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SNI and SNI Digital Baghdad Neurosurgery Online Meeting, held on October
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23, 2022, the meeting originator and coordinator with Samir Hawes, universities of Baghdad and Cincinnati Iraqi Neurooncology, Part 3, Update on Neurooncology
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Worldwide, 60 Minutes LD
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The speaker will discuss updates on neuro-oncology. The speaker is Dr. Terah Patel, Department of Neurosurgery University of Texas Southwestern Medical Center. Now we have
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Dr. Toral Patel,
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she's assistant professor in UT Southwestern, she's a very eminent neuro-oncologist and he would achievement already, welcome Dr. Patiel for this meeting and we have the honor to have you here and
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we already have many comments from based on your experience. We are happy with that and now you have the full stage, you are welcome. Perfect, it's an honor to be invited to speak to the group.
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Thank you for the invitation As Summer said, I'm a neurosurgical oncologist. at UT Southwestern, I've been here for about eight years. And my practice is primarily intraaxial, elephant location
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tumors. Although I do some skull-based and extracial tumor work as well. And today, I wanted to talk about - I was asked to talk about new emerging techniques in neurosurgical oncology. And so I'd
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like to discuss a sleep motor mapping for a resection of intraaxial brain tumors. It may be particularly relevant with Dr. Mati's last case presentation of that insular glioma. I think as a whole
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in the field in the last 10 years, there's been a significant movement towards more and more awake craniotomies. And although for the surgeon, that provides a lot of comfort in terms of minute by
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minute real time feedback about the neurologic status of your patient, it's not always feasible to do an awake craniotomy on everybody, either for patient discomfort and a seizure discomfort set up,
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it's a big undertaking And so we, I do personally think we need to think about creative ways.
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to do some asleep mapping, particularly for the motor system so that we don't feel
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too scared about all hairy elephant location tumors and don't always have to think that if it can't be done awake, it can't be done at all. And so, you know, as we were discussing earlier in the
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days program, the basic goal of brain tumor surgery is to maximize the extent of resection, minimizing neural logic morbidity, the so-called oncofunctional balance. And we know that there is an
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increasing number of studies now that demonstrate that prognosis for patients with malignant brain tumors specifically is directly related to the center resection and performance status, KPS. And so,
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these papers, I think, are the best pieces of evidence in favor of aggressive surgical reflections for low-grade gliomas So, I just. years ago, get forward, but 20 years ago,
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it was not clear what to do with low grade gliomas at presentation. And so for many centers, there was a strategy of washful waiting, and you had a low grade glioma patient, they didn't have any
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neurologic deficits, perhaps they presented with the first time seizure, they're placed on an anti-seizure medication and otherwise fine and told to just follow up with imaging. And then once the
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tumor transformed into a high grade tumor, then we would operate then. And that was a readily accepted strategy for years and years and years until this very eloquent, elegant paper came out in
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JAMA in 2012 out of Jacolos Group in Scandinavia. And this paper used the strength of a nationalized healthcare system in a Scandinavian country. And in that country, if you lived in the northern
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half of the country, you had a hospital that you are referred to that have a strategy of what you can do. waiting, so maybe a biopsy, but otherwise observation. And if you lived in the southern
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half of the country, then you were referred to a hospital that had more aggressive surgical resection as the upfront treatment. And so although there's not a lot of randomized control trials and
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neurosurgery, particularly with respect to surgical treatments, this paper was the best evidence of something like that for low-grade gliomas. And it turned out that the patients who were in the
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resection preferred early upfront aggressive surgical intervention hospital did much better, much better in terms of years of added survival compared to biopsy and watchful waiting. And this is the
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first piece of very high quality evidence suggesting that upfront aggressive resection at time of diagnosis of a low-grade glioma was the appropriate strategy provided that the patient is willing to
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do it. And then this same group published in 2017 in the Annals of Oncology their follow-up data with five more years of of data and the solid green line is the hospital and which resection was
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preferred early and the solid orange line is the hospital which biopsy is preferred early. And so you can see that their curves, their capamira curves continue to separate as the years go on. And
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so clearly, if you can do a safer section and is better for these patients to do it upfront. And then the further published in JAMONcology in 2020, this, an analogous set of data, but not quite
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as elegant a randomization because it's harder. Probably. Particularly in the state, but published a piece of data that looked at high-grade gliomas and extenderversection and looked to answer the
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question, in high-grade gliomas, should we be trying to resect just the enhancing disease? Should we resect the enhancing disease and the non-enhancing disease? Is there a particular subtype of
