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Welcome to the 17th SNI and SNI Digital Baghdad Neurosurgery online meeting held on September 4th, 2022.
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The meeting originator and coordinator is Samir Haase, University of Baghdad and Cincinnati
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The speaker will discuss posterior interhemispheric approach for pulvinar and
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posterior thalamic lesions,
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anatomophysiologic basis of surgery. Dr. Ahmed A. Aljuburi, Head Department of Neurosurgery,
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Neuroscience Hospital, Baghdad, Iraq.
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The introduction is by Professor A. Hadi Al-Khalili,
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the former chair of the Department of Nurse Surgery at Baghdad University. The
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Jaburi, he is a graduate of medical school at 1993
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and he got his board in the year 2000 and then he got some experience in scalp-based surgery in 2008 and
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he got in fact scholarship or
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some degree with that fellowship in the scalp-based surgery and now he's head of the the oncology department and genetics research center. And he's a very well-known surgeon, basically on vascular
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surgery, but he does everything else as well. And so far as I got the number in front of me more than
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4, 000 cases he has done so far. And he's so young. It's amazing to do this number of cases with his young age So, Dr. Adnan, please, the floor is yours.
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Thank you very much. Good afternoon, good morning. Thank you very much, Professor Hadi. Of course, needless to say that Professor Hadi is the teacher of the generations of neurosurgeons. And he
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is not only a teacher, he's an inspirer, and he is the mentor of, I will not over exaggerate I will say hundreds of neurosurgeons that he taught. not only how to do the microneurosurgery, but how
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to think properly because he is an academic person in addition to a very professional microneurosurgery.
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Of course, Alee told me that I can present anything that I want. I'm not restricted in the subject. So I was a little bit surprised that it was a rather general meeting and each one can present his
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own common experience. My talk will be rather different. I will present some very specific topic. But through this topic, you can evaluate the degree of work that we are doing in the neurosciences
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hospital. I'm the head of neurosurgical department and this is 300 beds hospital, tertiary center located also in Baghdad, had been established, started as a reconstruction. in
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1998. And it is opened in 2002. And from that date to now, it's doing thousands of cases. As I said, it is a tertiary referral center, mostly for vascular, for tumors, for functional
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neurosurgery and for spine. And we have a little referral for the trauma because most of the trauma cases, they went to the neurosurgical hospital where Dr. Ranwar is presenting his wonderful
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experience in the neurosurgical hospital. I'm working in another hospital, which is called Neurosciences Hospital. And now its name is changed to Assadir-Witri, who is the founder of neurosurgery
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in Iraq. The name of hospital, Assadir-Witri Neurosciences Hospital. I will present my talk about very specific thing in your surgery which is rather practice, rarely, all over the world. That
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is the surgery of the thalamus. And the surgery of the thalamus is rather a new branch. Told recently, most of the neurosurgeons worldwide, they thought that the thalamus is forbidden place for
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surgery, and there are still some controversies regarding the approach to the
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thalamus. And because of its deep location, because of its very vital function, many neurosurgeons, they think that stereotactic biopsy followed by radiation is the optimum treatment, but this
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had been challenged by the leading neurosurgeons in the world, like Professor Spezler, Professor Lauton, Professor Yezerj, Professor Doling, to mention a few. I will present my own personal
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experience in surgery of a very specific location in the thalamus that harbors most of the vascular malformations and the tumor, which is the pulvinar and the posterior thalamic region. The pulvener
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and the posterior thalamic region constitutes more than 40 of the thalamic mass. So most of the thalamic tumors, more than 40 resides within this small part of the
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thalamus. Needless to say that the
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thalamus is the main relay station. The cortex is nearly blind for everything unless the signals are related to the cortex. By the way, because I'm basically, I'm neurophysiologist I had a master
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degree in neurophysiology. So I have an interest in the neurophysiology in addition to the neurosurgery. And I tried in all of my career to understand the neurosurgery from a functional perspective.
