So, it gives me great pleasure to introduce this symposium. It's going to go from now until about 3 p.m. Our two sister societies this year are the Asian-Australasian Society of Neurologic Surgeons and the FLANC, the Federation of Latin American Neurosurgeons. As you see, it's a full program. We have two moderators for each session. We need to really stay on time, and as you can see, we've put in a few minutes of discussion, and I will, of course, ask the moderators to use those minutes as they see fit to perhaps create some discussion. And without further ado, I'd like to invite Kate Drummond, who, of course, is the president of the Asian-Australasian, and Louis Borba, unfortunately, could not be here to represent FLANC. But, Kate, wonderful to see you. Thanks, Jacques. Just really wanted to thank the AANS for having the AASNS as sister society for this meeting. I think this trend of having combined continental societies at meetings is so important. Meetings shouldn't be echo chambers and mirrors where we all just look at ourselves and hear the same thing over and over again, but they should be places for new ideas and expanding our horizons to other ways of doing things, and I think this is the perfect way to do it. So thanks to the AANS for organising, and I hope that you all enjoy today and get some fresh perspectives. Thank you. Thanks, Kate, very much. And may I introduce Anne Stroik, our president, and whose meeting this is. Anne? Okay, thank you. So thank you very much. It's a pleasure to meet all of our global partners with us today. So part of the challenges of being president is you have to be at two places at the same time, and virtual is not accepted. So I just ran over here, so if I seem a little out of breath, it's because it was at a running pace. But I want to welcome everybody. This is, Los Angeles means a lot to me, and you'll hear in my president's speech later about why that is. I won't give you any other secrets other than that. But this is a great town to be in. It's a great place to have a convention, and I will promise you, on our plenaries, you're going to see the best neurosurgery sciences I think you've ever seen. We have four late-breaking abstracts that are going to possibly change neurosurgical care in the future, and so I'm really excited. Our scientific program chair is John Ratliff, and he has done an absolute spectacular job, and I've sat on almost all of his meetings and really kind of try to help steward this. So please enjoy that aspect of the meeting as well. As you know, we've got that global, after your global symposium, we have the reception. We've invited our entire membership to come. Now sometimes it's a little hard because when they come on Friday, they usually come late. So if we don't see a ton of people, it's because probably we do this on Friday when everybody's flying in. But you can expect my entire board to be there, as well as our advisory group. So we will definitely be joining all of you and look forward to that symposium. So welcome, and thank you for this opportunity to do this. Thank you. Now without further ado, I will get the spine module going. And again, thanks to Praveen and Mike Wang for moderating. The platform is all yours, guys. So welcome to the AANS meeting. We're very excited to kick this off. I think a lot of folks are still working their way to this side of the convention center. As you know, some of you want CMEs. This is something you can self-report. There's something new called the NeuroU, which is part of the AANS website. I encourage you to take a look at it. A lot of the meeting information, in addition to the handbooks, you can get online through the app as well on your phone. So please take a look at that. Please download the meeting app if you can, and you can report CME. You should get an email regardless at the end of the meeting, so you can report to CME as well. A couple notes, audio taping, video taping, photography, except by this gentleman, we generally discourage that. Please silence all your cell phones, and please also plan to visit the exhibit hall. I know this is a giant convention center. You can get lost here, but the exhibit hall is really what keeps this meeting going. So without further ado, I think we're going to kick this off with a very appropriate talk by Salman Sharif about global spine and a way forward. So Salman, Thanks, Mike. It's really my pleasure to be here. I thank Chuck, I thank Anne, Kate. It's really an honor to represent WSNS. This talk that I'm going to give today... So while I'm waiting, really, it's my pleasure to see so many friends, so many people that I haven't seen in person for a long time, and it's been three years since the last time I was in U.S., and it's wonderful to be here. And especially those friends who have come from all over the world, really it's an honor to be standing with you. Okay, brilliant. Thank you. I think it looks so nice, but unfortunately you guys can't see it very well. Can we dim the lights here? Okay, so I represent WSNS as well as the Spine Committee of WSNS, which I'm a part of and I'm chairing for the last year and a half. Well, what is the problem? The problem is that the quality health care by WHO is care that is safe, effective, people-centered, timely, efficient, equitable, and integrated. The problem that we have is global demographics and health changes, the way we work, what we do is rapidly increasing the number of people experiencing disability due to non-communicable diseases. Musculoskeletal disorders are the leading cause of disability, with 1.7 billion people affected, equating to 149 million years lived with disability. Spine pain is the main cause of disability, with more than half a billion individuals worldwide. In 2017, WHO launched the Rehabilitation 230 initiative to mobilize a global community and reduce the burden of disability. This is what we see in all the governments all over the world, and I think this needs to change with the help of those governments. So the Global Spine Care Initiative was started, and the current model of care in high-income countries should not be reproduced in low- and middle-income countries or in communities with limited resources in high-income countries. This is Spine Care 230's non-profit NGO, and mission is to improve lives in underserved communities through sustainable, integrated, evidence-based spine care. Vision, a world in which everyone has access to highest quality spine care possible. So this is a model that can be replicable in various places. So Global Spine Care Initiative model is like micro, meso, and macro, with the person who needs spine care, so person-centered, biopsychosocial, proactive, includes prevention, evidence-based, so basically delivery best possible, collaboration with providers, with self-carers, and then people-centered, focused on communities, and then integrated healthcare delivery through resources and system components together. Obviously all this can only play a role if we all get together and work in various ways. So global neurosurgery is about training, education, surgical camps, health system, policy and advocacy. This is all important. So majority of the people would need low-cost per person care, which is self-centered care, and the concerns is preventable spine disorders like injuries, osteoporosis. Providers, community healthcare workers, these are the main people that we need to train. And then come to primary care, so the cost has to be low cost. Concerns is common spinal disorders like neck pain, back pain, and what we need is education, health coaching, and non-invasive care. Then comes the secondary care, and obviously specialists, hospitals, clinical personnel, coordinated, and some will require this. So reduce severity, manage comorbidities, address risk factors. Then comes tertiary care, where patients come to us, to spine surgeons, to neurosurgeons, and to specialists. And few of them would require, and they'll be high-cost care. So if a history and examination is done properly, then a majority of these people will go into this area, where there's self-care and community program. Whereas if you have red flags, then you obviously go to emergency specialists, multidisciplinary or tertiary care that's required. So recommendation for a spine care pathway by the Spine 2030 were individual and community prevention strategies based upon potential risk factors, comorbidities, and associations. For clinicians to address an individual's need, prevention, intervention may be incorporated through the clinical encounter. And components of history and assessment can include information about modifiable and non-modifiable factors. So what are non-modifiable variables? We know this. Age, sex, obviously we have it. Genetics, prior history of spine or musculoskeletal pain. And the rest of them, obviously exposure, if we can reduce that, we can improve the scenario. So trauma, smoking, medicines, posture, vibration kind of work, bending, and other injuries, high BMI, obesity, low physical activity, et cetera. And psychosocial, which is very important nowadays. The way forward clearly established that there's need for space-integrated and sustainable spine care programs around the world. The success of all spine care, clinical research program, it can be delivered to many countries across many customs and cultures. Spine 20 recommended 2021 as spine care for people's healthy and prosperity. And Spine 20 is another advocacy group. I'm part of that as well, which goes around the globe to work with the governments, institutions, organizations to highlight value-based spine care and can help prevent disability. So its recommendations are intended to reduce the burden of spine related to spinal disorders by engaging governing stakeholders in the development of evidence-based policies. So Spine 20 recommendations are nearly the same what others have, except for a few things. They want to develop policies and support systems to reduce the increasing burden of disability on healthcare, the economy, and social security. And adopt prevention strategies to limit spine problems, promote balanced nutrition in young population to ensure that they get proper nutrients. Encourage osteoporosis prevention strategies and early detection, especially in older population. Create global awareness for the prevention of spine injury. Implement the principles of value-based healthcare and spine practice to optimize spine care in the global community. Global access to comprehensive healthcare for individuals with spinal injury to facilitate community inclusion, return to workforce, and improve quality of life. Recognize that low back pain is the leading cause of years left with disability and loss of function in this world. Create low-cost models to ensure right care is delivered at the right time. Define global standards for continuing education and training curriculum. Ensure the best healthcare for patients. Defining global educational standards and training curricula for spine practitioners and adapting them to local, regional resources in need. So lots of guidelines and recommendations have come out. NAS has developed eight guidelines. CNS, AANS have already developed four. The Spine Committee of the World Federation have prepared recommendations on six topics. So we have done on various topics which are shown here. And they're all on open access journals so that you can easily approach them. On top of it, the two other recommendations are in publications. So the Spine20 proposal is like this, that you develop action plans to provide universal access to spine care. You develop