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The Shanghai Surgical Neurology International and Internet Journal edited by Nancy Epstein
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and is an AI digital innovations in learning a new video journal all video interactive with discussion edited by James i Ausman in association with Sub Saharan Africa Neurosurgeons are pleased to
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present the thirteenth as a monthly series of Sub Saharan Africa International Grand rounds in neurosurgery held on the first Sunday of each month
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These meetings are held to provide global solutions to clinical challenges in neurosurgery seen worldwide
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moderator and organizer this meeting as a strata Bernard
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assisted by James Haussmann and given to an international audience in attendance
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The first presentation is an anterior communicating artery aneurysm Harness steamy perspective given by Johann Showcase Alaska is always a member of the Peruvian Science and Technology Foundation
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and is also an expert in cerebral vascular and skull base neurosurgery interventional neuroradiology stereotactic radiosurgery all formerly associated with the department of neurosurgery and Helsinki
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as a university hospital there where he obtained his PHD
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is also the associate and co -author of many books and papers written with Doctor Ernest naming and is now head of the neurosurgical unit in a hospital regional del Cusco School of Medicine at the
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University and Dina of Cusco in Cusco I wrote
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a diagram on the bottom of the page shows you the location of Peru and where Cusco is somewhat distant from Lima
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let's get started welcome everyone this is a we've been doing this for over a year and I'm so Glad to see the interest continues I'm sure more people will join in as we as we move into the aisle but
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we're we're going to have a number of presentations to date DR Johan show Velasquez is from Peru is is our guest speaker he will be talking about microsurgical management of Anterior communicating
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artery aneurysm and then Professor Theo from Dhaka I simply go will be giving a case presentation to compliment the guest speakers talk and then and then we'll have a case presentation about the
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cerebral plasmacytoid that from from the the the group in Kenya Doctor or Mauro or Kim in Okuma I think Dr Kamala is a pathologist boat but Welcome everyone Jim would you like to to introduce our
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guest speaker
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Johar Misha is from Peru he went to medical school in Peru I ticket to the San Marcos Medical School and then went on to do a fellowship you tell Me if I'm wrong you know how many what Fellowship with
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Doctor Herman see Me up in Finland I got his phd up there and has God I'm just on a huge number of papers he's written up there and he has been and to ernest Amy's right hand person for a very
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important assistant for for many many years and traveled when he was doing surgery around the world and so are really lucky to have somebody his major interest is in vascular although he's he's done
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work in other areas he's written books and and the the real valerie the reason that we wanted to have him is is because he is an accomplished person buddy comes from a part of the world which is very
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similar to to the Earth what other African colleagues are arguing in that it's a growing area of neurosurgery and in his perspective an aneurysm is very practical which has been doctored harness name
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is in that around the world people are doing a lot of interventional work and so forth we can talk about that later but DR ernest name he was the one who is promoted The the direct surgical approach
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to aneurysms and actually has done had done such a superb job he was able to do the surgery in very short periods of time at low cost with excellent results which is exactly the challenge that you
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have now so ah he'll be back with us a number of times in the future and we thought his experience would be very valuable so I hope dessert did I leave anything out your home is a red herring is fine
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saw thank you for again for your words Yes I was combining professor as naming off he said in all the last years and here for sure we have learned many things from this giant man and yet I am here to
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share with you some of his key points in the end a philosophy fall asleep in both a challenge and I know reasons so if I can is that if you let me start I kind of stay Please Thank you welcome again
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thank you so much for participating with US and agreeing to be our guest speaker your recording your recording this right is being recorded great okay Yes saw a Yeah I was thinking that I could cover
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when our time so by the time i prepared that far that time but I think I can manage the time until you were going to speak basically about the tricks and the deeps of the SAT and the reason why
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because his name is Perfect perspectives because at for sure he was one of the men who cooperated most recent maybe in the world them and although M CA aneurysms are more frequent in the in Finland
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well the second most frequent reasons there are that a km artery on the recent stop
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at this lecture is based on this publication they have an obligation a mate in two thousand and eight and they were looking for that then operative technique and operative techniques of this for the
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management of these honorees and so on to all critical information also you can find in these two books they are freely available now you know the the the thinking microsurgery basics and tricks
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policies in the two thousand and eleven and also we have published tanks to surgical neurology international disobedience surgical Atlas where you can surely find manny Mania on their resumes and all
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those that they just that what Professor Harold Jimmy was using for for treating those challenging cases storm we can see now the anatomy of this on their resumes wiki by the San Antonio said a lot of
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arteries on their resumes in this five segments you'll know they won and from the bifurcation guaranteed bifurcation until the day come the actual date from the Akin until the general of the Gods
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Callosum the eight three goin through the den of the Corpus Callosum and the place where the petticoat that robbery colossal artery aneurysm or originated under a four and a five segments that already
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by that by the imaginary line in the coronary is shorter and about the prevalence as I was telling so MTH bifurcation bifurcation aneurysms are more prevalent in finland now basically it might be due
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to some kind of genetic differences in the population yet but in more serious a commodity and the resumes are the most frequent to globally came why is this challenging because of the complexity in
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the anatomy Yeah so there are a lot of whoa ama the Non and architecture InC and Interrogate time aspects running around is a commodity and also when you find the aneurysms in that place there are a
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lot of anatomical variations yeah and for sure that the location of this on their resumes make them challenging and all the bustle at bay for a dozen running on all done note of neurovascular elements
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that are around this area make make this and the surgery the challenging game and usually this the origin of this a common interest appeared in between the dominant a one segment and anterior
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communicating artery mill on the dome is often located between the two a two segments and to one of these I agree the God aspect in this and the reason is to recognize this a recurrent artery of
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Huebner and the other pair for eight years during the surgery and in more serious business are very complicated there are no reason saw it carries a lot of morbidity and mortality especially if the
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notice audience that are treat in those cases are not so specialized and the one moreover these are discount offer structure brings up and side of the diastolic dysfunction so through the spell for a
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or that damage in that before acres that are running around this aneurysm when we can get those neurological same dumpster and so for US already what we need is to have a very precise anatomical
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knowledge for the dissection and also we need or we must i avoid injuring the front aloft during the regression Yeah but all the suspects are very difficult to when you monitor large or complex
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aneurysms so that the aim of the surgery is basically to clip this aneurysm but respecting the normal anatomy around this on resumes usually the sign
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on their resumes and that they'll come again in our theory they appear with sure at night to hemorrhage and they are usually richer richer with aneurysms and yet even in front of of what we know
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generally about the size of a or risk size of don the recent flurry of June this and aneurysms even can break when they are very small so in the knowledge that we have about seven million Millimeters
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off and the resumes in the anterior circulation for treating them maybe is not suitable for the case of this acre mannerisms because they the media the medium size of the of the only reasons treated
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in the cities for example is seven millimeters which means that even a smaller aneurysms where's your turret okay so this is also very important to take into account for the phenomenon in patients
