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Welcome to the 20th SNI and SNI digital Baghdad neurosurgery online meeting, November 26th, 2023. The meeting originator and coordinator is Samir Haaz, University of Baghdad and Pittsburgh
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Speaker is Dr. Wamith E. Matty.
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He is speaking on neurooncology through complex cases. And now we want to invite Dr. Wani of Assam Métis. His father is the
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Dr. Assam Métis, a well-known radiologist, one of the founder of Radiology in Iraq. And he's very radiology oriented in your research in and based in Iraq and now working on a satisfactory
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neuroscience teaching hospital. And he will share his presentation of one-year oncology cases. Dr. Wani is a well-known teacher for young resident all over his years since he's resident. And
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usually, we expect that complex cases end with Dr. Wani that's his reputation it's good and bad at the same time. So, based on his experience, we are honored to have him here and to share his
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experience. The stage is yours, Dr. O'Mib. Thank you, Samar. I want to be here once again. Thank you for having me. Today, I will talk about neuro-oncology through complex cases. I'm going
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to share two cases, often your oncology Our first case is a 36-year-old female that presented an unconscious to the AR in one of the southern cabernorates of Iraq, where they did a brancet discount
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to her and the 3rd of July, 2023.
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This is the brancet discount, and as you can see, there is a colloid cyst and the 3rd ventricle with hydrocephalus, or what we call a biventricular hydrocephalus because of the obstruction of the
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two-phoraminar of Monroe, and there is effacement of the cell side.
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This is the sagittal and polynomial reconstruction of the axial images, and we can see it is in the third ventricle, so it's a typical case of a hyperdense colisist with hydrasophilus. The
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neurosurgeon on cold decided to do an extended ventricular drain. Here is the postop imaging. This is the postop CT scan. We can see the frontal extra ventricular drain, extended ventricular drain
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here The frontal arm, which will only decompress one of the ventricles, while the other ventricle will remain and not decompress because of the obstruction of the foramina of one row.
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The patient regained her consciousness, but what happened after that, the patient was kept on external ventricular drain for 12 days till 16th of July, 2023, when the neurosurgeon has decided to
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do a. by
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ventricular shunts, bilateral VP shunts. We can see there are two ventricular shunts in the frontal home. He used the coffer point.
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And this is the three-year reconstruction. We can see there are two shunts that are connected by a Y connector and one peritoneal shunt.
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If we look closely to the shunt, we can see here a fixed medium pressure that is available in his hospital. It is not a high pressure shunt. So, after that, the patient was shunted. The tumor is
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still there on the 24th of July. The patient is presented with signs of overshunting. We can see here there is attention pneumocrophilos, with Saboteur all the fusion, and he has done a borehole.
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evacuation to try to treat the size of overshunting which created more air inside the brain.
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The patient lost her consciousness and then transferred to another hospital in Baghdad to the admitted to the ICU on the 20th of July.
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This is the emergency scan that was done and the patient continued the clinical condition continued to deteriorate when one of my colleagues, he called me and asked what we are going to do This was
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become a scale score, the six, so he asked me to take over the case.
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Now it's difficult to decide what to do now because there are many things on the stick. We have overshunting, we have two bilateral shunts and the tumor is still there.
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Let's look at the case We have two lenient incisions for the cohort points
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for the shunts and this is the borehole that has been done to evacuate the tension pneumococcalus. It is down in the temporal region.
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So we decided to do a flap
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by connecting these two linear decisions to go interhemispheric transcalusel to resect the colisist. And at the same time, at the beginning, we have to remove the shunt to end the overshanting. So
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this is an intraoperative images of the cases Here, we can see the brain is collapsed. It's - it falls away from the urine and from the fox,
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dissecting the interhemispheric fissure. We can find the callosa marginal arteries with the inferior sagittal sinus, then going inferiorly to the corpus callusum. And this is the callosa incision.
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Here, we use the brain retractor just to know the length of our incision.
