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SNI, Surgical Neurology International, a 2D Internet Journal,
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an SNI Digital, Innovations in Learning, a 3D video journal, interactive with discussion, in association with the Sub-Saharan African neurosurgeons,
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they're pleased to present the Sub-Saharan International Neurosurgery Grand Rounds, held in the first Sunday of each month. This is the fourth Sub-Saharan Africa
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International Grand Rounds meeting, devoted to the topic of global solutions to clinical challenges in neurosurgery.
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The discussants are from Africa, Iraq, France, Persia, USA, and other countries The
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moderator. is a start-up Bernard, who is the head of the program committee, and James Oesman.
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The second topic of this meeting is the diagnosis and management of Sub-Aricnoid hemorrhage in any environment, an interactive discussion, what we do, when, and why.
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The second topic of this meeting is the diagnosis and management of Sub-Aricnoid hemorrhage in any environment, an interactive discussion, what we do, when, and why.
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The discussants are Estrada Bernard from the United States and Liberia, Alvin Do from Liberia, Sammer Hose from Iraq and the USA, Saeed El-Consory, who's from Persia, France and the USA, named
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from Nigeria, Sam Ojigobam from Kenya, multiple attendees from Africa and Europe,
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and students and young neurosurgeons and students from multiple countries. While you're looking, while you're getting that set up, I'll just say, I think an important point that Dr. Haas made was
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that it
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optimally, it's optimally set up with an elective process, and then once you develop the infrastructure and a protocol, then you could move on to doing more urgent cases. Anyway, Jim, it looks
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like you said, you wanna get started? Sure, I think everybody, can everybody see this? Yes. Okay, well,
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anyway, this is actually,
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a complimentary talk to what Sammer gave, Estrada and Sammer and Popsie, perhaps Ayeet, and members of the audience can participate. It's an interactive discussion. This is some things that Jean
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Barrett has talked about. Let me give you
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a case and see, let's see what you do. Hey, here's the first case. And this is a case for anybody everywhere And we're gonna ask, I can't see the audience here. So you may have to ask some
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people who try to, but this is a 35-year-old male, and it could, Elvin could see this case. There's, comes in with a sudden headache. He collapses,
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he's in the ER. If he's hours away, he may not make it, he may die. And so you may never see him. But this is a case where it comes to the ER. He moves all of his extremities, but he's not very
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responsive, he's got a stiff neck. his right pupil is larger than his left, his blood pressure is elevated, his pulse is regular.
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So, what I want the audience to do, the people in the audience to do, and I think you may have to ask people, Estrada, is what do you think the diagnosis, what do you, you've got some
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differential diagnosis you've come to at this point, what do you think? What's the cause? Anybody have some suggestions? What are the causes? Doctor, Doctor, do you have some, we have some
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residents, yeah? Yes, well, well, then maybe you can, you can have a few private residents and ask them to wait. Doctor Ashid, Doctor Ashid, are you on the
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call? Are we? Yes, yes, I am. So, we think about that, I'm following, yes. Okay, fine. I think, I think Doctor Ashid can guide you with the other residents who are here He's a fan of the.
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not of such a resident. So you could communicate with a policeman. Okay, Rashi, what's the differential diagnosis here? What are the causes of this? This is what you see, this is the patient,
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that's your exam. That's the history, it's very limited. The family brings them, that's all they know. What are you thinking about? What are you gonna think about other causes? Okay, so since
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there's a sudden history of headache in the colabs and signs of a meningismus with a stiff neck and so choreo, the right pupil being larger than the left or be thinking highest on the list would be a
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sabbarachnoid hemorrhage probably due to a spontaneous rupture of an aneurysm. Though the age of the patient is
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not typical
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of an aneurysm and then you have the right pupil So probably left. the than larger being
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thinking about a sympathetic system to the pupil is affected with the cranial number three and then you have a lab at BP's of 160-90 so top of the differential would be a ruptured aneurysm or
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let's say when I always do my differential diagnosis I always pick my first choice and then I say let's say it's not that what else could it be?
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Okay, amongst the vascular ones you would have an AVM to do a venous malformation
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of
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vasculitis as well.
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Okay, any other thoughts? Do you have some your colleagues that want to jump in and do this? There's no wrong answer so don't worry about it. Okay, everything you said I think we'd agree with,
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okay
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Does anything about the pupil being dilated on the right side? Does it suggest anything to you?
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Yes,
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that the training number three, might have been compressed. So it could help in localizing the location of the lesion.
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And you think of a posterior communicating aneurysm or something? Yes. Yeah, I agree with you. Okay, so let's look at the next slide. This is a differential diagnosis We agree with you. It's an
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aneurysm, all-suburrog night hemorrhage. Could be, could be an AVM, couldn't it?
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Yes. And or an inter-several hematoma, it would have to be in a silent area because he didn't, he's moving all of his extremities, right?
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Yes. Could be a carotid occlusion was falling in that hemisphere, isn't that possible?
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It is possible, yes.
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You have a bleeding disorder, you have a sickle cell anemia in Africa, and I'm sure you have clues could be related to some bleeding or occlusion, is that possible? That's very possible, yes.
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How about a tumor, could it be a tumor? Yeah, especially a hemorrhagic tumor, yes. Yes, hemorrhagic tumor. Or something else that's very disturbing would be a herniation opposed to your fascia
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syndrome, and that'd be possible Yes, definitely. And what about a midline lesions, you see people coming with colloids, cis, or third ventricular lesions, something like that, they bleed into
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it and they get a sudden occlusion, and they can just have a sudden collapse. Would that be possible? Yes, yes, I agree. Okay, so now here you've got your differential. Anybody else want to
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add some other ideas to this list? We may not be complete. Anybody else have any thoughts?
