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Welcome to the 18th SNI and SNI digital Baghdad neurosurgery online meeting held on October 23rd, 2022.
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The meeting originator and coordinator with Samar Hawes, universities of Baghdad and Cincinnati.
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Part 2 challenging cases from Iraq, personal experience from two neurosurgeons 60 minutes L and D. The speaker will discuss neurointology through interesting cases. Dr. Warmeth E Mattai,
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Department of
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Neurosurgery, Neuroscience Hospital, Baghdad, Iraq.
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Now we will start with the third talk out of or Dr. Wameer Matty, he's a friend. He's a, for me, he's a teacher during residency. He's very knowledgeable and neurosurgeon with a huge background
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from family with radiology. And basically during residency we, everyone afraid to talk with Dr. Matty about radiology because he has very extensive knowledge And
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he has very educating,
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let's say, trying during his career.
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And yeah, I'm happy that you are here and you have the stage to start your talk. Thank you, Samar. As I said, it's an honor to have me in the SNI. And I'm glad to present our work I will present
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six cases on your oncology.
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So, I'll start with the first case,
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it's a 24-year-old male presented with left-sided hemiparastesia of an weak duration. And this patient was an engineer, a licketeric engineer. So, we did, to him, brain MRI, the neurological
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examination was not eventful. We went to do an MRI And as we can see here,
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in the T1 axial sequence, we have this lesion, which is hypo-intense. But as we can see, there is no edema.
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There is little effect on the, or no effect on the adjacent lateral ventricle.
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So whenever we see an MRI or a lesion in MRI, we are going to define if this lesion is intra-orexaraxial For the T1 it looks intra axial. And I can't say no about that. But seeing T2, it's
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hyper-intense, so it's a cystic lesion. While reviewing the flare, we have what is called the dirty flare. There is no attenuation here.
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Going on to see the sagittal T2, and we can see it is from the posterior rim so this is being fissured So, this may be an extra axial, while viewing the diffusion-weighted imaging. We can see it
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has a restricted diffusion, and so it is an epidermoid cyst. It's an extra axial lesion in the posterior rim as part of the civilian fissure.
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So, basically, we are in this region. We'll be operating on this lesion For those lesions, I prefer to do linear incisions. centered over the super marginal gyros,
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and I want to avoid the central sulcus, the pre-central and post-central gyroi, and then in the surgery, I will go on. This is the craniotomy. In the surgery, I would like to open the distal
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part of the syrianfusion and the super marginal gyros, and will not do a cortical incision, because basically it is an X-Raxia lesion, so we don't want to make any cortical incisions and make a
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permanent deficit for the patient. For the localization, after opening the dura, I use the intraoperative ultrasound, and because we don't have dedicated machines in Iraq for neurosurgery, I use
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a hospital one, a hospitalized one. I use the vaginal probe, because it has a frequency of 55 to 75 megahertz, And we can see this is the epidermosis, and this is the cortex. So after the
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section in the distal part of the sodium pressure, we can see this purely white tumor, and this is the epidermosis.
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Start removing it. Then after finishing, we can see it is clear, the bed is clear, there is no arachnosis, there is no epidermosis, no contents We start to do wash with high rocortizone, 100
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milligram, and 1, 000 rinker, mill of rinker, and we do continuous washing to ensure that there is nothing left in there to ensure, get sure that the patient will not have developed a chemical
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meningitis and the post-operative period.
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This is the post-opsity scan, we usually do it on day zero. We can see the route here and this is that part of the civilian fisher
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And this is for case one, now case two,
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a 39 year old female presented with subboxyptal headache. And we did the examination and the neurological examination was any bit full, but for subboxyptal headaches, we usually do brain and
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cervical spine MRI, because sometimes there is a lesion in the posterior for said, and it can be easily missed, because you are concentrating on the cervical spine and missing the posterior for
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said, for this patient, we can see the brain MRI here, there is a lesion in the vermium volecular, it is hypo in T1
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This is the sagittal T1 and sagittal T2. We can see it filling the fourth ventricle here, up to the aqueduct of sylvias.