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This is the coli cyst through the foreman of one row.
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Then after evacuating its content, we can resect the wall. And this is the bit of the coli cyst after resection. So the patient was extubated once emerged from anesthesia and admitted to the ICU in
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the day zero where a glass become a scale score was raised to 10 And we did a brancet discount and the A zero and it took a closer look to that. Here we can see the coliosis is totally resected and
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we have removed
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the shunt. Let's see that this is the bone flap. And here is a 3D reconstruction. We didn't use the cochlear points as they were away from the intended craniotomy.
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we can see the crannetome is two-third anterior to the corona suture one-third posterior to the corona suture and we elect it to cross the midline with that crannetome because we didn't know if we are
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able to visualize the ventricle clearly because of the midline shift and the the
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singulate gyros herniation the subfalsene herniation so we elect it to to cross the midline to use both of the
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interemispheric fissures both sides of the interemispheric fissure the patient on the 2nd of August is conscious but she was a phasic unable to stand alone and she has no papilladema when we do a
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brain MRI for her after one week of the surgery we can see the XLT1 the sagittal and mononal T2 here the the stills I are opened there's no raise ICP so there is no need for the shunt for a as we can
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see in the axial T2, but in the flare we can see a lot of things are happening in the thalamus and hypothalamus,
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a lot of edema there. On the 1st of November in her last visit, she can walk with assistant talks, but not fluent.
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This is the patient on the 1st of November of 2023.
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So we have a lot of questions What was the right course of treatment for such an emergency? I think doing an EVD, then transcolosal approach for colloid resection. Well, if it was an elective case,
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the patient is conscious, we can do an endoscopic resection.
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A lot of learning points we will talk about. We're sure we are going to discuss that about permanent shunting, the choice of shunter pressure and the shunter flaps. overshunting and how to treat
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tension in mucophilus.
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Our second case is a 53-year-old female presented with two seizures in one week. A brain CT scan was done for her and diagnosed as a brain abscess. She underwent surgery in the form of a
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grand tummy in the 20th of September, 2022.
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This is the CT scan. I have only the post-op. I don't have the pre-op So, we are looking at the CT scan. This is the brain window. We can see here the evidence of craniotomy.
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And there is edema and the temporal parietal lobes with compression to the epsilateral right, lateral ventricle and the middle eye shift. This is the post-op CT scan. And this is the one window.
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And we can see there is a drain.
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The histopathology was fragments of 15 cm, revealed the wall of a brain abscess, there is no granular normal normal pregnancy, and the aspirate was a debris of inflammatory cells, so it was a case
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of a brain abscess at that time, of 20, 20th of September, 2022. The patient was kept on antibiotics and antibiotics, but on the follow-up brain seat scan on the 15th of November,
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the patient was still having edema conversion to the ventricle and the midline shift, so they did the MRI, and the MRI revealed there are brain enhancing lesions in the site of surgery. We can see
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here that there are multinodularity, and another one in the occipital lobe, more posterior to the first lesion,
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these lesions were not restricted, and this is the way it was not restricted in the B1000.
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And in the T2 we can see there are multiple hypodensities inside it not expected for such a brain abscess, and the edema is reaching away into the temporal pole
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Another, there is ankle herniation in there.
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So the neurosurgeon decided to go for another anacronia to me one week after this imaging, and he done the same through the same flap. We can see here there is a resection cavity, but still there
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is edema, and the brinset scan in the bone window here. This is the flap that is slightly erased, And again, they placed a drain.
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While the histobotology at this time revealed that there is a meningioma transitional grade 1, log rate according to the CHI67, there is 25 proliferation index.
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The patient was kept on antibiotics and antibiotics again. But in the follow-up, brain MRI with contrast, which was done on 29th of March 2023 Here, we can see there is still a mass that is large.
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It is not so hyper-intense in
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T2, it has some iso-intensity.