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that are carrying these aneurysms even though they are not tons of turrets so I and other aspects in this case decided that that there can be associated with other reasons especially in the AMC a
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bifurcation and for that it needs a really highly and expat experience yet the neurosurgeons game
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it's publication was made based on the group your data resist core beliefs one is the first place where professor Harrison's need me was the origin though he has spent around maybe fifteen or twenty
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years there and they collected the Go database for public Github for this publication until later when she moved to Helsinki then she collected data he collected again that database of Helsinki but
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this first publication is based on this and three thousand more than two thousand and thirty cents or more than four thousand nobody recent that the name you know in the in coop game
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some you know that Japan and Finland were like the privilege to places for for aneurysms maybe also because the archive screening and a population and also because of course of that genetic aspects
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and some
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aspects of the population like smoking or other risk factors that they were collecting and they made a place with a huge prevalence of other reasons now on to until that time there were over one
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thousand patients with aneurysms treated since the nineteen fifty one game so it was showing already that they they have they had a good experience in the minors enough of this aneurysms of course
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this a database also and show it not only share this near me said experience but also other neuroscience experiences that were operating in groups
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where we've had this
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in Atlanta and Asea on the Ot sims where more than one thousand Antenna from this more than one thousand around eighty percent of the AC on their way or where a command the only sims and or like a
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like a similarly like seventy or eighty percent of those patients were of direct cases and the median dia diameter of this an Arizona whereas you're seeing here seven millimeters
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and a giant aneurysm swear quite a few just fifteen and forty four mannerisms in this a kM area were also very rare only three on Navy Subs came
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i guess you can see that from or ruptured aneurysm in Finland around thirty percent are from the are coming from the akon the segment them but you can recognize as I was telling the beginning that in
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Finland the most prevalent than the reasons are coming from the MCL by Vocation Yeah and the second one is this a come on ever since
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the correlation with intracerebral hematoma on the interim into Galera hematoma is this one
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because of that close proximity that they have with the pentacles usually around twenty percent of the cases have intraventricular hemorrhage and another fifteen are having the same intracerebral
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hemorrhage
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and regarding the associated aneurysms most commonly associated aneurysms are these middle cerebral artery bifurcation the MC A bifurcation however also there may be multiple aneurysms in the owner a
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calm complex young like two persons or two percent of the population had two or more aneurysms on the same or a comb complex and even a couple emissions cut at three on the resumes in that in that
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area
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so Yeah this is certainly the bitter about anatomy when I share with your those lights you can where you can revise this segment and this anatomical considerations especially about the the the
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position and the placement of this a one segment came also about these
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Awan anomalies we can have frequently this hypoplasia or replace your duplication offended Thracian author of even the in infra of the course of this a one segment okay so you have also been the
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literature recover a lot of revisions about about this em anomalies in day one segments segments and of course this is a clinically important because we need to care than normal anatomy even though or
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more even more if em we have like a glassy of this one a one segment so we need to preserve carefully all the best as they are running around the analysis game importantly this mythical integral state
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the arteries or you know this medal ah arteries spurt for a toss -up year from the A one segment differently from the lateral better for a door that appeared other are getting from them in one segment
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and to all this go of course to the to the deeper structures in the brain and the diameter damascene of these are a pair for a dorsal may produce severe neurological deficits who came close where you
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can revise about how they claws and how they enter and in the interior are better for a so stance which kind of is structures that are irrigating obviously all the optic systems aren't part of the
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front the law Yup
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and you gain the preserve the preservation of these arteries this is a is very important when you are operating under the communicating artery aneurysm regarding these regret the artillery give them
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there were misses a big branch come in usually from the eighth to segment also can come directly from them and they were communicating artery or even it can come from it can appear from them a one
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segment and is very crucial to preserve this and this this artery and usually this and a half like a different course running around regarding the a one segment or like come in around sixty percent of
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the cases most of the cases and the Sara Huebner arteries it's a superior course regarding the A one trunk arthur also he trust an anterior course and up posterior course the eldest frequently macaire
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saw and during the dissection of the of the notice himself or day one segment going through that are all going going through the carrier and that approach or inter hemispheric approaches we should
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preserve this very important destructor of his size are essential for now then there are to avoid the neurological damage in the brain Cape St regarding that they are communicating our theory of Corso
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we know very well that these are structural joints of the anterior part of the Willis Circle and and we should recognize very well that normal configuration of these are a commodity since due to
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variations of the AOA segments also this can have different positions and also we should recognize how high it is and this structure from the skull base since this
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step is essential for choosing the correct approach for treating descended or completed notices
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when some other anatomical aspects also you know that there are communicating artery aneurysm they have more beer for a thirsty or going to the to the the Angelica structure so we should preserve them
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and preserve curtains near me also it was a she she commended on the importance of clipping those I notice hymns in the perpendicular manner yes though then you can avoid to damage or avoid or you can
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avoid clipping before it does the thought of running near to them to don the reason in this and it'll complicate the next segment game
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well yet we should have the usual idea as we were mentioning usually the reasons appear from a in the direction coming from the dominant a one yeah so Nieto de Busk lateral flow and the all these
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aspects of Danielson is coming and following the flow of this dominant the A one segment there and we should recognize that in the imagine of the Sir of these aneurysms
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and regarding the aid to sick mental roof of these two tool or their arteries this orbital frontal and front the polar arteries that are appearing near to the anterior communicating segment with
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others ready to turn usually directly into artillery of heaven they're abusing the a to segment also on to this is a very important while recognizing those structures during the Microsoft management
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of this know the Sims
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game we have we can have this or another miguel variations the norm and when we look at the two that are notices we we have the by the thought
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or we know that those animals Mascara running these different positions and we're recover this classification of the clan of that data complicating our theory on their resumes regarding the direction
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of the dorm not if the dumb is going downward though we can see it on the resume going toward thy skull base or if it
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is forward we have this for the protection or if it is upward it goes between the two and a two segments or even it can go backward looking INOX exhilaration sobbed and in cases of complex aneurysms
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wicker calf this and daddy bought them off of all this under a complicated North Carolina segment game and we are a recurrent also with this aspect that the aneurysms is usually originated in in the
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enjoyment of the dominant a one under the aide two segments McKay and rarely rarely appears directly from the Dinner complicated drunk Okay so
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the the technical aspects for treating those aneurysms that will be based basically on this direction under the direction of the dome
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came what they use for for evaluating those I notice homes where we know that the gold standard for the for the management of this underestimate is the digital subtraction angiography however in