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high-grade gliomas that particularly respond to. aggressive surgical management. And what Dr. Berger's retrospective review of many hundreds of patients showed was that in patients under the age of
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65 with a bleoblastoma, resection of both the contrast enhancing and non-contrast enhancing disease, if it can be safely achieved from first a survival benefit. But for patients over the age of 65,
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it does not. And this is very different than what I was taught in training, which wasn't that long as though 15 years ago or so, in which it was clear that the only surgical target for high-grade
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glioma patient was the enhancing disease. And the flare did not matter at all. And so, this is these three papers, the huge Apollo papers, and then this Dr. Berker paper in the last five years
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has really pushed the glioma field towards more is more is more is more is more, and so the more you can take out the better. And if you just look at the papers that are published, there are the
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number of publications favoring more aggressive surgical resections versus those that grossed surgery doesn't have a benefit are also widely disparate as the years go on. But as we all know and it's
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Dr. Mottie just nice. Can you go back to this slide before that? Yeah. I don't understand that slide. It favors more extensive resection and blue. And the red line says what? No significant
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benefit? Right. That's correct So no significant. So they chose two different results. No, this is just publications in the literature that say blue we vote for more aggressive surgical
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resections and red we think that they don't do anything. This is a sampling of how many publications in the year 2005, for example, favored extensive surgical resection versus those manuscripts
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that came out and said surgeries of no benefit and so as the years go on more and more papers say that surgery is a benefit, maximal center resection is a benefit, and fewer and fewer papers where
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that line really pattoes would say something like a biopsy alone is the same as a 99 resection. So I'm still confused. The red line,
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papers that were published that showed that
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there was a limited resection done and
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this doesn't have to do with it. It's just a number of participating stub publications over a period of time. Correct. It's almost a one set show. So what is no significant benefit for resection?
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What does that mean? So that would be like a paper that said, we had a cohort that had 95 of resection. We had a cohort that had a biopsy and both cohorts did the same, which I don't think anyone
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who's doing a lot would believe, but in 2006 you could still find some publications that would say something like that. Many more that would say something the opposite. But in 1992 or 93 the amount
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of publications that would vote one way versus voting the other way based on their data were quite similar. And so in the last 15 years there's been more and more people who believe through their
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data or otherwise that extent of reception matters.
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So, okay, go ahead. This slide really is only about publications. It's not about the science. That's right. The prior three manuscripts, one in JAMA Oncology, channels of oncology and JAMA are
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all the science. Okay, sorry. No. And so as Dr. Mottie said, you know, lesions like that one in the Enslur glioma in
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the Enslur cortex and Enslur lobe and lesions like this that are what we would consider to be the primary hand motor cortex area. can be difficult to reflect and difficult to give the patient or
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their family some guarantee about postoperative outcome and so motor outcome. And so although there's more and more data to suggest that maximizing et cetera resection is a benefit and I am a
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believer of that, maximizing et cetera resection while keeping patients full can be difficult, particularly let's say for a lesion like this. And so what are the strategies that have been developed
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in the recent past to maximize et cetera resection? Brain mapping, brain mapping is not new. Brain mapping has occurred for decades then very elegantly for that period of time. But the use of more
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sleep motor mapping techniques is more new and then intraoperative MRI. So you can get an MRI in the middle of your surgery to ascertain where you are and should hear extent of resection and
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understand what's left and what that relationship is to critical neuroanatomy. Although that is an expensive and sort of cumbersome operation. And then there's five ALA, which has been used in
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Europe for longer than it has in America, but this is an off fluorescence compound that can be ingested orally several hours prior to surgery. And then it breaks down into a compound that can be
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visualized under B-light with the microscope and it breaks down preferentially and is absorbed preferentially within high-grade glioma tissues. And so you can differentiate tumor from normal brains
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and that technique. And so all of these things can help us to maximize the center of resection. I'm going to speak about brain mapping, a particular area of interest of mine. And so this is the
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idea that elephant, cortical and subcortical regions in the brain can be mapped using electrical stimulation. And that when the brain is stimulated, you can elicit either a motor or speech response.
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And so this can be done in different paradigms, either awake or asleep and you can map the cortex or the subcortical regions or both. The typical awake brain mapping case looks something like this,
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and then maybe we will have seen this. And this is sort of the tried and true standard. There's a patient that's usually in some sort of lateral or semi-lateral position facing an anesthesiologist.