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And in the flare sequence, there is little restriction in the B1000, and the post-contrast showing a ring enhancing lesion And we can't see the second lesion, I think it is one lesion now.
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So, one of my colleagues, he called me and asked me what to do next and asked me to talk over the case.
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So, we decided to remove the bone that you are aspirated from the lesion and excize it with the aid of intraoperative ultrasound on the 4th of April, 2023. This is the intraoperative ultrasound.
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We use it to localize the lesion and here is the abscess. We can see here This is a video of the aspiration. This is the brain needle going inside the abscess.
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We can do aspiration guided by the ultrasound
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and here we can see the ossus.
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And then we resected the deletion, the lesion was, as you see, fleshy, no dealer, there's no smooth
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regions, this
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mass was first done by debulking, then resection.
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So, of course, of Brancid scan, we do on the day zero, fifth of April, this is the post of Brancid scan, the brain window As you can see here, the compression on the epsilateral ventricle
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decreased, and the midline shift decreased, the edema decreased in size.
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And the histopathology revealed a malignant meningioma, a papillary variant, which is WHO grade three, which is a shock
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for us. The aspirated from the bus revealed the staff epidermates,
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which is resistant to so many antibiotics, but luckily are sensitive to others.
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and the bone flap and the duala that we removed were having a pseudo-monos infection.
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We did a follow-up brain MRI three weeks later.
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This is the MRI. This is the T2 axial sections. We can see there the
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ventricle, return to a normal size. There is no more compression, normal line shift
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This is the flare, the edema, so much
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reaching down to the temporal pole. This is the dewy, the V1000. There is no more restriction. And
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this is the post-gaterinium T1 contrast. We can see no enhancement in the site of the surgery. So the patient was referred to the oncology, the radiotherapist started V mat with IGRT They give her
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a total dose of 594 degree and 33 fractions. of 18 dose per fraction.
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The patient was doing well. There was no seizures, no signs of raised ICP, but the radi therapist called me and told me we discussed the case and we elected to do a pet CT scan as it is a malignant
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meningioma to
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roll out metastases outside of the cranial cavity. And to our shock, we scheduled a pet CT scan on the 19th of July, 2023. And there was a good for us no evidence of residual or recurrent disease,
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but there was multiple lymph nodes in the immediate stanum and hyalur, which was suggested to be effective more than your plastic.
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This is the brain and this is the pet CT scan.
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And this is the lymph node, the hyalur and lymph nodes. And this is the pancreatic one and they decided to. to do a follow-up. After, before the follow-up, we did a current plastic with the
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titanium mesh on the 19th of September, 2023. Then the follow-up was on the 2nd of November, 2023, which showed there is a metabolically active price of proclavicular, paratrachial and lift,
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three bronchial, lift, high lower and abdominal lymph node lesions that were increased in size and number and
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FDG availability in comparison to the last pet CT scan and there is no evidence of residual or recurrent disease in the brain.
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So they decided to go to biopsy from the high lower lymph nodes, which was done earlier this month and the lift node biopsy was compatible with amitestatic malignant meningioma to the high lower
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lymph nodes So now the oncologist is doing an MDT about this case. and they are considering to go for a targeted therapy with PIVAS
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regime and the Vrolimos. Sometimes the difficulty in these cases is how to do a decision rather than the surgery itself. Thank
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you. Thank you. Thank you, Dr. Omi, the assignment for this nice presentation. I really expect the audience also have some questions and discussion about that. Obviously, really complex cases.
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And thank you for being with the limited time. So we can give time now to questions and answers. I really appreciate those two presentations.
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In the case of Dr. Netamati, I have two other questions pertinent to this issue regarding to his first patient or that the first patient he had presented, not because he inherited that patient from
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another doctor, is fine. You have a patient with a benign coloesthet in the third ventricle, right? If either of us suffer lose, if the chance, both chance will have worked fine, would have you
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done anything?
