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Welcome to the 20th SNI and SNI Digital Bagdad Neurosurgery Online meeting, November 26th, 2023. The meeting originator and coordinator is Samur Haaz, University of Bagdad, and Pittsburgh
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The program and speakers are, Professor A. Hadi Al-Khalili, former chair of the Department of Neurosurgery, Baghdad University. He is speaking on Hyetatid disease, presentation, management,
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and prevention.
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The next speaker is Dr Wamith. E. Mati. He is speaking on neurooncology through complex cases. Hello, everybody I hope you are doing well, good morning, good afternoon, or good night, or
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whatever, the place you are from. We are
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pleased to have you here. This is
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the 20th surgical neurology and national Baghdad meeting. Today, we will have two presentations followed by discussion, the discussion will be led by Professor Lazarev, and, um,
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uh, this, uh, activity is supported by the surgical neurology international and the SI digital. The recording will be available in the SI digital as soon as possible after the meeting and will be
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peer reviewed before posting there and we will keep you updated with the update from the SI digital. We think this is the future and where all the important peer reviewed videos will be available for
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all the readers related to neuroscience and general neurosurgery in particular. I want to say as well
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our dear friend Dr. Haidar Salih, who's my colleague starting all things together, is we want to just to pray for his mother She's very sick and the
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other thing I want to say that during the last I think more than two years we work with the SI Digital and the surgical neurology international team trying to education to separate education all over
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the world and supporting the generation worldwide. For the future meeting we want to announce that there will be sub-specialty oriented next meeting we are preparing a spine meeting pediatric and
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vascular. They are expected to be next year in one or two months, space or distance. And for the moderators, we have here, Dr. Jim Osman, he's a very well-known neurosurgeon. He's the
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editor-in-chief for the SI Digital and the owner for the SI Search Technology International Journal and the owner and founder of the SI Digital and also we have
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Professor Jorge Lazarif. He's also from the US UCLA. They will lead the questions and answer after the meeting. And for the presentation, which is the last part of my introduction,
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we will have two presentations. First, we will start with Professor Adiradi Falevi, who is a well-known, actually one of the founders of neurosurgery in Iraq He's a well-known scientist in
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neurosurgery and mentor for many people within and outside neurosurgery. He's very well-known with his encyclopedic approach, and he will talk about high-date disease presentation management and
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prevention. After Professor Falevi took, we will start with Dr. Wami of Assam Meti, was in your sedule from Iraq. And he's practicing now in Iraq. He will demonstrate some of the complex
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neuro-oncology cases. And after that, we will have a question and answer and the discussion, as we say, which is the most important. Just to say that we are very proud to have you all here. And
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for me, this is very special meeting because Dr. Mehtia and Dr. Felili are my real mentors during residency and after that, to have them and to show their experience to others. It's the thing
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that makes me really proud. And I think being good to our teachers is part of the thing that we want to deliver to the young people here. And yeah, the stage is yours, Professor Felili And you're
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welcome. Thank you. Professor A. Hadi Al-Khalili. former chair of the Department of Neurosurgery, Baghdad University. He is speaking on heitated disease, presentation, management, and
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prevention. My talk will be on heitated disease, presentation as Samara was saying, presentation, management, and prevention. Heitated in Greek is meant a drop of water and it can focus in Latin,
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hedgehog, and granulosas, as little grains In Babylonian medicine, Sist was referred to as seen in liver and lung of the carcass.
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And the term heidatosis was used initially by Lamarck in the early 19th century.
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There are many types of human tapeworms, including tiniasolium, tiniakanococcus. Of
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this, we have two types.
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a calicocas multilacularis and the calicocas granulosis. Kineosoleum, which produces neurocystic psychosis, is rare in our part of the world, and the definitive host is man, but the intermediate
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host is pig.
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And it is more in central and south America and Africa and Asia and Eastern Europe
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The presentation usually is headache, seizures, focal neurologic signs, altered mental status, aseptic meningitis, and others. And on the MRI, you can see this multiple lists, all over the
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brain, multiple lesions, and the interesting thing on the CT scan, you see calcified spots spread all over the brain.
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The Kannukokas of multilocalaris, definitive host is foxes, more red fox, other canids, including domestic dogs and
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wombs, intermediate host is rodents,
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and the human is an extental host.
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Distribution of Kannukkok, multilocalaris would be in Europe, near East, Russia, Central Asia, China, Japan, Alaska, and maybe other places. And the presentation depends on the size of the
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cyst, the location, the complication happens with the cyst. And you can see this, the CT scan and MRI showing the cyst T1 and T2.
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Addetid cysts, or addetid disease, is caused by the type of teethea, it can be focused on granulosis 5 species. are known of
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a kinococcus granulosis. Again, a kinococcus granulosis synostrictor, the sheep, which is the commonest, the equinus, the horse, the orthopedic, ortholipse, the cattle, and the kinetiduses,
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the camel,
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and the felids, the lion. So all these animals, maybe others also will be involved and infected by a kinococcus granulosis
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The dogs are definitive hosts, wild canids, foxes, and wolves, and less commonly cats. Intermediate horse, the sheep, horses, camels, cattle, and lions, and the human is again, is an
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accidental host, and what happens is when the sheep late the
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part of the tinier, which I'm going to discuss in details, on the grass, the sheep will eat that, and they will have the cycle of the infection, and then - vegetable or a fruits would be taken by
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mine accidentally before washing properly and then they will have the cyst developing in the body.
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Global distribution of the granulosis is the Mediterranean areas as you can see from this and Middle East, South America, Australia, New Zealand, Africa and Central Asia. There is no racial
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predilection, females are usually more affected than males, all ages affected and young people are higher than that. The teeny itself is about up to 8 millimeters in length and the head,
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it has four segments, the proglatives they call it, and the head has four suckers and that has these hooks, they go up to 52 hooks in the head. And in here you can see See the bowel of the dog
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with so many teetions attached to it.
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The gravid, which is the last segment of the tinnia, that's the most dangerous part. What it is laid down, it produces the cycle of the disease. And then this is the egg laid from that with a
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capsule there. And you can see here the egg has ruptured from the capsule and it's in the villi of the small bowel to go to the bloodstream.
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The egg each pro-glotid has 200 to
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800 eggs. And daily peak could be called recorded. Daily peak of 71, 000 eggs observed from dog harboring 12, 767 teeny. And eggs can spread up to 80 miles from the site in 10 days. That's when
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it is dried and there is wind, it will go with the wind to different places up to 80 miles. So it can be dangerous even not in the site of the lay down of the teeny
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The cyst has a fluid. which is normally clear, specific gravity is of one or seven, and then up to one or 15, and the pH is 72, 74, containing albumin and other proteins, salts, phosphate,
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calcium sulfate, sugar, fat, and other substances.
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The cyst has layers, and the body will produce reaction around the cyst, which is called adventicia in the case of the body, but in the brain it will be some very, very thin layer of probably the
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layer produced. And the cyst may be fertile and has granules and scoliosis inside, and they've seen a paper from Levenon some time ago, and they said in each one milliliter of fluid, they have 10,
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000 scoluses. So you can imagine how dangerous this if it is ruptures. And also it can be stale, there's no, there's no scoliosis or over inside.
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The growth of the cyst depends on the organ. Of course, if it is in the liver, the liver is a solid organ, the growth will be slow, but in the lung, it can expand quickly. And the brain, again,
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it is not as solid as the liver and not as soft as the
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lung. So it progresses and the increase in size is slower than
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the lung. But it increases normally one to two centimeters diameter in six months and six centimeters in a year and doubling in 10 to 20 weeks.
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Had that, it can involve any organ. They say, well, we haven't seen it in the teeth, but we have seen it literally everywhere. I have seen one in the retina of the eye at one time.
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It kind of led to the lung, the liver, the bones. And this is interesting case. A patient came to me with chronic back pain and leg pain.
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What I normally do with every patient I examine, I go to the peripheral pulses, especially in those with back pain, and they found there is no docile speed, there's no popliteal, no femoral, and
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then refer the patient to the cardiovascular surgeon, and he found high dieted in the bifurcation of the commoniliac. And this is really very rare.
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A clinical presentation depends, again, on the size of the cyst, location complications, like infrastructures, if there is affection, if it obstructs any organ.