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Because I do think that there is a rather deep value between our clinical practice and our basic knowledge about the neurophysiology. So this lecture presents a marriage between a neurophysiology, a
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pure neurophysiology, and how to invest this neurophysiological knowledge in neurosurgery. So this is the thalamus, can you see my cursor? Yes. Yeah. And as I said, it is a main relay station
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to the cortex. The cortex knows nothing about the external environment unless the information is referred or relayed by the thalamus. Here are the thalamic nuclei, more than 30 thalamic nuclei. I
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will not bother you about naming all these thalamic nuclei and here are the thalamic function, arousal and the laying of information up to the cortex vision. The cortex is blind, unless it is
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relayed by the lateral geniculate nucleus, which is part of the thalamus, hearing the brain is deaf, unless it receives information through the medial geniculate nucleus of the thalamus about the
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gustatory. Again, the thalamus would relate to the virus.
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and to the insula and also the general sensation through a nuclei of the thalamus. The only sensation that skip the thalamus is olfaction. For another reason, the olfaction is not filtered through
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the thalamus. It is referred directly to the cortex. Here's very important concepts of the thalamus that passed unnoticed by the neurosurgeons. I read all the articles that are written about the
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thalamus in neurosurgical literatures And no one mentioned this very important two types of thalamic nuclei. One is called first order thalamic nucleus. This is very vital, very illiquid. So you
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cannot play with this part of the thalamic nucleus from surgical perspective. There is other type of thalamic nucleus, which is the majority of the thalamic nucleus. It's called higher order
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thalamic nucleus. Here it does not relate to the cortex. It receives from the cortex and then it sends to the cortex So it is just like association fibers.
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Here it is a safe interizon. If we compare the thalamus with the brain stem, there are safe interizones to the thalamus. And now we are working on this area. What parts of the thalamus can act as
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a safe interizon that you can pass through it. And what parts of the thalamus you cannot play with it because they are very illiquid, just like the brain stem. These two concepts are very important.
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They are very modern. They have been discovered in late '90s and early
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2000s Here you can see, the black is very illiquid, is the first order neurons or first order nuclei, sorry. And the white, they are non-illiquid. You can pass through them. The pulvin are one
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of them, the MD nucleus. The nuclei that are adjacent to the form of Monroe, which means that when you are removing the colloid cyst, so you have some little way of manipulating the anterior
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thalamic tubercle, because it is rather. not as illiquid as other parts of the thalamus. You have to know the anatomy of these dark nuclei because they are very liquid, devastating permanent
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damage will happen if you introduce and treat yourself in these parts of the thalami. But these other parts, you can manipulate rather safely. And this is a paper from Professor Spezler who did a
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lot of thalamic work He mentioned that the pulvinar of the thalamus,
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if you see my cursor, the pulvinar of the thalamus, this area is remarkable in tolerating surgical manipulation. He didn't mention why. This paper is published in the neurosurgery journal in 2006.
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And he didn't mention why the pulvinar can tolerate manipulation. This because it is higher order nucleus, the pulvinar. It is not first order nucleus So it is a safe interizon to operate on the
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thalamus. or to consider it as a path toward the other parts of the Talamas, a safe interism. Sorry.
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Okay. Okay. Okay.
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I will skip some of the slides. The
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thalamus is the posterior part of the thalamus, the posterior part of the thalamus. There are two parts of the pulvenor, there are cisternal pulvenor and ventricular pulvenor. This also passed
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unnoticed by the great book of Professor Rotten. He only
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mentioned the ventricular pulvenor, but he didn't emphasize on a cisternal pulvenor, which is much safer than ventricular pulvenor. Here you can see that this is the pulvenor, but this is inside
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the ventricle. Here we are inside the ventricle, and here we are outside the ventricle. This is again pulvenor. Here is the pulvenor inside the ventricle,
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ventricular pulvenor, and this is the cisternal pulvenor. This is not forgivable. If you go to this part, as I will show in my slides by Professor Spetzler, he attacked the cavernoma and the
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pulvinar through the ventricle.