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There may be a camera and a microphone on them to amplify their visual and speech output for the surgeon to hear. And then the surgeon is at the head of the bed and there's a little cocoon or tension
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created so that the patient is not terribly claustrophobic. And now during the course of surgery, they're going to provide motor and speech, feedback to the surgeon so that the surgeon knows
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whether or not the resection can proceed safely. And this works well, but as I said, it's a quite extensive setup and you need special neuro anesthesia. You need a very calm patient. You need a
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really perfect interpretive environment for this to not turn dangerous or uncomfortable for the patients. And so places that do hundreds of these, I think do them very well. But if you have the
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occasional motor elephant lesion and you ask your anesthesiologist to do in a weight craniotomy two or three times a year, they might be, they might look at you funny, you know? And so there's no
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paradigm for a sleep speech mapping, but for a sleep motor mapping, you can do some things that are meaningful. And so, a sleep brain mapping with respect to motor is the idea that you can use
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modern neurophysiologic monitoring to map the motor system while the patient's asleep. And the advantages are the ones that I described. You know, you can alleviate patient anxiety. They're not,
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you know, panic that they're gonna have to be awake at some point during brain surgery. You can improve the control of intangible variables in the OR. So this is like N-Tidal CO2, Manitol
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Administration, brain swelling. You have a huge insulin tumor. You try to do that awake. And the patient coughs when the ET tube or LMA comes out and has a whole brainness out of the head. And
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there's a bunch of subarachnoid hemorrhage and it's hard to do a beautiful subpial dissection and all of this kind of stuff now. And so if the patient is asleep and you don't think he needs speech
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mapping, perhaps all of that becomes a bit smoother. And then importantly, you can also decrease false positives. If you have a glioma in the superior frontal gyrus and you know that that patient
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is likely to have a supplementary motor area syndrome, an SMA syndrome perioperatively, then that patient may become hemiparatic hemiplegic in the OR from an SMA syndrome that they will fully
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recover from over the coming days to weeks. But if they are plegic in the OR, it is the rare surgeon who can take that patient who's plegic and say, oh, it must be an SMA syndrome, I'm going to
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keep going, it will be fine. I mean, it's hard to know that that's truly a false positive, especially when you're getting that real-time feedback in the OR and your patient's no longer moving.
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And then obviously, for pediatric patients and operative time issues, you're doing the whole thing see that they're much easier. And so we looked at our data for a sleep motor mapping at
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Southwestern over the course of four years. We had 55 patients. This is an early part of my practice. Meeting age was in the 40s. There's a slight female predominance. And I selected patients
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based on the proximity of the tumor either the cortical or sub-particle motor pathways, both were included. And all patients had to have a post-operative MRI within 48 hours of surgery so that we
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could ascertain extended resection. And the operative details were that all patients were under general anesthesia with Tiva and then we monitored motor-vote potential, some out of sensory-vote
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potentials. And the way that I like to set these cases up is when the patients asleep under Tiva, you do your planotomy and then you take a one by four, one by six strip electrode and place that
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over the central sulcus and obtain a phase reversal recording. And this is done in concert with
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a neurophysiologist who has put little electrodes throughout the contralital honey body and all of the relevant muscle groups So they're getting EMG signal. and then they're sending a sensory
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stimulus from the periphery to the brain for measurement of scalp SCCPs.
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And so then I put that strip down and you get a phase reversal recording, you identify the central surface and now you know where motor and sensory are. And then you do direct cortical stimulation
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either via the strip electrode or via a monopolar or bipolar probe of the cortex to understand exactly where motor is And then I typically do that every one to five minutes depending on how close I am
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to the motor cortex vertically. And then once you're doing the resection and you want to know about sub-portable activity, then use a monopolar stimulator to map the cortical spinal tracts. And you
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use a general, excuse me, to move each use a general.
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Hey,
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use a general paradigm. Ava? Excuse me. Okay, I'm going to come in two minutes.
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I'm going to go lock myself in another room. I'm sorry, small children. And so then you use a monoclonal sub-portable simulator and you use a general paradigm that one milliamp of vertical or
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sub-portable simulation indicates one millimeter of distance away from the port of this final test. And so if I have a monoclonal simulator and I have a peri-rolandic lesion and I'm stimulating the
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white matter and I get a response at 10 milliamps, then I know that I'm at least within 10 millimeters of the port of this final test. And then I will bow that down to 5 milliamps and stimulate
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again. If I get a response, then again at 5 milliamps, I know I'm within 5 millimeters of the port of this final test. And then you can keep gating that until you know exactly how far away you are.