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Testing laboratory, cassone tests, indirect imagination, immuno-electrophoresis, ELISA, imaging, ultrasound will be helpful in the body-high-tadded CT scan, and MRI are the tests of choice.
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Treatment, medical benzimidazoles,
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which include albendazole, and the men deserve which have been knocked out. changed for decades. In fact, after now, they are the treatment of choice. Also, they can use prasaquantil and
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decolizamide.
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Treatment surgical is, the aim is complete removal. And there are many variations of that and many ideas came. Then cryo freezing was done by Saeedi in Iran in the 70s And of course, it would not
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be feasible in the brain. It can be feasible somewhere else, but I don't think it was really successful because it was not adopted anywhere else. And pericutaneous injection of maybe hypertonic
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saline, 20 formaldehyde is forbidden now to use it to be used in the past. Sets your mind and silver nitrates also be used by some people, but all they have no real damaging effect, complete
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damaging effect on the on the scoliosis.
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Prevention focusing on dewarming of dogs by medications to the dogs, vaccination of sheep and and dogs, slaughterhouse hygiene and public education, washing fruits and vegetables, although it is
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so simple, but it is really very, very effective.
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And it is recommended on the TV and back that when I invited Professor Gamel
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from New Zealand And he was advising people on the TV that saying what you need only to wash thoroughly your fruits and vegetables. Professor Gamel, one of the leading WHO specialists on that line.
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And this presentation, we emphasize on the hydrocyst of the brain, that's pine and the orbit
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A study I did in the 90s, studying
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1976 to 1985 cases, there were about 2222
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cases. and Medical City Hospital, which is General Hospital, they didn't have neurosurgery at that time. And the patients were 1, 368 patients. If they're in a fees hospital, which is
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exclusively Cardiotharasic hospital, there were 5, 550
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patients and neurosurgical hospital. Under the four patients, there were cerebral and 95 and spinal nine. In this case, we have six spinal cases with the Medical City Hospital.
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The age and percentage can see the spread all over, but 44
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under the 30 years of age. We are talking on high dieting in general, of course. Gender and organs, you can see that
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brain and orbit, again, slightly prediction, the prediction of females and bone and spine, more females than males.
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The organ incidence, you can see that the chest has 29, 30. The abdomen is 667. And the brain and orbit 05 and bone and spine, they have 08 of the total.
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Age and organs, you can see that this is the brain and orbit, you can see it more on this side, and this is the spine. You can see it's more on this side, more clearly on this graph You can see
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the brain and orbit on this part of the age scale, and bone and spine on the other part of the age scale.
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Cerebral had at its cysts.
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We didn't have at the big four CT
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scan, even with the CT scan, we can't see that in the plain x-ray, the inner table of the skull at the side of the cyst is lost.
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Well, indirect indication that there is a possibility of hydrated in this area because it's chronic. The bone is not affected. It is just probably by the pulsation. And this area made the calcium
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escape from this part. And in children, you can see increase in the widening of the sutures. And in late cases and rare cases, you can see calcification at plain x-ray CT
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scan, you can see well-defined space-occupy anglation, cystic, smooth outline, no peripheral edema, and no change in contrast. And in MRI, you can see that T1, T2, it's very classical of a
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cystic lesion.
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Cerebral high does it can be solitary or associated with other organs or multiple metastatic
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The solitary and adults usually it is posterior.
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and in children usually it is anterior. And this is supported by many workers, many papers published.
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Associated with other organs, the liver was seen in eighth cases and lung. So associated with all these cases with cerebral high dietid.
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Multiple high dietid, this can be, this is most likely to be metastatic coming from the lung rupture dietid. And this one, multiple, but probably it is due to head injury and trauma, which can
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produce this multiplicity. In a
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study of 95 patients, we've seen 47 males and then over at the 15, 53 and right and left almost the same.
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Presentation, as you can expect, as a space of grand lesion, nothing really fancy, but headache and vomiting, blurred vision. their consciousness, seizures, and nonspecific in some.
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Papaladema's 19 was seen, hemiparesis in 15, dysphasia, facial palsy, and other training nerve palsy.
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Surgical removal,
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you must ensure large cranial tummy and make sure that the edges of the bone you opened are smooth. There is no spikes in that edge of the bone because it may rupture the cyst as it comes out And
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tawling, you have to make sure that the tawling, you make it in a way that it will enable you to use the maneuvering, just gravitational help in case you need that to make the hydatid cysts on the
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more dependent part of the head to enhance the delivery of the cyst. Dowling Orlando technique, the hydrod section, when you put this water or lucho later in detail, and then between the cyst wall
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and the brain itself. And while salva maneuver, you can ask that he says it during your surgery to do valsalva to just make a little bit expansion of the brain and that will push the
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cyst, you know, easy way not easily.
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You can see here, this is a big high diatocyst.
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Solid 3-1.
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And then when you open the door, I have to be absolutely careful because you don't know that the high diatocyst may be underneath your cut. So it is very small opening you make and then blunt hook.
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You can use to enlarge that small incision and then use the patty then, the cotton patty to introduce it when you cut And as you cut, you can guide the cotton patty with the tip of your scissors.
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So you protect, as you cut, you protect the brain and the possible high diated underneath. You can see that the cotton patty is moving with the scissors. And then gently you dissect
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It executes the quality of the video because that was done at the time that was difficult to make any video literally. So use ads in the sector just to smoothly separate and then use the hydrogen
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section
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to push the cyst outside. You can use some pressure, very gentle pressure, if you want, without using excessive pressure, and then the cyst will deliver smoothly and safely
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And then
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the dura
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is closed. I like this,
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it will always provide room for using the whole exposure area.
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So the trick here is really to be very, very careful when you open, sorry,
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yeah, when you open the door, that's the main thing. A cure can be as achieved by the removal of ad ruptured cysts, and a fracture must remove all cysts parts and start elbendizor
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Spinal hydatid
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can be intramadillary, intradural extramadillary, intradural intraspinal, vertebral, hara vertebral. And you can see here, this is a my ideal, because at the time we did not have myelogram
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other than my deal, no cysts can, no MRI, so you can see the block here and this
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curd, curvilinear block The block here, that's all high that of the sponge or the oil, high that of the spine.
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You can see here, this is under the skin, and that's in the bone. And presenting symptoms, back pain, swelling, mono perises, para perises, as you expect with any special pressure on the
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spinal cord or the nerves. In the
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MRI, you can see it is a cyst, as you can see T1, T2. But the interesting thing is, it looks like vertebral osteomyelitis
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But the difference is, there is no osteoporosis, there is no osteolysis or cyclorosis, and the discs are normal. This is very, very important to remember.
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Now we move to orbital high diatocysts, which is my hobby. Presentation usually is proctosis is slow and painless, rarely painful. I had only one case with very, very severe pain, And I took
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that patient immediately to the family hospital and measured the - pressure of the eye, it was very, very high. So acute glaucoma produced by this hydrated of the orbit of that patient. Chemosis
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as subconductible edema, palpyril edema, orbital satellite, is visual impairment and the restriction of X-raycular movements.
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In the personal study of 15 patients, they've got some more, but orbital hydrated mostly 10, 10 were under 30 years of age and 10 females, five males, and right side nine and left side six.
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Presentation was silent progressive protrusion of the eye vision was normal in four, diminished in three and lost in eight patients because of late consultations. So most are fortunate for this
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disease to for the patient to lose to the eye where it can be treated. Fundoscopy was seen for papilladema in four, primary optic atrophy and secondary optic atrophy. with normal in three patients.
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Treatment, surgical removal, as soon as possible, and by anterior orbital approach.
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This is the lady, which we have shown, and that's after surgery.
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And another lady here, before and after surgery,
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and that's the highlighted. And this man, in fact, I operated when he was a child, and then one day I went to the Ministry of Health, and then somebody was calling me from behind, and then said,
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Dr. Doctor, do you remember me? And then that was 10 years after his operation, he is doing well without any recurrence.
