high income countries or the developed world And
1:01:12
that is everybody's got a lot of instrumentation. But it's also true in our country if you're in a place that's far away, you may not have a CT. Or you may,
1:01:27
NME is that is, would you say most hospitals in Sub-Saharan Africa have CTs or not necessarily? Well, I can
1:01:38
comment about Kenya King is divided in counties. and we have about, I think, 47 counties. And each county has a city. Okay, so you have a city of cities can. But, Joe Berg, can you hear us,
1:01:53
Joe Berg?
1:01:57
Hello, yes. You've traveled all over Africa. Does everyone have a CT? Most of them have CTs? Yes, I think it's usual to have a CT scan, yeah. Okay, so many. This situation 10 years ago, but
1:02:11
the number is increasing in all the main cities in
1:02:21
West Africa and Central Africa also I think Okay, so let's see, I'll just go through this quickly because we'll come to this CT in just a minute. So if there's no CT, how do you make the diagnosis?
1:02:32
How do you decide what to do or do you decide not to do anything? You take on an ophthalmoscope, you look in the eye, you
1:02:42
see if there's papillodema and
1:02:47
that may help you. Would you do a spinal tap? Anybody would do that? do that? Lumbar puncture.
1:02:58
Well those are your choices basically. So once you come with that then you come to what is your choices? So let's say you mentioned I think yes go ahead in this situation if the patient presented
1:03:07
with meningismus had a stiff neck sudden onset of severe headache you'd be suspicious of a subarachnoid hemorrhage and if he didn't have a head CT scan then a lumbar puncture would be would be
1:03:07
considered would be the path to pursue but in the in the phase of a third nerve palsy and the question of increased intracranial pressure there's going to be that concern for transcendental herniation
1:03:07
and if you were to do an LP so that should be in the discussion Good point. Do you think this could be a meningitis? Could present like this to a meningitis?
1:03:59
I guess it would be possible. Right? Yeah, well, well, but the sudden severe headache. Yeah.
1:04:06
But I guess it could be, it could be possible. Yeah. So, in the hospital, in the hospital, in the hospital, what did you say? Yeah, in our set of in Kenya, because of the easy availability
1:04:20
of city, this patient would get city. In fact, they rarely get number one chardon. In the earlier years, that would be an issue, you know, considered doing the other physicians would be seeing
1:04:31
these patients and they would do the number of punctures. But nowadays, hardly do we do lump of punctures on such a patient where the diagnosis is most likely sub-irconal damage and the city scan is
1:04:43
available, so the city scan to be done. The issue now comes to the next stage of management. That's where the big challenge now comes. You have diagnosed the sub-irconal damage from the city scan,
1:04:54
then what next? So you and Joe Barrett and myself and Strada Strada's not as old, Alvin, you wanted to ask your question, Alvin? Thank you very much. So I think looking at the clinical history,
1:05:13
the sudden onset that will gave anyone the idea that it is probably the origin should be vascular. And now regarding Lumba puncture, in a certain where there is no CT scan. And Professor Bernard
1:05:33
said, you already have an isochoria. And you are thinking, you said there is some kind of mass effect and probably raising your cranial pressure. And you have a lot of skepticism in doing Lumba
1:05:48
puncture. You got the fear of trans-tintorial radiation.
1:05:56
it would be a great of a challenge in that. What to do next? I think what normally, if I'm in situation of this kind, all right? What I normally do, I would have to discuss it with the family
1:06:12
and then they will have to sign Harry's consent regarding performing lumbar puncture because we do not know what is going on in the patient brain And I think it is a huge challenge. And now regarding
1:06:30
city stand in Liberia, Liberia, we have about 15 counties. And currently we have just three fortunate city scans in the entire country. And unfortunately, they are just two that are working. One
1:06:48
is in the private sector and one at another government facility. Thank you Terrific, terrific comment challenge. Terrific. Okay. So for people who don't have it,
1:07:02
that's what they have to think about. I think you outlined it very well. So let's say, either you've done a lumbar puncture or you've mentioned all the issues there or you've got a CT scan, which
1:07:15
I think most people would do first, okay, but you made a diagnosis that it's an aneurysm and the patient can't go anywhere because they don't have any money and they can't travel and so forth. So
1:07:28
now you're faced with a choice. What do I do? Do I do nothing? And do I wait until the patient, the edema resolves or whatever's happening and eventually you're going to have to do a lumbar
1:07:42
puncture if you don't know and you don't have a CT. Do you refer a patient? That's not practical in a lot of countries Or do you do an angiogram? Could you do an angiogram?
1:07:57
First of all, I was going to say, just before Nim finished there, there's some older people here on the call, like Nim and myself and Gilbert. And we grew up in an area in Australia. We grew up
1:08:08
in an area where there was no CT scans. And so the case I presented to you was common. And so you had to make all the choices that we've discussed here. And these are the difficult problem. But
1:08:22
when you got a CT scan, obviously it makes life easier. So let's say a CT is available. So we do a CT scan and that's what it
1:08:34
shows. Can somebody else there pick
1:08:37
call and somebody to tell us what the CT shows?
1:08:44
Nim is there another registrar that you might call upon? Well, Rashid, do you have another any colleague you want to invite? or you want to comment? Sure, let's have some comments.