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And in general, I'm sure within 5 millimeters of the port of this final test, it's probably time to stop. If you didn't get a response at 5 milliamps, and you know that you're somewhere between
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five millimeters and 10 millimeters away, and you may be able to shave the tumor down a little bit more safely. The resection in my center is halted for significant decrement in the motor vote
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potentials that are greater than 50 of baseline, or if you have to use increasing stimulation requirements to achieve the same motor vote potential response. So for example, if at the beginning of
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surgery, I can use tenderly answer response vertically to get a strong motor vote potential monitoring. And then by the halfway through surgery, I need 14 or 16 milliamps. It's a warning sign that
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something is not quite good. And if it's not because of a change in anesthesia, then it may be the price because the motor system is perturbed. Or if at the same amplitude, 10 milliamps, let's
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say is an example, now my motor vote potentials are 50 of the baseline strength and I might be worried about that also So this is our first 55 cases using this. we had primarily, about half of the
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cohort was gliobostomas, many others were malignant, high-grade gliomas. And then a few meds, DNATs and
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meningioma, but primarily gliomas and primarily high-grade and gliobocations were relatively distributed within the brain, many frontal parietal lesions as you would expect in the periromantic
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region. But many also were gliomas in the non-dominant hemisphere which I do not think that we needed an speech mapping. I chose to do a sleep with this motor mapping technique. And these are some
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representative images of lesions that I resected. You think this is a sleep-motor mapping paradigm? And so this is a sub-inspiral lesion that I did a sleep. This was a lesion in the Cucurophenol
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gyrus that you would presume that patients would have a supplementary motor area, a deficit in the perioperative period. And again, if that happened to you while you were doing the case away, you
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might be a little bit. shared and and stop short, which is a pair of romantic renal cell carcinoma metastasis with recurrence after radio surgery. And then this is a large high-grade phelimic
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glioma. Diffuse to find gliomas, it turned out an HDK 27M mutated region, all drug-musing and state motor mapping. Our institutional series, our mean extent of resection of 92, we had grocery
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resection rate of 58. And there's a significant last year that you would expect because you're using that data from the state motor mapping is say maybe a 98 resection or a 90 resection is the right
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balance for this patient. And so although the overall extent of resection is high, the data from the interoperative mapping informs not going for broke on every single patient. I do not have any
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patients who have been cooperative seizures and this was surprising but I think this because I primarily use a monopolar stimulation paradigm even for cortical mapping. And so the traditional
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portable mapping scenarios have used bipolar or ogemon stimulation and you get a more precise localization with a bipolar probe, but the pulse strain that's used is also more epileptic generation.
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So higher rate of seizures, but more precise mapping. And so it's a trade-off and you should decide patient activation, which you think is most important, but I use a monopolar probe and that is
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less seizure provoking. Can you leave? Can you leave that slide up for a minute? Yeah. No, can you go back to that? Yeah, it doesn't mean it auto-worthiness. So what you're saying is that the
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extent, mean extent of resection using your approach
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was 92, 83, right? That's right.
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But the gross total removal rate, that's with all the tumors, I don't understand the difference there is 58. Right so so that would imply that there are many patients in this cohort that had
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virtual resection rate is black or white and so it's either 100 or not 100 and so there's many patients in this cohort that had its center perception somewhere between 95 and 98 that would not have
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been included as a gross total resection so it decreases that number but it's still a relatively high volume of of resection and so the mean is much higher than the gross total because it goes to the
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binary.
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I'm not sure I still understand it so if you're going and you're working on a lesion
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and you're able to remove 90 or 90 of the lesion
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are you going to classify that as a gross total resection or not? No, only if it's 100.
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How do you know it's 100?
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based on the post chopper to them or mine.
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within 40. Okay, we'll come to that. The next thing is, I got that. Next one is
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22 of the patients had a pre-operative deficit. That's right.
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Of those, about 40 improved.
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And 10 got worse. That's right Mm-hmm.
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So what we've done is achieved a high extent of resection.
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What is the outcome of these people? Right, I'm getting to that, Dr. Alston. So
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10 of patients had new or worse than deficits immediately following surgery. And if you follow that up to three months, follow up, 3 of patients five percent of the cohort. how to new persistent
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motor deficits. So approximately 5 of the patients in this model will have new real motor deficits. And that's what I quote patients when I counsel them in the office that this is a technique that
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we can use and eliminate some of the await cleanotomy issues, but not all of them. Oh, wait a minute, wait a minute. You guys say 9 of the patients, one out of every 10, they had new or worse
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deficits after surgery and at three months, three patients had new deficits.