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And that is just the tricks of the surgery, which I thought would be useful to share with
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you So I thought to the skin, well the answer would be the response to about two centimeters would be just fine for the surgery. I think the tissue is there, or it goes up really and then it's down
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to the septum to get things open. This action has to be very careful because it doesn't come to rupture
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This is the octave fire, which is mucin sometimes during that section. So you may need to de-thermize it
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and cut part of it. Now the gentle retraction, you can reach to the tissues, what you hope to expose
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the hydrothesis. Listen, if the fire was usually action, but you spider with it. surrounding the two cysts,
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and that's the two cysts showing by putting the acoustics out.
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And the trick here, which has to be done properly, and that's you have to hold to the virus, usually action, but you're spider-belly.
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Persists with an armpit for such, preferably to armpit for such use. So that's not true, that's the armpit for such death, fixing the acoustics Now, rupturing the indices is the trend, and then
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you set out all the fluid and gently you do for such use, that they should be no good for such use. And just slightly, the indices out of the native you do for
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such use really gently, but as you press very firmly on the process, you come through the indices and then you leave out to leave some of the indices inside where the currents is inevitable will
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have gently to clean up the neck knee for steps.
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holding on the right hand and then left hand and gently coming out with some patience you don't do trash and then you must make sure that everything is removed as
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you see the fungus is clearly seaming without being evaporated and then this is the fungus coming out and that's all this is now is out and you can see that it's out and you have to wash the area of
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the cavity. That's the
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after the first step then you can see it.
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The second one, the first one is removed and the third step then you can make sure there is no post-operative reaction as there may be some allergic reaction. This is the help and then you can
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switch it layer-by-layer and then you listen to all the glass of sodium also switch it
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with a simple layer to get all functional.
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and then the suture will come to the scale and then you can see all the suture there.
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So, orbitally, to my satisfaction is solitary, it is not accompanied with any other hydrated in the body, and there is no recurrence when you rupture it, and I suspect that it is of different
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species other than that would affect the sheep, and it is the kinococcus equinox. This horse has orbital hydrated, in fact, reported
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Now with the current status of hydrated disease, despite the significant progress in genetics, genomics, molecular epidemiology, and treatment in the 21st century, and real breakthrough has yet
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to be made in hydrated disease management. Hydrated disease remains an ongoing problem and a global challenge WHR reported in 2021, WHR estimated the kind of causes to be the cause of 19, 300
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deaths and rounds, 8, 000 deaths.
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807 to 1000 this ability global globally each year and you of course are US three billion dollars for Sweating patient and losing the livestock industry or loss in the livestock industry The WHO has
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also listed a kind of causes as one of the 17 neglected diseases targeted for control or elimination by 2050 And Iraq I that a disease used to be called the cancer of Iraq by our professor Hall of
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Nanjing in two studies at MCH that's medical medical city hospital studying 1971 and 1973 case of three years the rate was eight patients pair 1, 000 admissions to the hospital but in a study which
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we jointly did in the 90s we studied three years of 1980 and 1982 to compare It was 4, 000
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in admission cases, admitted cases, to the general hospital. Many studies published from Iraq in the recent years. I'm so happy to see those publications. And in cerebral, we have from Mosul,
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2013. I'm at Hamoud, 32 intracranial hydrates.
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From Baghdad, Zeke Hassan and colleagues, eight patients to 2019, Baghdad safe, sorry, and his colleagues' case report. And I think Samir was in that case as well. Yeah. And 2021 from Mosul,
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Hamoud Shah, current colleagues, 19 patients. In general, everybody had that in 2021. Western from Baghdad, Rajav,
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from Rajav joined again in the 60 patients. And from Kurdistan, we have Araz, Aesir, 64 patients. And interesting that from Basra,
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scientists, they did it on sheep. And they found among 631 sheep, 73
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are infected with high dieted.
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In 1989, we conducted an international symposium on high dieted contributed by renowned international WHO especially from New Zealand. As I mentioned before, Dr. Gamel, USA from Oregon,
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Professor Rauch, Alaska from Professor Thompson, Canada from the Chandler and Turkey from Adena, Oglo, and others. It was very interesting today meeting. In fact, research, a
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strategy proposal for targeted musket research proposed in general, high dieted disease research three was proposed, presented, and that research three suggested that the researchers in basic
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research in lab diagnosis, in surgical treatment, these prevention, epidemiology types in the country, radiological diagnosis, medical treatment, education, any project in those lines, they
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can do that within a strategy, maybe three years, four years, and by the end of this time, we can get all the information and tabulate that and reduce the, conclude a proper strategy to, to
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study and to help and to treat the disease, not only nationally, but also internationally. In conclusion, we need more collaborative, multidisciplinary, national, and international teams to
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study all aspects of the disease aiming at its eradication, and thank you so much.
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Thank you, sir.
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Thank you for the nice presentation. I have questions. I think many have some questions as well and comments. I would request to start the second presentation possible. And then we can listen to
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the questions or discussion about the two presentation Thank you very much.
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The next speaker is Dr. Wamith E. Matty, neurosurgery IFA aunts. He is speaking on neuro oncology through complex cases And now
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we
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want to invite Dr. Wamith E. Matty. His father is the Dr. E. Matty, the well-known radiologist, one of the founder of Radiology in Iraq And he's very radiology oriented in neurosurgeon and
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based in Iraq, and now we're going to settle with three. a neuroscience teaching hospital. And
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he will share his presentation about neuro-oncology cases. Dr. O'Mill 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. O'Mill, that's his reputation. It's good and bad at the same time And so, based on his experience, we are honored to have him here and to share
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his experience. The stage is yours, Dr. O'Mill. 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
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going to share two cases. Often, neuro-oncology. Our first case is a
36:40
36-year-old female presented an unconscious to the AR in one of the southern government rates of Iraq, where they did a brancet discount to her, and the third of July 2023. This is the brancet
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discount. And as you can see, there is a colloid cyst and the third ventricle with hydrocephalus, or what we call a biventricular hydrocephalus because of the obstruction of the two phenomena of
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Monroe. And there is effacement of the cell
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This is the sagittal and coronal reconstruction of the exhale images, and we can see it is in the third ventricle. So it's a typical case of a hyperdense colonist with hydrasopholos. Then you are
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searching 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 ventricle drain here
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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 3D 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
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there on the 24th of July. The patient is presented with signs of overshunting. We can see here there is a tension pneumophilus with subdural effusion and he has done a overhaul. evacuation to try
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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 Priscidiscan 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 took on
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a scale score of 6, 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 shuns 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 shuns and this is the borehole that has been done to evacuate the tension pneumopholus. 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 overshaunting.
40:47
So this is an intraoperative images of the cases Here we can see the brain is collapsed. It's, it's fall away from the urine and from the fox.
41:00
Dissecting the interhemispheric fissure, we can find the callous-emerginal arteries with the inferior sagittal sinus, then going inferiorly
41:14
to the corpus callousum. And this is the callousal incision. Here we use the brain retractor just to know the length of our incision.
41:22
This is the coli cyst through the foreman of one row.
41:28
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
41:46
the day zero where a Glasgow Commiscale score was raised to 10 And
41:51
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 we have removed the shunt.
42:06
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.
42:19
We can see the crannetome is two-third anterior to the coronal suture, one-third posterior to the coronal suture, and we elect it to cross the midline with that crannetome because we didn't know if
42:30
we were able to visualize the ventricle, clearly because of the midline shift and the singulate gyrosherniation, the
42:39
subfalsene herniation So we elect it to cross the midline to use both of the
42:49
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
43:02
do a brain MRI for her, after one week of the surgery, we can see the XLT1, the sagittal and polynomial T2. Here, the
43:11
stalsi are opened, there is no raised ICP, so there is no need for the shunt, for a permanent shunt. As we can see in the Excel T2, but in the FLIR, we can see a lot of things are happening in
43:23
the thalamus and hypothalamus, a lot of edema there.
43:30
On the 1st of November in her last visit, she can walk with assistant talks, but not fluent.
43:39
This is the patient on the 1st of November, 2023.
43:45
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,
44:00
the patient is conscious, we can do an endoscopic resection.
44:05
A lot of learning points we will talk about. We're sure we are going to discuss that about permanent shunting, the choice of shunting pressure and the Shanti Flabs. of worshiping and how to treat
44:18
tension in macophalas.
44:21
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 grand tummy
44:35
in the 20th of September, 2022.
44:39
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.
44:55
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.
45:11
And we can see there is a drain.