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And please. If there are other residents there, please don't be embarrassed. This is an interactive discussion. We're all colleagues. Anybody else have any ideas? No?
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Nim, do you see anybody who could help us with some more ideas or any other ideas?
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All right, well, let's go on to the next one. OK, now he comes into the place. And that's the problem with us in
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the high income countries or the developed world. And that is everybody's got a lot of instrumentation. But it's also true in our country, if you're in a place that's far away, you may not have
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a CT. Or you may - Nim, is that is, would you say most hospitals in Sub-Saharan Africa have CTs or not necessarily? Well, I can
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comment about Kenya.
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Kenny is divided in counties, and we have about, I think, 47 counties, and each county has a city. Okay. Sure. You have the idea of city scan. But, but I, Jill Berg, can you hear us, Jill
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Berg?
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Hello, yes. You've traveled all over Africa. Does everyone have a CT? Most
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of them have CTs? Yes, I think it's, it's usual to have a CT scan. Okay, so many. This situation 10 years ago, but the number is increasing in all the, the main cities in,
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in West Africa, in Central Africa also, I think Okay, so let's see. I'll just go through this quickly because we'll come to this CT in just a minute. So if there's no CT, how do you make the
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diagnosis? How do you decide what to do or do you decide not to do anything? You, you, you take on an ophthalmoscope, you look in the eye, you see if there's papillodema. And that
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may help you. Would you do a spinal tap? Anybody would do that? do that? Lumbar puncture.
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Well those are your choices basically. So once you come with that then you come to what is your choices? So let's say you mentioned I think yes go ahead in this situation if the patient presented
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with meningismus had a stiff neck sudden onset of severe headache you'd be suspicious of a subarachnoid hemorrhage and if he didn't have a head CT scan then a lumbar puncture would be would be
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considered would be the path to pursue but in the in the phase of a third nerve palsy and the question of
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increased intracranial pressure there's going to be that concern for
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transcendental herniation and if you were to do an LP so that that should be in the discussion. Good point do you think this could be a meningitis could present like this too could meningitis?
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I guess it would be possible. Right? Yeah, well, well, but the sudden severe headache. Yeah.
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But I guess it could be, it could be possible. Yeah. So, in the hospital, in the hospital, in the hospital, what did you say? Yeah. In our setup in Kenya, because of the easy availability of
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city, this patient would get city. In fact, they rarely get number one chardon. In the earlier years, that would be an issue, you know, considered doing the other physicians would be seeing
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these patients and they would do the number of punctures. But nowadays, hardly do we do number of punctures on such a patient where the diagnosis is most likely sub-arachronal hemorrhage, and the
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city scan is available. So, the city scan to be done. The issue now comes to the next stage of management. That's where the big challenge now comes. You have diagnosed the sub-arachronal from the
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city scan. Then what next? So you and Joe Barrett and myself and Strada Strada's not as old, Alvin, you wanted to ask your question, Alvin? Thank you very much. So I think looking at the
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clinical history, the sudden onset that will gave anyone the idea that it is probably the origin should be vascular. And now regarding Lumba puncture, in a certain where there is no CT scan. And
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like Professor Bernard said, you already have an isochoria. And you are thinking you said there is some kind of mass effect and probably raising your cream of pressure. And you have a lot of
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skepticism in doing Lumba puncture. You got the fear of trans-tintorial radiation.
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it will be a great of a challenge in that. What to do next? I think what normally, if I'm in situation of this kind, all right? What I normally do, I will have to discuss it with the family and
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then they will have to sign Harry's consent regarding performing lumbar puncture because we do not know what is going on in the patient brain And I think it is a huge challenge. And now regarding
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city stand in Liberia, Liberia, we have about 15 counties. And currently we have just three fortunate city scans in the entire country. And unfortunately, they are just two that are working. One
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is in the private sector and one at another government facility. Thank you Terrific, terrific comment challenge. Terrific. Okay. So for people who don't have it,
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that's what they have to think about. I think you outlined it very well. So let's say either you've done a lumbar puncture or you've mentioned all the issues there or you've got a CT scan, which I
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think most people would do first, okay, but you made a diagnosis that it's an aneurysm and the patient can't go anywhere because they don't have any money and they can't travel and so forth. So now
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you're faced with a choice. What do I do? Do I do nothing? And do I wait until the patient, the edema resolves or whatever's happening and eventually you're going to have to do a lumbar puncture
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if you don't know and you don't have a CT. Do you refer a patient? That's not practical in a lot of countries Or do you do an angiogram? Could you do an angiogram?
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First of all, I was going to say, just before Nim finished there, there's some older people here on the call, like Nim and myself and Gilbert. And we grew up in an area in Australia. We grew up
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in an area where there was no CT scans. And so the case I presented to you was common. And so you had to make all the choices that we've discussed here. And these are the difficult problem. But
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when you got a CT scan, obviously it makes life easier. So let's say a CT is available. So we do a CT scan and that's what it
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shows. Can somebody else there pick
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call and somebody to tell us what the CT shows?
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Nim is there another registrar that you might call upon? Well, Rashid, do you have another any colleague you want to invite? or you want to comment? Sure, let's have some comments.
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Yeah, I think my colleagues are on the call, but.