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Finland the more centers they use the city A Cave scenes it said that the efficacy the the sensitivity and specificity of this city a similar to the digital subtraction and geography for aneurysms
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more than that diagram larger than two millimeters games home and it has it adamant that just seeing some the stall is invasive and you can really also associate or you can organize your your strategy
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by waiting other structures like the like the skull base or like the brain or there saw you're going to analyze better your approach you'll see in this SE Da them despite of the of the digital
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obsession and geography that is of course the gold standard in the imagined game and the request through the reconstruction of this element is very important to recognize this the foreign vessels that
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are going on the four main busses that are going on all day commentary you know the two he was on the two a tooth and even you can recognize of course that the perpetrators that the appearance of
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those structures can do and what we do or what they do in case of this negative DSC aneurysm but the image in which you really suspect that there is an aneurysm you sure you can compress the one of
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the internal carotid artery and you can make the diagnosis been held with with the
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game
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yet another important aspect to in the imagine is to recognize the sabbatical or anomalies especially the Spanish stations Hypoplasia to be more careful during the during the during the approach
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we can see also this bonus structures or is for sure even more important for planning the management of this giant Dora Jessie for aneurysms came and about the Microsoft he got a strategy and bear we
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need to have a good preparative planning yet and to choose the correct surgical approach though otherwise we really fail trying even to approach carefully this aneurysm and yet we need to evaluate the
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risk of due to damage the bear for a torso is important that I prepared these images and and yet the technical demands of growth requires a specialist neurosurgeon and all the tools that you might
27:43
need for thy sit for a careful dissection microscope day session of the doctors
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and the outcomes will be related to the greater manipulation yet how much you manipulate the normal structures will produce even the buses possum or will produce the neurological damage if you retract
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highly the front along
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the way we have talked about this
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and what to do in case of interested about her hematomas usually after you recognize the aneurysms and if the hematoma is small then you can go first and clip the aneurism if the hematoma is is large
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then you should go first to treat our two but quit at least partially them Tommaso it can reduce the intracranial pressure and it can also help you to do dissect carefully while there an atomic
28:51
structures that are inside and then we're going to fall for a moquet in those Emma Thomas that are usually enough from the love we can make small cortical incisions avoiding of course the eloquent
29:06
areas and term yet we can remove partially those madams in the case of interventricular hematomas and usually also it is rare that they can erase rare at least in the publication and the weather in
29:24
finland the door in Iraq that it is rare that the collocation of these external drainage is external identical or the drainage sardines there usually are going by microsurgery and our finest thread in
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all the cisterns yay to evacuate all the CSF and
29:47
lamine that analysis to evacuate to to reduce the so these hematomas know and and Yeah and although they were communicating artery aneurysms produce this interchangeable or hematomas so the posterior
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circulation are more related with this game and then yet air as I was telling I usually prefer her last name he was going through the learning the analysis and the opening dilemma that the remnant is
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entering the third ventricle in part of the hematoma or da da Da hemorrhoids and also allow in to release more CSF from the interventricular space
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Am I
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Yeah in in also in case of this acute hydrocephalus if if it is a if the patient isn't in a very clear designation of course you should go and tour or perform identical brightness immediately and but
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a in most cases after securing the notice him or you are surely the burn the sargent opens there let me know the terminologies for removing this CSF
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well which approach to use you know that in in Finland to look at near Me show it his lateral super orbital approach that the west uses for most of vascular on to to mars and located in the anterior
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is called base however in some cases you must just enter that Dario hinderance very approach on to in some other cases you can use also that tell you another classic Tatiana approach or even die or
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bit a SQL my cupboards and all of those half are from Adamant that is I am but I Am telling that the most common approach for and there are communicating aneurysms in Finland is the lateral super
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orbital approach which is a variant of the cherry on that approach but with the less
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and opinion of the Simple muscle and with a little bit more frontal location
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you can see also in internet with a parachute this lateral superior approach that is a B the other there's a link here to a place I I ask you kindly to go and check those videos similarly with this
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satyr in the hemispheric approach that I use it for high located the other complicated neither distance game yes those are most of these approaches that tell you that approach we can use for this don
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worth projecting aneurysms yes since it allows a better lateral axis but so far the plot is the preferred to be most cases and the hitter in speak approach is or is used when the eight KM is very high
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and we call that a win at the a company is like thirteen to fifteen millimeters from the skull base game the arbiter of democracy romantic approach can also reduce the frontal of the direction but
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sometimes a beside the space that the that that this approach offers is limited by the orbital content so rarely is and Joseph are rarely this approach is used to watch your city in Finland and yet
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even though this orbital seek a second medic approaches is demanding it may also produce some kind of offer that Arose Gonna injures or even of them are what you got in your Sam
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Okay and yet in the case of dysentery or he desert into Miss Erica Approach Yeah we just window and the reason is over thirty another fifteen millimeters from the skull base and you can really
34:14
minimize the brain retraction and and basically you go and follow the fox and the AH the cingulate Gyrus to your identify first up Erica dorsal arteries and follow from from from the start the proxy
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my law or besides Donnelly Sr and I usually you you follow that to a two segments for finding that a camaraderie is little beater more on omar it takes a little bit more demanding it takes a bit more
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time than the letters a broader approach but it boys are really the retraction of them from the love of the wreck the director Sir Giles and to get you really don't need even to remove this a birth of
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the front the love for accessing them the reason
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I game here regarding the CFS not just a case of ER en route to it it comes you go and open the allow me the dignity system and then the superintendents cistern and you'll realise the CSF and
35:30
sometimes this is enough in case of Richard or even selected and you have to read the notices even you should open not only does he stand but also the alarming that that'd be nice for additional
35:44
moving and in the case of the downward projected aneurysms you may require to open in the liquid membrane Yeah sure you can remove more more CSF particular picture was a rarely perform at the
36:02
inter operatively for CSF Diamonds since this opening of the Lumia Therapy Analysis was enough for for reducing the internal pressure and for our for allow in Utah to to go to a God complex
36:21
again regarding the general principles for the dissection of the aneurysm survey of course you should go to the first step for all this enables companies to release the CSF and the and you go through
36:34
the base of the frontal off if you go to the lateral Supra orbital or the Italian approaches and you can open all that he stands for releasing the CSF and for allowing you to see clearly the anterior
36:52
communicating a complex game and yet even if if that isn't the issue is insufficient for for the in the CSF you should go on have been entirely requests membrane Yeah through the of the triangle Onta
37:10
with that you can release more CSF aren't really that is very beneficial and it takes maybe three to five minutes for releasing even all tension that you have in the brain in the case of Richard and
37:25
the aneurysms antibody implemented brains came and you should identify the ipsilateral and contralateral a one segments the tube a two segments you should identify the record the artery of you from
37:43
there and of course the a cop segment was your identify all these structures then you're Gonna start placing the the the clips your temporary clips or pilot clips for finally place in the definitive
38:03
clip in the aneurysm
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in some cases yet in some cases go into the lateral Supra orbital approach you must respect this
38:17
Gyrus rectus located and it will allow you to to check the A one segment the ipsilateral a one segment and the aid to segment game and that should be a diner in less than one a centimeter long your
38:35
