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This is the 16th SI and SI Digital Bagdad neurosurgery online meeting held on August 7th, 2022. The meeting originator and coordinator is Samer Haus.
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Professor Yasser M. Hamandi of the Department of Neurosurgery of the L. Lorraine College of Medicine and College of Medicine in Bagdad, Iraq. We'll talk about the status of neurosurgery in Bagdad
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The experience, the Gamma Knife experience across all of Iraq
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The lecture is 30 minutes, the discussion is 15 minutes, over 110 days from 18 countries participated in this conference.
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who is the professor of neurosurgery at the
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Nahrein University. He graduated from medical school 1997, and he got his board 2005, and then he got
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the position of the assistant, scientific assistant for the total Iraqi board, the whole Iraqi board specialty, and then he is the chief editor of the scientific journal of the Iraqi board in
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general, not only your research, the whole board of your research. He is going to tell us about his experiences, leading experience and unique experience in Gamma Knife and Iraq. Professor Yasser.
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Salaamu alaykum, firstly I want to thank my teacher Prof Abduhadeh Khaledi and my colleague Samir for their invitation for this nice meeting and secondly I am honored to be to talk in front of my
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teachers and my colleagues and
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very nominated international neurosurgeons
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my talk is about the Gamma Knife experience in Iraq
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We have five centers in Iraq. We have Sudirwittri Neuroscience Hospital Center. We have in Baghdad and we have a touch private center in Baghdad. And there is a few near future unit in the medical
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city in Baghdad also. We have two established center in Basran, the north and the south of Iraq We have a new established center in
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Erbil, in the north of Iraq.
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The first center, the Sudirwittri government center, established firstly in 2001
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But because of the situation of the war, we can't work starting work until
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2016 We change the version of the unit. and starting the work in the beginning of 2016. The version was perfection. Then before a few months upgraded to perfection plus.
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We treat more than 5, 000 patients from
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2016 to 2022 A target private hospital is the first icon version, which is the version came after the
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perfection, working in started
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2021. And we treat more than 400 patients, treat it within the first eight months.
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The indications regarding the ERBIL and the bus center start before four years, I think. And in Erbil before one year,
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the version of Basva and Erbil is perfection.
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We treat the indications that treated in our centers with static brain tumors, single and multiple. We treat benign tumors, mening tumors, monomers. We treat gliote tumors, avial malformations,
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nasopharyngeal carcinoma, and pituitary adenoma functional and non-functional.
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We treat the trigeminal neuralgia,
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mucial temporal cyclorosis and cavernomas.
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The tumors are the indications of the gamma knife that we treated, we treat the deep-seated tumors, the focal brain stem tumors, not the diffused. We treat the recurrent tumors, residual tumors,
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patients who are poor, candidate for surgery, and we treat the tumor bed after surgery We do hypovisctomy for painful metastatic bone lesions. We do salvage treatment for aggressive glioma when
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there is no benefit from the radiotherapy after surgery.
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There is limitations in our centers. Other functional indications like tremor, corpus callizotomy for epilepsy, OCD, uveomerinoma are not doing till now, because as you know, the.
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when we talk about the OCD, it is the selection of the psychiatrist and also for
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the who can go for corpus cholazotomy, it is the decision of the neurologist and also for the uveal melanoma and glaucoma depending on the selection of
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the ophthalmologist and now the uveal melanoma, gamma for uveal melanoma
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came and can save the
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eye from extraction
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these are the two versions the perfection and the icon the perfection is a frame based while the icon is a frame and mask base.
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The icon
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has CBCT, you see the arm built in the CT, built in
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the Gamma Knife unit and there is a mask on the
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frame, there is infrared camera, as you see in the photo, this infrared camera indicate the
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infrared indicators in
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the tip of the nose and on the side of the head and this camera protects and to prevent the movement of the head and there is, whenever there is a little movement, the system will kick out the
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patient from the treatment and then reinstalling and then to restart the treatment. And this
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is for the protection of the important and vital structures of the brain. It is smarter software than the version 4 and ability to fractionate treatment. In the previous version, the perfection
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version, we can do only single session But in
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the icon, we can do hyperfractionation. Hyperfractionation means that we fractionate the same session
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into three or four sessions with successive days.
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This is important to decrease the side effect of the radiation, of the gamma knife, of the gamma arrays and more potent and more better outcome on the tumor treatment. and there is flexibility to
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treat patients with previous cranial surgery to use non-vasives or attack procedure. You know in
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this version we can do the frame base for some selected cases for functional like trigeminal or pituitary which is the tumor that you are near the optic nerve or when the tumor on the brain stem we
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don't use the mask because there is lateral movement in the
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mask and we don't need that for these indications but sometimes when there is the patient is
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need the hypofractionation or there's many previous cranial surgeries and there's no place for the for the screws, we do the mask which cannot be done with the previous version. And there is a
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safety features as I talked before, that camera and these indicators, safety features that prevent any wrong
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targeting due to the movement
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As you know, these photos, the
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indicators of the nose and on the side of the head. The limitation of the mask, when the patient is unstable or uncomfortable, we don't do the mask because of the movement. When the patient is
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obese, the indicators not appear for the camera And for the long treatment we don't prefer to do a mask. because like in the functional
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for the OCD, for the corpus callizotomy, the procedure may last for five hours. So we don't use the mask. For the lesions that need 70 or 100 gamma angle, we use different angles in the treatment.