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Jeff, Jeff, Jeff here, Abduwahi raises in, would you? Josh, please, what would you do? What do you, what do you see on this film, on this image? In this city, in the section, there is a
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Sabrikan ad homo region involving the own base of the system, especially the interpdenkular on the civilian system, and those are involved. So I'm thinking about Sabrikan ad homo region. That's
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excellent, okay. Do you see this a hemorrhage more on one side around the circle of Willis and just ahead of the brain stem than on the other? Yeah, it's more on the
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left
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side, let us say And what is that, what does that make? What does that make you think of? Yeah, you're doing great. What do you notice that make you think about? Thinking about an aneurysm,
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maybe a rough chart inside or also a temporal lobe, maybe have an extension inside the temporal lobe, maybe. So this is what I think about. And according to this site, so it could be
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a carotiparification, maybe,
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or MCA, M1, maybe n-goresin. So that's what I'm thinking about. Okay, good thinking. And so it would be poster communicating, could you get it with an anterior communicating aneurysm well?
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You'd expect more hemorrhage here, but I've seen that. And could it be a carotid aneurysm, yes. Okay, well, let's say, now NIMA, I would assume, if everybody's got a CT, they can do a CT
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angiogram. Is that correct? Yes, yes. So what do you see, Jeff, or what do you see on this Instagram here? This is not the same patient. So don't be confused about this. But this is, I got
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this off the internet. What's this CTE show? What does that show there with where the radar was?
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Yes, there is an balloon-like shape. So, and then yours is on the, maybe this is an M1 M2 bifurcation on at this
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level, or at
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this side. So, this is an allusion, maybe, or
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I don't think so. Very, very,
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very good analysis. You see the blood here, it could be a middle cerebral aneurysm. You really don't see the branches of the middle cerebral, maybe this one here, maybe not And, but you also see
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something here. And I wanted to point this out later. You don't see posterior communicating arteries. Maybe this is pure. We don't see, we don't know. Going into usually connects here to the
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proximal posterior cerebral. Here's the basilar. So what you wanna know is a patient have collateral circulation. Over 50 of the people do not have an intact circle of willis. And that's very a
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problem because it means they have to circle their circulation is to go other routes to get to where it goes. So you try to find that information but maybe a little bit here or the other thing is the
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CT scan is not definitive enough to show you blood in small vessels. So we're gonna come to that. Okay, you wanna say something, Jennifer? You agree?
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Okay, all right, we agree. So, okay, now a question that she had The United States and the United States. do you have a comment? I'm sorry. Professor Osman, I am see a lot of ladies are
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involved in this meeting. Please make it comfortable for them so they can talk. Oh, that's my make mistake. I can't see their faces. So I can't call anybody. So so we have to have people who
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just jump in. There's no criticism here. Okay, here we are now the timing of surgery. This has been in controversy for decades.
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Now I'm in your country in in in in Kenya. Do you do surgery when you can or as you do it immediately? Or when do you do it?
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Well, comments which I would like to make is first of all, we, as I said, CT scan is available nearly everywhere. It will diagnose the subarachnative marriage. But the quality of the CT scan is
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It's usually not so good.
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which we are having in those peripheral hospitals, the CT scans are not, they're not able to do a CT angiography. So this patient usually will be managed in a referral center that can teach a
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hospital. So let's say you're in Alvin's, let's say you're in Liberia and Alvin sees this, he's got a CT scan, he sees what looks like an aneurysm, patient is no money, he can't refer him
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anywhere, what's he gonna do?
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I think I think Alvin is down, will comment on that one. In
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my country, most of these patients, we now have centers where these patients can be handled. So we must look at the diagnosis of that sub-artner tumor from the CT scan, you'll refer that patient
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to a center which would have a neurosiger Now we have about 5 or 6 centers in my country.
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Okay. I'm sorry to interrupt you because I'm trying to move it along here. So these are your choices. And it's the same choice in all of medicine. It doesn't matter if you're an internist, if
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you're a nodal laryngologist, if you're a radiologist, you come down and you have choice A, B, C, or D. And notice it isn't surgery or medicine. It's choice A, B, C, or D. And what's choice
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A is doing nothing. And then what you have to do is choose the make the choice that has the lowest risk for the patient and the highest chance of success. Well, with an aneurysm doing nothing is
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not a very good choice, because 50 of the people are going to die really before two weeks, even if they reach you, and the rest are still at risk for more bleeding and death. So that has a lot of
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risk doing nothing, which is a risky choice. Well, is there anything better? Well, you can wait, we used to do this. Estrada, you and I, we did this, right? We wait until the patient
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settles down and the edema resolves, because at that time, people said you can't operate on aneurysms acutely, right? Is that true, Estrada? Yeah, well, early in my residency, that was
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the norm to wait for the edema to resolve, but then the conventional studies showed that the outcomes were worse Right. With waiting, and so that led to the evolution of early intervention for
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aneurysms of retinol hemorrhage. 'Cause you risk the issues of re-bleeding, you risk
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patients that coming from delayed cerebral ischemia. Uh-huh, Sam, are you still there? Yes. Sam, are you see this? You saw this in Baghdad a lot. People would come, they'd come to the
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hospital, I'm sure they go to CT. but your operating rooms were all full. How'd you deal with that? I mean, because the patient could die. Well, what did you do?
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Yeah, I think the norms mentioned by the first grad is the same. So once we started, the norms was not to do even a CTA because that may rupture the aneurysm. So I need to do a consent for the
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patient So the radiologist can accept to do a CTA because the norm is to leave the patient for the first two weeks and to stabilize and then try to treat it. And during COVID, once all the
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non-urgent procedures stopped aneurysm clipping was one of them. We stopped treating aneurysm because it's not, the norm is not urgent I'm not saying that. Decades ago, it's just four or five
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years ago. So it depends on the, I think it depends on the system that you are living in as a patient with subalachnoid hemorrhage. But I'm saying in Baghdad, in Iraq in general, it's not that
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urgent to do aneurysm surgery in general. And usually
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patient treated and then neurology unit. And sometimes, as you mentioned, sometimes one of the differential meningitis, so patient can be treated for a week as meningitis because the subalachnoid
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can be very little, not recognized in CT. And after a week of meningitis treatment, then the patient will be referred to you.
