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Welcome to the 19th SNI. and SNI. Digital Baghdad Neurosurgery Online Meeting, held October 23, 2022. The introduction will be the meeting, originator, and coordinator, SNR. Haas, from the
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Universities of Baghdad and Cincinnati
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The speaker will discuss my pathway in neurosurgery from Iraq. The speaker is
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Mustafa A. Moriarty, medical student, University of Baghdad College of Medicine, Baghdad, Iraq. The lecture and discussion is 17 minutes
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Thank you, Lord. Now we have Mustafa
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Ayat and Moro Ayati. Mustafa, are
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you ready? Yes, yes, yes. Mustafa is the sixth grade medical student and University of Baghdad, College of Medicine.
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I don't know what he will share, but he will share his experience That's our deal.
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And let's see the stage is yours, Mustafa, and yeah, introduce yourself, and please, okay, it's well shared. Okay, thank you, Dr. Haus for the introduction. So, hello, professors. Hello,
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everyone. I'm Mustafa Moro Ayati, a sixth year and final year medical student at the University of Baghdad, College of Medicine. Today, I'm really honored to to give this. presentation in the
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SNI bug dead neurosurgical meeting. And in this presentation, I will talk about my pathway in a neurosurgery as an experience from Iraq. So before me starting my presentation and talking about
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myself, my pathway in neurosurgery, let's review together the arterial supply of the brain by simple illustrations that I made using the PowerPoint designing tools to make simplified ideas to reach
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from the very basic anatomy. We got the blood from the heart. We have the aortic arch. We have on the right side the brachiocephalic trunk. We have two subclavian arteries, two common cartoed
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arteries by forcage and two the internal cartoed arteries, which runs inside the skull to supply the brain and the eye. And we have two external cartoed arteries, which runs outside the skull to
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supply the hidden structures. And here we have the anterior contribution from the ICA, the circle of fullest, into two middle cerebral arteries, and two anterior cerebral arteries. That was
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regarding the anterior cerebral artery. Regarding the posterior circulation, we have two vertebral arteries arising from the two subclavian arteries, the united front of the bones to form the
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basilar artery, which contributes to the two posterior cerebral arteries. So that was the basic anatomy to supply from the heart to the brain. Now let's focus, get another view on the right side.
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We will talk more about the external carted artery. We have the brachiocephalic trying, becoming carted, this is the ECA, with its two terminal divisions into the maxillary artery, which runs
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deep in the face, and the superficial temporal artery, which is two terminal divisions, the frontal division or branch, and the parietal division or branch. And here we can notice the close
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proximity and appreciate that proximity of the MCA, which is a branch of the ICA, and the SDA, which is a branch of the ECA. So let's dive more deep into a more complicated or advanced topic in
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your surgery, which is the cerebral revascularization So let's go. imagine, for example, you have a pathology on the right side here, this is the ICA, for example, a tumor or aneurysmaphytic
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liping or anything obstructing the
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blood flow distally, so instead of having the blood flows like this in the yellow arrows, we can benefit from the flow into from the ECA, this is the official temporal artery. And for example,
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directly suture the SDA into the MCA, if that's extra cranial and fratranial bypass to shun the blood to areas distal to the non-functioning or obstructed ICA. For example, this here is another
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illustration example in the
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cerebral aneurysm, this is the aneurysm after clipping proximally and distally, so how can the blood flows distally. And instead of the radar rows, we can make an artificial pathway, which is
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either a radial artery graft or a saphenous vani graft, for example, to shine the blood distillatory vascularized area. So this is the principle of the bypass in a simplified way. I started
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studying the advanced neurosurgical anatomy. I studied the second chapter, which is the suppressantorial arteries in the rotary cranial anatomy and surgical approaches. I studied the basic
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principles of our dress supply of the brain, suppressantorial arteries, their courses, their branches, divisions. There are even little details about them I also skimmed it through the cinnamon
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bypasses by Michael Laoten and the Coleratlas of Cereberemascolarization by Dr. Robert Spizzler. I didn't just read, for example, wrote on micro surgical anatomy. I did my own summary by
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handwriting on a paper with a pencil. I summarized the whole chapter in about 100 paper and make them as a bullet points and highlight some of the things that I may review later.