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Do that mean that the other 90 had no
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deficits if you follow them long term? That doesn't make sense.
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So this day - The tumor's good. Is the tumor gonna grow or not grow? That's what I wanna know what would happen. It's all this worth it. Is that the question?
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Well, yes, I mean, I would think it is because extent of resection will inform long-term prognosis in terms of years of life. But when the GBM recurs and the adjacent motor cortex, are they going
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to get weak again? Yes, for sure they are. But the question here in terms of does this technique, does this surgical technique work and results in safe outcomes, I think it's also a yes.
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Well, you're going to show some long-term results, aren't you? Well, I'm showing results of the surgery. I'm not going to show long-term results for every tumor type because, again, this is a
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technical paper about does the sleep motor matching results in safe motor outcomes, but not whether because 20 of the patients have GBN, some have DNET, some have ependomomas, some have METS, and
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so they're all going to have very different two and five-year natural histories.
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But this is about this technique being a safe operative approach.
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Okay, why don't you finish so that if you look at the literature review for a sleep motor mapping, then we did a prison analysis and look through hundreds of papers looking at mapping techniques and
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ultimately resulted in 13 that we felt a little more high quality papers between over 30 years approximately and there are 252 patients with the sleep motor mapping techniques described in the
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literature, and the extent of resection rates described in the literature vary from 80 to 92 And the personal resection rates vary from 65 to 89,
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depending on what paper you read and the rate of permanent motor deficit ascribes to the surgery itself varies from 0 to 21. Oh, from my experience, believable numbers
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Sort of take on conclusions about intraoperative stimulation that thing is that is an inclusive center for section. If you look in the literature and also our cohort versus our historical rates,
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it's greater than 75 in basically all series, including our own with mapping versus 58 historically without mapping because people get nervous and they stop short Try not to harm the patients. It
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decreases the rate of postoperative motor deficits versus versus not mapping, and it can be performed very effectively and easily under general anesthesia As we talked about on the prior two slides,
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the grocery section lags behind a center of a section because there's often a small amount of tumor that you very intentionally leave behind and motor eloquent regions and so virtual section, which
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is a binary output number will always be lower than the center of the section. If you say that grocery section is 100 which is the metric that I use And so these were some of the cases that we use
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with this technique this first case is very interesting. lesion is actually an appendomoma. It was resected 40 years previously in Lebanon, and then the patient moved to America later, and he had
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this recurrence in his 60s, his initial resection was when he was in his 20s. And so this was removed and despite the fact that it looked like he should have a significant new motor deficit in his
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right-hand following surgery, his motor function in fact improved because this was primarily compressive of his hand cortex because it was an appendomoma. And so you can see that that area actually
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looks fuller after surgery somewhat surprisingly. But I think that if you didn't have a motor mapping technique and you just saw this, you might be reluctant to take that patient to the OR for more
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than a biopsy. But to have positive motor signals throughout surgery is a very affirming thing for the surgeon gives you some courage to keep going And this is a hemorrhagic nail felt carcinoma in
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the passage. this in the motor cortex. And although there's no real technical challenge here, this is as close to the cortical surface, I use an ultrasound
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to make the portosectomy. I also wanted to make the portosectomy over a part of the cortex that didn't have any active motor sites. And so a sleep motor mapping was very helpful to plan the
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portosectomy between that and ultrasound so that you have the shortest trajectory, but also the electrographically most silent trajectory.