policies using the best available evidence. You build collaboration and innovation, translation research capacity with national, regional and global health. So we're all getting together. Develop international consensus statements. So that's what we all have been doing. Development of sustainable human resources. Promote evidence-based approach to spine care. Create a competent workforce. Improve the healthcare. So these are the community healthcare people. And recognize intervening on determinants of spine including physical activity, nutrients, et cetera that we talked about. What about low middle income countries? So this is a very nice paper in which they talked about a history, proper history, red flags, psychological factors, yellow flags. Focus physical examination to further narrow down differentials. Routine diagnostic imaging not indicated unless presence of red flags. Progressive or intractable symptoms. And EMG and nerve conduction study is not recommended as a diagnostic tool. Discography not indicated for assessment of spinal disorders in this group of patients. Ideal spine residence training should be something like this. This should not be limited to acquiring textbook knowledge, lab work, skillful and surgical, non-surgical manager patients with spinal disease. And the important part is non-surgical management of patients. Primary surgery training. We already have something like this. And we shouldn't be looking like that. Community education. Public minorities about common spine problems. So teach them. Educate primary healthcare providers. Educate physicians to pick up red flags. Early referral to tertiary care centers. So prevention of disability. We have already talked about it. So basically going about physical activities and exercise that's clearly shown that it's effective to reduce back pain and long-term better outcomes. Interactive spine neurosurgery e-learning and digital technology. So this is what COVID taught us. A lot of digital learning all over the world. During this time many societies got together and worked on this. E-learning significantly influences spine surgery training and practice. Most participants in the survey that we did felt that online education is a great substitution of traditional teaching methods and want to continue this practice post-pandemic. And recently I went to Africa and another course and realized that their knowledge, anatomy, physiology, basics of spine has changed completely. So what we used to see 12 years ago, 14 years ago, is not there anymore. Their knowledge is equal to our knowledge at this stage. And this is all because of this digitalization. So digital education is emerging tools in spine surgery education with free, low-cost mobile content with high educational impact. Interactive learning method that encourages the active participation of learning. And you need to do problem-based learning which utilizes clinical scenarios to teach problem-solving skills. So future. Future of global spine care is one that is characterized by innovations, collaboration, and personalized care. Use of telemedicine and digital health technologies, personalized medical approaches, regenerative medicines, and interdisciplinary care. These teams hold great promise for improving outcomes and quality of life for spine-related conditions. So what does a passionate spine surgeon should do? Give high-quality care. Educate patients, healthcare professionals, and communities globally. Evidence-based practice and working with interdisciplinary team educates for better policies and collaboration with policy makers, patient organization, and other stakeholders. Research, including clinical trials, scientific publications, share their knowledge by organizing workshops, training programs all over the world. Participate in health initiative globally and focus on improving spine healthcare. The way forward is global spine care involves a multifaceted approach that emphasizes patient centered, non-surgical interventions, collaborations, coordination among providers, and ongoing research and innovation. Improve the health and well-being of millions of people around the globe. So role of neurosurgery in global spine care. We wrote this chapter a little while ago in Isabella Germano's book. And global spine surgery is a flourishing arena in which its key players endeavor to make a difference through surgical camps, educational programs, training programs, healthcare system strengthening projects, health policy changes, development, and advocacy. In recent time, massive strides have taken to develop a coherent voice for this work. The leading players have begun to come together in this powerful solution. With this, the future of sustainability and improvement of spine education is bright. And I thank you all for listening. Our next speaker is Dr. Jiaqing Wu, going to discuss with us about multilevel cervical disc arthroplasty. Dr. Wu is here from Taiwan. Ladies and gentlemen, today I'm going to talk about multilevel or more than two level cervical disc arthroplasty. Since the beginning of 21st century, cervical disc arthroplasty has been accepted as an alternative to anterior cervical discendant infusion for surgical intervention of disc problems. Our group published this paper 10 years ago. It was the first retrospective study to compare two level cervical disc arthroplasty with ACDF. During the past two decades, there are reports from many prospective randomized control trials comparing one and two level cervical disc arthroplasty with ACDF. They unanimously have concluded that the clinical outcomes were very similar between ACDF and CDA. So the CDA also could preserve the mobility at the index levels. Praveen and I published several chapters on CDA. And CDA has been proven to be an effective and safe surgical strategy for patients who is one or two level symptomatic cervical disc herniations or spondylosis. In appropriately selected patients, CDA not only successfully yields neurological improvement, but also maintains surgical segmental mobility at a very low rate of complications or reoperations. The published indications of the clinical trials, FDA trials of CDA have included patients with reticulopathy or myelopathy caused by one or two level disc herniations at C3 to 7. Literature has demonstrated that one and two level cervical disc arthroplasty outscores ACDF in successful preservation of neck motility at the index levels by maintaining or restoration of the physiological motion of the cervical spine. In theory, when compared to one level of cervical disc herniation, patients with two or more levels of disc disease would benefit even more by CDA in motion preservation, especially with equally high rates of neurological success and the low rates of secondary or revision surgery. So the question comes whether these results could be translated into three-level disc herniations or spondylosis. Today, there are no FDA or prospective randomized trials comparing three-level disc arthroplasty to ACDF. So our group published this paper three years ago to look at the outcomes of three-level CDA. We compared 50 patients of CDA, of three-level CDA to a group of, to 50 patients of H6-matched control group of ACDF who underwent three-level ACDF. They all have improved clinical outcomes, improved GOA, improved neck disability index, improved VAS scores. Interestingly, between the groups there's no significant difference. So CDA and ACDF all yield very good patient-reported outcomes at two years. Regarding the perioperative complications, there were a few dysphagia, C5 palsy, and it's about the same in both groups. So the three-level CDA not only yields neurological improvement but also preserve the motions at the three index levels. You can see the ACDF group automatically losses about 21 degrees of neck motion. In contrast, the CDA group not only preserved the preoperative 21.8 degrees but also increased slightly to 25.2 degrees of postoperative range of motion. So the clinical outcomes of three-level CDA and ACDF were very similar during the follow-up of two years. The CDA not only successfully preserved but also slightly increased the mobility at the three index levels. Here's another example case of three-level CDA that we published. Here's a patient who has cervical herniation at 2, 3, 4, 5, all three levels. And we can see even a C2, 3 level can be approached through the anterior standard, anterior cervical approach. And here's the intraoperative photo of the after removal of the disc and the implantation of the artificial discs. And the patient got preserved motion at all three levels. In my opinion, single-level versus multi-level cervical disc osteoporosis, although the surgical technique is the same itself, but actually we are treating different patients. Here's the published FDA trials about cervical osteoporosis. All these trials are industry-supported. And they are mainly focused on only one-level patients. And Praveen wrote this years ago in General Neurosurgery, the best candidates for one-level cervical disc osteoporosis are patients who are young and with good bone quality and little fascia osteoporosis. But when it comes to three-level or multi-level patients, it's not uncommon to see these patients who has myelopathy. For example, this patient has myelopathy. And is myelopathy a concern? Actually the FDA IDE trials in the indications of these trials, they did not exclude myelopathy. These are indications of CDA in these FDA trials. So our group tried to look at myelopathy patients in a very special group of patients. These patients has congenital cervical stenosis. In these patients whose spinal canal is relatively small, with this small canal, when the patient has a cervical disc herniation, it has not to be a large disc. With mild or moderate disc herniation, it causes dual-set compression and subsequent myelopathy. So these patients are typically young, and we tend to, we treat these patients conventionally with ACDF. But it would be better if we can preserve some motion in these younger patients. At that time, that was five years ago, so at that time we weren't so confident about three-level osteoplasty. So we did this hybrid construct to fuse the segments that has less motion and put CDAs in those segments that has more motion. And we compared the results. In 20 patients who had these hybrid CDA constructs, when compared to other 17 patients who had three-level ACDF, generally the clinical outcomes were very similar, only that the hybrid construct patients has more preserved neck mobilities. You can see all the patient-reported outcomes of these two groups of patients were very similar. So the hybrid CDA construct appears to be an acceptable option in the management of congenital cervical stenosis. The strategy of motion preservation yielded similar improvements in cervical myelopathy compared with motion elimination in patients with congenital cervical stenosis. We also had another study to compare patients who underwent CDA with myelopathy and with radiculopathy only. The outcomes were pretty much the same. So CDA is good for radiculopathy and also for myelopathy as well. Especially when patients with more severe myelopathy, we did a study to look at those patients with preoperative increased intramedullary signal intensity on T2-weighted MR. You can see after CDA, the increased intramedullary signal intensity also got shortened after CDA. So in my opinion, multilevel cervical disc osteopathy should be suited for patients with primarily multilevel primary disc disease. For example, this is a patient, it's a 58-year-old female who presented