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a high yield point for me. After that, I integrated that theoretical knowledge I gained through studying and applied it to a real surgical procedure in the neurosurgical teaching hospital in Baghdad.
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The patient was a young age female presented with multiple attacks of strokes. She was diagnosed as having more and more disease. So the decision here was to make a bypass.
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And here are some of the CT imaging and geography. And here's the intraoperative images on the monitor that was put outside the surgical operation room on the lobby so that the students and residents
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can observe the surgery step by step. How to bypass doing the bypass. And here's a picture of us. This is me, Summerhose and
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other colleagues also during the surgery. Well after that, all of this integrated aimed by knowledge. So was surgery. I gained the theoretical knowledge. I did a life webinar on neurosurgical TV.
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And that was my really first like webinar, life webinar being recorded in public as an international level. It was the last day in 2022, 31
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December. It's topics was
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cerebral rivascularization, extracurranial intracranial and intracranial intracranial bypasses. So now let's get started to my journey. How I start? It started in 2019 when I met Dr. Samur Hose.
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It was a great chance and a great honor to meet him. He offered a special interest in teaching us. He made us
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dive through the neurosurgical field, exposed us to neurosurgery in more details, especially in our country.
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And then I attended the fifth It was held also on Baghdad in a neurosurgical teaching hospital in 2019, 2022. And here is me holding the Kataveric sheep head after doing a korean atomic procedure,
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which I will show the steps later. And here are my colleagues also in
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that mentorship. And during that mentorship, I really gave my first oral presentation in public. I was just about the third grade. I just finished the neuro-anatomy It was a really not good
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experience at all. Okay,
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here's the host lab, saying that more lab simulation, less brain complications. One of the things we really practiced and which was really interesting for us, doing simple procedures, simulating
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a real OR on simple stuff like egg. Here we are drilling egg shell without penetrating it, without buffrating it. as simulation to how delicate can we go without hitting the vital structures such
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as the brain in the OR. And here's me drawing my name on
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the eggshell. Here's also me drawing on a real bone, get a very good one of a sheep using this surgical loop. And here are some of the steps that doing a cata-veric craniatonic procedure on
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sheepheads, extracting the brain with its intact dura mutta. So there was a mission that you should not hit the dura while even in the animal. Okay, and the dura was cut. Okay, now this is the
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brain that is looked underneath. Integrated all that surgical skills, practical skills. I went to the OR and the first case I watched, it was an emergency case. Patient present with the RTA,
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road traffic accident. He had an extradiol haematoma after doing craniatomy, experienced on a cut-off, very cheap, I saw an observed surgeon doing it on a real human and evacuation of
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extraterrestrial hematoma.
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And this was my first time seeing a ball-style brain, you're a real human. I had also the chance and opportunity to be part of the global training project that held in also Baghdad in neurosurgical
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teaching hospital 2021 by upsurgeon psychomotor school training. They provided us with multiple
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samples that simulate the real brain approaches. So, for example, here is the taryonal approach. This is the frontal lobe, the
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parietal lobe. This is the temporal lobe. This is the salvia fissure. So, it really simulates the real human brain.
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And we practiced many things on it. For example, here's me under the microscope approaching the it's a real approach and also endoscopic approach. in the like in the CSF area underneath the brain.
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One of the things I really appreciated during my journey is that neurosurgeon tool is the radiology that the CT scan MRI of radiography and even a catheter endography all are needed to be
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well-interpretated interpreted to make a decision. So I really developed my skills in reading CT scans, native CT scans, contrast CT scan, MRI, catheter endography, MRI, MRV,
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and it was really a good appreciation that how a neurosurgeon needs this tool. Here are some pictures of me assisting in real operation and getting close to a neurosurgery procedure that's frail
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after me scrubbing in and sometimes assisting
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I practiced before that so try and get home, I did that. my first sutures, some of which are very bad, some of which are improved over time. And I also use the surgical loop doing a micro suture
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and using a very thin suture material.