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We have 90 degree angle and the angle, we
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mean, when we talk about the angle, the angle of the neck to the head. 90 degree, it is the standard, and
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the 70 is extended neck, and the 100 is flexed neck. And this cannot be done
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for the mask. And these angles used in the frontal and the two frontal and two occimital. lesions, sometimes in the trigeminal neurology, it's better to 110
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angle to reach the target. And this cannot be done with the mask.
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This is some examples and photos for the treatment This is
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a schwannoma, you see the photo before, this is before the treatment, and after six months, you see the central crosses, and after one year, it's more better outcome. This is
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after six months,
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and this is another
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picture for the schwannoma also This is before and after six months.
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This is the case for the. focal brainstem lesions, you see, after 6 months, there is this appearance of the tumour.
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This is a metastatic CA breast, this is before the gamma knife, and this after 6 months, and it's very good outcome regarding this metastatic tumours, and we see the result after 1 or 2 months
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from the session.
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And I think Dr. Abdenumir has the case with 5 or 7 lesions,
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more than half of them disappeared after 2 months. Perfect.
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We have, this is the case of meningioma, you see the
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results also after 6 months. This
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This is another thalamic tumor.
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before and after the six months. Thank you.
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Thank you so much, Professor. Yes, sir, for the very impressive work and results, and really impressed with the numbers which you have done with 5, 000 cases and then 800 cases within eight
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months. That's really wonderful So we are building up an experience which is probably unique, I think, with this massive number and with your eagerness and communication with other centers in the
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world, because you've been to many centers in Europe and outside Europe for this training. Thank you, sir. Any question? Dr. Osman? Yes, I have a question. Yes, sir, that was very, very
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impressive Do you do a biopsy to establish the diagnosis
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to all your treatments, like the metastasis I saw, and that would look like in a schwannoma and so forth. Did you do biopsies to know, should we share with your upper, what's your training?
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Regarding the guidelines, sir, we do the biopsy only for the glioma. You know, if it's high grade or low grade glioma because the high grade glioma, we shift the patient to radiotherapy, but for
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the low grade glioma, we do gamma knife. But other religions, we don't do biopsy, depending on the
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MRI results. And we send the patient for more than radiologists to confirm the diagnosis. Regarding the metastatic tumors, we depending on the diagnosis of the primary lesion because most of the
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patients referred for us primarily say breasts have previous surgery in the breast or they have thoracascope for the CA lung or another surgery outside the brain.
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This is for the cases that treated none which have not doing surgery before but we treat the residual tumors and the recurrent tumors with a non
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pathology.
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I'm sure what you're doing is being done elsewhere in the world not sure I agree with that but I remember reporting on a case in which it was a doctor whose wife had breast cancer and had a lesion in
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the brain he thought it was a metastasis and didn't treat it and the lady died and it was
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a meningioma and so I think what we're doing in the literature is full of information that if we rely on a radiologic diagnosis, that it's nowhere 100 as
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accurate as a pathology diagnosis. So it's obvious that that all over the world, not just what you're doing, but all over the world, if this people are doing this, it's going to be a practice
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which will not be 100 accurate
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Yes, we will be conducting the metastasis. We are talking about multiple lesions when it is a single solitary lesion or solitary lesion and when the surgeon can go through. So the surgery can't be
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done if we can't do biopsy for the meningioma, so why we don't remove it. But I'm talking about the cases that cannot be considered cannot be done or it is repeated will mark on small Indigenous.
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Okay, I understand. Thank you very much, very, very good work.
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Yeah, Dr. Yasser, thank you very much for this presentation. The Karolinska Institute donated the first camera night by Dr. Luxell to UCLA.
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And I was lucky to do the research on that. We had a eye melanoma, rabbit eye melanoma model that I did around 120 rabbit eye melanoma treatment And we showed that when UV on melanoma is there,
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gamma knife is the best treatment. We published four or five paper on that. And it's the doctor ran who was running the gamma knife. And let me to do the research on that. It is published, but
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it's really working very well. Those who work with gamma knife, they believe on it. And that's one of those believer also. Thank you very much, Mr. Michelle.
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One of our colleagues, Victoria, is now the most senior Gamma Knife graduate surgeons working in Colorado,
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NSCAR. Yes, we talk about that, but as I told you, sir, it's a selection of the ophthalmologist. Now, till now,
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many of the surgeons, even neurosurgeons, they don't believe in Gamma Knife.
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So, what about the ophthalmologist? Or the neurologist or the psychiatrist? So these are limitations, yes. It needs more awareness about the function and the work of the Gamma Knife, yes. One
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of the cases that we did on the rabbit eye, it was done, the pathology was done, and Dr. Rand went to an ophthalmology conference with the slides of all these cases, that our neuropathologist,
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Dr. Jan Brown, did all the study. There was no evidence of the recurrence, when it was done. So there is, after
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all, monologies were shocked to see such a good result of the Gamma knife for UVL, Mananamma. But thank you very much to bring this through the attention of the audience. Thank you, sir. Any
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other question, please?