1:09:01
Yeah, I think my colleagues are on the call, but.
1:09:06
Jeff, Jeff, Jeff here, Abduwahi raises in, would you? Yeah, Jeff here, please, what would you do? What do you see on this film, on this image? In this city, in the section, there is a
1:09:19
Sabarachnad homo origin involving the all the base of the system, especially the interpeneticular on the Serbian system, and those are involved. So I'm thinking about Sabarachnad homo origin.
1:09:34
That's excellent, okay. Do you see this a hemorrhage more on one side around the circle of Welles and just ahead of the brain stem than on the other? Yeah, it's more on the left
1:09:51
side, let us say What is that? What does that make? What does that make you think? Yeah, you're doing great. What do you mode doesn't make you think about? Thinking about an aneurysm, maybe a
1:10:02
rough chart inside or also a temporal lobe, maybe have an extension inside the temporal lobe, maybe. So this is what I think about. And according to this site, so it could be
1:10:20
a carotiparification maybe or MCA, M1, maybe
1:10:24
aneurysm.
1:10:26
So that's what I'm thinking about. Okay, good thinking. And so it would be poster communicating. Could you get it with an anterior communicating aneurysm? Well, you'd expect more hemorrhage here,
1:10:38
but I've seen that. And could it be a carotid aneurysm? Yes. Okay, well, let's say, now NIMA, I would assume if everybody's got a CT, they can do a CT angiogram. Is that correct? Yes, yes,
1:10:52
yes. So what do you see, Jeff, or what do you see on this Instagram here? This is not the same patient. So don't be confused about this. But this is, I got this off the internet. What's this
1:11:04
CTE show? What does that show there with where the radar was?
1:11:11
Yes, there is an balloon-like shape. So, and then yours is on the, maybe this is an M1 M2 v4 case on at this level Or at
1:11:25
this side, so this is an AOSM, maybe, or.
1:11:31
I don't think so. Very, very,
1:11:36
very good analysis. You see the blood here, it could be a middle cerebral aneurysm. You really don't see the branches of the middle cerebral, maybe this one here, maybe not. But you also see
1:11:49
something here And I wanted to point this out later. You don't see posterior communicating arteries. Maybe this is pure. We don't see, we don't know. Going into usually connects here to the
1:12:01
proximal posterior cerebral. Here's the basilar. So what you wanna know is a patient have collateral circulation. Over 50 of the people do not have an intact circle of willis. And that's very a
1:12:16
problem because it means they have to circle their circulation is to go other routes to get to where it goes. So you try to find that information but maybe a little bit here or the other thing is the
1:12:29
CT scan is not definitive enough to show you blood in small vessels. So we're gonna come to that. Okay, you wanna say something, Jennifer? You agree?
1:12:43
Okay, all right, we agree. So, okay, now a question that she had.
1:12:50
Do you have a comment? I'm sorry. Professor Osman,
1:12:55
I am seeing a lot of ladies are involved in this meeting. Please make it comfortable for them. So they can talk. Oh, that's my make mistake. I can't see their faces. So I can't call anybody. So
1:13:09
we have to have people who just jump in this. There's no criticism here. Okay, here we are now the timing of surgery This has been in controversy for decades.
1:13:22
Now, in your country, in
1:13:26
Kenya, do you do surgery when you can, or as you do it immediately, or when do you do it?
1:13:35
Well, the comments that you would like to make is, first of all,
1:13:40
as I said, CT scan is available nearly everywhere. It will diagnose the sub-artinodium origin But the quality of the city's can is usually not so good.
1:13:51
which we are having in those peripheral hospitals, the CT scans are not, they're not able to do a CT angiography. So this patient usually will be managed in a referral center that can teach a
1:14:07
hospital. So let's say you're in Alvin's, let's say you're in Liberia and Alvin sees this, he's got a CT scan, he sees what looks like an aneurysm, patient is no money, he can't refer him
1:14:19
anywhere, what's he gonna do?
1:14:23
I think I think Alvin is down, will comment on that one. In
1:14:29
my country, most of these patients, we now have centers where these patients can be handled. So we must look at the diagnosis of that sabbatical tumor from the CT scan, you'll refer that patient
1:14:43
to a center which would have a neurosiger Now we have about 5 or 6 centers in my country.
1:14:49
Okay. I'm sorry to interrupt you because I'm trying to move it along here. So these are your choices. And it's the same choice in all of medicine. It doesn't matter if you're an internist, if
1:15:01
you're a nodal laryngologist, if you're a radiologist, you come down and you have choice A, B, C, or D. And notice it isn't surgery or medicine. It's choice A, B, C, or D. And what's choice
1:15:16
A is doing nothing. And then what you have to do is choose the make the choice that has the lowest risk for the patient and the highest chance of success. Well, with an aneurysm doing nothing is
1:15:28
not a very good choice, because 50 of the people are going to die really before two weeks, even if they reach you, and the rest are still at risk for more bleeding and death. So that has a lot of
1:15:43
risk doing nothing, which is a risky choice. Well, is there anything better? Well, you can wait, we used to do this. Estrada, you and I, we did this, right? We wait until the patient
1:15:56
settles down and the edema resolves, because at that time, people said you can't operate on aneurysms acutely, right? Is that true, Estrada? Yeah, well, early in my residency, that was
1:16:10
the norm to wait for the edema to resolve, but then the conventional studies showed that the outcomes were worse with waiting. And so that led to the evolution of early intervention for aneurysms of
1:16:25
a regular hemorrhage. 'Cause you risk the issues of re-bleeding, you risk
1:16:33
patients that coming from delayed cerebral ischemia.