Aunt betty few or many meters deep just to recognize those two stretchers came and usually you should preserve the bear Mother and direct nights on the interference in the entire hemispheric site so
38:52
to also draw boy to rupture of the of the aneurysm yeah and in rare cases you may expand this recession but already you may you may have a patient with some kind of of peripheral dollar syndrome so
39:11
it's important to recognize all the structures and to get tourists to resettle his anatomical structure also only us as matter what you can eat for recognizing this arbuscular elements came and ye are
39:31
generally in Finland term one Sergeant operates the case and assistant is for some cases saw and are suited a tablet doctor can help you when you when you are operating alone is beside the results
39:47
came on to your surely of course you can also detract with your with your aspirator or with your right bipolar but yet or
39:57
most of the time you need to deserve the server Automatica and fix it a retraction for
40:06
cM very well all this elements in that they are communicating punks came soon and once you recognize all these elements you would the eclipse the eclipse may be and bought a one segments yeah and then
40:25
even you can put him in if you can see really the AdA segment you can also put the clip in about a two segments and finally you're Gonna put a pilot clip that was caused by a of zircon is near me like
40:41
the first clip but not ensuring all the are all not done not ensuring complete all aneurysm but it was enough at least to to reduce the volume of the aneurysm so you could put the pilot clip as much
40:58
as you can see it I notice him and then when you are doing that you can cooperate and step -by -step the dynamism to reduce the size was you recover reduce the size you can recognize better the neck
41:15
of the aneurysm and you can would a second or you can take out that pilot clip and put to death any deep sleep yet you can do this kind of movement as much as you recognize very well the neck of the
41:30
aneurysm them since you are taking and place in the aneurysm or or the clip in dynamism of course you should be very careful for not to to to damage in that neck of the aneurysm
41:46
but already you're you're you're a good control of the hemodynamics with the temporal eclipsing all the segments that cannot be more than three or five mi between three or five minutes you cannot put
42:00
temporary clips more than that time air and to avoid her of course around the that cetera vascular ischemia and to yea or if you are still there need more time for We're keeping the I notice him
42:18
you're going to remove the temporary leaps add or improve the circulation and it again and again and go go back with the same temporary glimpse for the second or third stage and also it has been seen
42:34
that when you put many times this temporary eclipse you can producer has Hester notice of those a one segment so you must be very productive with your with your with your clip -in to yeah this cannot
42:49
last long or to avoid all the all the sir damage in the brain came and yet the most critical part in in the clipping of this aneurysm is to avoid the aneurysm the damage Done Edison Base since the
43:12
reparation of this neck is Beriberi Difficult okay so we should be very careful when the when where plays in and take another taking out the the nine reasons that the eclipse sorry and yes for sure
43:30
pre -operative you should check that your clip which kind of clipped the you reduce an term yet it should be like one point five the link of the link of the neck yeah that's them somehow the character
43:47
clip the correct size of the cliff of what you are going to juice it ensures a good closing and also in some clips we have seen that when you place the clip too deeply there isn't a low resistance or
44:06
lower grossing pressure in the proximal part of the leap saw this proximal part of the clip should go a bit Far from the from the NYC Yeah which means that the neck of the aneurysm should be at the
44:25
middle part of the of the clip
44:31
and once you get finally the or the aneurysm clip it so you can reduce the size of dynamism or with with with your bipolar okay and then if if the glyph doesn't allow you to to to clause all aneurysm
44:56
you can use a second clip you can use the technique of the double clip -in Yen as saw you put first darkly for US close to the next to the neck of the Nelson and the second clip is place it under this
45:13
ugly pia ensuring a complete Illusion of the neck came in many cases also you can cut the dome of the honoris in the sack of that notice him and send it for research or for some anatomical studies
45:34
if you have use it to for a long time this temporarily clipping or you have Joseph many a times these temporary clipping you can apply Papa Berlin to preserve the pastor spasm and is a good test
45:49
strategy what was used during Finland a proper reading a small Gato nights can be applied over the air segments to avoid these buses passing game and while there are of course also different some
46:07
somebody Asians in the strategy according to the direction of the Dorm you know and then we will see We will see that a bit later so but also in
46:23
what to do when we are
46:27
going to clip donaldson but we have a southern literature of the interpretive should have done the reason
46:36
we should try to make an initial console with one small cut or night and assumption under section two or on on the on the place where it was broken okay and we can compress there with a Katana under
46:52
suction tube and if if that is uncontrollable if the bleeding is uncontrollable we can use this I didn't know seen induces cardiac arrest it can darkness the geologist put her end up those adenosine
47:07
saw it gives you like one minute or between thirty seconds to one minute time for for a cardiac arrest and in that time you can really improve your caribbean and you come a place properly the clip
47:23
game
47:25
and also another strategy of course is to once you have said that the only reason leak and you are with your got an idea and your urine suction tube but you should go and tried to to clip temporarily
47:44
die to a one segments game and finally you can use a pile of clip to a place and that for the initial placement of these clippings in the in the area where where the analysis is leaking game and also
48:06
if if the if the roof choice at the level of the Nick Dennis little bit more challenging you should try to reconstruct the base their temporality Yeah and I could see that her in where when I was with
48:25
rivers or canals near me he could try to reconstruct the even the naked or with eclipse so he put directly a small clips on the neck and then put a second clip like a double clip technique for trying
48:39
to close the borders of the of the rupture
48:44
or trapping is of course not recommended but if in any case you cannot close the the diane this leaking then maybe you should consider this a strategy for saving the life of the patient but or or you
49:01
should plan if you have a good center that can allow you to make a bypass surgery so then you should plan for for doing that Ma'AM And but usually in all these strategies work well when I notice him
49:19
because of small small leaks yeah it's more of rogers before you're finally there clip -in are all these reasons came also we have seen a very small aneurysms that Arabs unit at this Ah desert complex
49:39
saw these very small aneurysms are two to three metres Sancha and sometimes even ara similar to this or blister like aneurysms and the treatment of these cases eyes a little bit challenging you know
49:55
but for this is buried the double clipping technique is a very useful technique just firstly you put the the pilot clip in the segment what you recognize of the aneurysm otherwise you're once you
50:09
ensure that the clip is is it's there you should put a second clipper under this to ensure all the closing of the game or near near the end of your arm or is it are we already on time
50:31
or how much more do you have to tug it okay is a couple of slides and then I finish
50:39
the game so the verification of this we can see of course by this dabbler we can also adjust the geography and the death interrupted at the interpretive and yoga and yoga future the microscope and
50:54
also Reagan years that he or Sam Okay I well I think all these are Yeah we just need to verify the complete occupation of vandalism and with that then we are sure and I could see or hear some cases
51:13
that the
51:16
that there was a placement of one small or a theme that they're inside the third ventricle through that I'm not going to be analysed so it also ensures that does CSF can still go out and when you have
51:32
this acute hydrocephalus and when you have also intervened declaring hamlets when all of this and it's lights are showing some details about this don were projected or forward projected or off were
51:48
predicted by cooperated on the resumes but basically in the main point on this aspects is to evaluate the best approach for looking at first the neck of the I notice him saw the position of the head
52:05
to the should allow you to go directly to recognize this and join enjoyment in Within that a one and done they were communicating aren't even the dominant a one on the and to the dominant a one
52:19
segment and anterior communicate in a segment game so and yet for complex on the reasons for the giant on their resumes or fusiform on the resumes you should also look very well the preoperative
52:36
imagine and you should be ready for also performing some kind of bypasses since this on Elizabeth's are a bit challenging for for treating
52:50
and this is a picture with professor can understand me and his memory look anything but that will be all the code can stop sharing screen career she stopped sharing screen for a minute
53:08
I want you
53:10
ashdown sharing screen let's go to the regular screen so he can see everybody
53:17
yes
53:29
he knew that the strata trying to see if I can
53:37
African Okay alright Thank you Thank you see Everybody here We Are I think that's Pretty Thorough Thank you for giving that comprehensive experience based on the experience of Professor in Finland any
53:57
any well I had one question for you it sounds like you preferentially me put my video on you preferentially what We'd like a CETA for imaging the economy aneurysm zIP but in which cases might DSL Be
54:14
preferable
54:17
maybe when you are having complex aneurysms you have complex medicine so then do you really need to recognize that dominance of thy wine or you'll need to really recognize all the muscular elements
54:32
properly so you can make a fashion at the desk which is that the essay Yeah so it's more functional it gives you more and time for for recognizing for for various small details in how the flow is
54:47
going through the arteries but honestly in most cases they're in the analysis more than two millimeters three millimeters city a works well but yet you don't recognize for example in the city a the
55:01
calcifications sometimes you that also his Abitur challenging you don't recognize very well the true size of the neck if you have a calcified aneurysm for example so in those cases in the case of
55:16
complex Anderson's yet you would really do that the essay Want me to make a couple of comments here strata first of all this an outstanding presentation or a incredible experience in detail that's
55:32
really important night one of the chat comments was I who'd like to have the slides or a copy this is recorded ah it'll be recorded available on Sai digital for everybody you can download it to your
55:44