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But it is not very forgivable, because just lateral to it here, you have the posterior limb of the internal capsule. So manipulating this part of the pulbinar can lead to a devastating hemiplegia,
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as it is mentioned by Prof. Sospezler, while if you go to this part of the pulbinar, can lead you to the same target away from the posterior limb of the internal capsule. This was the rationale of
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our work These
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are the -
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as you said, what is the function of the - as I said, the pulbinar is rather an area that is of safe entry zone. What's the function of pulbinar? It is a major attention center in the brain, but
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it works together with the frontal lobe and parietal lobe. Because I have no time, I will skip some of these slides, because as I said, it is a rather technical lecture These are the atomic
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regions that are classified by Spezler. and he put the pulvenor as an area number five and six for five and six. These are the posterior thalamic region by the classification, surgical
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classification of Spadzler. And he attacked these through this, prior to occipital trans-calusal approach. And here we have some notifications. We rather disagree with this approach And because I
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am the director of the Cadadary Club in Amman, I went there and I studied the thalamus and I choose another approach that I am presenting here. Here as you can see that there is potential
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neurological deficits that is because of this approach. There is visual complication in more than 50 of the cases. I often choose the another approach, which is another complicated suppressorabella
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infra-tentoria, contralateral but this depends on the steepness of the tantorium and also you can encounter many of the bridging veins. So, I went to a professor here this year. I spent some time
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in professor him this year. He did a wonderful job about the surgery of the movie lab, but he had no specifications. Sometimes he used mid-line, sometimes he used parameleon and sitting position
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with all of its danger. So, as I said, I did many, many courses in the my lab and I'm on, I'm the director of this lab. And I went there, I studied the best approach by trial and error, and I
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used this one. It is below the Lambdoyt posterior interhemispheric. It is below the Lambdoyt suture where there are no bridging veins. The, there
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is no incision in the seplenium or the posterior body of the corpus callusum. So there is no possibilities of disconnection syndrome. Both parts of the pulvenor can be seen simultaneously That means
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that it's external and the ventricular pulvina. And most importantly, you don't need to use retraction. Gravity works with you. And this is very important concepts as all of the neurosurgeons well
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know. And it is very easy and very simple, very safe. We put the patient to the park bench. The lesion is in downward against intuition. And we use nine centimeter incision, one centimeter below
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the midline, two thirds above the Indian, one third below the Indian And the head is inclined 15 degree toward the ground. This is the position, the position that we used after we studied it in
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the lab. As you can see, that the head is turned 15 degree toward the ground. I'm using Surjita, I prefer it over the Mayfield, though I have the Mayfield. And
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very simple linear incision. Most of the neurosurgeons that are using horseshoe, this horseshoe that can cut the continuous fibers the patient will complain of parastasia and dyesthesia. while this
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simple linear incision, faster in healing, and it does not leave any distancing complications.
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Here is the opening. I know, I don't use self-retail surveillance retractor. These springs that are provided by the company, they are flush to the skin. And then simple single per hole. And then
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craniotomy four by four, exposing the posterior superior sagittal sinus and the transverse sinus The most important thing is the issue of brain edema. This can be solved either by lumbard rain or by
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using dandy's point. Here is the dandy's point. Then you have this working space toward the pulvina. The retractor is used as a reminder, not as a retractor here. And my personal experience, I'm
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operating on 38 cases. The age range from three to 71. They are 18 females, 20 males 37 most of them are gliomas The gliomas, mostly the armpitocytic, benign. So the surgery is curative, no
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need of aviation, no need of chemotherapy. All you got under a glioma nine and one gli blastoma. Five cavernomas, one, three AVM and one bullet that presented with repeated abscesses. He went
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elsewhere outside the Iraq. They told him that the bullet is unapproachable. So the abscess accumulates again and again. And I remove the bullet and the patient is cured And there are two cases of
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arachnoid cysts. As you can see, these are the results. I have only one death that is in the postoperative edema by gliblastoma. The tumor was very vascular.