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to start with, but you know that,
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yes, to start with, you know that, as we discussed, Colois, there's a benign tumor. If we, if you resect it, there's no need for any adjuvant therapy. And it is the best approach not to place
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chance, you know, that chance,
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chance are not without complications, especially infection. Whenever you increase the number of chance, you are going to have complications sooner or later.
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No, even, even if the, even if the shots were functioning, I would remove them.
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And so, if the, if the chance were working, perhaps you're calling, we don't have asked you for the question.
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If the, if the patient was fine, then the, the patient would never had the removal of the cyst, I at the fully agree with you. that the removal of the cyst is the treatment of choice. And then
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also it is possible endoscopically, there's no question about it. What I'm generally saying is that the level of, that the discussion that you proposed in your presentation was what to do, but
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what to do in the first time. I fully agree with you that you approach the thing at the correct level. I am also asking those questions for the benefit of the youngsters who are here. So you said
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exactly the removal of the seas was that the right thing to do and never put a shunt in those situations. Why do you think that the patient has a fascia after the removal of the seas?
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Because it was unconscious for a long time. She was unconscious for about three weeks
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Ah, my, I miss that but so she was unconscious between three weeks after the placement of the shines and because of the overshounting and there was subdural effusions, subdural hematomas, then
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detention, mukkafalaskic, so there
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were many things going inside her brain,
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the thalamic lesion is not related to that, I mean, I don't think so I think it's one of the theories that explained the sudden death in cholocyst is having a compression on the
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thalamus and the hypothalamus and the arrhythmias that it caused. That's why we are seeing that in the MRI, the patient had never done MRI prior to the surgery. It was done only after the surgery.
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We did it to ensure that there is a non-subdural effusions, there is no
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hydroscophilus and there is no need for something, and for sure not to do so many brain seat discounts whenever we can do any MRI, it's better than. giving radiation to the patient.
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Perfect, so you're at the teaching point for our audience, for the young audience, not for Dr.
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Rassmann or Dr. Ozzar, or Dr. Ozzar, or the other ones who know the issue, is call the assist, don't chant, remove the assist, and the consequences of not doing it properly are impeding the
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quality of life of the patient. Has she improved or, well, she had such an issue? Yes, yes, and her last visit, she was able to talk, she can sit alone and only walk with assistance. Nice
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seeing you, thank you. Dr. Osman, you
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had to, you had to raise your hand? Yeah, a number of questions there. Dr. Madi, first of all, I always enjoy your talks. You do a very good job and you ask some very fun, good fundamental
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human questions all the time. and I have a high regard for what you do. And these are two cases. I think we have to put it in the perspective here. You're receiving these patients after they have
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been treated elsewhere. And so you're seeing patients that have complications if they didn't have complications, you wouldn't see them. I think there's a message there, I'll come to that. So in
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the college, this is perfectly understandable. I can understand a person who may not be familiar with it or may not have the equipment or the assistance to put bilateral shunts in somebody who
24:02
looked like they have a college system. It's been done for years. And in this case, it didn't work. Or for whatever reason, it didn't work and had incredible complications, which happened. And
24:14
then you saw the patient and everything you did was - I thought was very, very reasonable. It gets me to something I'm going to tell you about in the second case.
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The case with the brain abscess, again, a common thing that people would see, they treat. Maybe some people would treat it more aggressively, first time than others. There
24:38
could be difference of approaches, but you received the case after it became very complicated and found that there was a malignant tumor associated with meningioma and did everything that was
24:49
reasonable that you could to take care of that So you're dealing with a disease that had appeared simple initially, but actually turned out to be very complex and now is multiply metastatic. So it
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gets me to, and again, I think you're what you've done technically, your thinking processes, the question you ask are superb. Absolutely superb. And
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I couldn't have it, I couldn't ask a second question about anything you did When you get to that point, anything you do that makes sense, makes sense. But what it does do to me is it points out
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issues that are important in low to middle income countries and high income countries. And it can be solved in Iraq with modern technology if people don't spend their money on war. And that is
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television communication between centers like yours and those in other hospitals and other areas in the country, where you can pick up these cases where people can have conferences like we had
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televised in the past five series of conferences where people can bring their cases and discuss things and make them feel comfortable talking and consulting other people and not make them feel
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terrified that people are going to criticize them.