1:16:37
Sam, are you still there? Yes. Sam, are you see this? You saw this in Baghdad a lot. People would come, they'd come to the hospital I'm sure they go to CT. but your operating rooms were all
1:16:50
full. How'd you deal with that? I mean, because the patient could die. Well, what did you do?
1:16:58
Yeah, I think the norms mentioned by the first grad is the same. So once we started, the norms was not to do even a CTA because that may rupture the aneurysm. So I need to do a consent for the
1:17:16
patient So the radiologist can accept to do a CTA because the norm is to leave the patient for the first two weeks until stabilized and
1:17:28
then try to treat it. And during COVID, once all the non-urgent procedures stopped aneurysm clipping was one of them. We stopped treating aneurysm because it's not, the norm is not urgent I'm not
1:17:46
saying that. Decades ago, it's just four or five years ago. So it depends on the, I think it depends on the system that you are living in as a patient with subalachnoid hemorrhage. But I'm saying
1:18:03
in Baghdad, in Iraq in general, it's not that urgent to do aneurysm surgery in general. And usually
1:18:13
patient treated and then neurology unit. And sometimes, as you mentioned, sometimes one of the differential meningitis, so patient can be treated for a week as meningitis because the subalachnoid
1:18:28
can be very little, not recognized in CT. And after a week of meningitis treatment, then the patient will be referred to you.
1:18:37
Okay. Yeah. That's very good. So we're getting a broader perspective Some can do things and we can have a. Jim, this is an interesting discussion. I'd love to hear other people weigh in.
1:18:50
Self-experience. Yeah, I've both had experiences previously where waiting for, waiting that two week period and right before we were ready to intervene, the patient re-blit and the outcome was
1:19:07
dismal because of that waiting period. Anyway, I'll just - And I'll get some comments. Come and go ahead, ma'am Can we get some comments from the residents? Sure, let's do that. Then there'll
1:19:18
be participation also. Dr. Mesoma Silva, I don't know whether you can comment because you put a comment on the chat. Can you be able to give some comments on this case?
1:19:32
Could you give me a little while? I'm just
1:19:37
sorry, I'm not going to comment anything. I'm still a
1:19:40
medical student, actually. I'm just - Yeah, but I know medical student, isn't it? I mean, a few care medical signals.
1:19:48
I just expect to go, yeah. All right, we're glad you're with us. That's very nice of you to be with us. I hope you're learning something. Well, what Strata said was, I remember I was in the
1:19:57
same position as Strata was, I was, we decided we would wait. That was the practice at the time, and I was on call at night, and I heard a patient scream out in the middle of the night. It was a
1:20:08
patient we were watching with an aneurysm, he ruptured and died And it came to my mind that I sat there for an hour, and I sat and thought about this, and I said, I did nothing to help this
1:20:20
patient, and I can do better than this.
1:20:25
And so, going back to the risk and chance of success, the highest chance of success, the lowest risk, that was a disastrous decision. So, you can try to refer a patient, but a lot of people
1:20:37
can't do that. So, now what do you do? You just sit and you say, Well, I can't do anything for you.
1:20:44
that obviously has risk. Well, if I don't have a CTDC and I don't have a CT angiogram, does that mean I can't do anything? And I'm gonna go quickly here because you and I did this, you can always
1:20:58
do an angiogram. You get an angiocath, you put it in the carotid artery, that's easy to do. And you take one shot AP, one shot lateral. And if it was the right pupil was enlarged to do a right
1:21:12
carotid angiogram, at least you can do something. At least you can make a diagnosis and tell the family. So we wanted to show that. Okay, so we got a CT angiogram. We've got a hemorrhage. We
1:21:22
think it's probably host to your communicating. It could be middle cerebral. You see that here, be not for sure, but likely the percentage is going to be in the run, the post to your
1:21:33
communicating internal carotid. And you do this, and this is another patient. You find that the angiogram chose a middle cerebral aneurysm. And now what do you do? You're still in the same set of
1:21:45
surgery. When do you do surgery? Well, I remember visiting Japan and when Dr. Suzuki was the first in the world to say, we have to operate immediately on patients. Nobody in the United States
1:21:57
did it. Didn't do it in Russia, in the UK. And he had very good results. And so we brought that back to the UCLA, USA. We reported that and so far So people were trying to say, that's what you
1:22:14
should do. And this is what you're left with. There are complications with aneurysms. And these complications can be devastating. One is re-bleeding. There's only one way to stop re-bleeding.
1:22:26
And that's to clip the aneurysm. Or if you've got coiling, you can do coiling. But most people don't have that. So the only thing you can do is clip it at surgery Another complication people would
1:22:38
say is to get phasor spasm. And I'll show you a picture of that. I think I just had that here. Here's phasin spasm. You can't see the blood vessels. They're all spastic, whereas this is the no
1:22:48
vasospasm.