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Teamwork, also one of the most important things I really appreciated and noticed. And it was a really, I think, that I cannot describe by words. It's just like a family. We all have each other's
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back We support each other. There's no superiority, even between the doctors, between the professors. They have, they deal with each other. They work in harmony in the OR. Everyone knows the
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other is a step. They are well-prepared, for example, in the OR, even the assistant, the scrub nurse. They know these steps. They are prepared the tools and they work in harmony. Even with my
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colleagues during the mentorship program, the teamwork was really an essential thing I appreciate it.
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I think no achievement would have been accomplished without that teamwork. Even just awards, maybe a support that would be enough. Also, rapport and building a relationship with patient, between
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doctor and patient relationship was really think that Dr. Sandler raised us ethically about it. And also, rapport with my colleagues and friends was really essential.
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I also have the great chance to be a course coordinator of the 6th American Neurosurgeon and Mentorship Program. It was held in 2020, neurosurgical teaching hospital back then. Well, about the
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conferences I attended, there are actually two conferences. The first one held in Dubai in 2019. It was the 7th Hemorrhate International Neurosurgical Conference. It was me first time going
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outside the country for a scientific think like a conference. I was just an attendant. I listened to international level neurosurgeons presenting their work, presenting their presentations, their
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case reports, for example, or their papers, published papers. And I was really fascinated about the international level of neurosurgeons. And then in 2022, I attended the first pan-Arab
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neurosurgical Dandy meeting. It was held in Beirut. And here is me with my colleagues as an Iraqi delegate.
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This time, I was not only an attendant for the conference I did an oral presentation, which was the first time for me doing a real oral presentation of the American University of Beirut. The topic
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was the control over superior sexual sinus injury due to metallic ceiling fat blade injury. And
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there was a top five student presentation, get a prize. And I got the second place with a 17 vote. And the first one was Zahramajit, which is my colleague also from Iraq she took me first prize.
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which I'm really proud of as both of us from Iraq. And we achieved the first and the second place that was an international conference. Me about in medical school, we take in general, in general,
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like neurology, neurosurgery, neurosciences, basics, and two modules. In the second year, we have the basic neuroscience, including anatomy, physiology, histology and biology, et cetera,
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that basic science. I took a very good credit at it, about 85. And the advanced neuroscience in the 50 grade, including neurology, neurosurgery, and neuro-adiology, I get an excellent score at
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it, which I'm really proud of. So one of the things I really like as my hobby is medical education. I really love teaching. I love exporting my knowledge. So my academic experience, I have many
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courses, including infectious disease courses, acid-based disorders, cardiology courses, fluid echoelectrolites, the vascular supply of the brain, which is entirely important to be highlighted
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here, and the celebratory vascularization.
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I have more than 70 hours of medical education, whether recorded videos online, life meetings, et cetera. About my clinical experience in neurosurgery, I have attended more than 15 operations
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different from brain tumors, spine surgeries, arterial venous malformation, and generally the neurovascular procedures. And I attended two procedures of gamma knife, and I have more than seven
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calls in the vascular unit And I attended more than six calls in the emergency room, and also more than five calls in the intensive care unit where we have the chance to practice examination and
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follow-up of patients who are really comatose, for example, we check their plasma coma scale, we check their flight cells regularly and how we take care of such patients.
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One of the things I really understand, lately is the exploitation concept. After me getting all the knowledge I talked about previously in this presentation, me studying books, attending
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operations, go to conferences, getting, gathering all the knowledge for myself. There is a concept of exploitation, how I export my knowledge. I will, there are many different ways I did that.