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There is no hydrocephalus and the cordy and the cerebral cell size are opened, but there is some dilatation of the ventricular system, but there is no active hydrocephalus.
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And do we? Again, it is restricted So it is another case of an epidermoid cyst in the fourth ventricle. For such lesions, we go into the sub-oxibital approach, median approach, and do craniotomy
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for such benign lesions, not craniectomy.
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And after opening of the cisterna magna, we can see here the cerebellar hemispheres, the tonsils, this is the cord, and the obex, and we can see the purely white humor, start the same thing it
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from. first do the bulking then we can dissect the membrane from the pica, both pica and when we do that we do it with high magnification, sometimes we call super major microsurgery, when we are
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doing it for more than 50x magnification, 20x magnification to get sure that we can't cut the pica out of this membrane
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and here after finishing the work we can see the floor of the fourth ventricle up to the aqueduct of sylvias.
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This is the post-op CT scan. It is a sagittal view showing our cranial tummy with the opening of the foramen magna and going in the telovellar approach to resect this epidermal cyst.
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And this is the post-op MRI, the dewy, ensuring that there is no residual in the fourth ventricle This is the
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flare
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images, the sagittal of flare. We can see there is no hydrocephalus in the post-op.
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This is the patient that has no deficit.
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For the first case, this is a four-year-old female that presented with headache, repeated vomiting. It was in one of the governor's rates since the southern improvements of Iraq and Nissan They did
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the CT scan and they discovered the hydrocephalos. with the fourth ventricle tumors. They did an urgent VP shunt, and then referred the patient for us after doing an MRI. Here in the MRI, in the
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axial T1 review, we can see the shunt in place in the ventricle. There is no hydrocephalus. And looking into the axial T1, we can see this horrible, huge fourth ventricle tumor in T2. It is
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occupying and dilating the fourth ventricle.
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We can see in this Agital T1 that this is so huge,
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two more, and for such cases
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that are from the
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peripheries of Iraq and the southern region, when we think that the patient will be lost in the follow-up, we do cragnectomy, not cragnotomy We can see here the contrast enhancing,
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it is evidently enhancing.
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So here we do a cragnectomy in the
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posterior sub-oxibital median approach.
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And following the micro-annure surgery principles, we resect the tumor and here in the post-op day zero CT scan, we can see our tract and the fourth ventricle is opened This is the
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tumor up to the equiductal cells and this is the. in a place.
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For the fourth case, this is a 41-year-old male presented with a left-footed rock
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which progressed slowly to involve the left lower limb. This poor patient was first diagnosed as a case of discoproducts and treated as such for a period of time. Then when he has progression in his
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weakness to involve the left lower limb, he went to one of the adjacent countries and he has it treated as a case of plexitis. Again, with no benefit, he progressed. When he presented to me, he
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was on a wheelchair.
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In the examination, we saw there is a colonus and the left foot indicating that there is an upper motor and your own lesion. So we did a
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brain MRI for this patient and here we can see the axial scan and this is the key one post-contrast you can see there is a huge falsie and mini-joma
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it is a homogeneous enhancement it is occupying the middle third of disappears and sagittal sinus and this is the
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sagittal and in the coronal we can get sure of its base on the faults for such cases we can differentiate them from para sagittal if we see the cortex above them
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so we went into surgery and for such big lesions we don't do linear decisions we still are doing big flaps for lesions that are mini-jomas ABMs that are cortical so we can get sure that we can remove
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and we can see the whole mass and remove it after opening the Dura we can see here the air retinoid and cortex covering the mini-joma
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with
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little dissection of the arachnoid. We can see the base of the main geoma, then we start to do debasing, de-vascularization, then debulking of the tumor. This is working on the base.
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Then we can do debulking and use the ultrasonic surgical aspirator to debulc these tumors. And in the last step, we're going to do a dissection of the capsule from the adjacent normal white matter.
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And this is the post-op day zero CT scan showing there is a big hole in the brain.