45:16
The histopathology was a 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
45:30
case of a brain abscess at that time, of 2020, 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,
45:47
the patient was still having edema conversion to the ventricle and the midline shift, so they did the MRI and MRI revealed there are brain enhancing lesions in the site of surgery. We can see here
46:02
there are multinodularity and another one in the occipital lobe, more posterior to the first lesion,
46:11
these lesions were not restricted, and this is the way it was not restricted in the B1000.
46:19
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
46:34
Another, there is ankle hypniation in there.
46:38
So, the neurosurgeon decided to go for another acronym 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
46:54
is edema, and the brain set scan in the bone window. Here, this is the flap that is slightly erased, And again, they placed a drain.
47:09
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.
47:23
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.
47:42
It is not so hyper-intense in
47:49
T2, it has some iso-intensity. 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
48:06
think it is one lesion now.
48:11
So one of my colleagues called me and asked me what to do next and asked me to took over the case.
48:20
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. We
48:34
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.
48:47
We can do aspiration guided by the ultrasound.
48:53
And here we can see the hostel.
48:60
And then we resected the lesion, the lesion was, as you see, fleshy, no dealer, there's no smooth
49:07
regions, this
49:10
mass was first done by debulking, then resection.
49:17
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 You can see here, the compression of the epsilateral ventricle decreased
49:31
and the midline shift decreased, the edema decreased in size
49:36
and the histopathology revealed a malignant meningioma, a papillary variant, which is WHO grade three, which is a shock
49:45
for us. The aspirated from the bus revealed the staff epidermitus,
49:52
which is resistant to so many antibiotics, but luckily are sensitive to others.
49:59
and the bone flap and the duala that were removed were having a pseudo-monos infection.
50:06
We did a follow-up brain MRI three weeks later.
50:11
This is the MRI, this is the T2 axial sections. We can see there the
50:18
ventricle, return to a normal size, there is no more compression, normal line shift
50:25
This is the flare, the edema, so much
50:29
reaching down to the temporal pole. This is the dewy, the V1000, there is no more restriction. And
50:38
this is the post-gadirinium 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
50:53
her a total dose of 594 degree and 33 fractions. of 18 dose per fraction.
51:02
The patient was doing well. There was no seizures, no signs of raised ICP, but the radiotherapist called me and told me we discussed the case and we elected to do a obesity scan as it is a
51:15
malignant meningioma to
51:17
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,
51:35
but there was multiple lymph nodes in the immediate stanum and hyalur, which was suggested to be effective more than your plastic.
51:45
This is the brain, this is the pet CT scan.
51:50
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
52:03
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 for a particular parathric hill and lift,
52:18
three bronchial, lift, high lower and abdominal lymph node lesions that were increased in size and number and
52:26
FDG availability in comparison to the last pet CT scan and there is no evidence of residual or recurrent disease in the brain.
52:35
So they decided to go to biopsy from the high lower lymph nodes, which was done earlier this month and the left node biopsy was compatible with amitestatic malignant meningioma to the high lower
52:49
lymph nodes So now the oncologist is doing an MDT about this case. and they are considering to go for a targeted therapy with PIVASU ZIMAP and EVROLEMOS.
53:05
Sometimes the difficulty in these cases is how to do a decision rather than the surgery itself. Thank
53:17
you. Thank you. Thank you, Dr. Omita. I'm with you for this nice presentation. I really expect the audience also have some questions and discussion about that. Obviously, really complex cases.
53:32
And thank you for being with the unlimited time. So we can give time now to questions and answers. I really appreciate those two presentations.
53:48
Now we invite Dr. Farley Lazar who can give his opinion question and answer session of the discussion. Welcome, Dr. Lazar. Thank you, thank you. First of all, I mean, fantastic the
54:03
presentations, both of you are not, I'm not the words extraordinary presentations. Congratulations to Dr. Marti, particularly across this very rare, if not impossible to hear somebody sharing
54:19
complications. Right? I did surgical at the procedure and the patient is a facey graftor. I had never had any surgeon in an international forum admitted so directly.
54:36
My first thing is an outstanding management in both of your places, but
54:47
in order to follow the actual order, I would like to all, if you agree with Dr. Khalil, if I, I got it ceased and then. with the come to your group, no, if it's okay with Dr. Hoss. One,
55:04
Dr. Halle, that is expressed that there was a, that there is an interest of the WHO to declare, I thought it ceased one disease of the past by 2050, right? Yeah Now, is this theme led or the
55:24
Iraqi doctors have an active participation in this project in the WHO? Not to
55:31
my knowledge, it's just a suggestion.
55:35
I see. Because as you show, there are interesting papers from Iraqi doctors, Iraqi neurosurgeons and clinicians, even to
55:47
2021, there is no literature on, either it's on syllable or either it's used at least. on the American literature or in the Americas, as the old continent of the literature. So I think this is
56:05
important to emphasize that it still is
56:10
a real problem in all that region, because there are papers, the most recent papers are coming from that particular region
56:21
One thing that I found very interesting also in your representation is that you were able to puncture the optic cyst, and there was no recurrence.
56:35
And to what do you attribute, what's your hypothesis, what's your - Yeah,
56:42
I've done, in fact, some of them, I've taken the cyst for microscopy, and there was no skullysis
56:50
And also I think this is from the difference stream.
56:55
and that's the Aquinas strain. That's the usual one which is sheep, which is common in the brain and then the liver and the lungs and everywhere. So this is special strain which affects only the
57:06
orbit. And when you have it in the orbit, you don't see it anywhere else in the body, like the brain or the lung or the liver when you see it in different places. So probably it is different
57:15
strain. This is an assumption, and I have no proof for that, but it needs to be proved And this is what I think it is.
57:25
But your primary advice to everybody who is listening, and I can transmit to others, is if you have an assist of the orbit, it's reasonably to assume that it's safe to puncture the assist, that it
57:40
will not be retranced. Of course, there are all the ifs and ifs, no? Yes, provided you remove everything there, and you wash properly and make sure there's no debris left inside and provide it
57:51
to take the funders, make sure that the funders is out. completely.
57:56
And and that case of the is the I that it sees from the from the horse, the equinos variation, right? Yeah, that's right.
58:09
Yeah, it's from that. One thing that passes me off I that it sees and that is related also somehow to Dr. Mantis at the presentation is that cerebral I that it sees, they don't cause cerebral
58:19
edema. Absolutely. Yes. Yeah, there is no peripheral edema at all. This is a very important one. Why is that?
58:28
Because it's very slowly. There's no inflammatory reaction around it. No irritation. It's very smooth and easy. Yeah, because a large I that it sees to follow in your timetable, which was very
58:41
good, will be something six months, no growing six months, but there are obsolescence of tumors and great devastating edema. So I was standing I don't know if it's very sad or not. comments.
58:52
There was one comment of the colleague from Cape Town stating that in South Africa, 50
59:02
of the cases are associated with
59:05
HIV. That's an interesting phenomenon, whether there is a relation with the immunocompromised, no? Dr. Sahara, I think she's available as well
59:17
Yeah,
59:20
so what are your thoughts of that 50 being related to HIV is immunocompromised or
59:30
coincidence? Yes, Dr. actually, it's a common disease in the farm communities and it affects sheep but it can transfer to
59:41
human and those human are mainly the immunocompromised. They They had a study that showed that there's 50 percent. of the people who are infected with high data who are accidentally discovered are
59:59
HIV-positive. There isn't a lot of papers regarding that topic. There is one that reports seizures, and they couldn't further investigate due to COVID, and then this case was complicated later on
1:00:16
by showing signs of increased intracranial pressures
1:00:24
Sorry, go ahead, please. So, there isn't really many documents or many
1:00:31
published research, but it is still discovered accidentally, and the main treatment is surgery, so they do radical surgery when it is discovered
1:00:45
Yeah,
1:00:47
but the case is, or Professor Lazar. the cases which we have dealt with over these years, we never had any reference or any evidence of immune compromised patients. They have normal patients
1:01:02
lively and everything is fine with them. So this, as you said, needs more work, more study and to see if it is related in a way in South Africa Yes, I think it's because also the farming approach
1:01:19
in Iraq and in South Africa is different. So it is not common among human and once the sheep gets infected because they send dogs to look after the sheep, look after the herd and that's why it gets
1:01:38
transferred to the sheep And then it is when it's transferred to human there is a high percentage of new compromised people Yeah. You know, HIV is coming in South Africa and the African continent.