with myelopathy symptoms, but also severe arm pain and arm numbness with slight leg numbness and it was refractory to rehab. So we took her, you can see the fascia joints are pretty much preserved and it's mainly the disc problems. So we did a four-level osteopathy in this patient and this was the X-ray one year and a half post-operation. Finally we published a review article in Genespy about multilevel cervical disc osteopathy. We did a permanent research from since the year 2000. In a total of 957 articles published during the span of 22 years, there were about 24%, one quarter of these articles, these papers are actually level one evidence. If we count level one and level two, the percentage comes up to 33%. So there are a lot of literatures, there are a lot of publications about CDA. It's probably the most scrutinized surgical procedure in the history of spinal surgery. You can see the amount of these publications came up dramatically during the past decades. There are more and more CDA papers and there are less ACDF papers using ACDF as a comparison. And also regarding the index levels, there are more and more two, three, or multilevel publications on CDA. So CDA is an established surgical management for one and two-level cervical disc herniation and spondylosis. The success of motion preservation by CDA with low rates of complication has outscored ACDF in patients without deformity. For more than two-level disc disease, the surgery trends toward multilevel CDA or hybrid ACDF-CDA according to each individual evaluation of each level of disc degeneration. We also published this video regarding hybrid cervical disc osteopathy. This is a good candidate for hybrid construct. You can see there's deformity of kyphosis at C345. So we did ACDF to correct the kyphosis and take care of the compression. And for 567, it's a pretty good preserved alignment. So it's good for CDA. And the true or relative contraindications for cervical osteopathy are kyphosis or incompetent facades, osteoporosis, cervical ankylosis. For example, this is a patient who had two-level discs, but there are severe deformity or kyphosis at the segments. So it's better suited for ACDF. This can be easily corrected by ACDF, definitely not a good candidate for CDA. We also published another paper to look at the incidence and the risk factors of imprint dislocation after CDA. This is a retrospective cohort analysis of 756 patients. This is one example of the multi-level disc CDA that has dislodged in the middle, C5-6 has dislodged, and subsequently we revised it with ACDF. So in this study, the incidence of imprint dislocation was 0.07 percent, which was five out of 756 patients. That was 1,236 levels. The most important and the most critical risk factor is kyphosis. You can see the odds ratio is as high as 15. All these migrations happened within 1.5 months post-operation and were all revised to ACDF safely. So again, the contraindications of multi-level CDA actually is about the same, is the same as those contraindications listed in the FDA trials. Just that more than two level disease might be considered not a contraindication in selected cases. Also, I would like to add on that OPLL is definitely not a good idea, not good indication for CDA. Here's another example of a good candidate for multi-level CDA. This is a 58-year-old female presented with arm pain, bilateral hands numbness, and leg weakness for five months. And the MRI showed primarily four-level disc disease, disc herniation, even with some increasing intramedullary signal intensity in her spinal cord on T2-weighted MRI. And we did this four-level osteoporosis for her and the post-op. This was a two-year post-op x-ray, it's pretty good. So in conclusion, I think multi-level CDA is a viable and effective option for selected patients. The more levels, the better the outcome. Also, disc osteoporosis outscores ACDF, particularly in multi-level diseases. Thank you. Thank you, Dr. Wu. Our next speaker is Dr. Osdrebo Falavigna. He's joining us from Brazil. He's going to speak to us on radiation safety and spine surgery. Osdrebo. Okay. I want to thank Jacques for the invitation, the opportunity to speak about radiation safety and spine surgery. I have nothing to disclose. I'll talk about the spine surgery exposure to radiation, the knowledge and attitude of spine surgeons worldwide. And I'll give some tips of 10 steps of how we can overcome radiation exposure. So let's imagine Pravin, you have 30 years old, okay, right now. He is excellent surgeon, deformity surgeon, still use radioscopy. So Pravin wants to have this question. How long does it take to exceed the radiation exposure for a lifetime? So we have this publication that shows that at maximum 10 years, you exceed, you surpass your lifetime for radiation. So Pravin, you need to work more than 10 years. So how can we manage this problem? And this is why we see many surgeons outside that use radioscopy-assisted procedure that become with high incidence of cancer. So if you look orthopedics, around 29%, non-exposed workers, about 40%. And if you can say, okay, but I don't do any surgery with radioscopy, I'm safe. Of course not. You are not safe. Because every time you prescribe like CT for a patient or for your family, you also has increased incidence problem of cancer. So the first Australian study shows that we found 24% greater incidence of cancer in CT-exposed group. And the second is US study that shows a prediction of future cancer risk of 29,000 people relate with CT scans. That brings me one conclusion that we cannot see, smell, or feel radiation. But believe me, it exists and can be very harmful for the body. The good news is that there is a way to overcome this type of problem. So I'm going to focus my lecture in this two study that we publish about knowledge and attitude of spine surgeons worldwide, not only in Brazil, but worldwide. What we found is that this is a cross-sectional study. This was a survey answered by AOSPINE members. We studied some variables like speciality, years of experience, surgeon's position during fluoroscopy, and many different practices that we usually do every day in operating room. So we got almost 1,000 participants. The participants have equal number of years of activity. About two-thirds was orthopedic. What we found is that surgeons take care a lot with lead apron, about 96% use lead apron. Thyroid shield is widely used. You still have a room to improve education for lead glasses, only 70% use protection for the eyes, and lead gloves. But when I was analyzing these numbers, what astonished me was that never or rarely use of dosimeter badge was about two-thirds of the spine surgeons. So two-thirds of spine surgeons, they have no idea about what is their own radiation exposure. We know that the lead apron, we need to take care. Every time that we use, we need to store in racks. So the good practice was observing 60% of the participants that use the racks or shields. Even if I manipulate right the lead apron, we need to, from time to time, to assess those apron because 73% of times, the tolerance limits for lead equivalents, it's lower. So you think that you are protected by the lead apron, but you are not. And one thing that I learned from lead protection that is never, never 100% protection. If you look this article that's about radiation exposure to thyroid, even if you use thyroid shield, you still have some radiation above or below the thyroid shield. So the lead protection is only 66%. That means we need to use another type of practice to protect ourselves, not only if I'm wearing the lead apron, the thyroid shield, I'm protected. We have some clinical scenarios like this, which is the best surgeon position during lateral lumbar fluoroscopy. We have the scenario A, the surgeon is on the side of image intensifier. And scenario B, the surgeon is on the side of beam source. Think A or B. What do you think that is correct? Which thing that is A? Raise your hands. A. Okay. 10, 12, B. Okay. So the correct answer is A. That is, the answer was right in 36% of spine surgeons. So one third of surgeons said that the chance the surgeon to receive less exposure is to be on the side of image intensifier. And those correct answer was mainly from surgeons from US and Canada. So the problem is that every time you have a lateral fluoroscopy on lumbar spine, we have the back scatter from the same side of the beam source. So if you are on the side of beam source, you have 53 times more than if you have on the other side. That's only 2.2 on the opposite side. If you are promoting surgery in obese patients, this number is even high. So another question, which is the best position of the fluoroscopy to deliver the laser radiation to the surgery during the AP view? So scenario A, the x-ray source is below the table. Scenario B, the x-ray source is above the table. So 10 seconds, what do you think? Scenario A is correct. Raise your hand. A is correct. B is correct. So the right answer is scenario A. So if you take a look, the x-ray source, once it's below the table, all the back scatters go direct to the floor and not if you go to scenario B that is above the table, the back scatters go to the upper part of the body of the surgeons. We need to worry not just with ourselves but also with the patient. So which is the best position of the fluoroscopy to deliver the laser radiation to the patient during the AP view? We have the scenario A, patient near to the beam source. Scenario C, patient near to the imaging intensifier. And scenario B in the middle. So what do you think is the best for the patient, A, B, or C? The right answer is scenario C. Scenario C, the patient received only 6.5 rats. On scenario A, it's almost three times more. So this is another question that we try to undertake to the spine surgeons. We know that fluoroscopy, we can select the continuous versus pulsate mode. And we ask how many of them select always the pulsate mode. So you see that 52% always select the pulsate mode. And the reason is that once you use the pulsate mode, you reduce by 56% the radiation time. So always use the pulsate mode. We know from the literature that the spine surgeon hands is exposure 12 times more than non-spinal musculoskeletal procedure. So we ask for the surgeons how many of them just take out your hands during the fluoroscopy and the answer was two-thirds of them just move away their hands from the field during the fluoroscopy. Mostly the surgeons based in Europe and North America. About distance from x-ray source, we know that as much we stay distant from the fluoroscopy, safer we are. So we ask how many of them step away from the fluoroscopy during the fluoroscopy. It's just to step back one or two steps so it's so easy and 77% said they do that. The other said no we stay in the field. So that's that point is important because once you are three meters distant from the radiation, the fluoroscopy unit, you have almost zero radiation. So just step back and give the fluoroscopy then you're going to be safe. So I want to give you the radiation safety. Simple 10 procedures that you can use in order to reduce your radiation. First, understand that there is no safe risk-free dose threshold. The second, use lead protection but you have to understand it's not 100%. It's a combination of attitude from the surgeon that you can protect yourself. Be aware of your own radiation exposure. So we need to wear all the dosimeter badge. It's very important for us to understand if you're doing the right job or not. You start with the operons on the specific racks. Stand always on the imaging intensifier side. Keep