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This patient recovered his power by the end of one month, he can walk along,
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and because of the huge size, we thought that this may be not a great one, but the histopathology showing a mini-geome of a plastic grade one, that we are just following by
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MRI Her fifth case is a 53-year-old female, presented with progressive power-operacies of six-month situation with loss of sphincter control in the last two weeks. Again, this patient was treated
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as a case of discoprolabs for a period of time, but when she developed the sphincter control, the loss of the sphincter controls, they thought that it is a case of coda equina or maybe
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conosmudularis, but when presented on wheelchair and examination show there is bilateral mobinist design, we went to do an MRI from C1 to L1 to get sure of the. lesion, and here in the sagittal T2,
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we can see there is a lesion in the D3. And we do the cervical, yes, the hands, the upper limbs were normal, but we do it for localization. So we know that this is in the D3.
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By viewing the T2 MRI and seeing, this is
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an intra-dural extra medullary lesion that is hypo-intense in T2 So we are thinking of a midioma.
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And this is the contrast enhancement.
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This is the Excel T2 scan. We can see the tumor pushing the cord toward the left side.
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This is one of the principles that we use. I viewed in a book by 1986. I remember it is called Advanced Techniques in Neurosurgery. So we can get sure of localization. You know every neurosurgeon
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will be in distress until he finds and sees the lesion. So we can, by doing a laminectomy, then filling the field with normal saline and bringing the probe according to the way it is placed, we
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can view sagittal or axial or sagittal views. It is a 2D. And we can get sure that the lesion is there before opening the dura. And we can see here, this is the saline, this is the posterior dura
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this is the tumor that is hypericolic and this is the
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anterior dura this is the CSF then we proceed to open the dura and view this meningioma again applying the
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principles of meningioma surgery with the
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devising the vascularization debulking and then the section it is removed totally and the patient also
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regained her walking by the end of one month
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This is the last case, it is a so debatable case, it is a 47 year old male presented with a glass of comma scale of 8 out of 15. The patient had history of the upside of the hemiparesthesia three
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years ago for which he did a
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CT scan, this is the CT scan, he was diagnosed with a case of a stroke, a
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schematic stroke and treated as such for six months
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with no benefit, then he go to one of his relatives, he's a neurosurgeon, he ordered an MRI and discovered there is an insular glioma, this is the clear sequence, we can see the glioma involving
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the insula, going into the temporal lobe and into the frontal lobe, so I discussed with him the surgery, the patient refused the surgery claiming that he cannot. have
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hemiparices or a possibility of hemiparices here.
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So after three years, he came unconscious. He did CT scan to him, showing there is an increase in the size of the tumor.
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And there is a hemorrhage in the posterior part of the tumor causing compression on the ventricle, midline shift There is ankle herniation, saphalcyn herniation. That's why he developed an
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unconsciousness. He did an urgent
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MRI.
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This is the axial T1.
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We can view the temporal part, going into the frontal part by the ancynate fasciculus. It will be ancynate fasciculus and into the anceulae.
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So now the patient is unconscious and his family who are discussing with us. the possibility of doing surgery to rescue his life, but without having him paralyzed, or hemiplegic.
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Our thoughts were to remove the temporal part and part of the frontal and the insular part, but leaving the posterior part intact,
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along with doing
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a decompressive craniectomy and the duroplasty. So we can make a space for this patient. This is the decompressive craniectomy. And this is the duroplasty that was done in the end of the surgery.
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We stored the bone in the abdomen. So we went to do temporal lobectomy.
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And again, after doing the temporal lobectomy, we went into the insular This is the circular surface, but we know that. The shape of the insula is a triangular in shape, not circular in shape,
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because this cell class is named, because it encircles the cell class. There is two approaches for insular tumors. Either you go transylvian or transylpurpular. For me, I'm fan of a
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trans-purpular approach. Because we are doing a temporal lobectomy, we can go through the superior temporal gyrus into the insula
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Remember that these are the superior longitudinal fasciculos and the inferior frontal occipital fasciculos. Both of these white metal tracts, they are supplied over the insula, one above and one
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below. So we can preserve them and preserving the motor cetera, both serially. This
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is the frontal upper column, and this is the superior temporal gyrus. Because the sylvian transylvian approach will get to it to have this. approach in order to see the circular surface, so that
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we prefer to do the trans-apertular approach.