1:01:55
Very interesting. Thank you. Thank you.
1:02:00
Anybody here?
1:02:04
Okay.
1:02:09
Can I comment, Victor Lizzaro? Yeah, no, no. Yes, please.
1:02:18
You are in charge. Actually, I want to say that we have answered because in our lab, back in Baghdad, the neurosurgical lab we use the sheep head for simulation of neurosurgical procedure.
1:02:31
And within one of the courses, one of the training Dr. Alpha at that time, just call me and say that, oh, this will change to a real training. There is a vision inside the brain of the sheep.
1:02:43
And it was how that exists. So the training continued to remove the mask. Yeah, this is how it's common, especially in
1:02:55
back there at that time. And I have a question for Dr. Talil, because I think I have a case reported or under publishing. It's about high diet, it's just in the cavity
1:03:10
of, in
1:03:14
the cavity of intraceurobrol hemorrhage So, intraceuro hemorrhage, cranietamic cavity, and now the patient for them to indict the system, which was very, very rare, unexpected, and difficult to
1:03:21
believe for me. And I noticed from the presentation that you said something about trauma as well. Yeah, yeah, the multiplicity of the high diet in the brain usually is the setting, and they are
1:03:37
dispersed all over the brain But if it locally multiple, most likely it is due to trauma for heterogeneity and that would shake the assist and mix.
1:03:50
some tear of the wall and then it would be metastatic. This is published in fact, we haven't seen it ourselves, but this is published and I just learned it from the literature.
1:04:00
Yes, thank you. But I got it to produce bleeding, this is of course this coincidental, most likely. Yeah, thank you. Thank you I have, can I make a comment? Please, please, yes you. First,
1:04:06
thank you, Professor Hariri, for this great presentation. You know that we're still endemic and that is just, that it has just can be diagnosed on brings it is
1:04:27
cancerly. There is no need for
1:04:38
the MRI to diagnose it. This is number one. Number two, as some remember, We did a CME on cortical incisions back in 2015 in your surgery teaching hospital. And one of the subjects we were
1:04:54
talking about is the length of cortical incision for a high data cyst.
1:05:01
Yeah. Are we going to do about half of the diameter of the cyst, three quarters of the diameter of the cyst, what if it were below the underneath the motor citadel, what if it were in the
1:05:14
broadcast area, what shall we do, the length of the incision? So, there are
1:05:21
no many literature reviews about this subject.
1:05:27
Well, the one I showed, in fact, that the cyst was showing through the cortex, as you have seen in the video. But the length of the incision, I think maybe half will be with enough of the
1:05:39
cortical diameter of the cyst Usually assist. which is in the brain usual when it is bigger, it would show somehow through the cortex of the brain.
1:05:53
We haven't seen in fact, because our cases were late, we haven't seen anything inside which needs a real big cortical incision, maybe just you can see thin cortex over it, but the majority you
1:06:06
were showing through, but in any case, I think you're right if there is underneath important centers, you have to be really well manipulative and you see they're the best place like, by the way,
1:06:21
to use navigation, neural navigation? I use only the interpretive ultrasound. I see because we use neural navigation for instance, at the time in 2002 when I had the patient, the doctor, in fact,
1:06:36
the lady, the doctor, she had the tumor underneath the broccoli areas and then we have to go beside with the help of the navigation have to go behind and then gently remove everything there. So I
1:06:48
think in this case, it's neuro-navigation would be of help for me. And by the way, I was very, very impressed with your work and I'm proud of you really, very proud of that. Thank you,
1:06:59
Professor. Thank you. Yeah, one important thing, and I don't say to the professors, I say it for the occasional, for the many future near essentials in the audience is, it is vital to ask the
1:07:14
patient if he's a left-handed or a right-handed patient, and based on where the, the, it is ceased, right? I mean, a right parietal system, a left-handed person has a different significance
1:07:26
than the other way around, no? Absolutely true. And that gives a, again, the question that somehow links to Professor Smathey at the presentation is, you have somebody with a cease that is
1:07:39
sitting in order to assess that system. Fortunately, those mostly are parietal, because of the carotid going straight to the middle server, they're rarely temporal, or not temporal at all. I
1:07:51
don't remember any system going from the temporal force of backwards. But
1:07:57
you have a system sitting on a very eloquent area, so-called eloquent area. What do you do? You just sacrifice the cortex and hope for a good rehab. And I think that's the approach that has to be
1:08:11
done But
1:08:14
the question that you had at the conference about how wide or long has to be the corticotomy in a particular patient, speaks volumes of how creative you are. Because I don't order the last one, but
1:08:33
I never heard at the conference on how big and wide a cortical incision has to be So that is a fantastic.
1:08:42
should be saying that I have a cranial charm we just had let's give it so and then
1:08:50
the edges of the bone are spiky and then you have to be absolutely sure that there is no sharp edge in the bone but with the cranial term I think there is no problem of that nature yeah no no
1:09:03
absolutely and has to be as white as as anti possible I was saying the that leans can we is there any at the question no no can we come to Dr. Matty because of a relative question can I have a
1:09:18
question first on the hi
1:09:33
that please please yeah just a continuation of discussion because I think it's it's related I have two point I think at some point we have been teased to avoid the electrical control and hi that it
1:09:36
says to use more than mechanical because maybe increase in rupture So obviously this is a controversy one or it depends on personal experiences. I would like to listen to Dr. Khalil opinion as well.
1:09:51
And as the point that Dr. Omid raised about the length of incision, I think one of the take-home messages from this meeting that this is if the surgeon think that it may be glioma, he will do a one
1:10:07
centimeter incision, one centimeter of the cortex And you know, with the resection, you will have more and more space. This is the usual tumor approach for the cortex. Or even if it's just a cyst
1:10:18
or cystic tumor, you need to aspirate and that's it. While here we are proposing a different strategy because the high diet, you don't need to squeeze the high diet. That's why the professor
1:10:30
Thalia started with saying that should be why the cranial tummy because this is a hugely different based on the assessment. on the imaging, so I think one of the take-home message can be this, for
1:10:44
general practicing, or especially for neurosurcision, who take the decision on a cronyotomy size, that think of how that is, if there is no argument, if there is just a very smooth, if it's
1:10:57
endemic, this have a huge potential to change their cronyotomy strategy. Again, I would ask Dr. Kalini about his comment on the
1:11:10
thing that I asked.
1:11:12
Yeah,
1:11:14
you
1:11:16
said that I think, yeah. I agree with you.
1:11:21
If you are, Jorge, if you're just asking questions related to Dr. Hallelujah's presentation, I have some. If you want to discuss Dr. Mottie's presentations, Are you waiting for the second?
1:11:38
part to do that, but how do you want to proceed? I have some questions for Dr. Honey, but I see Dr. Almani has some questions, maybe we should answer his first. Yeah, I would agree growing
1:11:53
first with Adati because Dr. Mati's presentation is also wealthy and rich. And so let's finish with Adati, it's his first and then we go completely to Dr. Mati So Dr. Altamini is asking the
1:12:10
question. Raise his hand, yeah. Thank you so much. I'm really happy to be part of this group of people. As a pharmacist, I may be the only pharmacist or the only pharmacologist in this group.
1:12:26
And I'm happy that I got the chance to broaden my knowledge about the Haidatit, Haidatitist. As a pharmacist, as you know, as a pharmacologist who taught pharmacology for so many years in Baghdad,
1:12:41
in America, that my focusing is on the side effects and the, let's say the pharmacantic and pharmacodynamic properties of drugs used in the treatment of the tap forms or the high dietists. But
1:12:59
today I got like a different opinions or different things So I, as I said, it's a chance for me to know more about this kind of parasite disease. I don't know if Dr. Hele or Dr. Mitty or Dr. Sam
1:13:16
or any other one of the owner people in this group has come across the use of Ivermectin in the treatment and the treatment has at least experimental laboratory and studies.