the x-ray source below the table during the AP view. Always place the patient far from beam source. Use post-mode fluoroscopy. Remove the hand on the field and step three meters away from the fluoroscopy. With that, we can live long and prosper. So I hope to see you soon in Las Vegas next year to further discuss radiation exposure. Thank you. We have a couple minutes. Feel free. I think we have a few minutes. Are we able to activate these microphones on the table here? So, Selman, can I start while people are getting warmed up? It's early in the morning. I love your talk about global neurosurgery and spine. You know, obviously, you know, living in America, you know, we're very dependent on implants, biologics. You mentioned osteoporosis, new technology. It makes spine surgery really amazing. How do you see this playing out in the rest of the world and say in your native country, right? How do you see that being translated? I think it's already there. A lot of it is there, but at the same time, it's common sense that's important. I think everything that's there should not be used. We know that. Every patient who comes into our clinic does not need to have surgery, and every patient doesn't need to have artificial discs, for example. So, it's just that, you know, I think we need to be careful. If, for example, you were living in that part of the world where it's really, really expensive for everything. If you spend for one patient versus you can spend for a hundred patients. So, you'd probably want to do that because, you know, that common sense tells us that. And, frankly speaking, majority of the results are pretty good overall. I think with complex spine surgeries, it's different. And yes, where it's required, you should use whatever resources you have, even if it's expensive. Thanks very much. Jiaoqing, I was really fascinated by your talk, and I haven't seen that much experience with such multi-level arthroplasties. You probably have one of the largest experiences with that in the world. So, what do you choose as your age cutoff for doing a multi-level arthroplasty? In the US trials, we really didn't see anybody basically over age 58. So, I'm just curious, you know, do you have experience doing it in more elderly patients? Do you have a problem when these patients become osteoporotic and get into their 70s? And does the arthroplasty then have problems at that point? Yes, that's a very good question. I think age itself is not a critical problem. I regard, I consider these patients bone quality, as you said, and it really depends on how degenerate, how much degeneration does that index level has. If it's too much deteriorated, if there's too many spurs, it's already ankylosing, or there are a lot of fasciitis during arthroplasty, I would not recommend cervical dysarthroplasty. Again, it's only reserved for selected patients who has motion preservation will have more significant impact on his daily life. And when they get to their, I don't know how many years you've been doing, but if they get to their 70s, are you seeing any problem when they have osteoporosis develop? What happens with those multi-level arthroplasties? I think it does, it is not worse than ACDF. We still see a lot of patients with, even we know osteoporotic patients are not good candidates for CDA, but again, these patients are not best candidates for ACDF either. We need a lot of instrumentation of biologics to maintain the bone fusion, so I would not consider age or osteoporosis as the only factor for CDA. And then how do you choose, you know, laminoplasty versus multi-level arthroplasty? I personally try to go interior as as long as possible. I tend to do interior over posterior because I think it's involved less muscle and the patient recovers better. And what about the swallowing problem? I think, I don't know why, but I think we see less swallowing problem in Asia. When I was in the States, I think there are more swallowing or dysfacial problems, but I don't know why. Maybe it's related to BMI. Astroball, great talk. I found that, you know, what you're saying, it really, I think, struck the audience because it was something you can take home to try to improve your own personal health, right? You know, doing a lot of MIS surgery, obviously this has been a big impediment to adoption, say in East Asia where people are terrified of radiation in Japan, Korea, China. What do you see as like the future? I mean, you offer some very practical ways of minimizing your personal exposure, but if you're busy you're gonna get radiation, like you said, right? And as you said, if you minimize radiation, you're compromising some element of safety to the patient, right? What is the right balance there? Because if you want a long career, as you say, you're gonna do a lot of surgeries, you're gonna get radiation, do new technology, like disc arthroplasty, you need radiation. What is, what do you think is this headed towards? Do we need to be more image guidance? Do we need better software for floral machines? Where is it headed to, like in Brazil? Yeah, my opinion, I think that first we need to educate the right people, the residents, the fellow, and even us as experienced surgeons, because sometimes we use the old habits in every work and we never think about radiation exposure. So first, education is very crucial in this time of thing. After we finish that survey, we send out all the results and how to change those results. So educate people is always the first thing. The second is improved image. So now we have neuro-navigation, we have robotics, so we can handle better with radiation exposure. That is not on my practice. I still use my brain as neuro-navigation. I use my hands to put the pedicle screw by directly. I use the fluoro, yes, but I take care of myself every time that I use fluoro. One smarter guy inside the operating room is the anesthesiologist. He's never inside during the fluoro. He's always outside. So we need to learn this from them, because they never step out the room after me, always before me. So it's so easy. So we need to use the lead apron, the thyroid shield, yes, but still some easy things like remove your hands from the field, step three steps away from the fluoroscope unit. Sometimes just move away your head from where the x-ray is doing. Just move away. There's a few things that we can do in order to improve, but of course we need to have more image guide. Every time we do MIS, image guide is amazing. It's essential to do that. Neuro-navigation is going to improve ourselves. Robotic and Pravin, you can speak because you do all neuro-navigation. Robotic can improve, but it's still in many, many places. Fluoroscopy is the only option that they have. Do you have your own lead? Like I find that that's one of the things that it's interesting. Please, Ramsey, please come up. There's microphones over here. You know, I find that, you know, the couple hundred dollars you spend to buy your own lead is an investment worthwhile, right? I mean, it's not a lot of money and it could save your life, right? Yeah. Will you introduce yourself too, please? Yeah, that'd be great. We can hear you. Yes, it's on. Just a quick comment on this. You brought up a huge issue. It's not just mine. In Endovascular, we're moving so quickly. We have many, many of our neuro-infected patients who are never well-trained in navigation safety. And I've seen so many people who are not significantly sick in this area. And I think that in 10, 20 years, we're going to see the problems. Absolutely. Yeah, you're exactly right. You know, at our hospital, our neuro-interventionalists who have been doing it for some time, they have a pretty high rate of lymphoma, actually. And in addition to that, you know, I see some of the patients come back after they get aneurysm treatments and, like, there's a big patch of hair missing on the side of their head. So, I mean, these are not things that we really think about or talk about. But, you know, getting lymphoma at the age of 60-something, that's a real problem. Please, yeah. Will you introduce yourself as well, please? Yeah, and where you're from. I'm from Tampa, Florida. I have a question for Dr. Wolk. I saw the numbers of the study you did, and one of the complications was dislocation. You have five cases and 786 patients. That seems too much. You're one of those patients. That complication, you don't see any CDF. Can you tell us about the outcome of those five patients? The second question that I have for you is timing from surgery. For three levels, you know, each replacement is 280 minutes, almost four hours. That seems way too much. What are you doing to improve the timing of the duration of the surgery? Number two, and then the last question would be, to put these replacements, you have to use a lot of x-rays to do it right. Are you using, have you changed your practice from one implant to another to make it faster? Yes, thanks for your question. Regarding the operating time, we calculate the time from the start of anesthesia till the end of anesthesia, so it looks longer. But actually, I've seen Praveen operate on these patients. I'm about as fast as Praveen. And regarding the radiation exposure, I have, as the technology evolves, the implant company has tried to improve their implant design to make it easier. So I would say, now we do osteoporosis, we need less radiation, less floral than we needed 10 years ago. For example, when at the time we were doing brain disc, it needs a lot of milling and checking on x-rays. Nowadays, there are less keel, less design with the keel, so we need less time for floral check. What was the other question? Dislocation. Dislocation, yeah. These patients, fortunately, we follow up these patients quite often, and so we discovered the dislocation early, although the image looks horrible, but actually the patient was only mildly myelopathic, and after we revised it with ACDF, they all did fine. Ramsey. First thing, thank all of you. Just speak a little louder, yeah. It's okay, Ramsey. Yes, go ahead. Just a quick question about the global spine. The issue with the global spine in Africa and Asia, we can actually talk about, but how can you supply resources or help in these countries, especially in Asia, for instance, you have to make the dollars in order to do one lift of the spine and things like that. So what is your organization doing for that? Thank you very much. Actually, at the moment, as we said, we are discussing, talking, coming up with plans, and discussing with the local governments. So all those local governments are involved. So actually there are seven, eight governments in Africa also involved here. On top of it, I'm the chair of the Spine Committee of the World Federation, and our objective for the last one and a half years was completely Africa and nothing else, and now South America. And the idea behind that is we're doing hands-on workshops for them, teaching them basic, teaching them how to do it cheap, how to do it quick, and making sure they understand what they were doing. Beforehand, the knowledge wasn't there. Now the knowledge is there, so it's easy to teach them, and it's quick, competitively from before. One last question, please. What's been your experience with arthroplasty in general in this patient population? I would consider this arthroplasty for mildly myelopathic patients. For spinal cord injury patients or trauma patients, those severe myelopathy, I would do still fusion ACDF. Great. Thank you so much. In the interest of time, we're going to wrap up this session. I'd like to thank our international speakers for a wonderful lecture