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cavernoma totally resected in the five cases. There is improvement of the ocular movement. There is improvement of the motor function. And there is no change in two cases. In the AVM three cases,
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I'm operating
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AVM in deepovina As we said that some of the new surgeons think that the AVM here is probably for gamma knife. We did surgery for this AVM, and it was curable and eventful surgery. I'm using the
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Kinevo microscope, Kinevo 900, and I'm using the mouth switch, which is 30 reduction of operative time. And I'm also using a foot switch. So there is no need to take your hands off the surgical
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field. You are always paying attention to the surgical field You can move, you can focus by the mouth, and you can zoom by your feet. I will present only one case. This is a young lady presented
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with progressive hemiparesis, and there is no speech disturbances. And as you can see, there is well-circum, circumscribed, hyper-dense region located on the left pulvenar. If you come from here,
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then this is the left hemisphere. She has normal speech. There is very small ventricle to tackle this cavernoma So we choose the posterior
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intermispheric transpulvenor approach. Here's the MRI, as you can see, intensely enhanced, located in the posterior thalamus. Here is the surgery.
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Here you can see the patient in a park bench position. This is a dependent hemisphere downward. Here is the basal vein of Rosenthal, the bridal occipital artery. Here is the seplenium. There is
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no seplenium incision. We develop a space below the seplenium We develop a seplenium laterally. Here is the pulvinar. This is the cisternal pulvinar. This is
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the anterior calcarine vein. We studied these veins. This is rather small vein, draining very small area on the anterior calcarine region. And in most of the cases, you can sacrifice it without
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any ill effect. We measure the visual field and visual acuity. Nothing happened, but you have to distinguish it from the basal vein of Rosenthal, which lies just below it and it dives in the
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ambient system here.
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I am developing a space. This is the pulvenor. And we have the navigation. This is the steel eight navigation system. Then you have to determine the entry point through the pulvenor. This is the
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pulvenor. The police don't confuse the pulvenor with the quadrigeminal plate. Quadrigeminal is here. We did not open the tantorium because the tantorium will stop us. And you can see that now the
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cavernoma came into the scene Of course, it is meaningless to evacuate the old blood and cavernoma. You need to remove the wall of the cavernoma. So after evacuation, you have to dissect the
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cavernoma. Here we are through the cisternal pulvina, which means that the internal capsule is rather away from us, the posterior limb of the internal capsule. Here we are using the disacra as a
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disacra and the wall of the cavernoma,
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is very gently delivered. You can see that the gravity help us. There is no late arthractor on this hemisphere. By the gravity it is downward. So there is no visual complication as it is monitored
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in 50 of the latins and specular cases. Here's the bright occipital artery. You have to preserve it, of course, needless to say. And then, the staplenium is up. It's preserved. This is the
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tantorium You don't need to open the tantorium because it is epsilateral. Very gradually, you can remove the whole cavernoma. Here you can see this is the sack of
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the cavernoma. Of course, as I repeated the emphasize, evacuating just the content is a meaningless surgery. And I think all of us will agree that Gamma Knife has a very little role in the
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cavernoma. The only hope for this young lady that this cavernoma is bleeding repeatedly, I want to recognize fact that thalamic cavernomas
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have higher complication rates, higher bleeding rates than the cavernomas elsewhere. And here,
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for it to results, this is the cranotomy, and this is our journey from here. And here you can see no cavernoma. This is the post-op. Of course, we always search for the evidence-based medicine,
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pre-op post-op, and this is our journey And this is the job form that is placed here. She has then semi-plegia before the operation, pre-op,
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and post-op. And here is the patient.
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There is some residual weakness, but at least she is no more wheelchair-bounded. Here there is another child, 10 years old, with the pulvinar atumor. This is a phylocytic astrocytoma here It is
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the same surgery because I have
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perhaps I'm passing by time. Here is the pulvina. No need to open the tentarium. Of course, it is optional. If you need more vision on the other side, you can open. You can see there is no
23:24
retraction. No retraction, no visual complication. Taking the perforators away from the entry point and then removing the tumor. Remarkably, the thalamic glioma is very distinct from the normal
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tissues. And we do know that the surrounding tissues is rather forgivable. It is a pulvinar, an atation center, but there is substitute for this atation center in the frontal lobe and in the
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parietal lobe. So this is a safe interizon for the thalamus, not very liquid, but don't go inferiorly because here are degenerate nuclei and
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don't go laterally because of
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the internal capsid. You can see it very clearly separated and let's remove all. is a rather routine work.