1:13:35
on the Ivermectin, the controversial drugs, which is, we all know that there was some big issue about the use of Ivermectin treatment of COVID, and it was not approved, but the research done by
1:13:50
Moderna to encapsulate the vaccine as the mRNA vaccine, and then oily capsules made it very good way or very good reason for the experimental studies to go on the proceed with encapsulating
1:14:10
Ivermectin and using it at least in animal studies to treat the hydrolysis and to limit or to shrink the hydrolysis. They found some good success or they found some good, they reported good result
1:14:25
if they use Ivermectin to use it as a target of the drug
1:14:32
And pharmacy these days, the new approaches are to give the drug directly to the area where it should be working. Like for example, in the high that is in deliver, they send it to the liver
1:14:46
through, they call targeted administration of drugs rather than giving it through the gastrointestinal tract or oral route of a demonstration And this new technique has shown that in lab studies that
1:15:04
it caused some shrinkage of the high data cyst. It may give like a new approach in the future because albin dazole, membrane
1:15:22
dazole, as you know all,
1:15:25
they have low absorption and albin dazole is better than membrane dazole The side effects of almita as well, almita as well, vermox antalbanza. as they call them in the brand names,
1:15:33
the prices have gone so high and the rate of using of this, although it's limited with the better hygiene or better health profile of people, the use of these drugs are less but still because of the
1:15:51
domestic pet people have dogs in their houses. So there are drugs used for dogs which could be the reason why the rate of or the prevalence of infection with the high death is less and less all over
1:16:08
the world, not only. Regarding the survey given by Dr. Khalili, the number of cases reported in Iraq, I'm wondering if these are officials, I mean, and adopted by the Ministry of Health, or
1:16:24
these are just personal, let's say, communications are limited. If these are official, I feel this good. It's not bigger than, much bigger than what is reported in the United States of America
1:16:39
or even in Europe. European countries has probably 015 or 015 per
1:16:49
100, 000 cases. So those numbers given by Dr. Khalili are, I mean, very good numbers in case these are considered to be official or reflect the total numbers in Iraq, although these are just for
1:17:04
limited area. Thank you. Thank you so much. At the end, I need to
1:17:12
thank Dr. Omeela and Dr. Sambar. I'm very happy with their presentations as new doctors, compared to your generation. They are doing a great job. I congratulate them If these two guys are your
1:17:25
students. I'm happy that these are the best doctors I have seen probably in this area at least this time. Thank you so much. We all do,
1:17:37
as you know. Just answering your question that figures are only SNF figures, most of them are my personal, some of them are joint surveyed, then some of them published, some are not, but they're
1:17:50
not official figures. One point I would like to mention that in Turkey, they tried to use Mabendezol entrasist,
1:18:01
20 of Mabendezol, they injected it in the cyst,
1:18:06
but I don't know, they claim something, but I'm not sure that's correct because Mabendezol has to be, has to be metabolized in the body before it be active. That's number one. Number two, as you
1:18:17
said, Mabendezol when you use it systemically, it's low absorption, so that's why you use it at least three months would daily do us.
1:18:27
And thank you. And I don't want to take much of your time for this.
1:18:34
Thank you, ma'amut fa'la, you the rose your hand, yeah.
1:18:39
Hi everyone, ma'amut fa'la, 15th stage medical students at the College of Medicine University of Laudad. First layer, thank you for
1:18:57
Dr. Adel-Halyi and Dr. Juanita Sam for the nice presentations. It's very interesting My colleagues, my question is about the high-dotted cyst. And recently, during this month, I was observer in
1:19:05
surgery for high-dotted cyst. The patient was two years old, children on the high-dotted cyst was in the temporal lobe. My question is, what is the possible source of high-dotted cyst in this age
1:19:21
of growth? of the drawing this age. It's with limited exposure to environment, to untied, especially in the time of the infection.
1:19:34
What's the possible source of the
1:19:40
high-data system, this child or children in this age group or below the two years old or even in the two years, four years old preschool age? Thank you. Thank you Thank you for this question. In
1:19:58
fact, it be reported even one year old child with high-data system of brain. So that's why it is in general, younger people are affected more than older people in the brain and the orbit as
1:20:12
well. Well, the contamination can be from different sources. If this child you are referring to is living in
1:20:19
the farm, just patting on the contaminated dog with eggs and contaminated sheep. This patting on it, it may get some scolaces to his or her mouth, to ingest. And also, they feed them with some
1:20:37
vegetables, some grains, even one year old, sometimes they give them. So it is always by ingestion and of contaminated food, usually vegetables or maybe fruits.
1:20:53
Dr. Asmuth, where are you? Raising the hand? Yes, is everybody finished? I just wanted to ask some questions for Dr. Adi and Dr. Madi, but Dr. Adi first, if you're going to do it
1:21:04
individually.
1:21:07
Hi, I'm,
1:21:10
is interested in your presentation. Obviously, it shows that disease is, is disease rampant in the low to middle-income countries. It's not present commonly at all in the higher-income countries.
1:21:24
And the question I have is in relative to public health.
1:21:29
If you take a
1:21:32
hydrostatic disease as a parasitic infection, how does that relate in terms of a health problem in Iraq to other infectious diseases such as tuberculosis or what are the other more common diseases?
1:21:48
And I'm approaching this from the perspective of the government If we have a certain amount of money to spend on diseases, how do we spend that money in order to get the most effective treatment to
1:22:00
the most people for the least cost? So I'm looking at really what the various distribution is of infections and resources available. Well, I'm sorry, I cannot give you exact figures, but surely
1:22:17
there are more important diseases to look after other than I doubted, still had that, it remains very important because it can produce problems which are sometimes, even with surgery, can be
1:22:33
detrimental when ruptures or it will be metastasized. At tuberculosis, I'm not sure if it is a big issue in Iraq now, maybe it's some big issue in some industrial countries now, resistant to
1:22:48
medication.
1:22:51
I had to have no figure, so I cannot say that, but a public health person can answer you properly, but this may be, after Sahar can jump in here to give an idea.
1:23:04
Unfortunately, I don't have figures regarding that. So, as you said, Jim, rightly that the budget has to be spent wisely to more important diseases
1:23:21
I'm biased about, I doubt it because I think it has to be looked after and then done properly, dealt with properly. But I can get you an answer for that from the public health guys from Iraq. Well,
1:23:34
it's okay. Let me go on and then you'll get the idea of what I'm saying. When I went to Peru, the public health minister was a cardiovascular surgeon. And I asked him a question, if I gave you a
1:23:45
billion dollars, what would you do with it?
1:23:51
I expected to receive a different answer. He said I would spend it on sanitation. Yeah, that's right. And so we have to think about this. Here we're neurosurgeons. I'm listening to this. We're
1:23:59
talking about how long the incision should be or what we should be doing. Neurosurgery is a
1:24:08
luxury specialty. What are the most important
1:24:14
illnesses in the country and where should our resources be spent? If I'm in the government issue, that's one of the, that's what I would do. And that's true in your country. It's true in our
1:24:25
country. It's true in every country, whether it's higher or low in middle income countries. Of course, if that's not a consideration and there's individual, individual liberty and individual
1:24:36
freedom and not government control, then obviously it depends upon who has the money and who spends it and the money gets spent on the people who have the most money that treatments do.
1:24:48
So, one has to remember about that. If you have a certain kind of a health system that allows individuals to get paid for based on what they make and what their position is and so forth, you get
1:25:03
certain results. If you have government control, then what you have is somebody else selecting what should be treated In Britain, for example, they eliminated the number of hip replacements to
1:25:18
treat, even though there are any more. They've limited a number of drugs that you can treat various diseases with because it costs too much money. And I went to Belgium and there was an orthopedic
1:25:30
surgeon there who needed a hip replacement. He couldn't get it because the country ran out of money. He had to wait another year. So we're dealing with a public health problem Many of the doctors
1:25:41
that recognize the disease. How do you eliminate it earlier? Obviously. You've got to get rid of the contamination that occurs in the rural areas and so forth and so on. And in the improper meat,
1:25:53
that's education. So do we spend money on education?