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For example, I have a research gate account and I have a YouTube channel with many playlists, one of the playlists is
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the, it's termed as the second chapter of Roton, the Supraet internal R3 series. I talk briefly about each of the vessels, the ICA, the MCA, the PCA, and communicating arteries and the cerebral
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angiography also. In a few minutes, demonstrating the basic levels. I have participated in two books as a chapter author, the Pineal Neurosurgery and the Neuro-Trauma and multiple choice questions
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I have a. also assisted in three published articles and contributed to them. The first one is the intransisterinal papa variant toxicity in anterior circulation and urozemic liping. A surgery, it
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was a literature review. It was published in the Romanian neurosurgery in 2020. And the second one was a surgical control of a superior sashtal
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sinus injury due to metallic ceiling found blade injury, which I presented in Beirut on the on the oral presentation It was published in the Muslim sorry medical journal. And the later on it was
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letter to editor, the Cadaver free simulation training in micros neurosurgery and experience from Iraq, as I showed you the head of our experience at the beginning of the presentation. It was also
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published in 2021
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in the world in neurosurgery journal.
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Last but not least, there are many attendance of scientific activities I've started And during my med school started from may be the first year I attended some workshops, but the real work started
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in your surgery since I began and find my interest since 2019. You can notice here I want to highlight that every year there is a new accomplishment, new achievements, new attendance of scientific
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activity. For example, 2019, 2020, 2021, 2022, and hopefully, 2023, there would be a new attendance of scientific activity.
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So how do I see neurosurgery in general? Well, I see a neurosurgeon, just like a goalkeeper in the penalty shots, that everyone knows that it would be a goal, but if the goalkeeper casts it and
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saves the goal, he'll be the hero in the story. So that's just my imagination about how I
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see it.
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My current position, I am the president of the Walter Identity Neurosurgical Club Iraq, and I was one of the founding members and chief scientific officer of that
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club. Lost, but not pleased, I want to thank Dr. Samrith Hose. for all this support. And he really raised me scientifically in a neurosurgery and ethically how to deal with patients and
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colleagues. He has enormous support. And this is me picture with Dr. Summerhose after giving me some bruises on the shoulder so that what doesn't kill you makes you stronger.
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And thank you all for your listening. I hope you enjoyed my presentation.
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Yes, we did. It was very good.
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I enjoyed that. Thank you. Yes.
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Thank you. Thank you, most of
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all. I think I should highlight that most of around. Now, in the first positions, like a grade wise in the medical college And this is new for the Iraq in
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your surgery that people were in the highest grade in the medical college. Thinking of your surgery. This is not a common trend. Usually, if you have very good marks in the medical college, you
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are. You can choose any branch. Okay. And this is like a different setting than us And you guys, it's the opposite. And you guys, if you want to know your surgery, you should have very high
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marks and Eric, at least. It's, it's completely the opposite. You don't need any marks. If you want to go to neurosurgery because the people not interested in neurosurgery, usually people with
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high grade go to branches like, I don't know, ophthalmology, or ology, radiology, that's the branches. And people with the lowest scores, like me, go to the neurosurgery. So I think, I think
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Alim Ahmed is one of the first just to graduate, he's one of our team. Aktham is one of our team, one of the highest score all over Iraq. Most of us, one is also one of the highest score
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on graduation. And now we have most of our, I think he's the first in the score now in the, in the, back that culture of medicine So this is very new culture, very new concept. And I think they
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will inspire the next generation. we don't know people with high school and neurosurgery yet. They will be the first with high school to enter neurosurgery in Iraq. That's one point to say because
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this is related to the background and what you give today, most of all, I like it. And I think this is like a roadmap for many people on how to do things in the right way and how to make
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the most of everything. I think it's very good. If we combine all what you say with you being one of the highest score in the college already, I think this is a very, very nice model for people.
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And
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this is number one, number two, something I should share here that when we do the, CTA think, when you say about the CTA, you think you remember the
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resident and Eric when you are there. So can you share this?
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My experience when there were residents in the hospital and you examined them about the radiological in the skill lab, you took them overlap, you asked them many questions about
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the images And they were really confused about them, even the basic things. And then you asked me later after them and tell me what's this, for example, the spot diagnosed, for example, I
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answered you. Some of these slides, I really haven't seen them before, it was my first time, but I got them, I could get them correct And then you tell the resident that I'm a resident too, but
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at the end, you surprised them that I was just a third year medical student. knowing, having acknowledged in their ideological skills.