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Okay. Yeah. That's very good. So we're getting a broader perspective Some can do things and we can have a. Yeah, Jim, this is an interesting discussion. I'd love to hear other people weigh in.
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Self-experience, yeah, I've both have had experiences previously where waiting for, waiting that two week period. And right before we were ready to intervene, the patient re-blette and the
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outcome was
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dismal because of that waiting period. Anyway, I'll talk to you more on that in a minute. Come on, go ahead, name Can we get some comments from the residents? Sure, let's do that. Then
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there'll be participation also. Dr. Mesoma Silva,
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I don't know whether you can comment because you put a comment on the chat. Can you be able to give some comments on this case?
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Could you give me a little while? I'm just sorry, I'm not going to comment anything. I'm still a medical student actually. Yeah, but I know medical student, isn't it? I mean, a few PM medical
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signals.
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I just have to expect to go, yeah, all right. We're glad you're with us. That's very nice of you to be with us. I hope you're learning something. Well, what Strata said was, I remember I was
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in the same position as Strata was, I was, we decided we would wait. That was the practice at the time, and I was on call at night, and I heard a patient scream out in the middle of the night.
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It was a patient we were watching with an aneurysm, he ruptured and died And it came to my mind that I sat there for an hour, and I sat and thought about this, and I said, I did nothing to help
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this patient, and I can do better than this.
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And so, going back to the risk and chance of success, the highest chance of success, the lowest risk, that was a disastrous decision. So, you can try to refer a patient, but a lot of people
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can't do that. So, now what do you do? You just sit and you say, Well, I can't do anything for you.
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that obviously has risk. Well, if I don't have a CTCC and I don't have a CT angiogram, does that mean I can't do anything? And I'm gonna go quickly here because you and I did this, you can always
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do an angiogram. You get an angiocath, you put it in the carotid artery, that's easy to do. And you take one shot AP, one shot lateral. And if it was the right pupil was enlarged to do a right
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carotid angiogram, at least you can do something. At least you can make a diagnosis and tell the family. So we wanted to show that. Okay, so we got a CT angiogram. We've got a hemorrhage. We
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think it's probably host to your communicating. It could be middle cerebral. You see that here, be not for sure, but likely the percentage is going to be in the run, the post to your
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communicating internal carotid. And you do this, and this is another patient. You find that the angiogram It shows a middle cerebral aneurysm. And now what do you do? You're still in the same set
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of surgery. When do you do surgery? Well, I remember visiting Japan and when Dr. Suzuki was the first in the world to say we have to operate immediately on patients. Nobody in the United States
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did it. Didn't do it in Russia, in the UK. And he had very good results. And so we brought that back to the UCLA, USA. We reported that and so far So people were trying to say, that's what you
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should do. And this is what you're left with. There are complications with aneurysms. And these complications can be devastating. One is re-bleeding. There's only one way to stop re-bleeding.
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And that's to clip the aneurysm. Or if you've got coiling, you can do coiling. But most people don't have that. So the only thing you can do is clip it at surgery Another complication people would
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say is to get phasor spasm. I'll show you a picture of that. I think I just had that here. Here's phasm spasm. You can't see the blood vessels. They're all spastic, whereas this is the no
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vasospasm. And
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people said, well, we have to wait till the vasospasm goes away. I know it is in my 60 years, nobody knows that a treat phasm spasm, much less the cause. And the only way you can treat phasm
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spasm is to clip the aneurysm, and treat the blood pressure and do that So you've got to clip the aneurysm. So if you really sit down and think about it in a logical manner, the only thing you can
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do is clip the aneurysm and so depending upon your environment, you have to do it as soon as you can do it. And Sam or said, operating rooms are available. We couldn't do it all the time and so
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forth. Other complications you get are hydrocephalus and you put a ventricular drain in. Well, a lot of people say if I put a drain in, they're gonna get infected. We had a way of doing that.
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where you essentially put a drain in the ventricle, but you bring the distal end out of the abdomen, like you're gonna put a VP shunt in. And those long ventricular drains don't get infected. Long
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ventricular drains don't get infected. So you can keep them drained for a while. And you wanna keep the, make sure the patient's blood pressure is absolutely perfuses in the face of as spasm. Okay,
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that's what we're doing. The other thing, there's a paper in the literature that says, What can you do? Well, if I don't have much to do, one thing I can do is lower the patient's blood pressure
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because there are papers, this is one of them, and there's other papers in the literature came out of London, Ontario saying, if you lower the pressure, intra arterial pressure, that's directly,
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that is directly correlated with the pressure on the aneurysm wall. So as the patient's blood pressure comes down, the pressure and the aneurysm wall diminishes in the chance of rebleeding is
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lowered. There are also some agents like Epsilon Amino Caprog acid, which were used to delay rebleeding. I think we found them helpful. Okay, I don't know that I was going to go into this surgery
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here about this or not. There's some basic simple principles. If you decide you want to do it, you can use loops, a microscope, a bipolar You don't need all the fancy equipment in the world. You
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have to have some clips. If you don't have clips, you can put a suture around it. And that gets back to this choice you have in the end. And the choice is, what am I choice? And if I do
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something, if I do something, is that better than doing nothing?