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And after doing the transfer particular approach, we can see the MCA and this branches, then we make small decisions in the insulate and
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start taking out the tumor by suction, whitening the approach, then resecting a bigger part of it.
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And this is the principles that we do in the insular approach
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Again, this is the day zero post of MRI, a CT scan, when the patient regained his consciousness after the surgery. He was having a lift, hemiplegia, complete dense hemiplegia. And the family
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was happy, he has regained his consciousness, but worried about the hemiplegia. We said, wait, in the day two, day three, he can move his lower limb, and at the end of one week, he can move
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his upper limb, and after two weeks. he had gone back to normal. But this is a debatable case, whether to follow a gross total resection, safe maximum resection, or just as the patient's
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relative won't, just to ask you his life, without doing a gross total resection. And then we can discuss the matter of free surgery for resecting
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the part that remained in there We can see the surface and herniation here, released at the ankle herniation too.
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But the hemorrhage and the posterior part is left in place. We can see here the mushroom capping because of the raised ICP and pushing of the humer outside of the
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decompressive craniectomy.
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This is the MRI at the end of two weeks You can see that we have removed the interior part and the interior part in the insula. and temporal frontal, but we have left the part that is going on the
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motor center.
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This is the patient and the end of the weeks.
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Thank you. That's amazing. Thank you, Dr. Munir. Thank you, Dr. Munir, my tea for this. I
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hope it was a cook. It was very good. What was the histology of the last case? It was a glioblastoma multiforme, a secondary one. Yes Grade 4, yes, it's a secondary glioblastoma multiforme,
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because he had the
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insulin glioma three years ago that was upgraded.
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I see.
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And I will say I am impressed by the use of ultrasound. I use ultrasound all the time still in practice, you know, with all the fancy new technology and brain lab and this thought and the other, I
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think ultrasound is a fantastic adjunct in the operating room, it's the only real time imaging. apart from the intraoperative MRI and much, much more facile than the intraoperative MRI. They're,
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hey, I'm just,
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you know, I think Dr. Mati is a very fun of
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intraoperative ultrasound. I think we can go back to the teaching to some teaching point, Dr. Osman, if you want, with Dr. Mati, can you put your slide up in the slide? I think it should slide
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as likely to show that the students should see, it's a dramatic slide. It's a slide, which is the tumor in the fourth ventricle, you have the hydrocephalus and the obstruction. But before that,
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can I make one comment? Please do. When we do glioblastoma surgery, we tell the patient and his relative, this is a trade between removing so much of the humor and. reserving some function that
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we will know when it will be lost, like the motor function. We don't know if this motor function will be present for one month, two months. It is temporary. It is not long-lasting that the tumor
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is highly aggressive, especially if we are dealing with the primary glioblastomas. Do you agree with that, sir? Yes And one more thing that we
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discuss with the patients, that if the tumor regroup, will we offer them a re-surgery or there is no re-surgery for such
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tumor? Well, we wrote a paper about this meeting. I'm going to answer you in a little round of our way and ask the students what they thought of these meetings
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I was overwhelmed with their responses, they liked them very much, but some of them said
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You gave me a chance to dream for the future. You gave me examples of people in Iraq who were doing fantastic things.
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And so there's an aspect of hope.
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If you didn't have hope in Iraq, everybody would be depressed, give up and say, we're destined to be like this for the rest of our lives. We're going through something like that in the United
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States, although they don't want to admit it
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And the answer is yes, you have to be the conveyor of truth. And I know you agree with me, that's what you just told me. You have to tell them the truth, but you can say, look, I'm not perfect,
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but I can do some more if it recurs, and I used to do recurrent surgery on tumors. And what I do is I just, because if you turn the whole flap, they can infect it and so forth. So it only opened
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a little bit of the flap, do a little craniectomy and go in it and take the tumor out. So, it was a way to keep them, have them have a quality survival for more time. Once it gets beyond quality,
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what's the point? That's each individual's decision,
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but that's what Dr. Hari was talking about. And so, I know you agree with me because you wouldn't ask those questions, and I would guess my nearest feels the same way, but we're just a physician
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We're there to help people, and I can only do the best I can, and I'll do anything I can to help you. That's what you're saying. I'll operate on you, and if it comes back, you have a choice with
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your life. So, my choice, it's your choice, right?