1:25:58
Do we, the cases that you may see, maybe the cases that are extreme? Dr. Madi has some cases like that. So the question I have is that, and then Dr. Ghazi said something about Ivermectin,
1:26:14
Ivermectin, well, I don't want to get into this, but this is an extremely valuable and important contribution. It turns out that in
1:26:25
COVID, Ivermectin, which was an enormously effective treatment in Peru, South Africa, in Africa, in Bangladesh, because they didn't have the funds to go and use vaccines, and it was also an
1:26:41
Indian, the disease disappeared, nobody wanted to report it. That's because there was no honesty in the press and there was no honesty in the reporting because the drug companies were trying to get
1:26:52
everybody to use the manufactured vaccines. But nobody wants to know that yet because it's still being suppressed information. But Ivermectin was an extremely powerful and effective drug could have
1:27:05
eliminated millions of deaths and we would have had a much more successful treatment. He is absolutely right So my question is, what's the cost of the endosome? Is it a treatment that can be, do
1:27:19
you recognize some of the symptoms? You recognize it earlier on when people get it in the brain. It's obviously more advanced. My guess is, what percentage of people get that? Is it 10, 20, 30?
1:27:31
And do they, when they get the drug treatment, is that eliminated right away? So that's become very helpful. Can you answer those questions, Tyler? Yeah, I think you're all right That's why in
1:27:42
my research theory, I put public education as a very important topic in the research. Because if you don't educate the people, then you have an effect on the prevalence of the disease. And using
1:27:57
this drug, as you mentioned, and Professor Razi was mentioning earlier, I think so many drugs being used experimentally to get to treat, I doubt it. But none of them really has yet surpassed the
1:28:13
end result and the end result. I think in the near future, we will have something, you know, but so far we don't have any. But let me ask you this question. The number of people who come in with
1:28:24
symptomatic, high data disease, most likely it's going to be cerebral, but I'm sure it could be other organs. If that does that represent the total number of the people who are infected, 10 of
1:28:36
the people, 20 of the people, or 80 of the people.
1:28:40
Well, I would guess nowadays people what's going on, and there are centers dispersed all over the country. For instance, in Neurostatica site, as I mentioned in my earlier talk, that we had only
1:28:55
one center in Iraq and then three centers. And now we have, every province has a center and with many good neurosurgeons all around. So consulting to these surgeons with any complaint neurological,
1:29:11
it would be easier And then you can detect the disease early. With the facilities available all over the place, all over the country, it is going to be easier. At that time, we didn't have CT
1:29:23
scan. We have just
1:29:26
nothing in fact. CT scans solve the problem only planics, right? And then nowadays it will be easier. So 10, 20, maybe I would put it in that range. So 10 or 20 really wind up
1:29:42
in more intensive hospital and more extreme carers, what you're saying, yeah, the rest can be taken care of. Yeah, that's right. Very good figure. So what we need to do is get people to
1:29:51
recognize that stage and then maybe try to get that earlier, is that correct? Yes, absolutely right, yeah. Okay, and then we have drugs that treat them. Dr. Ghazi, what's the cost of El
1:30:02
Bendazole in Iraq? Is it something everybody can afford? That's a very nice question, Dr. Osman. Actually, Vermok's brand name is no longer available because Mavindazul is made as a generic made
1:30:20
by many companies all over the world and it's much cheaper. In the United States, the price has gone like, I don't know how many times fold, like 100 times fold recently, 10 years ago It went to
1:30:35
like a thousand of dollars for a thousand of tablet,
1:30:44
a dollar per tablet, which was not that much before. That is the lobby of the giant pharma. When they consider something is no longer available as a brand, they increase the generic price.
1:30:57
Al-Bintazole and Verbox generally are cheaper. I'm retired now. I don't have a current price these days, but I know they were nice, good prices But the use of these two medications for
1:31:13
Al-Mintazole, I mean, for tiniest, a genata, or high dachts. In America, it's less than the
1:31:19
usage it for other worms, like other kind of intestinal worms. It comes as a four tablet dose of Mintazole, Al-Bintazole, Al-Bintazole, Al-Bintazole. I don't know the price, but for tiniest is
1:31:36
like a long-term treatment, like 3 or 4 cycles. There is a break between these cycles that use it for three weeks and then you stop it for 14. That is for long-term treatment, Dr. Osman, but I'm
1:31:50
not sure about the prices. The prices went higher than before when the brand name Vermox has been stopped. Very interesting, very interesting response.
1:32:05
And
1:32:10
it talks to, it addresses how the pharmaceutical industry is trying to take advantage of the healthcare system and the patients. It's true in our country and in a great deal. So if I'm a farmer and
1:32:17
I'm in rural Iraq and my child gets infected with high data disease, can I afford to treat him?
1:32:27
And well, in my time, everything was free. Everything
1:32:33
in the hospital name and health service was a free drive out. What about now, Dr. Ghazi, is it is it is it is the drug so is the drug so cheap that it can be treated or now is it I'm unable to
1:32:45
treat it because it's too expensive and I don't make that much money.
1:32:50
Dr. Osman, as you said, giant pharma, what to make money and they get the chance to increase the price by changing the patent for nothing important but they even changing a color of the shape of
1:33:04
the dosage form will make it as a new patent and Iraq, the price is compared to the US dollars. Yeah, they are very cheap and they can easily be afforded by many people. The income of the Iraq
1:33:18
people these days is higher than 20 years ago and I think it's very affordable and it comes from different. You know, India is the pharmacy of the whole world. Most of this medication, if not
1:33:32
active medication, the pro drugs, are made in India and China, most in India, and the prices are very low. So I think it's very affordable in Iraq. Okay, so the key is education, sanitation,
1:33:47
getting people to the doctor earlier if it becomes more complicated, Heidi. Obviously the drugs are available, but it still means that the pharmaceutical companies and other people trying to
1:33:59
deprive people of healthcare because they raise the cost is intolerable It's a crime.
1:34:07
Absolutely. It's an absolute crime and the physician should be united to oppose that. That's costing the country money, it's costing them lives. If you wanted to rate the cost of what the
1:34:19
increased cost of drugs are to the people when they don't have to be raised, that's a national crime, should be punished.
1:34:30
It's a punishment of the people, I think that's unfair. Well, if I add something, if you don't mind, I don't mention the name that's one of the CEOs or the owner of a public school company. I
1:34:43
think went to jail for increasing the prices like several hundred falls. I will not mention the name of the tax. I'm very sorry. It's true everywhere. And in our country, they haven't been
1:34:56
punished, but I think you're absolutely right. And I'm very happy to hear what you said Hadi, I think to me, and that was a very interesting talk. And
1:35:06
obviously, many doctors, they're not a treat the disease. They don't recognize it. When it gets very complicated, they need help. And that's perfectly understandable. If I'm a government
1:35:18
official, I'm going to be asking all the questions I was asking. Yeah. For that, it is important to go back. I disagree also with the Minister of Peru It's not sanitation, it's education. And
1:35:32
the education is the broad thing. One education is also the education of the physicians, the political education of the population, the education of everybody involved, and sanitation as well, no?
1:35:48
To which, I mean, I want to rescue from sanitation the importance of neurological diseases. Neurological diseases per se, everyone, including psychiatric, are the most important cause of days
1:36:05
living with disability in the world, except sub-Saharan Africa, except that belt, that around Congo, Mali, Mauritania, Sudan, everywhere else in the world, the neurological diseases are. So
1:36:25
it is important also for us to, at the focus, not only in the area. what can we learn from the outcome or from the evolution of the patients if we make a longer or at the shorter incision because
1:36:41
we are causing disability and not only in that particular individual but in our overall understanding of the brain. In the case of Dr. Matty, I have two other questions pertinent to this issue
1:36:60
regarding to his first patient or that the first patient he presented not because he inherited that patient from another doctor is fine. You have a patient with a benign coloisist in the third
1:37:15
ventricle right with either ocephalus. If they, if they, if the chance, both Christians would have worked fine. Would have you done anything?
1:37:36
Yes, to start with, you know that, as we discussed, Colois Services is a benign tumor. If you're resected, there's no need for any adjuvant therapy. And it is the best approach not to place
1:37:49
chance. You know that chance are not without
1:37:54
complications, especially infection, whenever you increase the number of chance you are going to have complications sooner or later.
1:38:05
No, even if the chance, we're functioning, I would remove them. And so if the
1:38:15
chance were working, perhaps you're calling, we don't have asked you for that the question,
1:38:22
if the patient was fine, then the patient would never have the removal of the season. I, at the fully agree with you. that the removal of the seeds is the treatment of choice. And then also it is
1:38:34
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 what to do
1:38:48
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 exactly the
1:39:05
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?
