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The Glasgow Neurosociety
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in association with SI, or Surgical Neurology International, and SI Digital are happy to present
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the abstracts and discussion of the 10th anniversary Glasgow Neurosociety meeting held in November of 2022 in Glasgow, Scotland.
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Hassan Ishmael is president of the Glasgow Neurosociety at that time. He's from the Wolfson School of Medicine at the University of Glasgow in Scotland and the United Kingdom
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Faculty commentators are Likith L. Akhandi, who's the consultant neurosurgeon at the Queen Elizabeth University Hospital in Glasgow
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And Amy Davidson, a neurologist, also at the University of Glasgow, also at the Institute of Infection, Immunity, and Inflammation in Glasgow, Scotland.
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Other Glasgow neuro hosts were Alidith Middleton, Vice President of Glasgow neuro,
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and Edica Choudry, another Vice President of Glasgow neuro.
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Hi, everyone Welcome back to our session. Our final speaker for today is Rishi Harisha. We'll be talking about his research analysing the effectiveness of endoscopic endo-nasal approaches and the
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surgical resection of tuberculum, celium, meningiomas. 100 per tuition. Hi. Thank you so much for having me. I'm very honored to be here in the presence of such a committee in which there's a
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lot
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of expertise. So thank you so much for having me.
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My name is Rishi Harisha. I'm a third year medical student and I study at the University of Manchester. So this
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was a systematic review that we conducted in order to look at the effectiveness of endoscopic endo-nasal approaches and how they compare and how they sort of the data that we have with regards to the
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resection of tuberculosis and endiomers. Now
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I'm just going to give a brief introduction about what these are just for someone who might not be versed with this. So before I go into talking a little bit about the specifics I'd like to just talk
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a little bit about why we decided to do this and how this was was really done. So this was a topic that was this was a
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a systematic review that was conducted solely by medical students and there was no senior supervision that was involved in this. This was a topic that was suggested to us from one of our placement
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supervisors and we decided to look into it in a bit more detail. So I'm just going to open up the data that I have now and just share it with you so if you can just plan with me for one second please
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Okay, so just talking a little bit about what endoscopic endo-nasal approaches are. So when it comes to the
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surgical resection of tuberculum-cellular meningiomas, like we said, tuberculum-cellular meningiomas are a distinctive group of meningiomas, they're present in the supercellular space and they have
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attachment, deural attachment to the tuberculum-cellular meningioma, to the chi-ismatic sulcus and to the diaphragm-cellular meningioma. While traditionally these are actually removed through a
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wide variety of microscopic transcranial approaches, recent applications
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of concepts from endonasal sinus surgery where this concept actually originated from allowed neurosurgeons, especially those who are working with autolaryngologists to resex call-based tumors, and
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obviously this could also work with regards to tubical and salomonin tumors. Now, this has been a, I believe, and I'm not very well-versed with neurosurgery, but I think this has been a topic of
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debate for quite some time along with neurosurgeons because data which came from, there was quite a few systematic reviews published on this specific topic in
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2013, in which the result, the data basically said that there was no significant approach for endoscopic end initial surgeries compared to your traditional transcranial approaches. However,
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data coming from a couple of years ago, starting from 2018, I think there were some systematic reviews published, which mainly said that there was in fact a benefit to EEAs as compared to
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microscopic transcranial approaches, so we just tried to explore that from a student perspective and and we tried to gave our input into the topic. So this is where the idea mainly came from. So
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there have been many benefits that have been theorized for endoscopic endonasal approaches as compared to transcranial approaches.