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And I wrote some additional updates in nurse surgical oncology in the interest of time. I don't think we have enough time to go through all of these, but I will say that these are some of the things
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that I've been incorporating into my practice more in the last five to 10 years. Laser interstitial thermal therapy is a laser-based therapy that's used I think has particular promise for nurse
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surgical oncologists for regrowing lesions after radio surgery. likely has a cohort of these patients that is hard to know exactly what to do too. You don't know if they have radiation in the
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process or if they have progressive real tumor. And
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you may not feel comfortable doing a repeat, reduce surgery session with them. And so, RIT can be a nice therapy for that. Deep seated or previously, you know, termed unresectable gliomas,
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butterfly gliomas, phalamic gliomas, more and more people are using RIT for those. Gamatyl is a brachytherapy in which cesium seeds are
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implanted into something that's basically a collagen matrix, like dourgion. And there's an increasing experience with that in the states and likely will be
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transferred to other places soon as well. But Gamatyl is this idea of being still in a brachytherapy along the recession cavity at the time of surgery. And so there's some anecdotal experience in
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neurooncology advances in the last few months for using this in recurrent hybrid gliomas. There's ongoing clinical trial looking at this upfront treatment of the resection cavity for metastases that
31:43
are surgically resected, as opposed to doing post-operative SRS to the cavity, which theory has a benefit and is well-published. By the LA, as I said, it was useful for discriminating hybrid
31:55
glioma tissue for normal brains. I think I don't think that that's usually that difficult hybrid glioma tissue looks pretty different than normal brain, where I think that this could have
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significant use as low-grade gliomas. Right now, the signal-to-noise ratio for five LA and low-grade glioma tissue versus normal brain is not sufficiently high, but the company and the
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investigators are working on ways to amplify that signal. And then the new action on SRS is the idea of giving radio surgery to metastases that you plan to surgically resect before you remove them.
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And this is in efforts to decrease the incidence of post-operative leftamininatal disease, which is clearly increasing as cancer patients and brain metastasis patients live longer. And so you would
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give new adjuvant SRS, gamma nides, radium surgery, vernacular rubber system you use to the metastasis and then take them to surgery in the next one to seven days. And then the idea is that every
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cell that is
32:54
in the tumor has already received a lethal dose of radiotherapy And so if there is some microscopic spillage when you remove the tumor because either you can't take it out on block or because you take
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it out on block, but there's still some microscopic spillage. And hopefully those cells will have received a lethal dose of radiotherapy and the incidence of retinal disease will be decreased. And
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then lastly, next-generation sequencing, which we touched out
33:23
in Dr. Meneer's lecture about Praneer Franciomas, it has shown promise in several. Um, brain tumor states in which there are clearly mutations that can be targeted with medical therapies. I don't
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think it's the end all be all. And I think that it's hard to imagine, but that's going to be the answer from originally be almost I have so many mutations. But for some for some tumors that really
33:44
have a driver mutation or two driver mutations. This might be a part of the answer and decrease morbidity Can
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you leave the last side? Can you leave the last slide up for me? Okay. Can we ask some questions, Sam?
34:02
Yes, sir. First of all, Dr. Patel, I think really a
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very nice summary of what's going on in the field of oncology. I'm going to ask you some questions I want you to take them personally, but I just, I started working in this field in 1962.
34:25
who saw the patient who was treated with intercorout and methatrixate, that's the first or the chemotherapy and developed a brain tumor model. The NIH used to screen BCNU
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and CCNU and then wrote chapters on this. So I ended work on the blood-brain barrier.
34:49
There's, I really am sorry about this, but there's a paper that was published, you might know, was published in 1940
34:57
in the journal Brain by Dr. H. J. Shear, S-C-H-E-R-E-R. Are you familiar with that paper? I am. And in that paper, he takes a series of 100 or so patients with different kinds of brain tumors.
35:17
Any sections of brain from multiple sections from one end to the other, right?
35:25
In the glioblastoma category, he found that
35:29
about 30 percent of them would be localized, and the other 70 percent would be diffuse. Yes. Is that correct? And even diffuse to the point where they crossed the corpus callosum to the other side
35:42
of the brain. Oh, yes. Dr. Bucey, Paul Bucey, who founded Surgical Neurology International, was a very famous neurosurgeon in Northwestern, very controversial He had done a man and he did a
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hemispherectomy to
36:02
remove a gliable astoma. And he wrote an article, he was very honest, the man came back to curse me
36:06
because it recurred in the other side.
36:11
And the answer is in Dr. Shearer's paper. Again, I'll say for the students who want to look that up, it's in brain It's March 1940, Shearer, S-C-H-E-R-E-R. It's an outstanding paper. I wrote a
36:27
chapter in textbook based on that. And so what he says is this tumor is basically incurable, except for perhaps a selected portion. And we don't know which portion that is. If you look at
36:42
glioblastoma, isn't that correct? I don't think any of them are curable. Okay, I understand that's an admission. Okay, I don't take it personally, but okay, that's very important. And so we
36:55
started out and we would take what we visually could see at surgery. It was nowhere as good as your
37:05
resectioned using cortical stimulation and so forth and so on. So you can do much better than we do.
37:14
And there was a paper published by the doctor who was head of neurosurgery at MD Anderson in Texas, okay.