computer this is the kind of presentation you want to look over more than once and many times you can print it out if you want an s and a digital is a chance to do that too so you can have it for your
55:57
home computer which just prints out the complete audio and I think what we can do ah your hum in the future is there are twelve hundred harness niemi videos on Sai Digital NS and I and you can text
56:14
them out and then in the future meetings you can go through in a calm aneurysm or other different aneurysm and you can show again what you said described in this introduction which essentially will
56:26
emphasize all the points and you may take a few cases to do that but I think that may or may help I I think we're just a couple of comments what would what he would professor whose name he is doing is
56:40
show you that you can do this in Africa it obviously takes a little time take some experience if you can go to the ot or if there is an autopsy or go to the morgue you can operated when they take the
56:54
skull off you can if this is done very often and and you can try some of these approaches to the aneurysm or you can use it if you're over cadaver and work on that it gives you ways to do that so
57:09
there are other things you can do you can get a skull and and use various different approaches are many ways to do that and basically what Dr Ernest Nemea said there's two two things that cause death
57:21
from an aneurysm one is re rupture and the other spasm we didn't talk about spasm will do that in the future but reroute sure is is the key item and what Doctor Ernest Niemi is is showing us he's
57:34
doing and what your home is doing is as you don't don't go directly to the dome of the aneurysm that is not the thing to do what you want to do is to anatomically show all the branches leading to
57:48
incoming from the aneurysm and as he was showing you go peripherally and you work centrally and then you get yourselves you can control the the vessels feeding the aneurysm and you can dissect it more
58:00
he puts a temporary clip or a pilot clip on the aneurysm and even to sexual more so he can adjust the final club is that correct Zhao Johan Yes Yes this is best strategy and he uses his spinal
58:14
drainage is basically opening the limited terminology she endure and the the approach a lot of people today are using are very and very interested in the minimally invasive approaches the problem is
58:31
you have to be experienced to understand that because minimally invasive approaches means you have minimal visualization and so we always use a larger craniotomy and and as time goes on and you get
58:45
more experience you can narrow it down and so forth but I always found that that's very helpful and and so forth so that stops them one of the major issues temporary cliffs you have to have those
58:57
those are clips that are less strong than the permanent cliffs if you go to a meeting I'm sure there's an Africa also you can find some temporary clips are usually applied with the same clip folder
59:10
and A and and they just damage the vessels less if you apply a temporary to get control so so those are some points I I am Edinburgh and Ilana no chair but I don't want to take a Lotta time I think
59:28
that's basically it but I think we'll have your humpback many times in the future to talk about approaches to aneurysms I know you're all see Andrews is more frequently and he can help with that and
59:43
you can present some more cases and so forth or A I just wanted to make those comments and if other people have other questions please please ask the questions
59:55
any other questions or comments
59:59
DR theo will be giving his presentation momentarily but wanted to have the opportunity for for people to respond to the valid cause presentation
1:00:17
Sam Samuel eg Obama as a question in Chat OK so now I have a question for now when he gets to the end of the presentation know where my discussion but have it okay the duct Dr one F in the chat
1:00:36
indicated that the the greatest presentation that he wonders about or she wonders about types of clips preferable for a cut artery aneurysm Yeah Yeah in in in Finland in the beginning they were using
1:00:51
eclipse also then then of course yes as eclipse but actually the clips should be just basically on the size of an edison on is more important to to to recognize but it was the length of the clip and
1:01:08
that of course also that according to your approach you would choose also the shape I believe even if you need some kind of angle it clips or statically sarah in on a song I think it really needs are
1:01:22
you really need the first check them that the anatomical variation than automaker accomplice of the Sir Aneurism and according to that you will select properly the deep don't forget to to put one
1:01:37
point five are there longer or one point five and the size of the of the aneurysm of the neck of the aneurysm thus the clip should be one point five size than than the the size of the neck of their of
1:01:55
their noticing so that is at least that will ensure you not to
1:02:02
sleep the dark sleep later you
1:02:06
to that one assuming you're making a reference the place in the clip Perpendicular to a comment that parallel otherwise you would run the risk of compromising the contralateral vessel yes that is very
1:02:21
important also yeah that is very important so with that you avoid really the debate for eight of the therapeutic maybe that behind the neck of reason and of course with that nowadays with the
1:02:34
interpretive angiography you can really see how are they going to buy substantive you are really ugly being sama sama important restructuring
1:02:46
doctor has you had a comment please go ahead
1:02:52
Fenner Oh Summer morning cinema
1:02:57
everybody is his summer of Sam SR is A is is a both an intervention list and a in a certain surgeon is from Iraqis and Cincinnati and go Ahead Yeah I don't get it Thank you for this nice presentation
1:03:18
was it out of expedience I didn't appreciate that that's very helpful I think for all that involves a few comments here I first to that comment also from dictator or Oarsmen about the
1:03:35
dumb political thing I think Yeah for it depends on the setting based on my experience I have all the clips used multiple time especially with the temporary clip you can use it multiple times so with
1:03:50
the time it will it'll lose the the typical pressure required to whenever possible I will not use temporary clip in general unless it's a rupture cases because sometimes it cause injury to the R three
1:04:04
R I totally agree with that especially with the preoperative imaging CETA showing some classification I will be A little bit cautious too is like an overuse of temporary clip I and another point is
1:04:18
that the exposure I think they've taught osment also mentioned that the I I think it's totally different and the settings can rupture an arab charter so for the rupture differently
1:04:32
I would go with the larger exposure opening with diversity stand available and would the would the Arab chairs Yeah sometimes I rupture with the very regular shape and you resent that maybe ok Let's
1:04:48
do a Mini Tokyo and I'll only do his helmet minimally invasive approaches does the thing that sometimes we do and Yeah I agree on that like larger exposure and overlays required for rupture angry or
1:05:05
large giant aneurysm and the last comment is that on defenestration and and after your home nation the dominant technology for the Fenestration importance just to mention that actually in the
1:05:21
guidelines I I that the available guide nonetheless version is still they they put them the guidelines that the administration of laminated them nowadays has no evidence
1:05:38
to be beneficial about actually I think they depend on all the referendums that a central France has suggested specially done down the fenestration of what climbing terminology and the liquid membrane
1:05:51
for example has been is very beneficial to prevent long -term hydrocephalus and especially a sit and go from trying to notice him an idea thank you again for this nice lecture similar are you doing
1:06:07
into vascular approaches where you're into reasons I Yeah when or if you comment on for a comment or a comb artery aneurysm just the weather that might be lower likelihood than other sites for
1:06:24
forgetting a complete inclusion
1:06:29
Yeah I saw at least here in the states right now is that endovascular first that's that that's not all so for not only that we think that we can get it and simple coiling especially with then little
1:06:45
with all the patient it makes sense to start with gliding even that we know neil and we inform the patient that is that hi Heidi I am ultimately in a highly likelihood of recurrence maybe up to twenty
1:06:58
percent but it makes sense to start with God and especially with those Arab chart of all the Arab charter will start endovascular first still I think that your chair and the current state does I think
1:07:14
that is not the best option and for the call them Pizza Air isn't that simple aneurism Yeah you can argue that a well experienced open a cerebral vascular surgeon can do them easy deal with their M C
1:07:28
A calm and a well equipped endovascular at center also kind of direct read them safely but for the complex aneurysm I think here will be there or will offer team to decide I remember multiple cases
1:07:46
that I think it's is difficult to treat very complex ugly aneurysm involving one of the branches for example and then we end with the combined treatment which I think it will be definitely an
1:08:00
interesting concept to think of which is for example if you put the pipeline and the akon it's very Do you because you may jail one of the eight roos but a few time do a three two eighty three side
1:08:19
-to -side dentist and most of the brief before the application of pipeline that will change the whole equation so now you have a three tray three and it's the most is like bypass distally and then
1:08:32
it's very safe to put the pipeline for any ugly looking aneurysm think this is a change to the equation usually those three phone to have multiple trial of clipping multiple trial or the fly are pink
1:08:46
or endovascular to pen that's not typically three of them I Yeah I think combination of treatment is one of the good options right now available and the best option it is is to have a deep discussion
1:09:02
between worth and your bicycle outside and a surgical site and mainly dependent on the experience I like the more experience Open was going to available which is less and less right now the easier the
1:09:16
discussion I Am sure that your figures are that's very good if there if there aren't any other burning questions though will switch to the presentation by professor then from the shake onto D of
1:09:33
university in Dakar Senegal Welcome professor thea you can you can share your screen and and proceed Thank you
1:09:48
i Johan there were many compliments for your lecture so I wanted to thank you for it
1:09:55
thank you very much
1:09:59
The next presentation in this Sub Saharan International Grand Rounds is given by Professor Ma by the job which is the Chica Anta Diop University
1:10:14
in Dakar Senegal
1:10:17
Senegal is located in Asia and the West Side of Africa Dakar is it's capital as you can see located on the map in front of you
1:10:32
Thank you for the presentation Dr Johnny Shook It I now share one case of rupture a any reason to in our unit
1:10:45
is twenty twenty twenty year old female with no particular medical history you will have a good headache with a left Hemi better be any better these few days is that the headaches and she was admitted
1:11:02
three weeks after the bleeding in our unit and she would classify that that and three an official tweet