1:22:52
And people said, well, we have to wait till the vasospasm goes away. I know it is in my 60 years, nobody knows that it's treat phasin spasm, much less the cause. And the only way you can treat
1:23:04
phasin spasm is to clip the aneurysm, and treat the blood pressure and do that So you've got to clip the aneurysm. So if you really sit down and think about it in a logical manner, the only thing
1:23:15
you can do is clip the aneurysm and so depending upon your environment, you have to do it as soon as you can do it. And Sam or said, operating rooms are available. We couldn't do it all the time
1:23:25
and so forth. Other complications you get are hydrocephalus. And you put them in trick and they're draining. While a lot of people say, if I put a drain in, they're going to get infected. We had
1:23:36
a way of doing that. where you essentially put a drain in the ventricle, but you bring the distal end out of the abdomen, like you're gonna put a VP shunt in. And those long ventricular drains
1:23:49
don't get infected. Long ventricular drains don't get infected. So you can keep them drained for a while. And you wanna keep the, make sure the patient's blood pressure is absolutely perfuses in
1:24:03
the face of his spasm. Okay, that's what we're doing. The other thing, there's a paper in the literature that says, What can you do? Well, if I don't have much to do, one thing I can do is
1:24:12
lower the patient's blood pressure because there are papers, this is one of them, and there's other papers in the literature came out of London, Ontario saying, If you lower the pressure, enter
1:24:22
arterial pressure, that's directly, that is directly correlated with the pressure on the aneurysm wall. So as the patient's blood pressure comes down, the pressure and the aneurysm wall diminishes
1:24:36
in the chance of rebleeding is lowered. There are also some agents like Epsilon Amino Caprog acid, which were used to delay rebleeding. I think we found them helpful. Okay, I don't know that I
1:24:50
was going to go into this surgery here about this or not. There's some basic simple principles. If you decide you want to do it, you can use loops, a microscope, a bipolar You don't need all the
1:25:02
fancy equipment in the world. You have to have some clips. If you don't have clips, you can put a suture around it. And that gets back to this choice you have in the end. And the choice is, what
1:25:14
am I choice? And if I do something, if I do something, is that better than doing nothing?
1:25:22
Is that better than doing nothing? You have to make the choice or is the patient. Okay, so you can lower the blood pressure, you can try to get things ready, We'll show you some other things
1:25:32
you've got to talk to you and aesthesiologist. It should lower the blood pressure when you put it, putting the frame on or you're making your incision 'cause all those things can cause blood
1:25:42
pressure, elevation and ruptures before you even open the flap. Okay. And do you need to have some relaxation? If you see Dr. Herner's Nimi's videos, they're all on SI or SI digital
1:25:58
And that's practical because he talks about things that you can do surgically when you don't have intervention. And he's done a superb job. He's passed away now. But you'd give man a towel to the
1:26:10
patient to reduce the pressure on the brain. You may put a spinal drain in it and he would prefer to, he opened the lemon a terminalis, that was sort of the things you do. So are those things,
1:26:22
are those risks you wanna take or is letting the patient alone a better choice?
1:26:28
And then you go. put the patient in the intensive care unit or have them washed and get vitals. Do you have them? Most people don't have an intensive care unit. When I went to Chicago, we started
1:26:40
one. It was normally the intensive care unit for trauma, but we put anyone for neurosurgery. And so, I mean, as time goes on, you're going to do those things in your hospital. There's a long
1:26:52
ventricular drain. Watch the hernestemic videos. They're on SNI and SNI digital. You can see how he handles this. There's some instruments you can use, simple instrument. And Sam has showed some
1:27:04
of these instruments in his talk. You put a little cushioning forceps right across the aneurysms. It's a temporary clip. Or you put it across the crowded artery. You need a little help. That's
1:27:17
something you're going to get some clips that are expensive. And you have to have a clip-applier. This is a clip remover, which allows you to remove it and also to apply it. It's It takes all
1:27:29
kinds of clips. So you can buy one instrument or you go to a meeting, you buy one clip a plier. Bipolar, everybody's got some kind of bipolar. You use that. Here's a bipolar forceps. And it
1:27:42
happens to be an irrigating forceps. It's both a cushion forceps and it provides irrigation. So the forceps don't adhere to the blood vessel. There's things out here. Just a few words. Yes, Sam,
1:27:55
please Please, Sam, what do you say? Right, considering the time of intervention, the challenge we have with many of the specialists do not arrive on time. They don't arrive on the window that
1:28:09
would encourage one to go in straight away. And the tendency is to stabilize the patient. Comorbidities also are very frequent. Some of them have uncontrolled diabetes or controlled hypertension
1:28:23
And then sometimes they come already with chest infection.
1:28:29
So these comorbidities die enhance and we have to wait and stabilize them in order to go in. Also if the angiography, we do city angiography. If angiography shows the versus person, then you are a
1:28:43
bit worried that the outcome may not be as favorable. Why Russian? Why not manage the percent conservatively? Or until the percent stabilizes before you go in The risk of abbreviate is always there.