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Is that better than doing nothing? You have to make the choice of a patient. Okay, so you can lower the blood pressure, you can try to get things ready, We'll show you some other things you've
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got to talk to you, anesthesiologist. It should lower the blood pressure when you're putting the frame on or you're making your incision because all those things can cause blood pressure, elevation,
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and ruptures before you even open the flap. Okay. And do you need to have some relaxation? If you see Dr. Hernandez, Nimi's videos, they're all on SI or SI digital and that's practical because
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he talks about things that you can do surgically when you don't have intervention and he's done a superb job. He's passed away now. But you'd give man a towel to the patient to reduce the pressure
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on the brain. You may put a spinal drain in it and he would prefer to, he opened the laminate terminalis of the things you do. So are those things, are those risks you want to take or is letting
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the patient alone a better choice.
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And then you go. put the patient in the intensive care unit or have them washed and get vitals. Do you have them? Most people don't have an intensive care unit. When I went to Chicago, we started
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one. It was normally the intensive care unit for trauma, but we put anyone for neurosurgery. And so, I mean, as time goes on, you're going to do those things in your hospital. There's a long
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ventricular drain. Watch the hernestemic videos. They're on SNI and SNI digital. You can see how he handles this. There's some instruments you can use, simple instrument. And Samra showed some
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of these instruments in his talk. You put a little cushion forceps right across the aneurysms. It's a temporary clip. Or you put it across the crowded artery. You need a little help. That's
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something you're going to get some clips. They're expensive. And you have to have a clip-applier. This is a clip remover, which allows you to remove it and also to apply it. It's. It takes all
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kinds of clips. So you can buy one instrument, or you go to a meeting, you buy one clip a plier. Bipolar, everybody's got some kind of bipolar. You use that. Here's a bipolar forceps, and it
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happens to be an irrigating forceps. It's both a cushion forceps, and it provides irrigation. So the forceps don't adhere to the blood vessel. There's things out here. Just a few words. Yes,
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Sam, please Please, Sam, what do you say? Right, considering the time of intervention, the challenge we have with many of the specialists do not arrive on time. They don't arrive on the window
36:22
that would encourage one to go in straight away. And the tendency is to stabilize the patient. Comorbidities also are very frequent. Some of them have uncontrolled diabetes or controlled
36:35
hypertension And then sometimes they come already with chest infection.
36:43
So these comorbidities tie our hands and we have to wait and stabilize them in order to go in. Also, if the angiography, we do city angiography. If angiography shows the versus person, then you
36:57
are a bit worried that the outcome may not be as favorable. Why Russian? Why not manage the percent conservatively? Or until the percent stabilizes before you go in The risk of a brave lady is
37:09
always there. We appreciate that. But very
37:13
occasionally we are lucky enough to get cases, good aneurysm, good neck, clepevo, and patient's condition is stable enough to encourage us to go. In fact, two days ago we had one complex
37:25
aneurysm, but it took more than ten days before we could go in because of all these factors that we persisted to stabilize the patient eventually clipped it on Friday And as of today, the
37:38
presentation will be very well.
37:42
Those are terrific comments Sam, they're very practical and because everybody doesn't have all those fancy things, so okay, I try to do, let me do a little more or you want me to stop and finish,
37:56
it's up to you Well, I think we, we're getting beyond, I would like to try to stay on on time so I think we should invite other comments if I don't comments and we should probably try to wind it
38:10
wind it down we can certainly come back to this topic in the future if if there's interest Additional interest, but
38:17
I wanted to want to make a comment,
38:21
it's all about what Sam said, I mean we may have some principles that have evolved and how we've practiced but the practicality of the location will will dictate how things go And they, there is the
38:36
concern about re bleeding, but operating in the face of. of vasospasm has dire consequences as well. And you mentioned about the amicryle, the epsilon amino caproic acid. I think it certainly
38:52
reduced the risk for re-bleeding, but the reason it fell out of this favor, I think, is because it tended to increase the
39:03
risk for vasospasm. Name has a comment, please go ahead. Thanks very
39:06
much
39:08
I wanted to thank Professor Osman for this presentation, which was very nice because the residents who participated were able to get some insights on the general management of these conditions. And
39:26
my comment is, really, most of what I would have wanted to say has already been said, that the management of these conditions depends on where you are, and sometimes the constraints are the big
39:38
challenges. I can talk about Kenya and because this is where we're practicing in Kenya at the moment we have referral centers about five or six referral centers and in those six referral centers
39:53
there they're distributed evenly distributed within the
39:59
country so and probably I would say it's a radius of about let's say 200 miles okay that's about maybe three almost 300 kilometers so patients have a choice you know we so when one makes the diagnosis
40:16
then if there's a need to refer those patients can be referred but then as you know these are very acute cases and there are ones where we can refer and get good results are the ones who present early
40:29
and let's say they haven't bled but the patient who has bled then want to stabilize that patient until he's stable enough to to be referred for. the management and then of course the situation is
40:42
that that patient who you're going to stabilize you have about 50 of them who will bleed again and therefore they'll be candidates for further management so when you're stabilizing them there's that
40:56
natural selection where if the patient is going to bleed again he'll bleed and therefore he'll not be the candidate we are going to refer to the other centers for further for further management and
41:08
that's just a a natural process but in the if if it happens like now in a big sense a town like Nairobi where let's say such a stationary races where the patient is diagnosed with Nairobi then they
41:22
can have access to neurosurgical care almost immediately and in a big town like
41:31
Mombasa or Kishumu and Eldra, if the patient is in the big towns then they can have access to neurosurgical management immediately and then the principal here now would be usually to stabilize the
41:42
patient and to surgery if the indication for surgery is there. And what we have noted here is that most of our management has moved away from angiography.