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Sometimes, of course, you need to use the indoor scope to see this angle,
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the most lateral angle.
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Here you can see the normal tissue
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This is the last piece
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There is a clear line of demarcation between the normal thalamic tissue and the tumor. This surgery is a curative. No need of radiation therapy. I followed this child for the last five years and
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she is doing very well. This is the postoperative MRI. Here is the preoperative and the postoperative and here is the child. Two years later, she is perfectly normal, no radiation, no
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chemotherapy Kavarnoma, this lady is very young, 20 years old, 26, she has shunted. And this Kavarnoma in the thalamus lets many times, this is the location of the, I will skip the operation
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and this is the postop. This is the preop and this is the postop and you can see this is a DVA, it is not a residual Kavarnoma. I hope that I can show it in the video. This is developmental venous
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anomaly that should be respected This is pre-op and this is post-op.
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avm also in the thalamus here you can see that there is an avm located in the pulvinar in a young boy and it bled twice this is the hematoma and this is the avm
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here is the avm by flare study again I will skip the surgery and this is the post-op
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here you can see pyrocytic huge pyrocytic astrocytoma in six years old he came comatose and this is an enhancing wall an actively proliferating wall of course if you put omaya here or if you just to
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drain this one then you did nothing to me here is the post-operative course got a resection and the child is totally cured and I followed him for the last three years he's doing very well the
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pyrocytic despite its very ugly appearance it is very benign and the child is doing very well another case free and post.
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Here is, there is ethereal meningioma. This approach can not only be used for the regions of the pulvenor, it can also be used when the ventricle is small. And here is on the left side, it can of
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course go transcortical, but this is left and very small. Then we choose the medial pre-cunial approach that had been invented by Professor Yesergy. Here from pre-cunius, it is the same thing.
27:06
And here is the post-operative, a linear incision. And he has nothing, no visual impairment This is correct access papilloma. And somebody put a
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shunt on the ipsilateral side, which makes opening on these areas rather cumbersome. We came from the medial side, and this is the post-op, and here is the shunt.
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AVM
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on the pre-cunial area can also be resected through the same approach. This is a pre-op, rather big, perhaps it is special martin grade four or three.
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the post-operative reception, a young lady. So in conclusion, the follow-up of the pulvenor and the posterior thalamic region are not uncommon and they can all be approached through a simple
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posterior interhemispheric situated below the lamboed suger and the patient in the park bench position with the lesion downward. According to the recent understanding of the thalamic physiology,
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there are safe interresonced enthalamus. And as I said, I'm working on this issue because I think this is important. We, as a neurosurgeons of, I hope I'm wrong, a very dim idea about the
28:21
functional localization in the thalamus. The pulmonary posterior thalamic region can tolerate a remarkable manipulation. As is mentioned by Spedsler, why because it contributes with the higher part
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of the concenters for attention, posterior atmospheric approach can also be used for arterial tumors through pre-cunial approach.
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and medial parietal occipital lesion, such as AVN. And thank you very much for your listening and sorry to take perhaps much more than the time that's allowed for me. Well, time was worth it, Dr.
28:56
Radman. Thank you
29:06
so much. Thank you very much, Professor. Well, I'm really surprised that this world-class surgery, meticulous surgery, and then you said it's a simple and easy surgery, and you're one of your
29:11
slides. Yes, Professor, I'm speaking about the approach. Yeah, for you, it's simple and easy, but it's very important. No, no, for all of us, Professor. We are very, very proud of what
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you have achieved. Really, this is unique.