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Yeah, so it was really a moment of proud prize. So when we are teaching
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the new interns about the neurobiology, I usually invite most of her to be there in the back. And people thinking through his answers, like he's maybe a senior resident And at the end, they
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discover that he is a third year medical student. And
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it's a nice experience when he's a proud of himself. We are all proud of him. And it's a huge message about focusing. I think you share with us the vascular thing that you already interested in
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before me. And I think, yeah, I should congratulate you for
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your achievement until now. And we will wait. graduation to come back again and work with the team more thoroughly. Thank you, Mustafa. Ahmed, yes?
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Hello. Actually, Mustafa is one of my best friends and I didn't knew about her achievement. His achievement until now and I'm very amazed by him. I'm really proud He didn't tell me.
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Many of his achievements, I knew it here and I'm amazed
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and I'm congratulating him. Because he's very shy, but that's the point. He's very, very shy. He came with China's. Yes, Dr. Luan. Yeah, I congratulate Mustafa as well, very good at the
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presentation And I will say, taking something of your last slide, of your slide, of the penalty, By the way, my team in Argentina is a river plate. And the player who is kicking that penalty
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kick is from river.
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So that I will forget that.
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It's river, that's river. That's it, let's tell you a monumental, and I don't know who is the guy who had the lack of stopping that penalty kick But now, being serious in the analogy is this. We
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talk about ACA aneurysm, or we talk about whatever the pathology. And I think that it's worth studying, what is the patient who has an ACA aneurysm, or a middle-cerevera laboratory aneurysm, or
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what we know about the patient who has the syringomyelia, what do we know about patients who have syringomyelia, Not what do we know about this specific individual who happens to be that the father
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of three children? No, no, no, no. What's the understanding of what happens, how the patients with ACA percents? And this, both again to your analogy of the goal keeper. In the World Cup in
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2006 in Germany, Argentina and Germany tied one one one And they went to the penalty kids. And the penalty kids, Germany beat Argentina and of course was a period victory because Italy was waiting
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for them and Italy will have beaten any of them. Italy won that the championship got here. But the, the, the, the point is, the Argentinian goal keeper was very good, was a very good
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neurosurgeon The German Gorteber also was a very good neurosurgeon. But why Germany beat Argentina is because they studied the Argentinian players and they knew beforehand to which side they will
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keep. So they knew that Ortega keeps to the right. So before Ortega started running, the German gold goalkeeper was leaning to the right or to the right. I mean, we are on the other side, no?
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What I mean with this is when you, it is important to the study say, okay, I have a patient who has an aneurysm of ASEAN. I'm not at the vascular surgeon. I don't know very much about those
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things. But okay, what else do we know about what happens to those patients? What other information we can call it? And that information is there in your medical records, in the medical records
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of your hospital. Anybody can go and see anybody. I mean, I am inspiring, if possible You go and allude, I mean. patients with ACA aneurysm, what happened to the master? How did they present?
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When was the time of the
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time of the presentation between the treatment, 24 hours, 72 hours, seven weeks? What do we know? So this goes again to your wonderful, most often the wonderful presentation and use that slide,
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which is very good I mean, nobody knows it was real, I know it was real, but because that's my thing. But
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at the point is, again, the good goalkeeper as the good neurosurgeon, he doesn't stand in front of the kicker and says, okay, let's see what happens, no? And I go to the left and I was lucky.
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I go to the right, I was lucky. No, that the good goalkeeper knows, okay, this guy has an ACI arterionism I have to be very very careful because In the post-op in day seven, they develop
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diabetes incipidus. For example, that's the possibility. So what can we know about the patients per se, or the biology of the patient based on that disease, though?
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Okay, Professor, thank you very much. No, no, thank you.
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Thank you. Thank you, Mr. Faufau.
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Hope you enjoy these presentations.
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30:53
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31:01
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