41:57
We now do the city
42:02
angiography, city angiography and from city angiography make the diagnosis and then the patient undergoes surgical treatment So we don't, we don't, that patient is not subjected to digital
42:12
subtraction and geography in our, in our setup here again. Mostly because of cost component and the fact that the city angiography gives you quite a lot of information that the modern city
42:27
angiography machines gives you a lot of information and one is able to make a decision and to the way forward So as I said, the scenario I'm giving is in Kenya.
42:40
Acadia is very, very different from the other African countries because we have managed now to train quite a number of neurosigements and set up quite a number of referral centers. And again, there
42:52
is private health care. In the private hospitals, the treatment is completely different. And the private hospitals, of course, everything is available and the patients get very, very good
43:05
quality treatment. Now, again, as I said, these are the type of cases which we can rarely refer out of the country, because unless it's the elective type of aneurysm, let's say what,
43:19
let's say post-recommodicating aneurysm or something like that. But most of these type of emergency cases, there's no room for referring them out of the country. So we have to see how we can handle
43:31
them within Kenya. Thank you. Okay, well, I think I think there's a hand up, Ned. First of all, if anybody wants to leave, it's 941. We've gone for an hour and a half. If people want to stay
43:48
a little more and ask some questions, fine. Ned had a question. I thought Mustafa Ismail also had a question. Ned, do you want to ask your question?
44:02
Hi everyone. I hope you are doing well I'm just having a comment about this email tomorrow. So yeah, thank you for providing this to the eye. And we've got nothing to important. And as my
44:16
previous role as part of
44:28
this, as a small part then to do
44:34
the part of this, of life and that will be it. how the medical student is able to provide such a help and provide this standardization as Zephyr has said. It's amazing and it's
44:49
a wonderful opportunity to have.
44:54
And I think it is a given that it gives the best like experience about the good standardization so how to help the patients and to be better always. Thank you.
45:14
Okay, Mr. Office, thank you. All we and then Emmanuelle. All we, you had something you wanted to ask, Roshid?
45:22
Yes, thank you, Professor Osman and Professor Strada and Professor Mungoam as well. Mine is, you had mentioned in the absence of clips
45:34
the point of a suture. I wanted maybe for you to expand more on that because the challenge sometimes we have here is all the time is availability of clips, I wanted to know if there are any
45:47
alternatives that you might be thinking of, thank you. Yes, I'll come, we'll come to that in a minute. Emmanuel, Sunday you had you had some question
45:58
Yes, thank you very much, I'll call this for you for a second, so very exclusive. I think I'm going to talk about, I'll talk about the future, the last, the last, the
46:12
person that took class has already asked about that However, I want to talk about the role of
46:19
loma puncture in a survival point bleed, usually in patients that presently it's like now, I'm talking from Nigeria here, patients who present lives Visually
46:34
after three days. Visually the This can be not be able to show this so paragonally. So in such situation, the only way one can be able to know if it was history, if it was bliss, if it's what
46:52
might be, is to do with the number of punctures. Now the lower puncture that we've done at this time we show is anticormic fluid. And this will give a suggestion, a high suggestion, a high
47:05
suspicion that Gary's your walls will bleed in that space. Now if this lower puncture has to be done, it is said that a small caliber needle should be used by an experienced physician, he was also
47:21
a joint anesthetist to do the lower puncture source, to avoid, to avoid a coating in this patient. Thank you very much Oh, that's a very, very, very good comment, very intelligent. a small
47:38
born needle because you have to make slightly some kind of a diagnosis. And
47:45
that's correct. So any other questions I have? I have this in raised. What was that? Sorry. Yeah, Dr. Osman, I have one question from you and Dr. Strada. In the very old past, when there
48:02
was a very large no reason, I heard they put a piece of cotton, muscles all around it to let it sculptorize. I have heard about it, I never saw it, but I want to know, because you have been
48:17
through all this process of the aneurysm treatment. Was it done and how was it done so you can share your experience with all of us? Well, there's a couple of questions. One is about cotton and
48:29
the other's about a ligature. Cotton, we used to do that you're absolutely right, Ollie, put cotton around it because. cotton would cause fibrosis and therefore you would think it would at least
48:42
promote some healing around the aneurysm. In fact, if you couldn't clip it all and there was some protrusion you put cotton in there to do that. I think long-term studies show that that was not as
48:54
effective as we thought. They also came out with some glue. Some glue that we used to put on an aneurysms. We did some research on our laboratory. Maybe Sam was there and they did that but it
49:06
showed that it really ate away at the aneurysm wall so that isn't good. So the best thing to do is to see if you can clip it and we've gone through
49:17
that. I can't put them full-screen here. I don't know what the problem is. They're various instruments. Here's an example of a clip going on the answer, aneurysm. If the aneurysm is still large
49:28
you're going to evacuate it. Now the other thing is you can't put a clip on it and you saw this in Samers They used to make a, a, a ligature carrier, but you can do this with a, a, a pushing
49:41
force if you put a, a, a ligature, a silk suture around the neck of the aneurysm loosely, you get a, on the other side of the aneurysm, you go retrieve it, and you very carefully tie it down.
49:54
And, and that used to be what people used to do for aneurysms if you don't have clips. It's perfectly reasonable thing to do It's best to try to practice that in the, under the microscope in the,
50:05
in the operating room on a, on a sponge or something. So you get the skill in using both hands and bringing the suture so the knot closes slowly on the neck and it doesn't tear the aneurysm. That
50:19
would be, that would be one thing to do. So you can use a ligature If the aneurysm is still big, you can evacuate it. I won't show you this. This is a video. I won't show you that. And what's
50:31
new? I think I have Samara went into coiling. People are using smaller flaps. You don't have to do that. You can use a large flap if you haven't done a lot or if this is the first view you're
50:42
doing, you get a larger flap. You need to see what you're doing. Minimally invasive surgeries for takes a lot of skill to do that. We saw and Sam has showed that 3D views. You don't need all that.