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Some of them, them actually being, you can actually avoid brain and optic nerve manipulation and retraction. You can actually deep-askillarize this cult-based blood supply before the tumor
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resection. And surgeons, I think many people within this field actually believe that they have better outcomes. So we actually tried to explore that in a little bit more detail. So with all of
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that being said, I'm just going to go into the specifics of our work now. So this was a
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systematic review. And we mainly did this, the search, we obviously came up with a search strategy, which was mainly looking at some terms. So the terms that we use were typical in sedimenting
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geomers, endoscopic endonated approaches, and transferring approaches. And we did a preliminary search on MEDLINE and on MBase. We, so I have the Prisma chart with me, we actually came up with
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around 211 papers out of which from both MEDLINE and MBase. And now around 58 of them would duplicates. And once we'd removed the duplicates and once we'd actually assess the full articles for
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eligibility based upon the inclusion slash exclusion criteria which I'm going to talk about now. We came up to around eight papers. So that was what we were able to include. I do appreciate that
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there have been other systematic reviews which have been more successful, which I've actually found on more papers, which are much more extensive stir strategy, but this is what we could do from
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this student perspective. So the eligibility of the studies for our paper, we actually focused on those papers
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that talked about the interventions to increase cleaning uptake. We looked at RCTs, we looked at studies that talked about mainly the extent of reception, the visual improvement with this type of
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surgery, the chance of all factory loss, and also about
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CSF leakage and some other relevant parameters that we could find. So that was what was the methods of the study. Now, just talking to you a little bit about what we found and what we can share,
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is that first you're just coming from a discussion point of view endoscopic skull-based surgeries. do actually have certain advantages. Like I mentioned, you can actually obviate your brain
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structures and you can actually traverse any neurovascular structures as well. But we also found that there are certain disadvantages to EEAs as well. So I think some of the, and obviously I'm not
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a neurosurgeon and I'm not very well versed in this field, but some of the stuff that we could find out that was mentioned by other people in this field actually said that the disadvantage of this
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procedure was that there was a relatively restricted working space and
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there was also dangers of inadequate thorough repair that would have done. And another major limitation was in terms of training doctors to actually perform these kind of surgeries. So I think there
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is a significant amount of training that is required not only for neurosurgeons but also for auto-laringologists working this field. and training in terms of how to use an endoscopic sinus and how to
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perform these kinds of surgeries.
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And acquisition of these skills are actually slightly even more difficult for neurosurgeons as compared to autolaryngologist for neurosurgeons rarely use endoscopes in other surgical procedures. So
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these were certain limitations and these are certain things that we found. These are certain things that I can actually limit in terms of training and in terms of the availability of start to
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actually perform these surgeries. So just coming on to our outcomes and what we found out from our study, I'm just going to summarize this very briefly is we found out the, in terms of total
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resection, the gross total resection in the endoscopic endo-nasal group was about anywhere from 65 to 92, whereas in the transcranial.
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and the trans-cranial cohort is about 74 to 92 percent, so slightly higher gross resection in the trans-cranial cohort as compared to the endoscopic cohort. However, we also found out that visual
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improvement was actually higher for the
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EEAs as compared to the traditional approaches. The cerebrospinal CSF leak was also slightly higher in your
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trans-cranial approaches as compared to your endoscopic endo-nasal approach cohort. And intraoperative arterial injury was also higher in the trans-cranial approaches as compared to the endoscopic
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endo-nasal approaches. So this was what we could find. But again, that being said, there have been lots of studies have been published with varying results with regards to this and varying
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outcomes as well. So we do appreciate that this study might have not been done very comprehensively. And
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there's been a lot of papers that we've missed, so there's a lot of limitations to this study. And the major limitation to this study was that we were not able to find an adequate supervision to
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sort of guide us with this, but this is what we found from a student perspective. With that being said, one of the major things, just to conclude that I would like to talk about, is
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from what we found at least, we found that EEAs could be, if not more successful than TCAAs, they could be equally as effective as TCAAs, and obviously they're slightly less invasive as well. So
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therefore, they could be considered as an alternative, and I'm not very well aware about how many surgeons and how many trainees actually learned this procedure, but It could be something that the
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future. cohort of neurosurgeons and medical students going into neurosurgery could possibly benefit from. And there's been a constant drive into not only in neurosurgery, but in all fields of
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medicine to move towards less invasive sort of surgical procedures. So this could be something that could be considered. And that's it from me. Thank you so much
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Thank you, that was very good, very comprehensive.