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Our young doctors, students who are interested in mathematics and physics, any question?
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Come on, there must be one.
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Can I ask one question? Do you do for pala matomy also? Because they used to do it for pala matomy at the first place in
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Karo Ninska, Dr. Lexa was using, do you do that over there or do you just go with the DBS because Dr. Heba, few last month on the session, she's doing great job. I don't know if she's on the
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audience or no, but that's one of the main indications that Dr. Lexa made this Gamma Knife and he got a Nobel Prize for that in 1974.
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I think there are two people with questions I don't see them.
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For questions, so. Please go ahead, please. Yes, hi, doctors. First of all, thank you so much for this amazing presentation about Kalmanife. I think it's very interesting to know all of these
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cases and they're different. No, excuse me, interrupt you. Can you say, tell us who you are, where we are? Oh, okay. I am a medical student. I'm a fifth year medical student in the
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University of Baghdad, Iraq. Wonderful I'm very interested in this topic, as I said, the different cases were very, very, very interesting to see you. My question is, does the gamma knife and
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does procedures have any effect on the cranial nerves?
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Many of
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the cranial nerves can be protected. All the cranial nerves or all the vital structures can be protected by a risk.
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shielding software found in our system. When
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we are talking about the risk of the cranial nerves, we are talking about the first about the tharmic and about
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the optic chasm. And
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we can
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deserve 12 to 15 grey without any risk.
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We measure the risk and we measure the gamma rays that are reaching the vital structures before approval of the treatment. So we are
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not allowing to give more than the
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mentioned grace in the guidelines. But the problem is that when we hitting the tumors, the first month or first two months, there is an Oedema Oedema Oedema, and the Oedema may make a pressure on
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these vital structures, and we gave measures to prevent that, and most of the side effects is a reversible side effects Great, Fatima,
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Fatima and Dixua.
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And good evening everyone, Pat and Juan, fourth year Medical Students University about that. First of all, thank you, Professor for this presentation, I have one question, was most common cases
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you deal with in Iraq and was the impact of Iraq experience on gamma-nog in your research in here?
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Most of the cases, not only in Iraq, but I think in the world, it's the men in German, and there's some countries have the metastases and the vascular malformation, more I think in Japan, but
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in Iraq, the most, it's the benign tumors, the men in German, and secondly, the glial tumors and the metastatic tumors. And what about the question? It was the impact of Iraqi experience on the
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gamma knife in your surgeon, yeah.
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We have six years experience, we have, we treat more than 6, 000 patients. In Baghdad, I think about 500 or more in Basra and maybe a hundred of case in Arbi. Okay. Thank you. Thank you.
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Thank you. Thank you Fatima. Mohammed Amara, please Yes. Thank you everybody for presenting. My name is Mohammed Amara. I'm a first student. I just wanted to ask, could
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a technique like gamma knife replace DBS? And if so, would it improve the area of neurostate burnetics?
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The gamma knife is the, yes, there is a treatment for trauma and the Parkinson disease and the work of Gamana is ablation.
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like that before the DBS. There was ablative surgery and the gamma knife working as ablative surgery for the targets.
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And I believe in the near future the surgery or the surgery is not only the neurosurgery will be minimal and invasive and maybe in the future there is no non-invasive surgery. So I think that will be
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instead of the DBS and the near future. Thank you. We have two
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more Thank you very much.
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Go ahead. Okay. Hello. Thank you for the interesting topic. I wanted to ask about the safety of this gamma and how many sessions it needs usually. And does it make a full recovery? Thank you.
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Regarding the sessions, we treat the tumor or the target only one time Sometimes we need to repeat the treatment after one year or more than one year. Regarding the safety, it's a safe maneuver.
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We do it with the local anesthesia. The effect of the gamma is not more than one millimeter from the target. And we do safety measures We plan the
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risk area, and we told the.
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the gamma, the gamma knife, don't go to that risk area and
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I think it's a very good
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outcome. There's no perfect outcome for every maneuver, but I think it is a good outcome for most of
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the indications and the indications is upgrading
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for years, not that indications today and there is many lesions now, not yet approved by FDA
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approval, but they are working to
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many
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more than indications than I mentioned before. Thank you.
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Well, at the end of the first session, thank you so much, Professor Abdul-Amir and the Professor.
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And yes, sir, for the wonderful presentation and enlightening us of what you are doing and your struggle and success. Thank you so much. Now, I give the session to Samar to take over, please
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Thank you, Professor, for the presentation. Thank you, Dr. Yasser, for this, I think, systematic, well-informed patient data. And I think it's definitely a building experience that we are
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all proud of. Thank you for participation. I will start, I think, now, the good thing that we are catching with the time. Thank you, Dr. Khalil, for managing that part of the meeting I'm
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almost there. It is good,
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and I think we have one of the students have a question. We can give this question later at the end of the session. So.
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