1:11:11
the city showed these instruments very hematoma be a little bit of a dhamma in the right frontal lobe and also a bit of bleeding in the Corpus Callosum sister sister
1:11:32
the enjoy city was done and rebuild this acre and the reason why she's up enter your projecting one and maybe
1:11:45
on the junction between the A one and the left a one and a two junction
1:11:52
since eg vandalism was ruptured we decide food to treat her by and the only option available for US is a surgical option so we upgraded her after I found plenty twenty six days after the bleeding
1:12:09
the question was what would what should be the best approach for these was and the reason we use for almost all of our patients are children are approached for a comment reason and I think it there
1:12:25
was not this this is this is a dhamma and hematoma in the in the right frontal lobe I think I think we should go from the left side because MCM looks like the slice is oriented from the left to the to
1:12:42
the right and the neck is maybe more reachable from the left side but since the patient had one already left hemiparesis we we choose to go right side in order not to to create another problem
1:12:59
In the in the left Hemi Semi soon
1:13:03
so that based on either position vs a society slight it's extension of the head already has two allowing us to to to decompress and two to let the frontal lobe
1:13:20
descending by the the gravity and not to to put a lot of iteration on the on the on the on the frontal lobe
1:13:30
all our case if you start or located by the opening of the the Sylvian Julian Future I think it is very important to help a lot to do not to put a lot of nutrition on the frontal lobe and here you see
1:13:50
the starting of the opening and you see the the yellow coloration signing the the Bleeding Amnesty during steam and now he arrived the the OPTO character Jumps Cistern we are opening and draining some
1:14:09
CSF Leeches which help us a lot to obtain the the Bran blended luxation and now we arrive onto onto the object the red opting Nope we decided the direct made between the optic nerve under the annual
1:14:26
rhythm you can the NSM come out into view here was Anterior projection and here we have to to to to be very careful not to dissect here before having the control of the vessel it may be sometimes very
1:14:42
difficult and you have to go posteriorly to find the A one a one from the dead he said as it's the outside and also for the contralateral site
1:14:56
now he has tried to tried to and he wants under the end the museum
1:15:02
by dissecting the Eric noted under the energies and now you can see
1:15:09
the right a one going to the next and here you can see coming into heels the left anyone
1:15:17
very important to dissect the the A wants before before going to move to dissect the dome from the from the frontal lobe
1:15:30
now reopening the interest of future little bit in order to find a way to go be to go behind and the reason you do all that without temporary keeping you didn't use temporary temporary clipping for
1:15:45
all our cases will be just if you saw that the that dissection would be would be possible without a temporary coupon clipping so we did that and now we're getting all the Aneurism around the dome of
1:16:02
the ones I edited around do any of them do and now you see here you have you have different arbiter from arbiter actually very stuck to the ends of animism and we'll have to do to upset
1:16:18
the salmon is the the actually describing a loop and very stuck to the to the enemies on wall
1:16:30
you have to to dissect that and to detect completely before putting a clip
1:16:36
how you do it vs the dissector and your finances the visit wasn't just the Microsoft
1:16:50
now that Archie is the debts
1:16:55
it allow us to go to the desert to the contrary decide to see the left have a tUS a to to be able to control where we are putting our cliff think it's very important to control the the to a tos and if
1:17:11
we can do the continental U ignored or sold to to be sure our clip will not compromise all that vessels here he continues a diocese positioned behind the the NSM Do
1:17:27
and now you're trying to understand mosey honor to me before putting a clip
1:17:37
sometime not very easy
1:17:40
when you have
1:17:43
more blips more than one bled for them here we have a second blame here which is more proximal
1:17:57
and now the first repeat is a pilot flipped we put it in order to to continue the dissections is not defined a clip is a pilot clip which allow us to exclude those up to the most fragile part of the
1:18:12
energy them in order to to continue the dissection
1:18:23
Yes Arizona is not totally the dome is now totally detached from the optic apparatus
1:18:31
and will calculate the dawn
1:18:56
after after you complete the basic show you tried to put another clip in order to exclude all the all the all the dog because the first clip is not
1:19:09
is not really not the the best we can have because you have some part of the the neck which left behind so we replace VVD and Juliet Jacques our our first clip to put it more money
1:19:28
in order to exclude all the ones that don't
1:19:34
but this one clip will not be sufficient if you have to add another one the control that the patency of all the branches because our mac and up the rope but here you see that you have one blip here so
1:19:49
we put a small clip on display and I think he's not doing any really good after that after after we detached the the Doom from all the searching we see that you'll have some neck here that was not not
1:20:11
into the the clip blade so that was the final final clipping these three straight clip and here you have to put two traders are not too too too too too too too long here because you can compromise the
1:20:28
junction of the A one a two junk some of the left side
1:20:34
because that was the operative video
1:20:37
the patient had a bit worsening of her left hand body but it improved after few days she was discharged home after the the seventh postoperative day and when I saw her at the last photo at six months
1:20:51
the no no look at the exam was normal The possibilities city showed this clip and no auditioning ischemia on complication thank you for your attention
1:21:09
excellent that was very nicely done thank thank you so much for that presentation you really
1:21:16
exemplified many of the principles that Doctor valid because it talked about but but Dr Vasquez do you have any comments
1:21:27
a very nice case you have anyone that I can follow in the universal principles for the good my Grandmother Sally Yes
1:21:38
Yeah I had one comment that that might be better useful also that sometimes and we saw in some experience we've had some experience on that case that when you calculate time to match that on the
1:21:54
calculation can go even near to the neck of the aneurysm so it can produce a case of the
1:22:05
roger in the future so it happened at the wicket of the few cases seen in Finland when we were when I was there saw there was an analysis of why a couple of patients that were operated under the cliff
1:22:20
west very well blizzard so they have our restructure and since we've had all be us there so we could analyze the videos and how as the strategy of the of the clip -in saw
1:22:32
of course we we didn't definitively name at that that the reason that we were thinking that one a risk factor for that may be the excessive calculation of the sack of donelson that can go even to the
1:22:47
normal wall of the heart that he saw I think that that that is very important you should calculate just to reduce the size of that of the SEC but without going far in download a man was that sometimes
1:23:03
you cannot recognize event but but the calculation can split little bitter but otherwise very nice case and yet you are using the serial number theory on that approach so but maybe also it could be
1:23:16
through that later also probably that have roads but Yeah that in that case okay Thank You
1:23:25
Jim Did You have any girlfriends thought it was an excellent job and very nicely just sector does they think I agree with I your homage demonstrated all the principles of exposing their anatomy and
1:23:40
then gradually getting to the point where you're doing the clipping excellent job
1:23:50
Yeah the very very well then I must Admit I think I might have been inclined to respect the Gyrus Rectus I admit that approach but fit very very very nicely done separate Doctor Jose did you have a
1:24:04
comment yeah actually this is a very nice and well I would say microsurgical principles the way of deception went to the blonde websites one given the sharp distinction is very well demonstrated I new
1:24:20
enjoyed and Yeah I can see the day that is that little bit of toxification on the exchanges authentic on that toilet Kate My initial opinion the documentation if he was okay this neck will need more
1:24:36
than one clip because even though we can see the first or the second clip is not very close because that is a thickened neck in a way because of the classification It using multiple Tan Demo clips was
1:24:52
was makes sense in this case in addition to the proximal a blurb it's well covered I I I really appreciate that and the two points here I think you mentioned digital sort of Testament to the
1:25:05
importance and diagnosis some people call legitimate come on flame he went on I I I think there is no much in the literature by the way on that if you search their literature you'll find only maybe
1:25:20
one or two like series dedicated to this very famous sign that we all know that there is a Java strict Testing I don't want this means that it's almost bought the monarch for a cum on your resumes and
1:25:35
both those papers I think it's in the US and I published otherwise that is unknown much like long series Justifying as it Is What a prognostic sign or not it's a sign that different region with regret
1:25:48
or not is that a long term psychological effect based on that jet starts to seem I don't want that has nothing going back to the literature like an infocus of that time and it's threat even as an
1:26:01
ideological assign that is known in a series for that just something to flag maybe for future research on interest and another point if I time is that the orbitofrontal artery it swelled mentioned
1:26:15
that how it's detected I think the same applied for the job for electricity my Toma is the same for orbitofrontal if he was saturday literature on orbital frontal hematoma you will find it here and
1:26:28
there and a common Eurozone theories but there is no papers on the orbitofrontal frontal are three is it safe to close it or not nobody said anything about that just check the literature you will see
1:26:44
that I think that is the only one paid federally that name the orbitofrontal artery and and it's also published in this and I and in that paper we describe that in some cases especially with superior
1:26:56
directing a call money orders and sometimes the ache we need to sacrifice that to automate your front door because it's the only existed in time for the Fisher because all the anatomical illustration
1:27:09
we'll describe the orbital frontal Orator as going lateral from the eighth to actually it's from the fourth floor of a millimeter from the first four million meters of a two but on reality it's not
1:27:20
going to get it it's going interior within the interim Mr Frederick Fisher so that will make it on the way of the Superior Aneurism on sometimes if it's a rupture in your resentment deodorant you may
1:27:33