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Thank you, Professor. Great certificate for you. Can I make a comment, Tari? Please. Please First of all, Dr. Ahmaud, that was an outstanding talk. And I invite you to submit to you. this
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talk which I think has very good information to surgical neurology international as a paper and one or two parts. You may know in 1980 or 1990
29:56
we presented the approach of the three-quarter prone
30:01
occipital side down approach to the pineal region which is very which is similar to what you're doing. You're going above the cerebellum for the same principles to get to the thalamus. I think I
30:14
think it's an excellent approach. It achieves all the goals that you said which is minimal retraction, avoiding a vascular structures, important structures. What was very important to me is your
30:28
observations physiologically about the first and second-order neurons in the pulmonary and I thought it was a superb piece of work and I can tell you it we
30:41
Sugita frame, same position, same things, I'll send you the paper. It's an outstanding presentation, I want to tell you that, outstanding. And it ranks among
30:55
the best in the world. So in the presentations of others, for example, who were working in Dr. Amara and it was working in the hospital and does an immense amount of trauma work and clinical work,
31:12
his achievements are also outstanding. And so are the dean of the Medical School, Dr. Ahmed. So I congratulate you. This is first class job. Thank you very much, Professor. Absolutely. I
31:23
appreciate it in these words.
31:29
I agree with Dr. Osman, and I was just checking on my phone while you were talking whether did you publish that thing, and apparently you're in publish, which is great. Invitation to surgical
31:42
neurology, this is, yes, this serves to be - I will submit this paper, I'm just completing the paper, I will submit to the surgical neurology international. Fantastic. When you send it, send
31:52
it to my attention. Make sure that I see it. And if you don't have enough room, you can publish it as part one and part two. Yes. It is a superb talk. Yeah, thank you very much. And besides
32:06
that, we're gonna have your talk on video and it's international. Okay. Yeah. Terzama, do you have anything to comment on? Yeah, definitely. Thank you, Dr. Ahmak, for this very nice
32:22
presentation. I feel proud to show this advancement doing in Iraq and how we tackle this such a difficult, let's say, eloquent location with more added risk with the difficult lesion, I think.
32:40
Yeah, we are all proud of your experience and your scientific pathway in doing things.
32:47
For those who don't know, maybe I didn't work for Dr. Ahmed directly, but he inspired me about microsurgery, about he's the first person to introduce not only for me, for I think, for my
33:01
generation or my years that who's wrote on, how to study wrote and how important is wrote on And from that point, we can go to the next steps and achieve more. And as Dr. Fermi said that, Dr.
33:17
Ahmed makes things easy. I just remember I talked with him after a surgery and he said, oh, I have like maybe four distinguished approaches I used to learn this from me. And then go to another
33:30
mentor and try to learn more. And keeping this in mind till today helped me a lot me a lot like make things easier. then I have the courage to advance more and that's what I want to say here
33:48
and I'm proud of you. Thank you. Thank you very much, Dr. Samur. Thank you for your comments and I'm sure you are one of the most promising young neurosurgeon and we rely many on you to push the
34:03
wagon of neurosurgery forward in Iraq, not only in Iraq, in Iraq, in Arab countries, in the region and even in the world. Thank you. Great. Absolutely right.
34:15
For both of you. Any any comments, any questions,
34:20
please, from our audience? Yes, please, Dr. Anjam. Yes, so needless to say that I'm proud about your talk, Dr. Ahmed, and very happy. You know that we join together a lot of surgeries and
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we join such cases and I am
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I want to say that when we talk with the patient about the risk of this operation, it is very disastrous, but I always be mentored by Dr. Ahmed to say that we should work hard and we should
34:55
emphasize ourselves to do microsurgical and microsurgical techniques and microsurgical approach. So really he is, if you are close to Dr. Ahmed, you can know that he dedicated his life for
35:15
this microsurgical techniques and operations and I am needless to say, I am proud of him. So thanks for his night talk. Thank you very much Torrenza and John. He is my lifelong friend and partner.
35:28
Of course we are working together. My private work is in north of Iraq in Kurdistan. In a part hospital, is the head of neurosurgical department there. And we are working together for the last,
35:41
perhaps 15 years, doing weekly, perhaps six, seven craniotomies at the weekend. And he's a great partner and a great friend to mine.
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Any more questions, comments?
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The video editors were Mustafa Ismael, College of Medicine, University of Baghdad, and Fatima Ayad, fourth year medical student, University of Baghdad
36:17
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