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I think this is a mindset that we have to introduce and it's true all over the world. It's true in our country. And this is a high-income country. people need to be able to be honest and say I have
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a problem. I need some help. I need some consultation and you can give them that consultation. That may have helped you in these cases. And
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so it also points up to the fact that it's important to have conferences where people can feel free to talk to people like we're doing here. And if you can feel uninhibited to refer a case and not be
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criticized by the doctor who receives a case, I haven't heard you say a critical comment about any case you've received, my compliments to you. So I think there are multiple messages that come out
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of this. In the first case from public health, in the second case, what can you do with the limited resources you have to bring the best quality of medicine to the most people that are at for the
27:11
least cost? And I think that's the same problem we have in our country, although people don't want to recognize I think we can spend more money and then we'll get the better result that center.
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So I think that we all in the, everybody in the world has this problem to deal with. There are no unlimited resources for health care. It is not unlimited. We have to feed people, we have to
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clothe people, we have to get them jobs. These are things that are very important. And in neurosurgery and in medicine we, have to find simple, simple, reasonable treatments and ways of treating
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people. We have to prevent drug companies from basically stealing, stealing health from patients. They have to be persecuted as criminals.
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And the same here is we ought to be able to reuse these resources so we can bring your talents to people all over Iraq and make them feel comfortable. They can call you earlier. You have a chance to
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look at these diseases You're an extremely talented neurosurgeon who's done an outstanding job. I've gone over your videos many times.
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And obviously, you have talented people in Iraq. You have talented people in many countries. We have to use them. We have to get them all used properly. We have to use our resources properly.
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That's what I got out of this. And I hope the students get the message 'cause if you don't go into neurosurgery and probably a fraction of this audience will, you can go into public health. You can
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go into medicine. You can go into other specialties. But these are things you've got to keep in your mind. That's why you go into medicine I'm here to help patients. That's my primary goal. My
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goal is to be the best I can for the patients. Treat them as they are your family. You're the best you can for them. And if something stands in the way, you've got to stand up and you've got to
29:08
say, that's not right.
29:11
Thank you very much. Yeah, well, Jim, you were talking about the limited resources. Professor Ari and Slemania, he's with us now. that in the time of sanction, we used to take the blocked
29:25
shunt, and we clear it, we clean it, we
29:30
reinstallize it, reinstallize it, and then we put it back again because we didn't have shunt at all at that time. And we either relieve your patient to die from progressive hydrocephalus, or you
29:39
do something which you don't believe in, but you have to do it. And the limited resources which we had during the sanction was beyond imagination So many operational lists were canceled because we
29:54
don't have oxygen. That's where possibly this will be in some of the limited resources countries now. We don't know. You remember Arir?
30:06
Actually, do we
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need more missiles, or do we need more medical care? Yeah.
30:16
I hope the decision makers will listen to the other,
30:21
Well, I'm sure the students are listing because their hearts are right in this and thinking about this. And when you grow up this and get more influence in the medicine, that's where you ought to
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be. Not where pharmaceutical companies or business people or even doctors who want to make money are injuring the individual patient. That's unacceptable. It's unacceptable Yeah. Many surgical
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procedures done now and necessary. Many investigations, including radiology, MRI, and others, and characterization.
30:57
Many of them are unnecessarily done for the sake of money apart everywhere. Dr. Mahdi, you are not in that category. You are a very compassionate, thoughtful,
31:10
considerate, skilled human being and neurosurgeon.
31:18
with the representative of her state father. Thank you, thank you.