37:24
Yes, and what he showed is if you had this in a large series of patients, that's a paper that's quoted throughout neurosurgery. The more tumor you remove,
37:37
the longer will be the survival, right?
37:42
And actually, if you add it up, it turned out to be two months.
37:47
That was the average length of survival he would add. And this is a disease that has an average mortality of 90 within two years or 95 and 50 in the first year. So neurosurgeons are dealing with
38:05
this very complex disease. Then people developed some kinds of agents that imaged the tumor. That's where the 5A LA came from. And we used to work on fluency.
38:18
which would light up when you put ultraviolet light in the tumor bed and you take out what's, what was shining under ultraviolet light and the five ALA is just another iteration of that. The answer
38:28
is neither works because of the fact that the tumor is infiltrative into the other hemispheres. And from Dr. Shear's work, it's not only into one gyro, which sits into many gyroishes or gyroi.
38:42
You agree with that Okay, so now we have Dr. Berger who comes and he says, I don't like this. I'd like to do surgery. He worked with Dr. Ojumman, who is a seizure specialist and he went in and
38:57
he stimulated the brain and tried to say, I'm gonna do a better resection because I'm stimulating and I'm not gonna cause a deficit. And in his publications, he says he's got 3 of the patients who
39:09
have a deficit after surgery
39:14
The question is that I asked you. and I ask him, is how long do your patients live?
39:22
I'm not getting that answer. And the question is if they live, and my guess is if in 70 of the tumor, 70 of the
39:31
patients, you can't see the tumor. You can't image the tumor. It's gonna stay there. That's gonna recur. And if you look at the science, you have to have a log 10 to the 11th log of cells is a
39:48
hundred gram of cells. If you do a surgical ANOVA, you reduce it by two logs that should now attend out 10 to nine. Give them radiation therapy, you reduce it by another log. You know, you're 10
39:59
to the eighth. You give them chemotherapy, you got another log, it's 10 to the seven. I still got over a million cells. Oh yeah. And it's gonna regrow. So what happened, what we're only, What
40:11
we're doing here is providing a patient
40:17
temporary palliation from incurable disease. Is that true? Oh, of course. Of course, I don't think anyone would argue that or I wouldn't argue that. No, they do argue that. They do argue that.
40:30
'Cause I find you're trying some, you don't and I appreciate it and I appreciate what you're saying. But I want everybody to understand what the total perspective is here. So now we've made some
40:43
gains And if we use a cortical electrodes in the stimulation and you're showing them with a weight and sleep to surgery, and you can remove more. Question is, if I'm the patient and I've been there,
40:57
if I'm the patient and I'm gonna go through all this for two months more of my life, do I wanna do it?
41:07
That's what Dr. Hadi was saying when he talked. That's what we talked after that about, Do we do the same thing for everybody?
41:22
Yeah, you have to ask the patient. So I understand that, I've been a patient, okay?
41:25
And I've been doing a doctor, I've been with a randomized controlled study for
41:30
bladder cancer, the tumor went away for a while, it came back and then I had choices of well, I could do a variety of things, which include more chemotherapy or chemotherapy, which I had a 60
41:43
chance of overcoming. Or I could do a total cystectomy, totally remove everything
41:51
and I chose the latter. Why? Because I didn't want to be in the diminishing statistics. We can't do that in our surgery. Dr. Bucey tried, he failed and he wrote a paper honestly admitting it
42:05
because it's an infiltrative disease. And I think, you're right. I think what we need to do is the patient needs to know honestly from the doctor what I can do to help you. If you want more time,
42:18
I can try to give you more time. I have a pretty good success rate with this, but I can't stop the tumor from coming. Now, they're working on immunotherapy and Linda Liao has some patients who
42:31
last up to five years, but it's still a deadly disease. You disagree with anything I said? No. Okay. Okay. So I just said, I didn't say that to to make it personal, but what I want people to I
42:47
want people to understand is there are surgeons out there who are promoting a procedure like this. I'm not sure they're telling everybody what you're telling your patients.
42:60
And that is that we're still humans. We don't know everything about this disease. I can do the very best I can to help you. just like Dr. Manir was doing with cranial friend geomas. And he showed
43:13
us you can get into trouble with that, which I'm very honest. And
43:20
Dr. Matak showed that in some of his patients.