1:28:56
We appreciate
1:28:60
that. But very occasionally we are lucky enough to get cases, good aneurysine, good neck, clippable, and patient's condition is stubborn enough to encourage us to go. In fact, two days ago we
1:29:10
had one complex aneurysine, but it took more than 10 days before we could go in. Because of all these structures that we persisted to stabilize the patient, eventually clipped it on Friday and
1:29:23
there are some today's presentations. Be very well. Thank you.
1:29:29
Those are terrific comments Sam, they're very practical and because everybody doesn't have all those fancy things, so, okay, I try to do, let me do a little more or you want me to stop and finish,
1:29:42
it's up to you Well, I think we, we're getting beyond, I would like to try to stay on, on, on time, so I think we should invite other comments if I'm in comments and we should probably try to
1:29:56
wind it, wind it down. We can certainly come back to this topic in the future if there's interest, additional interest But I wanted to want to make a comment,
1:30:07
it's all about what Sam said. I mean, we may have some principles that have evolved and how we've practiced, but the, the practicality of the location will will dictate how things go. And they,
1:30:22
there is the concern about re bleeding but operating in a phase of. of vasospasm has dire consequences as well. And you mentioned about the amicryle, the epsilon amino caproic acid. I think it
1:30:38
certainly reduced the risk for re-bleeding, but the reason it fell out of this favor, I think, is because it tended to increase the risk for vasospasm.
1:30:50
NIM, you have a comment, please go ahead.
1:30:55
Thanks very much I wanted to thank Professor Osman for this presentation, which was very nice because the residents who participated were able to get some insights on the general management of these
1:31:10
conditions. And my commenters, really, most of what I wanted to say has already been said that the management of these conditions depends on where you are and sometimes the constraints are the big
1:31:24
challenges. I can talk about Kenya, and because this is where we're practicing, in Kenya at the moment we have referral centers about five or six referral centers, and in those six referral
1:31:39
centers there they're distributed evenly distributed within the
1:31:45
country. So and probably I would say it's a radius of about, let's say, 200 miles, okay, that's about maybe three, almost 300 kilometers, so patients have a choice, you know, so when one
1:32:02
makes the diagnosis, then if there's a need to refer, those patients can be referred, but then as you know, these are very acute cases, and there are ones where we can refer and get good results
1:32:14
are the ones who present early, and let's say they haven't bled, but the patient who has bled then want to stabilize that patient until he's stable enough to be referred for. the management. And
1:32:27
then of course, the situation is that that patient who you're going to stabilize, you'll have about 50 of them who will bleed again and therefore they'll be candidates for for further management.
1:32:39
So when you're stabilizing them, there's that natural selection where if the patient is going to bleed again, he'll bleed and therefore he'll not be the candidate we are going to refer to the other
1:32:52
centers for further for further management. And that's just a a natural process. But if it happens like now in a big town like Nairobi where let's say such a stationary races where the patient is
1:33:07
diagnosed within Nairobi, then they can have access to neurosurgical care almost immediately. And in a big town like
1:33:17
Mombasa, Okisumu and Eldra, if the patient is in the big towns, then they can have access to to neurosurgical management immediately. And then the principle here now would We usually to stabilize
1:33:29
the patient and do surgery if the indication for surgery is there. And what we have noted here is that most of our management has moved away
1:33:41
from angiography. We now do the city angiography, city angiography and from city angiography make the diagnosis and then the patient undergoes surgical treatment So we don't, we don't, that
1:33:57
patient is not subjected to digital subtraction and geography in our set up here again, mostly because of cost component and the fact that the city angiography gives you quite a lot of information
1:34:12
that the modern city angiography machines gives you quite a lot of information and one is able to make a decision and to the way forward And
1:34:22
the scenario I'm giving is in Kenya and I have. Acadia is very, very different from the other African countries because we have managed now to train quite a number of neurosigements and set up quite
1:34:35
a number of referral centers. And again, there is private health care. In the private hospitals, the treatment is completely different. And the private hospitals, of course, everything is
1:34:48
available and the patients get very, very good quality treatment. Now, again, as I said, these are the type of cases which we can rarely refer out of the country, because unless it's the
1:35:01
elective type of aneurysm, let's say what,
1:35:05
let's say post-re-communicating aneurysm or something like that. But most of these type of emergency cases, there's no room for referring them out to the country. So we have to see how we can
1:35:17
handle them within Kenya. Thank you. Okay, well, I think I think there's a hand up, Ned. First of all, if anybody wants to leave, it's 941. We've gone for an hour and a half. If people want
1:35:34
to stay a little more and ask some questions, fine. Ned had a question. I thought Mustafa Ismail also had a question. Ned, do you want to ask your question?
1:35:49
Hi everyone. I hope you are doing well. I'm just having a comment about this
1:35:56
video tomorrow. So yeah, thank you for providing this to the eye. And we don't know, I think it's important. And
1:36:10
as my previous role, like a
1:36:16
small part, then to be the departure of life, the parts of life that will be there.
1:36:24
how the medical student is able to provide such a help and provide business standardization as Zephyr has said. It's amazing and it's a wonderful opportunity to have.