31:23
So I guess if there are no more questions pending, we understand
31:29
the summary. I will say for the people that the two lessons, one expressed dramati really and enthusiastically and emphatically by Dr. Alsman. We all agree with that. And my personal thing again
31:43
to Dr. Matty and in which he did not mention or did not criticize his colleagues and he was open to share the many complications that aroused from the patient. We all have complications. The
32:02
neurosurgeon or the surgeon who says that never had any complications or has very few complications. Either he's not doing surgery or he's lying And the complications, that's the unfortunate things
32:17
The textbooks gives you the impression that everything is pre-stringed from A to B to B to C, C, D, no? Diagnosis, treatment, outcome, and this is not how life it is. Now, that's why we have
32:31
the training and I sincerely hope, and I know that the many young people who are listening, who are listening from both of you, from Dr. Hallele and his experience, and from Dr. Matty, and his
32:46
attitude, you know. And we keep Dr. Maas, Dr. Lausman message
32:53
to the heart as well, you know.
32:56
And if anybody has any other questions, we will close this issue, if you agree with someone. Don, I'll make some comments. Please, please, excuse me, I think, but that is your comment.
33:14
From the many things that we teach to our residents, the first of which is being a safe surgeon. Don't risk the life of your patient. And it's okay to ask for help. We all of us want to help you.
33:30
Even if you are far away from us, we have rushed into another of the coordinates to do the surgery. So it's a privilege to do that. This is one Number two, as always, it's
33:46
less painful to learn from other faults. So when we are sharing them, it's for teaching purposes, for them to learn.
33:55
And as we say in your surgery, it's all about complications. And when you become more expert, you know how to deal with them. And when you are more expert, you know how to avoid them. This is
34:07
the complication avoidance
34:12
Okay. If it's been known that the real surgeon is the one who decided not to operate, was able to decide not to operate. And the surgeon has his knife in his pocket, better than the, not
34:27
necessarily better, but safer than the surgeon who puts his knife in his hand.
34:34
That's absolutely right, Heidi. And Dr. Matty asked, raised a question and one of our last meetings
34:42
He didn't answer it. But he said, If somebody comes in and they have a left dominant hemisphere stroke, middle cerebral artery occlusion, and they have massive edema, and they're a phasic and
34:56
amiplasia, what should I do?
35:01
What should I do as a surgeon, as a technician, which you're not, You're a surgeon, you're a physician. As a technician, you can all do a lot of things. You can operate, you can do this, and
35:13
the next thing. The question is, what should be done? What is the humane thing to do?
35:22
And that was the question he was asking.
35:26
And that comes from a doctor, a soul. And any question or comment from
35:34
presenters, final thoughts, final comments for the closing remarks?
35:41
No one? Okay. So I just want to let you all that the recording of this meeting will go first through editing, then peer review, and then will be available at the
35:56
SNI digital, hopefully as soon as possible. And we will share also the recording with you for those who want to share it, and also for those who want to, I attend the presentation again and thank
36:11
you everybody for being here. It's an honor to listen to all those experiences. I'd like to
36:21
ask one thing. I wish everybody here would send their comments.
36:31
We can't do better. I left the operating room, asked everybody, what could we do better? And that's what we need to ask here. What can we do better to teach you better to help you better to help
36:43
the patients better and send the comments to Sam. That would be immensely helpful. We're spending a lot of time and effort trying to bring this to you We want to know if it's worthwhile. If it's
36:55
not worthwhile, what can we do better? We want you to teach you
36:59
better. And I thank you very much. Thank you. Thank you, Professor. And thank you all. Thank you for everybody. Thank you for your time. And see you again in the next meeting and have a great
37:13
day. Have a great time. Thank you. Bye bye Thank you. Thank you.
37:19
Thank you. Thank you. Thank you so much. Thank you.
37:27
Thank you so much. Thank you. We hope you enjoy these presentations.
37:35
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37:50
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37:55
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