need to sacrifice that and our cities we try to preserve that there are three but in some instances we sacrifice them that has no effect and that was That i do have that paper that took okay we need
1:27:46
more series focused on that the Arthur the sacrifice vs preserve whatever that function is not well described and I think you highlighted dwell and the operative video it's it's very nice done
1:28:04
The figure in the other comment is actually excellent presentation so strata and we should go to DR amaro in an Okuma will have a presentation from the last presentation isn't cerebral plasma Cytomel
1:28:23
a very rare Tumor i jeremy or moral and Mindo Keema both from Nairobi Nairobi and Kenya
1:28:36
Doctor on Amaro is located in Kisi in Kenya and the each teaching and referral hospital and Doctor or Kamala is a pathologist consultant and pathology at the University of Nairobi at a fellowship in
1:28:56
neuropathology at the University of Wisconsin and he's located in Nairobi
1:29:03
and you are correct on sure yes such a name would you like to introduce your colleagues discussing the cases cerebral bathrooms like dama Okay Thanks Dr Janet Tomorrow is a newly qualified
1:29:17
neurosurgeon who is walking on about Perry for hospitals QC and he's the face Agenda in case the hospital is one of our plentiful hospitals and he's change your setup and your surgical units in that
1:29:32
area and Doctor El Tema is an oral pathologist so doctor
1:29:38
tomorrow the present Dickinson Doctor Kim always give the pathological findings of that guest Doctor Jeremy Morrow would you like to to come on on the call and reintroduce SF please
1:30:30
omar are you Ok you can note I you were sharing a screen go go ahead and if you would click the slideshow then we would Yeah
1:30:45
HMM
1:30:47
is it visible now nobody's senior zuma is not the it's not the right screen hawk
1:31:01
May have the the taps and
1:31:07
as a Tampa cerebral plasmacytoid at the top maybe if you clicked that
1:31:17
Okay just a minute he will use doing that the Samurai are
1:31:24
a number and the and Sam Mohegan bomb after seeing the presentations and seeing the meeting and seeing what's happened over the past year with these meetings I think you have a you have a lot to be
1:31:39
proud of for all the work you've done to try to build neurosurgery and add sub Saharan Africa and your bear if You're if you're seeing this as another compliment to you because a these are really fine
1:31:53
presentations anywhere
1:31:56
okay Dr Moore you may proceed it looks like we were all set up
1:32:04
oH
1:32:07
ok though then I was bitterly that cause KC dating and if are are less futile isn't on their level five hospitals in Kenya
1:32:19
Okay so decide presented the case the patient was a sixty five year old female who presented with a stroke headache and scarlets reading this is a five month history then the swelling was in the left
1:32:31
parietal region the book that was gradually notice it but as I was progressively increasing in size and also the visitor that she'd had the stroke headaches that global initially and why that mutant
1:32:44
ninja that's called three or ten days she had no metallic metal speech deficits she had no visual and deficit there was no confusion for somebody to changes in the past medical history was not
1:32:56
contributory to neglect munitions years the alert and oriented in time pleasant person that people are reactive to light formulary tends to be the better size within normal limit fitness exam
1:33:09
examination she was a lot GCS fifteen or fifteen she had that left parietal region swelling as you can see on the image on the right was painless and from it seems to be rigidity from the bone and it
1:33:22
was not by that day it was free from my leg skin and besides it was around six centimeters by six centimeters there there was no motor sensory deficits aren't getting enough and policies and our
1:33:35
speech was also no money so he conceded to just one of the images for our position during surgery and the skin my liking of our history and seizure and that that much of it seems to be related cause
1:33:49
there's there's out but the religion was the butt of the swelling was around the parameter eliminates the the small and swelling again slightly below the lesion above the Supra articular region
1:34:03
and the pre -operative concierge doctor but I did an MRI scan and this or that you wanted to add flair image so you can see the left parietal region sailing at this I saw intense to the Grey matter
1:34:18
Twenty one and it was a bright abe intends to happy death to grandmother on on T two with a clear CSF glove to conceal on the posterior aspect of the of the mass the leisure denoted island flair with
1:34:33
ASIC I see that the religion was a genetic edema that was surrounding their mouths when I contrast can religion without picking up a lot of contrast by the gossip Paraphernalia of the region that
1:34:45
bunked at it as a contrast enhancement so there is an alleged image of the of the Tijuana with contrasting because it is durant the announcement the collision this seems to be in the air originating
1:34:58
from there durant Dura so this was an SWF because we're looking for an area of necrosis to do the legion and as you can see that undigested blur the Illinois area of blooming artifact and this or that
1:35:11
day for generated image so I did a blew and then a DC map and you can see how it Is and bright said there's a bright signal on DWI and on and on and and you see him up there is and it'll of way low
1:35:26
signal so this signifies an average of six years to probably the legion was a type of cellular
1:35:34
so preoperatively thought process over probably a three lizards probably could be a million joma could be a metastasis RI solitary fibrous Tumor I I was following the signal on an amen in Jamaica was
1:35:49
holding the scene along T y ninety two by the enhancement was not as ivy doesn't really expect an arm and in Joma though he did have their enhancing to rotate and I we did that we were not able to get
1:36:02
us at the city scan that she she had initially before before them ray was one of those lustful would endeavour to see the aid of my peristalsis that would actually help us to narrow down bloods them
1:36:14
and enjoy them In terms of metastases he did not have the history of any primary malignant legion before this time and so that one was the second on that on that day of the differential diagnosis and
1:36:29
that's the strong and nothing component of the lesion was not mine it was not visible on this and we do not have any beneath destruction that that's trying to help us to narrow down glad I met
1:36:40
justices
1:36:42
dumps off and solidify the Duma this one is usually an editor janice and they usually enhanced after generously uncontested announcement trials we had to sit on the city and the and the and MRI scans
1:36:55
there are not as in hunting as you'd be expect for it I totally thirty if I rescue my so we thought probably could be I mean in drama that would be the face of depression diagnoses but to be this this
1:37:05
sturdy potential just as I cannot do so because of that and scarlet before meeting the illusion that you are able to see on this kind of Yada actually the family and they agreed that we could go on
1:37:18
with a with a sad daddy for us to initially get the tissue for diagnosis as well as that he lived there mass effect that you are having based on their religion and also to correct the deformity that
1:37:30
the lady had on the skull and that was progressively increasing in size so those are the primary reasons why he wanted to go in for surgery so he positioned the patient supine and we did our parental
1:37:41
history of seizure and as you can see we didn't die we did up and the lads and scapula into because you are thinking that probably the literally would have been where they're born so we thought that
1:37:51
whatsoever the construction of their born with a cranial breath is so because the challenges getting I do not patch for this patient so I thought I'd obviously be cranium and this is what I will use
1:38:02
for the construction of the Dura so Read I did open the skyline to last and they have said today that the cranium for the construction of their daughter st OH Brave I'll show you the some of the
1:38:15
images that he had improper Italy but there was a one day about hostesses on the scan with episode pretend regret that a cleaner that does not involve the Duma after I did the clinic the craniotomy a
1:38:29
those involvement of the Doura that was I had entered the in aspect of the of this God and those I mean drugs are extension of the Juma they are those that does design intact brain to my therapist and
1:38:40
the tumor seems to be more tragic why would receive a gross total resection we did that with the Connector me so we did I do repair and who did as a kid I know plus David a it once I meant to do that
1:38:56
just the thought I didn't have a video for this theory but these are just some of the representative images for this identity so this is after we did they came to me and you can see here you have
1:39:07
there they do rather than better claim them that I have a set to to useful The construction of the of the Doura because it's a there's an area of humor humor radical government of the Dura the dignity
1:39:19
this was pointing to was that it ever had their newborn was was in the tomb I was involving on there and they do
1:39:28
so after we're done day the opening of the doura and like I said there's a there's a but I get it appearance of the Dura so this the spot of that era that was involved and so that is part of the era
1:39:41
that I was able to detect and a constructor that better cranium so the rickety the legion it seems to be well differentiated from their normal brain and it gutted them hetty of Alpha hemorrhage on the
1:39:54
surface of the tumor so as I was able to develop a brain to my Tapas and by going through the sub directly space and about and separating between the tumor in the brain and then now after we be able
1:40:09
to dissect that the tumor and grassley then I did have a better career now rip and neural repair with a with a better credit that I had harvested initially and then this is just there to do the the
1:40:24
repairs they have a craniotomy with their been summoned that I used a that I used to stay before the subject than you usually do this a switch at a sutra attachment to attachment to hold on there that
1:40:42
they couldn't hopelessly today they're born
1:40:47
so the initial phase of their post -operative fast officials admitted in HD you just admitted that for one day you anticipated to get them water deficits but she was able to have an inductor motor on
1:40:60
the contralateral side so after this one why they stay in there to do a downgraded back to the what the headaches that result unless you do not have any metallic nephew as ambulatory and the second
1:41:12
day and the discharged after three days so read a discussion with their doctor can work with the preliminaries allergic or exhausted I'm going to show and they'd be able to discuss those are good at
1:41:24
Oncology result Oncology consult which I think we had a meeting and two weeks ago and there are some pending information in investigator that we are doing and follow up was it was initiated with a
1:41:36
patient because of the challenges in getting a good scan for the patient and you're still not been able to get us gun from the patient because of challenges getting a good scan but something they are
1:41:47
planning up with when you meet up with the patient after discussions So I'd probably just show some images end of they still legit that and ally invited a camera to give our commentary as a as a show
1:42:02