1:36:41
And I think it is a given that it gives the best like experience about the greatest standardization so how to help the patients and to be better always. Thank you.
1:37:00
Okay, Mr. Officer, thank you. All we and then Emmanuelle. All we, you had something you wanted to ask, Roshid?
1:37:09
Yes, thank you, Professor Osman and Professor Strada and Professor Mungombi as well. Mine is,
1:37:15
you had mentioned in the absence of clips
1:37:21
the point of a suture. I wanted maybe for you to expound more on that, because the challenge sometimes we have here is all the time is availability of clips. I wanted to know if there are any
1:37:33
alternatives that you might be thinking of, thank you. Yes, I'll come to that in a minute. Emmanuel, Sunday you had some questions?
1:37:45
Yes, thank you very much. I'll call this for the president of very exclusive. I think under the talk about the future,
1:37:56
the last, the last, the person that took class has already asked about that. However, I want to talk about the rule of
1:38:06
loma puncture in a survival plate. Usually in patients that are present, it's like, I'm talking from Nigeria here, patients who present, usually after three days,
1:38:24
This can be not be able to show this so far economically. So, in such situation, the only way one can be able to know if it was history, if it was bliss, if it was not
1:38:40
bliss, is to do with the number of punctures. Now, the number of punctures that we've done at this time, we show is anticormic fluid. And this will give a suggestion, a high suggestion, a high
1:38:51
suspicion that garys It was
1:38:55
a bit bleached in that space. Now, if this blow-up of cancer is to be done, it is said that a small, caliber needle should be used by an experienced physician, neurosurgeon and aesthetics to do
1:39:10
the blow-up of your source, to avoid trans - to avoid a coating in this patient. Thank you very much Oh, that's a very, very, very good comment, very intelligent. a small born needle because
1:39:25
you have to make slightly some kind of a diagnosis. And
1:39:32
that's correct. So, any other questions I have? I have this in raised. What was that? Sorry. Yeah, Dr. Osman, I have one question from you and Dr. Strada. In the very old past, when there
1:39:49
was a very large no reason, I heard they put a piece of cotton, muscles all around it to let it sculptorize. I have heard about it, I never saw it, but I want to know your, because you have been
1:40:03
through all this process of the aneurysm treatment. Was it done and how was it done so you can share your experience with all of us? Well, there's a couple of questions. One is about cotton and
1:40:15
the other's about a ligature. Cotton, we used to do that you're absolutely right, Ollie, put cotton around it cotton would cause fibrosis and therefore you would think it would at least promote
1:40:29
some healing around the aneurysm. In fact if you couldn't clip it all and there was some protrusion you put cotton in there to do that. I think long-term studies show that that was not as effective
1:40:40
as we thought. They also came out with some glue. Some glue that we used to put on an aneurysms. We did some research on our laboratory. Maybe Sam was over and they did that, but it showed that
1:40:53
it really ate away
1:40:58
at the aneurysm wall, so that isn't good. So the best thing to do is to see if you can clip it and we've gone through
1:41:03
that. I can't put them full-screen here. I don't know what the problem is. They're various instruments. Here's an example of a clip going on the answer, aneurysm. If the aneurysm is still large,
1:41:14
you're going to evacuate it. Now the other thing is you can't put a clip on it and you saw this in Samers They used to make a ligature carrier, but you can do this with a cushion four steps. You
1:41:28
put a ligature, a silk suture around the neck of the aneurysm loosely. You get it on the other side of the aneurysm, you go retrieve it and you very carefully tie it down. And that used to be what
1:41:41
people used to do for aneurysms. If you don't have clips, it's perfectly reasonable thing to do. It's best to try to practice that and then under the microscope in the operating room, if on a
1:41:54
sponge or something, so you get the skill in using both hands and bringing the suture so the knot closes slowly on the neck and it doesn't tear the aneurysm. That would be one thing to do. So you
1:42:07
can use a ligature. If the aneurysm is still big, you can evacuate it. I won't show you this is a video. I won't show you that What's new? I think I have Shamer went into coiling. people are
1:42:21
using smaller flaps. You don't have to do that. You can use a large flap. If you haven't done a lot or if this is the first view you're doing, you get a larger flap. You need to see what you're
1:42:31
doing. Minimally invasive surgery takes a lot of skill to do that. We saw and Samra showed that 3D views. You don't need all that. It's good to have it. And for an intervention list, it's very
1:42:44
important. Do you need all the fancy instruments that companies are telling you about? You don't. The basically simple instruments. Cushing four sips, some clips, a bipolar, and a microscope or
1:42:59
loops. That's all you need. And you can do most of these things with the other instruments you have. Neuro-navigation, well, if you want to find an easier way to find it, yes. If you don't have
1:43:09
it, you can find it.