this morning, and we'll go on to the vascular session with Dr. Marcos and the team. Thank you. This was a very stimulating session. I might change my practice and become a spine surgeon. You guys are having so much fun with this. Thank you for a wonderfully conducted session. I'd like to introduce my co-moderator, Rock Chen from University of Texas in Houston. You will see the session, unfortunately, we're stuck with a beverage break having to be at a certain time. We will have our first speaker, and then we'll have our other three speakers. I'd like to introduce Bassant Mishra, who is going to talk about the role of microsurgery in aneurysms, and then he happens to also be the head of the WFNS Foundation. He'd like to give us a seven-minute summary of the work being done in the WFNS Foundation. Good morning. Thank you, Jack. Thank you, Mr. Chairman, for this opportunity. It's indeed a pleasure to come back to L.A. Let me share with you some of my thoughts about aneurysm microsurgery, which people think is no more relevant in the management of aneurysm. First, there was a very nice talk about radiation safety. For your safety, do microsurgery rather than endovascular to reduce your radiation. That's the first indication you should be doing microsurgery rather than endovascular. I have no conflict for this paper. We all know microsurgery is more definitive, is more durable, there is higher morbidity. If you can reduce the morbidity, that's probably the way to go. This is the brand data published in General Neurosurgery 2019. You can see that this much more definitive is microsurgery. The crossover was very high. What about the various trials? There were four trials. In fact, none of these trials showed that endovascular treatment was better. ICET, of course, showed one-year results, but not at five and ten, BRAC, FINISH, and the Chinese study. I'll give you some examples where it is indeed necessary to microsurgery and endovascular surgery doesn't offer the cure for these patients. Some examples, this is a patient with a young man who was presented with acute subdural hematoma in another center, had a decompressive craniotomy. Do we have a timer somewhere, Jack? I can't see the timer. I don't know how to go about it. I'll give you three minutes. This young man who had acute subdural hematoma, had a decompressive craniotomy, presented in coma, survived, and then was sent to us for definitive treatment. This aneurysm, the whole ICA was diseased, which has burst through the subdural compartment and produced the subdural hematoma. When he came to us, we advised surgery. We thought we'd bypass or do something, but he ran away, not unusual in my country, to come back after a year with progressive severe headache and hemiparesis. We went on to operate, and we excised this aneurysm because this was eight centimeters. The radiological graft was not enough, so we decompressed the aneurysm in the middle fossa, and we did the bypass. You can see there was an unruptured basal top aneurysm also. We sent this patient for endovascular treatment that failed. This was about 10 years back, and then sent back to us because the PCA was incorporated in the aneurysm. That time, in another sitting, we did the clipping. This aneurysm, I don't think is, even today with all the armamentarium we have, is appropriate for endovascular treatment. This is what was done, and the patient was fine. This is another gentleman who had a trauma, who had a pseudoaneurysm. When he presented to us, he had hemiparesis, he had blind on the right eye, and he had epistaxis recurrent. The patient was still uptended, so we asked our endovascular colleagues if they could do a flow diverter or something. I don't do any endovascular treatment. They tried, and they did multiple studies, and then multiple 3D with radiation exposure, but finally they found there was a fracture segment lying in the aneurysm, and they thought that it would be dangerous to put a flow diverter because that would probably tear off the vessel. They sent back to us, and a simple treatment of a bypass, a high-flow radial artery bypass. The difference when you do an aneurysm which is pseudoaneurysm like this, we have to trap it, not only like it in the neck, because they can bleed from the pseudoaneurysm. So we have to go back in the intracranial compartment and clip the ICA proximal to the ophthalmic artery so that it doesn't back bleed. An aneurysm like this, this patient present, it's a lady who presented in coma, with this giant aneurysm which has bled, and this was the circulating component. It's probably much more difficult, it's bilateral MCA, this had bled. All the vessels you can see on this, and it still can be treated by microsurgery clipping, that's what we did it, and you can see the vessels are still intact. The patient recovered over a period of time, remained hemiparetic on the left side, and he came back for a second sitting for the other side, which was done successfully. If I can, they told me I can go to the, I can fast forward by going to, I don't know how to do it, but if I can't then I'll skip the video. They told me I can go to the fast forward, there is a, they said there will be a bar there, but I can't see the bar. No, there's no bar here. They said there will be a bar on that, but I can't see the bar. Anyway. Okay, that's fine. So that was the aneurysm. I just wanted to show how it was not possible to do endovascular treatment, and we did a special technique where the aneurysm clips, the blades were perpendicular to the ICA, that is the ICA infusive of aneurysm. The intercortical and PCOM was incorporated into the aneurysmal segment, so we did multiple clips, which are the blades perpendicular to the artery, unlike the usual common garden technique where they're parallel to the main artery, and we could manage to clip the aneurysm. This is a Moammar disease presented with subarachnoid hemorrhage from the aneurysm. You can see that the P1, P2 junction aneurysm, and that had blades, so we clipped that aneurysm and did a HTMC bypass. Probably easier to do this in this way rather than going for endovascular treatment. Presenting with ischemia, this lady, 70-year-old lady who presented to our neurologist with an infarct. It was small, fortunately he investigated and found a very distal MCA aneurysm which had clotted, and that was the cause of her infarct, and so we opened up and we decompressed the aneurysm, and we could open up the vessel, and the patient, over a period of time, had a good outcome. I think I'll have to skip the video again. I just saw the clot there. It moves automatically, I don't move it. It's going, timer, is there a timer? It's automatically, I'm not moving it, it's moving away on its own. The slides you mean? Okay, so anyway, this is another gentleman in his late 60s who presented again to our neurologist with an infarct, and then it was investigated, the small circulating component at surgery. You can see the huge aneurysm with a large clot there. I don't think this can be treated by endovascular, so we had to open it up and did the revascularization of that procedure. And a patient's presenting with a mass effect. Now this is a gentleman who had all his vessels are diseased, and he presented a visual compromise and headache to us. You can see this was the artery which was causing the problem, the right ICA, and of course the left one is also diseased, the posterior circulation was also diseased. We didn't know what was the best way to go forward. We sat on this patient for a period of about a year, when he forced us to do something because he was losing vision mainly on the right side. So I think we bought some time. We did a bypass. We ligated the carotid artery in the neck and did a radial artery bypass graft, and there was vision stabilized for some time, and then he was followed up with us for about a year. After that, he's lost to follow-ups. I really don't know what happened to this patient after that. This is a young man who failed endovascular treatment maybe 15 years back, and then this was a distal ICA, unruptured giant aneurysm presented with visual compromise and headache, and this again failed endovascular treatment which was sent to us. It was a very thick wall. As you can see, the ICA is blown up there with the aneurysm. We couldn't put any clip without holding the aneurysm neck with a bayonet forceps so that we can put multiple fenestrated clips, the clip blades remaining parallel to the parent artery, first proximal to distal and then from distal to proximal, but still we could not take care of the whole aneurysm because there were some, the perforators were getting compromised, so we left that a little bit, and this is the ICG post. You can see the MCA, ACA, but there's a little bit of circulating aneurysm there. This is how he came to us, and this is what was the after our surgery, and this was much easier for the endovascular colleagues to take care of it, so sometimes we can join hands to have a good outcome. This is a more recent patient, last year, and this is a 62-year-old gentleman who presented to us with sudden onset of headache and vomiting in September, presented to another center in 2019 with sudden onset of headache and vomiting, vision going down on the right eye, movements of the right eye gone down, sensation on the right side, fifth nerve involvement, and this was a giant, actually, highly thrombosed, cavernous carotid aneurysm, huge one, actually. This is the aneurysm, so they put the first flow diverter in October 2019, and fortunately, couple of months down the line, the vision kept going down on the right eye and started reducing the vision on the left eye, and he ultimately became blind on the right eye, the vision was going on the left eye, so they put another flow diverter in February 2020, and again, unfortunately, two months after that, the patient became blind on both eyes, and you can see the huge mass effect this aneurysm is producing. The aneurysm is actually very well taken care of, there's very little small circulating component, but by this time, one year down the line, after two flow diverters, the patient became blind on both eyes, and he presented to us last year with blind in both eyes and started having epistaxis. He presented to actually another endovascular for a second opinion, and you can see the cross-circulation was very poor, so they could not ligate, they could not sacrifice the artery, and they could not do anything more, so they sent to us, the patient had already were uptended by that time, huge mass effect, and headaches, and epistaxis, but they're worried about the patient may bleed to death, and that is when we did a high flow bypass again, and ligated the carotid in the neck, and subsequently, the epistaxis stopped, but he subsequently developed hydrocephalus, for which we did a shunt, and now he's actually much better, of course he remains blind. This we published last year in a case lesson. Now I think the complications of flow diverters are underreported, very, very underreported, because in my practice, I get a lot of patients who come for a second opinion after treatment, and I think this is a very appropriate indication, because I think this is standard of care, at least in North America, for an unruptured large ophthalmic aneurysm, the standard of care today in many centers across the world is a flow diverter, and that was done in this particular patient, and you can see good, the aneurysm is taken care of, unfortunately, three months down the line, he started progressive visual compromise, which was not responding to steroids, and that's what, when