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And we always have to remember, it's a patient's life, it isn't my life. The patient's taking the risk The surge is not taking the risk.
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Sure, one way to answer that maybe the time period for recurrence, if that tumor recurrent within one to two months, I don't think that it will be beneficial to have the battle one more time. But
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if the recurrence was more than six months, eight months, ten months, the more the time period, we will do the recurrence for the recurrence of those of Lyoblastomas. I
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had a patient who came to me because he had
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met metastases from a testicular cancer to
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his brain. He had one or two removed before. His sister was a rehabilitation
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therapist.
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It came to me and I said, Just what you said.
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But his family said, I don't see why you want to have any more surgery.
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He said, I want to have the surgery. I want to live a little bit longer.
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And so the lesson I got from that is I can't make the patient's decision. It's not my life
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And here's a man who had every statistic against him and even in spite of that, wanted to have two or three more months of life.
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What's wrong with that? Nothing.
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And I know you understand, I can just see about your face, you understand what I'm saying.
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But the message I'm trying to get to the students here is you're a doctor and we're living in a world where some people have forgotten to be a doctor, they're a mechanic, or they're working for
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money and the patient comes last. what I'm saying is the patient comes first.
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And that's what you're saying.
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I don't know if it's relative to the subject, but when we have a giant M1, ischemic stroke. So if you are going to do a decompressive craniectomy for those patients or not as part of our work, we
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are reluctant to do such surgery leaving those patients not in their past life. There's no much to do. They are especially when it's dominant. They are aphasic. They have lost half of their body.
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I don't know what do you think about such surgery? The decompressive craniectomy for an M1, ischemic stroke.
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I know what the science says, and you show to you, the science says, well, I can extend their life. What does a patient say?
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A patient says, do I want to be in bed, hemiplegic, do I want to put my parents, my family through that or not? And that's what you're saying. That's the question. Yes. It's usually not the
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patient decision, but it is relatives They usually lose consciousness by the time they consult us and the fifth day, the day of maximum edema.
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Yes, right. I was operating in a patient in Egypt, Alexandria, Egypt, and the patient had a, we were doing an aneurysm, patient, surgery actually went pretty well, it was a difficult aneurysm.
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And so I went home thinking, Hey, that's fine. The patient got worse at night, good developed edema The residents didn't call me, nobody called me.
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the next day, it
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was too late. I was totally devastated.
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It could have fixed that man. It could have helped that man. Just like the patients you showed, who had the tumor in the third ventricle with the hydrocephalus, that years ago, people would have
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said it's incurable. It wasn't not only to just take it out in a difficult area, but the hydrocephalus, one way,
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because the tumor was blocking the CSF passwords. That's what I wanted to show. So you had some many teaching points in your science, and I enjoyed it. That's actually, that's what make this
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meeting more free to talk with, talk through, and to be more interactive, because these are lessons from different parts, each one based on his experience, and try to share his idea, his opinion
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and. As you always said, nobody knows what's the exact truth or which one is the correct option, it depends on many factors. I
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should say that your case is Dr. Matty is very interesting. I expect that, that's how you teach us based on history examination T1, T2 flare I doubt that there is many people around the world to
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now make this sequence like slide for T1, slide for T2, slide for flare, slide for doing that sequence, the same sequence that you teach us like 10 years ago, I don't know, with the tool for
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each patient to one hour or more I think this means a lot for your patient and that's why I think
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As Dr. Osman say that not everyone, not everybody do many recurrent cases, but I can say with your, I don't know, a few years. And as a surgeon, you are doing a lot of recurrences for other
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people. And that's what we do personally when I see a very complex case, okay, send it to Dr. Mehti, because it has the potential to just have the extra details and to do the best for the patient.
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