1:43:13
Find where the end here. If it's an A3, and you're a semi if it's, you go down to the proximal. uh, into your cerebral arteries and you follow them all the way out. There are ways you can do
1:43:23
that. And the question is everybody's telling you about all these new treatments. The question, what's the proof? They're a value. What is the proof? And frankly, in most cases is very little
1:43:34
proof. What about the future? Uh, in the future, we're going to be dealing with small vessel disease. This is an example of 20 of strokes or lacunar strokes And this is a seven tesla angiogram,
1:43:49
which shows vessels less than a hundred microns in one of the cells high in the brain. That's who we're going to see. Uh, and, uh, interventional angiography is going to deal with that. Here's a
1:44:01
patient that was reported in us, SNI, and it was, uh, 10 years ago from Japan, a man who had dizziness collapsed at an occipital lobe infarct They didn't know what it was. They treated him with
1:44:14
aspirin. He came back later with more dizziness. He lost consciousness. Then he did an angiogram. They show both vertebral arteries were occluded. This is his angiogram. He had one carotid
1:44:24
artery. There was no posterior communicating, you could see. He had another one here on this side, you couldn't see it. But if you did a CT angiogram, and this was on seven Tesla, you wouldn't
1:44:36
probably see it on regular angiograms. He had these small corkscrew vessels going from the carotid back to the posterior cerebrals. Here it is in the lateral view He had basically revascularized his
1:44:49
brainstem. He went ahead and had a bypass and revascularized him. So what I'm telling you is that we're also limited by the technology we have. With three Teslas, we see certain things. With
1:45:08
seven Tesla, which is available in very limited places around the world, very limited, but that's what's gonna happen. You're gonna see this in the future.
1:45:14
And here is just showing you what the future is gonna be. of paper from Japan showing that really the cause of aneurysms is macrophages, it's an inflammatory disease. In the macrophage and involved
1:45:27
the blood vessel wall, it causes an aneurysmal dilatation. They produce this in animals and they then fed the animals with, first of all, they gave them some agents to produce an aneurysm. This
1:45:39
is the aneurysm here in purple And then they treated them with an agent that stopped the macrophages or the inflammation and the blood vessel and it healed. So are we going to be looking at the end
1:45:52
of the century by biochemical treatment for amourysms? You got to think about that. We've got a paper
1:46:00
on SNI digital on the molecular treatment of AVMs. And what they've done in Japan is they've got imaging agents that that will go to the macrophages and the aneurysm you can image it. And you can
1:46:13
see essentially if the aneurysm has got macrophages in it, then you know it's gonna rupture, and that can be a way of telling how to do it. So anyway, what we were trying to do today is to tell
1:46:26
you is we don't know everything. And here is a film I showed on the talk on the Future Surgery. This is an image taken a year or two ago on the galaxies in the world. There was a thousands galaxies,
1:46:41
and this is in a limited view. There's probably millions And other inhabitants in the universe, likely there are statistically. So what do you do? You've been grateful every day that whoever got
1:46:54
you, worship helps you. You're a human being, you use all the talent you can to do the very best you can do every day, to help your patients with life-threatening challenges. That's why you
1:47:05
became a neurosurgery. So what is the best answer here? And that gets back to this chart I had you looking at some time ago What choices do you make? and the choices turn out to be basically very
1:47:21
limited. Do you choose treatment A, treatment B, treatment C, or treatment G? Is doing nothing better than doing something? Is waiting until the patient's stabilized better. You have to decide
1:47:37
for your environment. Should you refer a patient? Well, my patient doesn't have any money. What are you gonna do, say, well, you're gonna die? Can you do better than that as a neurosurgeon?
1:47:49
Can you do an angiogram? You don't have a CT angiogram. You can do an angiogram. We used to do them all the time before we were their CTs. So don't let people discourage you from doing things that
1:48:01
allow you to help your patient. You're a certain neurosurgeon, you're talented, you're intelligent.
1:48:09
Try to help the patient as very best you can. So you've seen a lot of things today You've seen how you can do. telemedicine, tele-proctoring. We've talked about how do you treat diagnosis and
1:48:22
inurism in an area where you don't have all the equipment. It doesn't matter. There are choices you can make. And if you are in an area where you have a more developed centers, then you do
1:48:33
different choices. Sam has talked about things that you do if you don't have them. And we had somebody talking about why you have to do a lumbar puncture and how you do it. None of those are wrong
1:48:44
None of those choices are wrong. You have to do the best you can. So anyway, that was the message we wanted to bring. I'm sorry if we went over. Anyway, thank you very much. Astronaut, you
1:48:56
wanna close? Or I'm sorry that we went over, but I wanted to get that. So when we get the video down, we can have other people can see it. Sure, sure. Well, thanks. That was well done and
1:49:07
comprehensive. I think it stimulated a lot of thought And one thing I wondered about is. You know, Sam had mentioned about volume and NIMM has a different experience. And so I think the question
1:49:24
that comes to mind is, well, I would ask NIMM, are you having enough volume that the residents have ample experience such that when they leave, they
1:49:40
feel competent to address and your intracranial aneurysms with open surgery? And I think that's particularly relevant if you're having residents that are going to places where they might be the only
1:49:56
neurosurgeon in town. And then that brings up the other question. If there's variation in volume, is there any movement to have regional centers where residents from different parts of Africa my go
1:50:12
to.
1:50:14
regional centers of excellence that get more experience than what they may have had in their local situation. So I'd love to have a couple of comments about that and then we should probably close out.