he presented to us, this is yet another patient, ACOM aneurysms only coils, no flow diverters, but again, he developed bitemporal hemianopia, which was not there preoperatively, a pre-endovascular treatment, so this is yet another patient, okay, can you go back one slide, or can't, okay, right, all right, and you see, he also had a large aneurysm, and presented with headache and diplopia, but then subsequently went on to a multiple flow diverter, and became final, was hemiplegic, bed-bound, so this is, these are three patients over a period of six months, we see, so I think there is problem of under-reporting. So if we see a patient like this, this four-centimeter unruptured aneurysm in a lady, with a visual compromise, we would advise microsurgical decompression, and we did a bypass to reduce the risk of ischemia during the temporary occlusion, and we took care of this. This is a child, we see, heavily thrombosed, 12 years back, presented to us, two-and-a-half-year-old child, altered sensorium, hydrocephalus, we did a shunt, the child became asymptomatic, we sent to our endovascular colleague, it was 12, 13 years back, as you can imagine, there was, this is the technology available there, they put 17 coils, the aneurysm was taken care of, unfortunately the child very rapidly deteriorated, in two days he started extending, went on to ventilator, the shunt was working, so we had to go in and do a skull-based approach, decompress the aneurysm, I don't have time to show the video, and we decompressed the aneurysm, clipped it, and five years, he was going to school, he had ocular motility, 11 years down the line, he had a mild hemiparesis, the aneurysm was taken care of, he was fully functional. Three minutes. Okay. So if you see a patient like this, this is an adult patient, similar aneurysm, so this is what we do, we would advise, especially with a mass effect, and I think this is sometimes surprisingly easy, this was a skull-based approach, exactly the same like the last child I showed you, Aussie approach, extradural anteroclanectomy, intradural posterior clanelectomy, and we did not have to open the aneurysm, because the neck was completely free of thrombus, there was thrombus above it, so we could clip it with two multi-curved, very large clips, titanium clips, and took care of the aneurysm, and I just want to show that this is the PCA, the branch is okay, so now this is the immediate post-op CT angio, but these are complex aneurysm, so the multi-clips always need to have a DSA, and this is the DSA, and the patient is playing cricket, which is a very popular game in our country, in one of the state now. So I think old-fashioned clipping is still, there is a place, so flow diverter is a good thing, but it doesn't take care of everything. I think the complications are under-reported, so we need to individualize, I think it's microsurgery to my mind, going to stay, and again, repeat, for your own health, do microsurgery, not endovascular, to avoid radiation exposure. Lastly, my last slide, I invite you to Jaipur, the pink city of India, it's a beautiful place, come with your family, this is September, I think September 2 and 3, and contact me, or go to the website, this International Anioma Society meeting. Thank you very much for your attention. No, Basant, you have your other talk. The third one, yeah. Yeah, so I stayed within my time for a change? You did, yeah, I'm very surprised. Very unusual for me, very, very unusual, I was so scared. Anyway, so I'll just give you, Jack asked me to talk a little bit about the WFNS Foundation, there are males flying around everywhere, and we think that there is nothing happening in WFNS, but really, honestly, there's a lot of things happening, and the foundation is the arm which takes care of a lot of young people, and especially in LMIC, and I'll give you just some idea for gentlemen or ladies who are here, who probably do not know much more about this foundation. So this is the new executive body, which was formed in November 7, 2021, this is WFNS president, we all know, Nelson Weisoku, professor, and this is the executive body, ex-officio members, secretary, which Professor Akio Morita is here, Professor Nasser from Egypt, he's not here, but he's the treasurer, so these are the ex-officio members, and these are the other members, I happen to be the chairman, and Gail Russo, Jesus Lafiente, and Mahmoud Qureshi from Kenya. He's from Spain, he's from our own country here. So the WFNS Foundation promotes the worldwide development of neurosurgery, mainly concerning basic neurosurgical issues and focusing on developing countries. The educating next generation is our focus, the worldwide development of neurosurgery, we have full training centers, which scholars are supported by a scholarship amount by the WFNS Foundation, and there are about 24, there were 24 postgraduate education centers for young neurosurgeons, where the centers take care of the young neurosurgeons with support, the WFNS does not pay for them, and then we also provide high-quality, low-cost instruments sets to people in LMIC young neurosurgeons. This was our vision when we took over, and in discussion with our president. This is the support the foundation does currently, the Rabat Training Centers in Morocco, there are five African young neurosurgeons that are supported, each with $500 per month, and this is in Kenya, and the five from local region, Zimbabwe Center 2, and Senegal 1. So these are the young neurosurgeons who are supported by the foundation scholarship, $500 per month. And these are the other full programs training centers, which the centers take care of the young neurosurgeons, the foundation doesn't pay for them, and this is the new one we started in Pakistan, this is mainly to help the Afghanistan young neurosurgeons. And they also take care of the, we don't have to pay for them. So, but we have problem because we don't know what is the quality sometimes, we don't know what is the quality of training there, who are training them, how much exposure they have. And the major, major, major problem today is funding, because the funding is just dried down in the last four years. And we need to know why are we really making a difference by training these young neurosurgeons. What are they doing when they go out to the society, are they contributing enough? We have, in the last one year, I have taken care of 300 plus applications. There were 700 applications for young neurosurgeons who want to have short-term fellowship for gentlemen and ladies. You can do it. They just need some support, maybe for boarding and lodging, even if you don't have to pay. There are many, many young neurosurgeons who want to come and visit you. So, please do help us with that. We need more. And we have discussed with our friends. And we have 17 more centers we are adding on for these young neurosurgeons for short-term fellowship, where the institute has to take care of that, usually for three to six months, at least the boarding and lodging, if nothing more. And these are the new centers, all centers of excellence in their own countries and training centers. We have four short-period training centers, and these are Italy, Pakistan, I think Salman's center here, the France and the UAE. We have, over the period of time, total 241 medical sets have been delivered. But honestly, this is a huge, huge problem, because you just don't have the finance to deliver anymore. We just have last one year we have delivered one, and we're going to deliver two more in the last one year, because the funds have just dried up. So, we need to appeal to all, be conglomerate to support it, but appeal to all neurosurgeons, even $500, $1,000, $5,000, that will make a huge, huge difference. So, please do try to do that. And you can have an international symposium and then contribute some money to the foundation or meetings. The advocacy, Professor Gail Russo is doing a great job with the G4 Alliance, and that is bearing fruit. As you can see, a WHO video on folate fortification to prevent spina bifida has become a reality now. We have some proposal to incentivize the people who donate. Maybe they can be called as ambassadors of WFNS. I think they can be maybe felicitated at the World Congress. I see the Congress president here, Professor Graham, maybe he could help us with that. And we could acknowledge the donors who are donating to the foundation in the website, or e-blast to the EC members that this gentleman or lady has donated to the foundation. We can have more partners to help us with that. We have had a voluntary neurosurgeons committee who are contributing both in person and virtually, and their second opinion on queries from young neurosurgeons, especially LMICs. We started a mentors program. Mentors, his or her views and memories. And these were some of the – this is Professor Spetzler, Professor Kobayashi, Professor Heros, and Professor Graham Teasdale. These were the mentors, and their memories and their views. Young neurosurgeons really enjoyed it. Professor Sami, this is Professor Banerjee from my country. This is Professor Andrew K., and Andrew S., and Andrew Grotenhuis. So we had a little more, a few more. So we also had some master symposium. We had some young neurosurgeons webinar. We have many education courses, both, which is initiated by us. And these were the ones which we initiated. The August 6th, we contributed $10,000 to the foundation from a virtual webinar by the sponsors. And then this is the Titopedia in Columbia. He's doing it where he's 100 – he's promised to support 100 residents. And so please write to him. This will be in August 2023. This will be a virtual meeting, but the young neurosurgeons will be supported. In person, we did in Agra. We are going to do it in Agra, just next week. We go back and have the meeting there, and we expect at least to contribute another $10,000 to the foundation. These are the ones which is planned, one in Kathmandu, one in Calcutta, and one in Dhaka this year. The humanitarian response, we are trying to support the Ukraine and Afghanistan. This is the Harvard group is supporting them. And please do contact me, and we'll be very happy to support it, but it has to go through the foundation. There's been some confusion for direct communication, but if you want the foundation to be involved, it has to be through the foundation. And I appeal to all members, societies, to please contribute. The one-year progress report, we have one new full training center, 17 new postgraduate training centers, G4 Alliance is doing a great job. We have the new initiatives. These are the efforts which we have done. We are trying to have some international symposium. Please indicate interest if you can, do it and contribute some funds to the foundation. I really appreciate the Hong Kong Neurosurgical Society. After my appeal, they were the first society to contribute as a society, contribute some funds to the foundation. As I said, we contributed 10,000. Please communicate with us if you have any comments, interact, criticize, but do join us in our effort to help young, especially young neurosurgeons in the LMICs. As I said, these young neurosurgeons do help, and they want to come and see you. So please, if I can do it in a developing country, I'm sure many of you can do much better than that. These are some of the few fellows who have visited my department, and they are so grateful, they are so happy after they go back, even with three months. This is a beautiful letter from Amzad from Iraq. This was about five years back. They were with us. And right now in my department, this is