43:24
So what we're doing is trying to do the very best we can with something that is I've been a challenge for at least me in neurosurgery for 60 years. And are we further along than we were to some
43:38
degree, yes. In Medell, Medell, the blastoma, we're way far along. We've gotten a genetic definitions of differences you were beginning to talk about that here and people are doing that, but
43:49
it's not commonly available. So the question is, what can I do for you as a neurosurgeon? I'm not God, I can do the best I can do.
43:60
And that's what Jorge was saying when I don't want to send a patient back to Peru who's paralyzed Nobody wins.
44:11
So I don't want you to think it personally, it's not a criticism. But my point is to, I've been in neurosurgery a lot longer than you have. To put this in the perspective of history, put it in
44:23
the perspective of a person who's had cancers. To put it in the perspective of the fact that surgery isn't uncomplicated. I've had complications,
44:36
which the surgeons didn't want to admit
44:41
So I'm basically trying to interject here into something called humility as a human being and humility as a neurosurgeon. What can I do for you? I'm here to do everything I can to help you, but I
44:56
can't, unfortunately, I can't cure it. It doesn't mean I won't try. And if you want me to try, I will try. I made a practice out of taking all the cases, no neurosurgeon wanted to do
45:11
they were 100 mortality at that point. We were able to sell a large number of those patients.
45:19
So I commend you on your work, I commend you on what you've done, but I'm trying to present to the people here that there is a deeper message here that affects all of us as in our research. It
45:32
doesn't matter if you're a Baghdad, or if you're in Dallas, Texas, or if you're in UCLA and in Los Angeles, 'cause fundamentally in the end, everybody faces the same human decisions.
45:48
Okay, I apologize if I've offended you. I didn't mean to do that. I'm only trying to give the students a perspective and the young people's perspective on what Dr. Meneer has been through, what
46:02
Dr. Monty's been through, Dr. Haas has been through, or he's been through, it's
46:09
humbly to be a nurse or
46:17
Okay, thank you. I'm sorry, Summer. I'm very sorry about that. Thank you. Thank you, sir. Thank you, Dr. Patel, for this nice presentation. I think he would lessons come from. I'm
46:33
personally, I'm vascular guy. I use the monopolar for the eloquent area cavernoma, and it worked very well. Although, initially, it's, it's, For me, it's a new experience to have the face
46:50
area on different parts of the cortex. For me, oh, what's this? I didn't expect that. But yeah, it was like subcortical cavernomas and just motor cortex cavernoma, but it went very, very well.
47:05
At that time, we have only the monopolar, we use it. And yeah, the patient has no seizure and it's very nice to understand more and more about those principles.
47:19
Thank you. Thank you for your nice presentation and if anyone have any question on Dr. Patel's presentation, I know she has a time limit. I want to say one other thing. You're a very good doctor.
47:37
You're a very empathetic doctor. There are doctors out there There are people all over the world
47:45
who are not not necessarily as good people. We live in the world there where there's some evil people and I don't need to tell that to the people in Iraq. There are doctors out there who want to do
47:56
this surgery because it makes money.
48:01
The patient doesn't matter. It makes money for the hospital so they like it. Be careful. Don't sell your soul to the hospital, not to the drug company.
48:17
Don't sell your soul.
48:20
It isn't worth it.
48:24
That's very interesting. Thank you for this nice presentation and it's very, very informative. I can tell and nice to know you and nice to have you here and we hope we will meet you in the future.
48:40
Thank you. Thank you for your talk to meet you. Thank you for your time. I appreciate it. I appreciate any comment or a question from the attendee or from the panel. Well, I think the people who
48:53
are left to think of these some comments, which is worthwhile for them or not. And
48:59
we appreciate that. And
49:05
I'm continuously impressed with what you do. You're a good doctor. And Dr. Monty, first I've met you, just a terrific job. And Dr. Patel, she's doing excellent work. And as I told you many
49:21
times, they didn't mean to make it personal I. just wanted people to know that you can have truth and science,
49:29
but people may misuse it for other purposes. That's a danger in our world.
49:37
Yeah.
49:40
So I thank you all very much. Thank you.
49:45
I already said that he has something and you should go early.
49:51
After his presentation with background, Dr. Munir Faraj presentation with the cases, then Dr. Mati presentation, and then the update with the technique from Dr. Patil We can now wrap up this
50:08
meeting and thank you everybody for the attendance. And
50:15
see you next month, basically. And we have maybe extra meeting within two weeks.
50:22
Focus more on the student presentation. And we will keep you updated. Thank you. Thank you everybody for being here
50:34
We hope you enjoyed these presentations.
50:39
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50:49
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51:09
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51:26
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