50:55
It's good to have it and for an intervention list, it's very important. Do you need all the fancy instruments that companies are telling you about? You don't. The basically simple instruments.
51:07
Cushing four sips, some clips, a bipolar, and a microscope or loops. That's all you need. And you can do most of these things with the other instruments you have. Neuro-navigation, well, if
51:19
you want to find an easier way to find it, yes. If you don't have it, you can find it.
51:27
Find where the end here. If it's an A3 and you're a semi, if it's, you go down to the proximal. into your cerebral arteries and you follow them all the way out. There are ways you can do that.
51:38
And the question is everybody's telling you about all these new treatments. The question, what's the proof, they're a value? What is the proof? And frankly, in most cases, it's very little
51:48
proof. What about the future? The future we're gonna be dealing with small vessel disease. This is an example of 20 of strokes are lacunar strokes. And this is a seven Tesla angiogram, which
52:02
shows vessels less than 100 microns in
52:06
one of the cells high in the brain. That's what we're gonna see. And interventional angiography is gonna deal with that. Here's a patient that was reported in a SNI, and it was 10 years ago from
52:21
Japan, a man who had dizziness, collapsed, had an occipital lobe infarct. They didn't know what it was. They treated him with aspirin. He came back later with more dizziness. He lost
52:30
consciousness. Then they did an angiogram. They show both vertebral arteries were occluded. This is his angiogram. He had one carotid artery. There was no posterior communicating, you could see.
52:41
He had another one here on this side, you couldn't see it. But if you did a CT angiogram and this was on seven Tesla, you wouldn't probably see it on regular angiograms. He had these small
52:53
corkscrew vessels going from the carotid back to the posterior cerebrals. Here it is in the lateral view He had basically revascularized his brainstem. He went ahead and had a bypass and
53:07
revascularized him. So what I'm telling you is that we're also limited by the technology we have. With three Teslas, we see certain things. With seven Tesla, which is available in very limited
53:19
places around the world, very limited, but that's what's gonna happen. You're gonna see this in the future.
53:27
And here is just showing you what the future is gonna be. of paper from Japan showing that really the cause of aneurysms is macrophages, it's an inflammatory disease. In the macrophage and involved
53:41
in blood vessel wall, it causes an aneurysmal dilatation. They produce this in animals, and they then fed the animals with, first of all, they gave them some agents to produce an aneurysm. This
53:53
is an aneurysm here in purple, and then they treated them with an agent that stopped the macrophages or the inflammation, and the blood vessel and it healed. So are we going to be looking at the
54:05
end of the century by biochemical treatment for amiurysms? You got to think about that. We've got a paper
54:14
on SNI digital on the molecular treatment of AVMs, and what they've done in Japan is they've got imaging agents that that will go to the macrophages and the aneurysm you can image it. And you can
54:26
see Essentially, if the aneurysm has got macrophages in it, then you know it's going to rupture, and that can be a way of telling how to do it. So anyway, what we were trying to do today is to
54:39
tell you is we don't know everything. And here is a film I showed on the talk on the Future Surgery. This is an image taken a year or two ago on the galaxies in the world. There was a thousands
54:53
galaxies, and this is in a limited view There's probably millions. And are there other inhabitants in the universe? Likely there are statistically. So what do you do? You've been grateful every
55:04
day that whoever got you,
55:08
worship helps you. You're a human being. You use all the talent you can to do the very best you can do every day, to help your patients with life-threatening challenges. That's why you became a
55:19
neurosurgery. So what is the best answer here? And that gets back to this chart I had you looking at some time ago. What choices do you make? And the choices turn out to be basically very limited.
55:35
Do you choose treatment A, treatment B, treatment C or treatment G? Is doing nothing better than doing something. Is waiting until the patient's stabilized better. You have to decide for your
55:51
environment. Should you refer a patient? Well, my patient doesn't have any money What are you going to do? Say, well, you're going to die. Can you do better than that as a neurosurgeon?
56:02
Can you do an angiogram? You don't have a CT angiogram. You can do an angiogram. We used to do them all the time before we were their CTs. So don't let people discourage you from doing things that
56:15
allow you to help your patient. You're a certain neurosurgeon. You're talented, you're intelligent.
56:22
Try to help the patient as very best you can. So you've seen a lot of things today. You've seen how you can do telemedicine, tele-proctoring. We've talked about how do you treat diagnosing an
56:35
aneurysm in an area where you don't have all the equipment. It doesn't matter. There are choices you can make. And if you are in an area where you have a more developed centers, then you do
56:47
different choices. Sam has talked about things that you do if you don't have them. And we had somebody talking about why you have to do a lumbar puncture and how you do it. None of those are wrong.
56:58
None of those choices are wrong. You have to do the best you can. So anyway, that was the message we wanted to bring. I'm sorry if we went over anyway. Thank you very much. Astrata, you wanna
57:10
close or I'm sorry that we went over but I wanted to get that. So when we get the video down, we could have other people can see it. Sure, sure. Well, thanks. That was well done and
57:21
comprehensive. I think it stimulated a lot of thought One thing I
57:27
wondered about is, Sam had mentioned about volume, and NIMM has a different experience, and so I think the question that comes to mind is, well, I would ask NIMM, are you having enough volume
57:45
that the residents have ample experience such that when they leave, they
57:53
feel competent to to address intracranial aneurysms with open surgery? And I think that's particularly relevant if you're having residents that are going to places where they might be the only new
58:09
surgeon in town, and then that brings up the other question. If there's variation in volume, is there any movement to have regional centers where residents from from different parts of Africa might
58:26
go to the regional centers of excellence to get more experience than what they may have had in their local situation. So I'd love to have a couple of comments about that. And then we should probably
58:41
close out.