April 18th, a few days back, a couple of days back, we just took a photograph just to show you that we have one lady, one man from Tanzania, a gentleman from Vienna, and this is from India, who are with us as young fellows, which are partially supporting. Again, I end with the invitation to the International Men and Women's Society meeting. Thank you very much for your attention. Thank you. Anybody has any comments before we go to the break? Moyamoya disease is defined as a clinical condition that the patient has an idiopathic progressive steno-occlusive disease of supra-cranial ICA. Clinically, pediatric patients always present with ischemia in their early life. In adult cases, the presentation could be ischemic or hemorrhage. Re-vascularization surgery, either by direct vascular anastomosis or indirect synangiosis to augment cerebral blood flow at areas of hyperperfusion, has been proven to be an effective management of Moyamoya disease. For direct re-vascularization, various anastomosis methods can be applied to increase the perfusion at the three major vascular territories of the cerebrum. For indirect re-vascularization, tissue with high vascularity, such as pericranium, outer layer of dura or muscle, can be used to create a close contact to the peer surface of the brain to develop synangiosis. To ensure that the best re-vascularization can be achieved, a combination of direct and indirect re-vascularization may apply. So this is a summary of the advantages and disadvantages of these two types of re-vascularization surgery. With a larger vessel caliber in adults, possibility of undertaking vascular anastomosis is higher. Therefore, direct re-vascularization is always a treatment of choice for adult Moyamoya. On the contrary, it is generally believed that younger patients have higher angiogenesis ability so that successful rate of indirect re-vascularization is higher in pediatric patients. So this is our way of performing indirect surgery. We isolated the superficial temporal artery, and then we bivalved the temporal latis muscle to allow the vessel to have a close contact on the PS surface after the dura opening. We refer the dura inward, and this is a procedure we call dura pepsi. And then we also use one bivalve of the muscle to cause a dura, so that means we perform EDAS, EMS, and dura pepsi on the same time. So for the pediatric patient, we always do this, and this is a result of one of our patient. For a very small child, we also perform multiple burr holes, and you can see the very good effect from those burr holes. Now we shift it into a small craniotomy because the contact of the pedicranium and dura will be more if you create a small craniotomy, and this is a result in the PDS patient. Again, in adults, we always perform bypass surgery in our group. And there are some risks of the ECIC bypass. One is a prolonged ischemic time during anastomosis that will create ischemia. The other one is a stenosis, or even occlusion at the anastomotic side. Then the treatment became in effect, and sometimes will be harmful to the patient because of the occurrence of ischemia. During the surgery, you may make damage to the collator from a major artery, and which is another risk of the bypass surgery. So in order to minimize ischemic time and to create a successful rate, we refine our technique for vascular anastomosis. After two anchoring stitches at both ends of the anastomotic side, we suture the vascular wall in a running fashion with very small loops, like this. And then this running suture is converted into interrupted suture by progressive pulling, tiling, and cutting of the suture material, as you have seen here. So this technique has three advantages. Number one, it's easier to maintain an even bite and gap on each stitch. Second, easier to visualize the inner lumen of the vessel at the last stage of the anastomosis. So you can prevent the heating of the optic wall to create stenosis of anastomosis. Third, it may shorten the anastomotic time from avoiding frequent changing of microsurgical instrument. Therefore, the patented rate will be higher, and the ischemic time will be shorter. Usually, we can perform an anastomosis in 10 minutes, within 10 minutes of suture. So since indirect revascularization has low risk and easier to be performed by neurosurgeon without training in microanastomosis, so this question has always been asked. Are indirect revascularization procedure in adult more and more patient as effective as in pediatric more and more patients? So there are several publications in recent years. So this paper from China shows that the result is controversial. And the other study from Gary Greenberg's group shows that direct revascularization procedure is superior to indirect revascularization. There are two meta-analyses published a few years ago. This one showing that there's no significant difference between these two type of surgical modality. But in adult patient, indirect revascularization is superior to direct revascularization. However, another paper from Korea showing that there's no significant difference. So there's no definite conclusion. In order to understand this situation, we have in our institution, we have two group of neurosurgeon treating more and more disease. A pediatric neurosurgeon, Dr. Guo, she's using indirect revascularization to treat more and more patient, even in adults. And I myself, as a vascular surgeon, I'm doing vascular anastomosis. So therefore, we collect these two cohort of patients and to compare the efficacy and the treatment results in our institution. So all the patient underwent the same institutional protocol. So the patient has a pre-op and post-op angiography and also the MR-provisioned study. And we use a surrogate station to define the severity of the more and more disease. We use Matsushima's grading system to define the result of the anastomosis or endosyne angiosis. So in a group of 22 patients, we operate on 38 hemisphere treating with bypass surgery. And this group of patients is a little bit older age, about seven, eight years older than the other group of patients. The severity is similar. And most of the patients has only STMCA bypass. In addition to the STMCA bypass, 11 patients has EMS and duroplasty. In the indirect group, the patient is a little bit younger age and female predominant. Severity is similar. And we perform various indirect revascularization procedure to this group of patients. So this is the surgical modality we use in this group of patients receiving indirect revascularization. So routinely we perform a duroplasty. In 19 hemisphere, we have EDAS plus encephalopiocine angiosis. So we use a pericranium to put it into the atomic site like this. And we have some technical refinement of this indirect meso. So we only perform revascularization procedure to the area with hypoperfusion. And over the temporal region, we use EDAS or EMS. For the other region, we use the EPS. And during craniotomy, we pay special attention not to injure the middle major artery. And this is our result in adult patient. So we evaluate all the patient with Madrashima grading with angiography. And in indirect revascularization group, we have 90% with a good perfusion after the surgery. In indirect group, we have 95% of patient with an improvement of the perfusion. So there's no statistical difference between these two groups in terms of the postoperative Madrashima grading. And we also measure the blood flow with MR perfusion. And we measure time-to-peak prolongation index. So this index was proved to be corresponding with clinical outcome in more and more disease. And it's inversely related to CBF. So a decrease in the time-to-peak prolongation index for more than 10% after surgery indicates there's an improvement of perfusion. So this is one of our patients. This patient is our worst adult patient receiving indirect revascularization procedure. So after the surgery, the prolongation index decreased to 20% from initially was 40%. So the patient has a very good improvement. So all the patient in 28th hemisphere, 90% of the patient receiving indirect revascularization has an improvement. For the direct group, 97% of the patient, except one, only one hemisphere has no improvement. So this is a comparison of these two groups' perfusion. And there's no statistical difference between these two groups as well. We have four complications in direct group. Two patient has a post-op, a small stroke like this. And two patient has pneumocephalus because we perform a small craniotomy. And this is a complication. We have this type of complication in two patients. So the complication rate is 13.3%. In direct group, we have 5.3% complication rate. One patient developed ischemia because we injured the middle major artery. The other patient developed hyperperfusion and resulted in intracerebral hemorrhage. So we did various type of anastomosis. The patency rate is 97.5%. The long-term outcome, three patient presenting with CUM is a better outcome. Patient presenting with cerebral ischemia has no new attack in the direct group. Two patient with IVH did not have any more hemorrhage. Only one patient with cognitive function declined, improved after four years, and then declined again. So this is a modified Rankine score for the patient. Then compared with the patient receiving direct revascularization, we have two patient developed TIA after the surgery, and one patient developed hemorrhage again. So the recurrent rate is 7.8%. So compared with this, this is the patient with hyperperfusion and ICH. So the conclusion is that these two group of patient from our data shows no significant difference. So indirect revascularization procedure may be as effective as direct revascularization, and probably safer because the complication rate is lower in adult patient. Immunomediator is a very important source of indirect revascularization. Stereoplepsy is mandatory in every craniotomy window, and the using of TTP mapping is a very reliable investigation for this cerebral perfusion. So I'm going to conclude my talk here. The last slide is showing that this is the Asian Australasian meeting we are going to organize in the next year. This is a counterpart of this meeting in Asia. So everybody is welcome to attend our meeting. Thank you. The next speaker is Dr. Hoheb Mira. He's going to give a talk about extradural mini pre-temporal approach of a complex vascular and skull-based lesions. Working, no? Now it's working, yeah, okay. Thank you very much for the invitation. No philosophy. This, for me, is very important because I wait for this for 23 years. The first time I knew Jacques, 1999, and he made me a very strong impression. And for me, I'm very proud to be here talking in front of him. He's one of my mentors. I always follow him. And for me, I'm very proud, really. And I never put nervous in operating room, but I'm nervous now because I'm talking in front of him. We can fix it. You can sit down. No, no, no, no. No, I'm not so much nervous. And this is my conflict of interest. I always hope to have more, but unfortunately, I only have one. And I always be very grateful with Dr. Evandro. I spent with him in 1999, 1998. And this slide I put because you can have things in your mind and you have a huge confusion. This is the confusion in my mind. And what you need for the confusion, you need to be with young people. The fellows and the residents are the best to arrange the things. I always ask them to arrange for me the things. And you see the previous slide is my philosophy in the military approach. And Ramon is my fellow. He's finished two years ago. He arranged for me