up there they may just look like him or he'll be on call
1:42:10
if the Cameraman comp
1:42:13
is
1:42:16
you can see my Screen I think the braves are a group like O'Hare Doctor Gamer
1:42:21
I saw he saw this patient maybe I should just put a solid first up tomorrow okay okay
1:42:29
so let me share them I am so this this patient and I was them because wanted to see I hadn't been seen in the hospital then he just said put this one up and
1:42:51
the
1:42:54
I sorry about that my name is Doctor come on my neuropathologist best in Nairobi so does a patient
1:43:04
the PM sixty as female are fighting the battle tomorrow and them She had presented the headaches and as you have seen shows these parameters Collie called one must which connect to me was done and I
1:43:19
received two specimens one was as cold bon app which was measuring roughly that and it had an irregular in a table and as submitted this for the cup and this soft tissue specimens and that I received
1:43:37
and AM with which I'm going to share as some images at now in me here is there some as lines of them of how this looks I saw this was attached to Dura up you can see and then add this bit under what I
1:44:04
want to demonstrate is these sheets of red densely cellular lower your legs more moron as cells and then we looked through these even there does that on the upper side and what I'm showing here is the
1:44:20
Euro and on the last side you can see this dense shit and there if I zooming in that these are cells some look at like there are new for itself but when I looked deeper these that
1:44:38
that a lot of the south had these a plasmacytoid and morphology and then I said while this is I have to live with your pleasant and could it be a plasma cell rich in Joma I tend to look around if
1:44:56
there are any meaningful kill yourselves and I could not to see and so based on what I've seen in these as Lights I I I requested Am and then the Doctor looked tomorrow at
1:45:15
consult say an oncologist but then the initial thing that I brought a here is the disease the a plasma cell is crazier Serie a plasma cell is crazier in which as I think it could it be a plus must a
1:45:36
tumor buses a myeloma I also requested for a minos I did acid one thirty eight which is a a plasma cell my cultures positive and I didn't email on it which is that guides US on meningiomas which was
1:45:50
negative I did that but afraid of my cause that the initial mock id there was a K six seven which was law then our dad asked the promoter to ask for other tests bone marrow aspirate the treffen as as
1:46:08
Haematological Saddam Bad Ben Johnson Saddam pretended to forests so I think what's the primordial share now is there what at the peripheral blood of him looked like
1:46:28
Saw am there was this what is called Rule of Permission to Laugh is Wham red cells that act as talk to each other it's it's the sign of a heaviness an hour sometimes what we see a lot in the plasma
1:46:45
her legions the tomorrow next night
1:46:51
so I requested a metallurgist to add to do and have had walk up and concede that the main thing was blocked I and about the bone marrow aspirate the tumour
1:47:07
yes on the bone Marrow aspirate report and that that's the one My Ross Bradley can be done that we see the reported served up tomorrow then the main thing which was being seen as mainly at increase in
1:47:22
abnormal plasma cells but there are not to the range Want to see my Lama dua up to ten percent if you go back Tomorrow I think the pictures and there are one or two pictures of these plastic Yeah I
1:47:37
like that one a dysplastic a glass myself and is and was significant and then AM on the Bench Jones Yeah those are some of them somewhat by nucleate some had desert typical nuclear you see in a plasma
1:47:54
cell is Craziest and and the Bence Jones Tomorrow
1:48:00
Yeah I think the the Benz Jones was negative was that correct yes it was negative evidence that the protein was negative so we conclude that these as being a plasma say from my Witches and I localized
1:48:17
disease as opposed to my Lama and which is a systemic disease thank you back to the promoter
1:48:29
thank you so much the camera a swamp and blending to meet the patient of probably tomorrow in the clinic and I will be able to discuss their their lead the as the munoz that I've been there and also
1:48:44
discuss with them colored just who is on board think about waiting for the day for this a win immunity for us to have a definitive diagnosis and then from directly to start treatment with efficient I
1:48:57
initially described it the discuss that bullshit probably the bullshit invalid said I do therapy and so maybe that is part of the plan that will have a discussion the patient after the oncologist has
1:49:08
seen the final results and you'll be able to connect the patient with a is irrelevant to therapy centers that we have probably are under threat or in but couldn't connect to Nairobi
1:49:21
so that I Guess I'd read for the different discussion I invited a panel for discussion and clarification Okay Thank you Thank you very much doctors
1:49:32
memorial in Khaimah
1:49:35
case of sounds like it's a solitary plasma said Tama and no indication that this is A is a case of multiple myeloma
1:49:47
Dr Moore I I Presume you have the you have the capacity for doing rate radiation therapy
1:49:57
facility we don't have and therapy facilities yes have a chemotherapy and do just that thing cause I think what's out there that day oncologists have just come from school just the same way I just
1:50:10
joined the department from from the university so used to be I still had the initial phase of developing a oncologist center but I believe we'll be able to do something for the patient and their
1:50:23
connection to that eleventh facility
1:50:28
I think when you when you when you have situations in which radiation therapy is is required but do you have a of playful referral that's in Kenya nearby
1:50:44
yes so that the closest facilities in eldoret eldoret is like three hours drive from from Kisii so that's actually there that first aid of the eighty five patients but then if we have we have enough
1:50:56
challenges are probably a lot of patients that are on on working then we need to find them in Nairobi that we have them the main facilities less families and eighty five patients
1:51:09
Yeah we're very very nice cases certainly is rare I don't think I've ever had one I ever had a case of cerebral plasmacytoid my Morgan Have you
1:51:20
I have not Yeah very very not a common situation but I think it's we're looking at the literature it looks like it's a rare case and I liked as a doctor Okay moi and the the the A is there to reserve
1:51:41
a tumor infiltrating the scalp or is this a hyper not only a hyper bone hyper static but a a a a GR a growth of the skin eye chemical factors can you comment on that
1:51:56
he saw there tomorrow is not safe for drinking today a barn on the inner table but the bulk of their other platform of apparel strategic so dead that they deplore was nuts in one bad day some form of
1:52:12
infiltration on the underlying say that so there's really very interesting what it says is we're getting a obviously a biochemical reactions are occurring that are causing a bone to grow I was an
1:52:26
infiltrating the scalp or not or was already a change in the scalp
1:52:32
and I know there's no cop I didn't see this cult dad Yasmin so so it it's very interesting here's a a neoplastic growth ed that has the features of a growing tumor in the brain and it's also causing a
1:52:50
reaction to the surrounding structures meaning of the metabolic changes going on there are massive Ah and it looks like the treatment is radiation therapy and or chemotherapy as I correct
1:53:07
I think the oncologist mentioned that chair that is going to be the treatment and the triad addition or treatment but I lifted them to Mecca decision on how best to treat these bishops so avoided if
1:53:22
they'd have done a biopsy the biopsy the swollen scalp and are taking the bone there wouldn't have made the diagnosis they had to do a craniotomy to make the diagnosis correct
1:53:39
I believe that I think of the greater mood the best option because we didn't have a legion involving the scalp and just a born and they they do right and the involvement of the Parenchyma legion
1:53:54
absolutely the best option for the efficient unlike about rules R multiple myeloma by your or your chemical tests rachel very interesting very rare case very interesting case
1:54:09
and the other comes from Me I guess that bringing the the issue of just doing the isolated biopsy and into discussion I Guess if if you just did a a needle biopsy like panic for drilling and getting
1:54:28
into the lesion the the optimal way to treat this given a diagnosis would still have been surgical resection followed by your Adjunct Therapy
1:54:40
but I guess the pre up by by by the imaging studies of preoperative diagnosis was that it was likely to be a meningioma is that is that correct DR moreau
1:54:55
know that that was my initial lead messages that to but I do believe yes sure yeah that that makes that makes a lot of sense
1:55:04
any comments from the IP the rest of the people in them in the media Arena we thirty thirty five people here which is good we had some actual subjects any comments from the audience strata
1:55:17
nothing in the chat any anybody Shama Shama
1:55:24
was a trend with that presentation this last one because his tunnel vision is to detect unusual what I've seen recently when the manager Kiss and Frontal I think it was I want only gun that groups let
1:55:41
alone to be in February Dysplasia and we underestimated the extent of decision from the imagine that Wendy's surgery when religion was approached surgically it brought much more
1:55:57
accessible serious than once radiology Immaculate imagine exposed to this college as a very tricky it is better to be on the safe side just live above sea may not be representative it but until a
1:56:12
brigid and with the inner determination to and plant result as much as possible so that was outbreak or that that was a lot of multiple myeloma in our sub region and that did become almost every kid
1:56:28
that we see now we have to put it on the front line is disconnected me and my Lama and to our surprise that they put it as their refresher diagnosis and in this case and that was a an interest in
1:56:42
kissing did
1:56:49
The
1:56:50
Elven do you have any comments Alvin
1:56:56
Kamara no professor following happening question Thank you Okay Blue stratos just assume excellent program Oh Yeah no I think Think I want to take the all of the presenters they were excellent
1:57:14
discussions an excellent demonstration of of surgical techniques I think I really see this being a very beneficial platform so thanks thanks everyone for for potential for your participation and we
1:57:30
will continue the series on a monthly basis the first the first Sunday at the same time and well these videos should show the video they should show up in a passionate digital and show you'd be able
1:57:44
to to look at a review or charge your colleagues downloaded on the computer and so you can think about it some more and we'd really encourage you all to think about cases you may have or presentations
1:57:59
NAM congratulations on developing a a group of people heard is doing very very very fine neurosurgery
1:58:09
yes okay well with that we'll we'll close the session and I wish everybody has a great rest of the day thank you again for for your participation thank you and thanks everybody thank you thank you you
1:58:24
enjoy this presentation
1:58:28
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