58:45
I don't know. No, there's no, okay. No, thanks. And we wanted to thank you for your presentation, by the way, before we close Yeah, okay, thanks, thank you very much. Can you answer some
58:56
of Estrada's questions? Yeah, let me answer those questions.
59:03
Centers of Excellence is something we have been considering, quite a lot here in Africa. But, you know, Africa is a very divided country. Each country is totally independent. So to get these
59:17
regional centers of excellence is not easy within the country. Like now, let's say, let me take, for example, Kenya within Kenya, then we have what we have, we call national referral hospital.
59:31
So, like, there are three national referral hospitals in my country. So, Canadian national hospital is a national referral hospital, and then the elder hospital is a national referral hospital,
59:48
and then there is another one called Kineta University, also it's a national referral hospital. Now, these hospitals are given more resources, and as a result of that, and of course, they have
59:59
training programs, as a result of that, you find that most of the complex cases go to those hospitals. So, therefore, the work load, like, if you take, for example, Canadian national hospital,
1:00:13
it would be seeing a lot of patients over at South America, not human rich, and aneurysms. And therefore, although the cases will be done by the city and
1:00:21
the Los Angeles. but the resident neurosurgeons who are completing their residency will get an opportunity to be taken through the surgical component of management of the basic straightforward cases
1:00:38
and therefore you find quite a number of the neurosurgeons who will finish will have that experience but by and large they still choose to refer to the national referral hospitals as I said because it
1:00:51
has a lot of backup and therefore such cases would then go to to those centers so the issue of setting up regional centers is something we have considered and as I said this because each country is
1:01:07
completely different geopolitically it's there are so many issues which come into play and which make it very very difficult to make to set up a center for let's say managing such cases.
1:01:23
the WHO and African Union have tried in setting up regional centers, but so far we haven't reached neurosagerie. I know, Kidney, for example, in East Africa, they divided some sections. For
1:01:40
example, a kidney center was set up in Kenya, and trauma center was set up, I think, in Del Salaam. And I think another center, whether it's for vascular something, was set up in
1:01:55
Moolago. So those
1:01:58
three countries, Moolago, Del Salaam, Tanzania, Del Salaam is in Tanzania, and Campale, Uganda, and Kenya, they set up three regional centers, which would cater for,
1:02:13
in Kenya, we have the Kidney Institute, which basically is for all the East African countries, and remember, East African countries, We're going to countries that are about 5 of the time.
1:02:22
countries now. But we haven't reached that level in Los Angeles yet. So I hope, I hope we can pursue that and take no surgery to, to that higher level.
1:02:34
It's hard to thank you, Nam. The purpose of tonight's talk was, there are a lot of people even in our country who are not near a major center. And so you have to make a decision about what you're
1:02:46
going to do. We had some young residents who are actually in New York and you're going to another cities where there's only one other neurosurgeon. We have Alvin who presented a talk last month on
1:02:57
how he handled some traumatic brain injury. And I was telling everybody, Alvin's video has been seen by what's a 1300 people or something like that. It's very, very popular because people are in
1:03:12
that circumstance, where they don't have all these opportunities. And so the question is, what can you do in our goal today. was to show various ways you could do that. One is tele-proctoring.
1:03:24
And tele-proctoring, the camera showed that it has to be matured. But it has, as Alvin mentioned, and as other mentioned, it could apply in places where there's limited neurosurgeons and you
1:03:39
could do that. Isn't that right, Sam, or we haven't thought about that, but you could find a way to help people who need some help besides just intervention. We have to think about that.
1:03:51
And we tried to present some cases starting from minimal, but what you don't know and what you can do, and you're still faced with the choice of, can I do the very best for this patient, or do I
1:04:03
just let him die? Those are personal choices, those are family choices, those are agonizing choices. But people who are watching this video are in places all over the world, and many of them are
1:04:19
not. do not have a lot of facilities or equipment. What we were trying to say is you don't need all that. And Askraude and I and Samir and Gilbert and Nim all did surgery before all these things
1:04:35
were available. Yes, you can do it better now, but at least you could do, you could help some people. Is that better than helping nobody? That's something you have to think about. Let me see
1:04:47
who else Alvin, did you want to say anything in closing here? And Sam, did you want to say anything before we closed? 'Cause we're over time.
1:04:56
Thank you.
1:04:59
Was it helpful, was Alvin?
1:05:02
Thank you so much. I thank you, it was very helpful. And I do want to take more time, but I want to extend my thanks and appreciation to everyone. Thank you. And Sam, you talked about.
1:05:18
going forward, we're going to address some of these issues in subsequent discussions and lectures. So let me leave it until I give a talk, eventually I give a talk on experience in the private
1:05:30
sector and whether we should always depend on government to grow a neurosurgical service. But we're going to line up with the lectures and presentations we're going to
1:05:52
make in the near future. Thank you. Okay, thank you. All right, Australia We've gone for two hours, which is an hour longer, I think when the program committee meets, we'll have to talk about
1:05:55
that. We still have 28 people here. Okay, thank you very much, Australia. Thanks, Jim and thanks, Sam, for your nice presentations, generate a lot of thought and see you next month, first
1:06:08
Sunday of October for our next grand rounds. Thank you all. Thank you Please send your
1:06:15
comments to Astrada and how we could do this better. We've experimented with lectures. We've experimented with case presentations. This was an interactive discussion. Let us know what you like.
1:06:31
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