1:50:30
No, there's no. Okay. And
1:50:35
we wanted to thank you for your presentation, by the way, before we close. Thanks. Can you answer some of Estrada's questions? Yeah, let me answer those questions. Centres
1:50:49
of excellence is something we have been considering. Quite a lot here in Africa, but you know, Africa is a very divided country. Each country is totally independent. So to get these regional
1:51:03
centers of excellence is not easy. Within the country, like now, let's say, let me take, for example, Kenya, within Kenya, then
1:51:14
we have what we call national referral hospital. So like, there are three national referral hospitals in my country. So Canadian National Hospital is a national referral hospital. And then the
1:51:29
Edward Hospital is a national referral hospital.
1:51:33
And then there is another one called Kineta University. Also it's a national referral hospital. Now these hospitals are given more resources And as a result of that, and of course they have
1:51:45
training programs. As a result of that, you find that most of the complex cases go to those hospitals. So therefore the work load, like if you take, for example, at a national hospital, it will
1:51:59
be seeing a lot of patients who are at some American or human range and aneurysms. And therefore, although the cases will be done by the senior neurosagiens, but the resident
1:52:13
completing their residency will get an opportunity to be taken through the surgical component of management of the basic straightforward cases. And therefore, you find quite a number of the
1:52:27
neurosagulans who will finish will have that experience. But by and large, they still choose to refer to the national referral hospitals as I said, because it has a little backup And therefore,
1:52:40
such cases would then go to those centers. So the issue of setting up regional centers is something we have considered. And as I said, this, because each country is completely different.
1:52:54
Geopolitically, there are so many issues which come into play and which make it very, very difficult to set up a center for, let's say, managing such cases Now, the WHO and the African Union have
1:53:12
tried. in setting up our regional centers, but so far we haven't reached neurosurgery. I know, Kidney, for example, in East Africa, they divided some sections. For example, a Kidney Center
1:53:28
was set up in Kenya, and Trauma Center was set up, I think, in Del Salaam. And I think another center, whether it's for vascular something was set up in
1:53:41
Moolago So those
1:53:45
three countries, Moolago, Del Salaam, Tanzania, Del Salaam is in Tanzania, and Campale, Uganda, and Kenya. They set up three regional centers, which would cater for, in Kenya, we have the
1:54:00
Kidney Institute, which basically is for all the East African countries, and remember, East African countries, if we're coming to countries, I bought five countries now. But we haven't reached
1:54:10
that level in Los Angeles yet. So I hope, I hope we can pursue that and take no surgery to that higher level.
1:54:20
It's hard to thank you, NEM. The purpose of tonight's talk was there are a lot of people even in our country who are not near a major center. And so you have to make a decision about what you're
1:54:32
going to do. We had some young residents who are actually and can you're going to another cities where there's only one other neurosurgeon We have Alvin who presented a talk last month on how he
1:54:44
handled some traumatic brain injury. And I was telling everybody, Alvin's video has been seen by what's a 1300 people or something like that. It's very popular because people are in that
1:54:58
circumstance where they don't have all these opportunities. And so the question is, what can you do? And our goal today was to show various ways you could do that One is tele-proctoring. And
1:55:11
tele-proctoring. The camera showed that it has to be matured, but it has, as Alvin mentioned, and as other mentioned, it could apply in places where there's limited neurosurgeons and you could do
1:55:26
that. Isn't that right, Sam, or we haven't thought about that, but you could find a way to help people who need some help besides just intervention. We have to think about that.
1:55:37
And we tried to present some cases starting from minimal, what you don't know and what you can do. And you're still faced with the choice of, can I do the very best for this patient? Or do I just
1:55:50
let him die? Those are personal choices, those are family choices. Those are agonizing choices. But we, people who are watching this video are in places all over the world. And many of them are
1:56:05
not, do not have a lot of facilities or equipment What we were trying to say is you don't need all that.
1:56:13
and Estrada, and I, and Samir, and Gilbert, and Nim, all did surgery before all these things were available. Yes, you can do it better now, but at least you could do, you could help some
1:56:27
people. Is that better than helping nobody? That's something you have to think about. Let me see who else. Elvin, did you want to say anything in closing here? And Sam, did you want to say
1:56:38
anything before we closed? 'Cause we're over time.
1:56:41
Oh, thank you
1:56:45
Thank you. Was it helpful, Mr. Elvin?
1:56:49
Thank you so much. I think it was very helpful. And I do want to take more time, but I want to extend my thanks and appreciation to everyone. Thank you. And Sam, you talked about. Yes, I feel
1:57:04
like going forward, I went to address some of these issues in subsequent discussions and lectures. So let me. leave it until I give a talk, eventually I'll give a talk on experience in the
1:57:17
progress sector and whether we should always depend on government to grow a neurosurgical service. But we're going to learn of the lectures and presentations we're going to make in the near future.
1:57:32
Thank Thank you you. All right, Australia.
1:57:35
We've gone for two hours, which is an hour longer. I think when the program committee meets, we'll have to talk about that. We still have 28 people here. Okay. Thank you very much. Thanks.
1:57:47
Thanks, Jim. And thanks, Jim, for your nice presentations. Generally,
1:57:56
a lot of thought and see you next month First Sunday of October for our next grand rounds. Thank you all. Thank you. Please, please send your comments to a strata and how we can do this better.
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