1:39:18
Because it was unconscious for a long time. She was unconscious for about three weeks.
1:39:25
Ah, I miss that, but so she was unconscious weeks after the placement of the shams. Because of the overshamenting and there was subdural effusions, subdural hematomas, then detention, mukkafalas
1:39:37
kicked in. So there
1:39:42
were many things going inside her brain.
1:39:48
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 coloisist is having a compression on the
1:40:02
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.
1:40:15
We did it to ensure that there is no subdural effusions, there is no need, there is no hydroscophalas and there is no need for something. And for sure not to do so many brain seat discounts
1:40:27
whenever we can do any MRI, it's better than giving radiation to the patient.
1:40:33
Perfect, so you're at the teaching point for our audience, for the young audience, not for Dr. Hasman or Dr. Osler or the other ones who know the issue, is call the assist, don't chant, remove
1:40:45
the assist, and the consequences of not doing it properly are impeding the quality of life of the patient. Has she improved or well, she had such an issue? Yes, yes, and her last visit, she was
1:41:02
able to talk, she can sit alone and only walk with assistance. Can I say, thank you. Dr. Osman, you
1:41:19
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
1:41:24
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
1:41:36
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
1:41:49
the college system, it's 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
1:42:00
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
1:42:12
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.
1:42:24
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
1:42:36
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
1:42:48
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
1:43:02
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
1:43:14
I couldn't have it, I couldn't ask a second question about anything you did
1:43:20
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 issues that are important in low to middle income countries and high income
1:43:30
countries. And it can be solved in Iraq with modern technology if people don't spend their money on war. And that is television communication between centers like yours and those in other hospitals
1:43:47
and other areas in the country, where you can pick up these cases, where people can have conferences like we had televised in the past five series of conferences where people can bring their cases
1:44:00
and discuss things and make them feel comfortable talking and consulting to other people and not make them feel terrified that people are gonna criticize them.
1:44:12
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
1:44:25
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.
1:44:35
And 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
1:44:46
not be 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
1:44:57
come out 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
1:45:09
for the 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
1:45:20
central.
1:45:22
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
1:45:33
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
1:45:47
people. We've got to prevent drug companies from basically stealing, stealing health from patients. They ought to be persecuted as criminals.
1:45:59
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
1:46:09
look at these diseases. You're an extremely talented neurosurgeon who's done an outstanding drop. I've gone over your videos many times. And obviously, you have talented people in Iraq. You have
1:46:23
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. That's what I got out of this. And I hope the students get
1:46:35
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 go into medicine. You can go into other specialties. But
1:46:46
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 goal is to be the best I can for the patients. Treat them as
1:46:58
they are your family. Do the best you can for them. And if something stands in the way, you've got to stand up and you've got to say, that's not right.
1:47:09
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
1:47:23
shunt, and we clear it, we clean it, we
1:47:29
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
1:47:37
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
1:47:52
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?
1:48:05
Actually, do we need more - Yes, sir, of course. Yes, sir. Do we need more missiles, or do we need more medical care? Yeah
1:48:14
I hope the decision-makers will listen to the orders.
1:48:19
Well, I'm sure the students are listening 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
1:48:30
be. Not where pharmaceutical companies or business people or even doctors who want to make money are injuring the individual patient. That's unacceptable. Yeah, unfortunately, of many countries
1:48:46
that take place in the world. It's unacceptable. Yeah, many surgical procedures done now, and necessary, many investigations, including radiology, MRI, and others, and characterization, many
1:48:59
of them are unnecessarily done for the sake of money, everywhere. Dr. Mottie, you are not in that category. You are a very compassionate, thoughtful,
1:49:12
consider it skilled. human being and neurosurgeon.
1:49:20
Thank you, sir. With the presentative of his late father. Thank you. Thank you. Thank
1:49:28
you, I think this
1:49:32
opportunity just to to mention that we have really lost last week one of the
1:49:38
our colleagues in your surgical colleagues in Nasri head of neurosurgery at this Nasri province south of Iraq. And he passed away before his time, really, it was a big loss to the province and to
1:49:51
Iraq. Who is there, Ali? His name is Haidar Makhliff. He's one of the first graduates from the American board of neurosurgery. Sorry.
1:50:04
Yeah. Yeah. So I guess if there are no more questions pending, we understand us. So the summary, I will fight for the people that the two lessons won. expressed dramatically and enthusiastically
1:50:19
and emphatically by Dr. Roseman. We all agree with that. And my personal thing again to Dr. Matty and in which he did not mention or did not criticize his colleagues and he was open to share the
1:50:36
many complications that aroused from the patient We all have complications, the neurosurgeon or the surgeon who says that never had any complications or has very few complications, either he's not
1:50:51
doing surgery or he's lying. And the complications, that's the unfortunate things of the textbooks. The textbooks gives you that impression that everything is pristine from A to B to B to C, C, D,
1:51:06
diagnosis, treatment, outcome. And this is not how life it is. Now that's why we have the training and I
1:51:17
And I know that the many young people who are listening, we are learning from both of you, from Dr. Hallele, and his experience, and from Dr. Matty, and his attitude, you know. And we keep Dr.
1:51:31
Mais, Dr. Osmond message to the heart as well, no? And if anybody has any other questions, we will close this issue if you are really summoned It's done, I make some comments. Please, please.
1:51:54
Go ahead.
1:51:56
From the many things that we teach
1:52:00
to our residents, with 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, Even if you are far away from
1:52:15
us, we have rushed. and to another that generates to do the surgery. So it's a privilege to do that. This is one. Number two, it's as all we always is less painful to learn from other faults.
1:52:30
So when we are sharing them, it's for teaching purposes. It's for them to learn.
1:52:37
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 the
1:52:49
complication avoidance. In
1:52:54
fact, it's been known that
1:52:59
the real surgeon is the one who decided not to operate. It was able to decide not to operate. And the surgeon has his knife in his pocket better than the, not necessarily better, but safer than
1:53:11
the surgeon who puts his knife in his hand.
1:53:16
It's absolutely right, honey. And Dr. Mottie asked, raised a question at one of our last meetings.
1:53:24
He didn't answer it. But he said, If somebody comes inand they have a left dominant hemisphere stroke, middle cerebral artery occlusion, and they have a mass of edema, and they're a phasic and
1:53:38
hemiplegia, what should I do?
1:53:43
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
1:53:56
the next thing. The question is, what should be done? What is the humane thing to do?
1:54:04
And that was the question he was asking.
1:54:08
And that comes from a doctor, a soul.
1:54:23
I need question or comment from
1:54:27
presenters, final thoughts, final comments for the closing remarks
1:54:40
Okay, so I just want to let you all that the recording of this
1:54:46
meeting will go first through editing, then peer review, and then will be available at the SNI digital hopefully as soon as possible, and we will share also the recording with you for those who
1:55:02
want to share it And also for those who want to attend the presentation again, and thank you everybody for being here. It's an honor to listen to all those
1:55:16
I'd like to ask one thing. I wish everybody here would send their comments.
1:55:28
We can't 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
1:55:40
to help the patients better and send the comments to Sam. That would be immensely helpful. We're spent a lot of time and effort trying to bring this to you. We want to know if it's worthwhile, if
1:55:52
it's not worthwhile, what can we do better? We want you to teach.
1:55:57
And I thank you very much. Thank you. Thank you,
1:56:02
Prosek. Thank you all. Thank you for everybody. Thank you for your time and see you again at the next meeting and have a great day. Have a great day. Have a great time Thank you. Bye bye. Thank
1:56:14
you. Bye bye. Thank you. Bye bye. Thank you. Thank you so much. Thank you. I appreciate it. Bye bye. Thank you so much. Bye. Thank you.
1:56:26
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1:56:38
This series has been supported by the James I. and Carolyn R. Osman Educational Foundation, owner of SNI and SNI Digital and the Waymaster Corporation, producers of the Leading Gen Television
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Series, Silent Majority Speaks, role models and the Medical News Network.
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This recorded session is available free on SNIdigitalorg. Send your questions or comments to OsmanSNIdigitalorg. Thank you.
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