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So for now, okay, you know, you're going to be in neurosurgeon, but before we're going to be in a neurosurgeon, as a layman or a doctor, if you had the surgeon gives you the two options to have
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a tumor from yourself or your relative to be taken on, which would you choose based on your understanding and studies. That's a very, very random question,
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Have you made an abuse on this, based on the study? So it would be the traditional transrenal approach. Why would you do that? Is that because of surgeon skill or is it because of the technical
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aspects of it? I'm not very well versed with the technical aspects of either two, but to the best of my knowledge, what I found at least is that the transrenal approaches have been something that
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have been tried and tested and performed for a very long period of time and with more data available, whereas endoscopic surgeries are relatively newer and if I was a neurosurgeon, I believe that I
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would be more well versed with the former, so that is what I would do So what are the ways of
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comparing or how would you mitigate this issue? with testing a time tested way of doing it was a new procedure which has come up and coming with new technology. How would you surgically compare and
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identify the outcome and what are the mitigating factors in order to avoid these biases? Yeah, so that's a very good question. So just to put out that to the best of my knowledge, the way to
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compare these things is quite difficult. But some of the ways you can do this is, first of all, to do, you know, a traditional study in which there is two different cohorts and then the
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populations that actually go into these cohorts should have similar disease backgrounds, similar socioeconomic backgrounds, and then let's say group A undergoes, one procedure group B undergoes,
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second procedure, and then you look at certain outcomes from group A, group B, and then you compare the two. So that would be the way of analyzing them.
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That's to my knowledge. So that is what we try to do with. Yeah, I agree with that. But the problem with that is the endoscopic is very rapidly expanding. So now 2013 is a totally different story
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to 2022 or 2023 in terms of endoscopic surgery And
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you know, chronotomy for tuberculosis, LA. meningumus is a big undertaking and a risk of seizures and driving other things. So obviously, it depends on the surgeon you speak to, you know,
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somebody might who's well versed in doing endoscopic surgery. But if you aren't asked me the same question about what I would choose, I probably choose the endoscopic approach.
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Right I'll pass it on to Dr. King to get it
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I'm going to bear that in mind, just in case I ever - No, no. The only problem with that is the CSF leak.
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It's quite difficult to repair but CSF leaks. But the thing is that even with a transcriptional approach, you can get CSF leak. And then if that happens, you have to go back to the intelligence to
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repair it through the nose So it's not
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as bad as getting seizures for the rest of life. You're not touching the brain. You're not letting the brain expose to hair. So that we end up just copy is better.
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Interesting. I mean, it's all very interesting stuff. I'm learning a lot about neurosurgery tonight, which is very good for
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me. When you were mentioning the kind of success rates in terms of reception, the two procedures, both kind of had 92, but then you just mentioned something that I don't. This is me picking up on
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random bits and don't worry if you don't have an answer to this. But you said that vision was better, with the
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Indonesia approach. Did they say why? If the reception margins are the city, like did they offer any reasons why, like things like that would improve or is it just one of these? Yeah, so what we
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mainly did was, in terms of this study, we weren't able to do a meta analysis. So we just did a qualitative review of all of the papers that we could find. So we literally just did a very basic
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pooling and then we just looked at the outcomes that paper A, B, C, D reported and then we just came up with final numbers. We weren't able to describe the nuances in detail and it is not
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something that I'm biased with, I'm very sorry for that, I don't know, I could not answer that question why. But obviously, this is something that we want to pick up and we want to improve upon
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before going somewhere with the Spanish script.
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You've already, I know in yourself that this is great work, especially when you haven't had any super, you've done this as a group of medical students, you've taken a subject that you're
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interested in, you've researched it and you've come to present it It's like, be more proud of yourself. This is good stuff and it's a good foundation. You know, I think you should be pleased with
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what you've achieved here.
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It's all right, anyway. That's right, me said my piece.
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So, any more questions?
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No? Thank you very much for that, Rishi. That was really interesting work. And so that concludes the end of our final discussion sessions. Thank you very much for watching our series and we
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really do hope you enjoyed the discussions that were involved. Thank you. Thank you. We hope you enjoy these presentations.
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