this and put the levels because for me, the teaching is very important. For me, it's not what can I do as a surgeon. It's what can the young New Returnees can do with the things that I talk. We finally can publish this in 2021 with other of my fellows who work in the United States. It's Rafael Martinez from Spain. This is a video. I'm not going to show you this video because we don't have time. I can share with any one of you all the presentation I have. Please, if you want the presentation, I can give you. This case only we did because we proved that a third nerve can be improved if you have a cavernous sinus meningioma. Because to me, everybody said to me, if you have a third nerve, you cannot improve. And the cavernous sinus surgery is very dangerous because the people is going to be worse with the cranial nerve deficits. It's still today. And for me, it's not like that. You can improve the patients. You can do a very good surgery. And for that, you need two things. Microsurgery and neuroanatomy. I'm sorry to repeat what all the people said, but it's very important. You cannot change anything if you don't know the classic. You need to be a master in the classic in order to change anything. If you are not master in the classic, you can do nothing. I make classic surgery for 15 years. The surgery that I learned with Dr. Evandro. And I was very lucky because I knew Akira Hakuba in 1998 in Brazil. And he published all of this. The extradural and anterior clinoidectomy that I like most. I do subdural, I do combined, but I like most the extradural because with the extradural, I can do a keyhole approach. With the other ones, it's very difficult because you need to open the sylvian fissure and expose and you need more space, okay? But you need to know the cavernous sinus anatomy. The best way to learn this kind of surgery is with paraclinal aneurysms. The paraclinal are the most simple. It's not good to say simple. It's the less complex surgery in the clinoid region. The meningiomas are more difficult. But the paraclinal aneurysms, if not a giant or I don't know, fusiform, are not so complex, okay? I know it's controversial what I'm saying, but I teach my fellows first with paraclinal aneurysms, after with meningiomas, after with sphenopetroclinal meningiomas. And then we have a good experience in this. Now we have 439 aneurysms of this kind. And then we change the philosophy that I learned with Dr. Evandro, the Dolenz approach or Jacob approach. Whoever you follow, you can name after them. I made for 15 years, but we changed in 2015 because I knew the instrumentation. The instrumentation is very important. You can not do surgery if you don't have a suction irrigation, a low-profile instruments, a low-profile clips, okay? I agree with the surgeons, the classic surgeons, who said, you know, this surgery is very dangerous because I cannot put the applier properly for aneurysm. I agree. What you need to do is change the applier. Develop a single-shaft applier, flexible applier, rotatable applier, okay? I love the supraorbital from Yuha, but I like most the miniterional because in a skull-based surgery, when you open the frontal sinus, it's a very rare problem when you have a patient with a mucosal. It's going to follow you for all your life. You need to operate one, two, three times and record and record, and it's terrible. And then the miniterional is defined for the superior temporal line. If you have the superior temporal line, you never open the frontal sinus. You need to be with young people. They arrange the things for you, and you need to follow your heroes. This is Dr. Natal from Mexico. He described the first version of the miniterional. After that, a doctor from Brazil, Eberwal Gadelia, described the miniterional with Dr. Spitzler, 2007. It's nothing new. I only copy the people, but what I can tell you, you need to know who copy. It's very important. You need to pick very nicely your heroes, okay? If you follow the wrong people, you're not going to make it. And then it's very important, why? Because Eberwal trained with Dr. Evandro, and Dr. Evandro loved the interfacial variation of the Yasakil approach. And for me, it's very important, the interfacial dissection, because you can reach more the clinoid, and then you can do better, for example, middle fossa peeling or whatever you need for this kind of surgery. And then I always record to anatomy to explain the things. If you think in terional, terional is not a balanced approach because you have two thirds frontal, one third temporal. But the mini terional, you have half frontal, half temporal, because the sphenoid reach is in the middle. And when you follow the sphenoid reach, you get the anterior clinoid. When you follow the anterior clinoid, you can cut the meningo orbital band, you can do the middle fossa peeling, you can take out the posterior clinoid, the kawase triangle, you can do everything. And then it's very important because the anatomy never lies, okay? And then we came with this word that is the key exposure concept. What is that? The classic from Jasser-Hill is big approach because you need light inside, like Kuching, for example. When you came with a microscope or endoscope like Perneski, you don't need a big opening because you can do endoscopy, okay? And then what Dr. Levandos said to me, if you have a low-lying basilar tip aneurysm, even if you do the huge front orbital psychomatic approach and you don't take out the posterior clinoid, you cannot clip. And that concept is very important for this kind of surgery. You need to expose the bottom, but you don't need to open wide outside. You need only to see and have a proper light. If you use an endoscope, it's much better. This, my fellow did this much better than me. You know, the extradural corridor is the key, okay? And then you need to go to dissect, to the laboratory. I have a fellow from Dr. Roton, Tomas Poblete. He made this dissection, and he proved that this is good. We published this. We made a keyhole version, decompression of the optic nerve. We can clip paraclinoid. We can take minijomas. After that, we came with extradural miniterional, okay? You can do paraclinoid. You can do minijomas. But we follow and further. We go to the mini-pretemporal. Why I put mini-pretemporal? Because Dr. Levandos described the mini-pretemporal approach in 1995. After his name, I put this miniterional variation. We published this in 2020. I go fast because we don't have time, and Jack always cuts me when I go more than... I pass the time, and he's very severe with me. Not without people, but with me, it's terrible. And then, remember, the instrumentation. The instrumentation is the key. You need to develop instruments. You need to design kerosene, design rangers, everything. Design suction irrigation like this one from Peter Lasik, because I love suction irrigation from the endoscopy. And then I want everybody use it, only Japanese use it. And then we develop these rangers, especially to take out with no drill, denteroclinoid. This is brand new. And then for what is this? Because everybody said okay keyhole is for simple things. I don't agree with that. You can do keyhole or less invasive surgery with complex lesions. Yeah and then this is a controversial of course, but the sphenoperitoclimate, the worst tumors, only 18 publications. The the biggest series, Kawasi published 10 cases in 1991, Kawasi. And then the series is very small. These terrible tumors, we can do for a miniterional. Because we use the extradural corridor. This is a miniterional. No sigoma, no orbital rim, nothing. Because we use the extradural corridor. This is the superficial sylvian vein that I cut. We take the esophytic portion. After that we release the optic, the carotid, the third, the fourth nerve. What's the difference with the with anybody else? I don't know. I love to do the dissection from the cavernous sinus to the cistern. Because I use the kamiyama scissor. The kamiyama scissor is curved in the side. It's different from all the rest of the scissors available. Okay now the lead from loton is similar. But in the time when I when I start with this, this is the only kamiyama we have. And then we can take this this kind of tumor. You see, not all the tumor. I take the tumor up to the monitoring and start to set the facial nervous suffering. And I go for retro sigmoid approach. Simple retro sigmoid approach. Sitting, semi sitting position if you want. If you want prone as well. And then you take all the tumor and you can get this kind of result. And then I said all the time, I can be a liar. I say I'll tell you all lies. But I only I only ask you to believe you to your eyes. Because I show you a video. I show you a patient. Okay. And then this is possible. I'm not saying this is easy. But it's possible. And then the extradural pre-temporal approach is a reality. And we published this. And these dissections are from Argentinian guy Maxi Nunez. Only to show you that it's possible to dissect. This is a miniterional. And this is the view that we can have for extradural route. You can get this in patient of course. You use lumbar drain. You open the cisterns. And you can you can see this. And we when we put the endoscope. You can see all the posterior fossa. We already operate in the posterior fossa using the cavernous sinus as the corridor. The surgical corridor. It's very very interesting point of view. Because I am NOT endoscopy guy. But I'm learning endoscopy. In order to do this kind of surgery. And then you can get all of this in patients. And this is a discussion that is up to date. 2022. Not only meningiomas for this kind of surgery. You can operate everything. Vascular, tumors, epidermocysts, whatever you want. But you must learn anatomy. Because the anatomy is the key. You need to take out the dura. You need to preserve the cavernous sinus. Nothing new. This is Ali Christ. This is Professor Johannes Niemi. Jack Morkos, Shekhar. Everybody said this before me. Okay. I'm not saying nothing new. Only a less invasive alternative that you can do. And then what's the difference with the classic cavernous sinus transcavernous approach that everybody told. The classic one is for the roof of the cavernous sinus. You release the third, the fourth, sometimes the fifth. But if you go for the lateral side, you release everything. And you don't have any bone. You only have the temporal, the tentorium. Nothing else. And it's much easier to operate from the side. Okay. How much time I have? Two minutes. Okay. And then cutting the meningoal vital band is not dangerous. It's almost impossible to have retinal irrigation from the, from the middle meningial artery for the people who said so. And then Dolan, Haku, Vacavaz, everybody talked about this before. And the mini-pretemporal approach is a reality. And you can take all these huge tumors because you use the cavernous sinus, as Ali Krish said, as a route, not as a final destination. Okay. And then you operate the geminal schwannoma. We don't have time for this. I'll show you anyone that want the videos I can give. You can operate chordomas, for example, and you can see the VB junction, the anterior spinal artery, the carotid artery. This is a reality. It's a patient. Okay. Look at this. You can all the tumor. Epidermolysis, the same. And of course, you can, you can as well treat vascular pathology, for example, dissecting superior cerebral artery aneurysm. And then you go for the middle fossa and do the same surgery, release the nerves, preserve the nerves, isolate the aneurysm. And then you can clip with a, with a proper low profile clip, take out the lesion and preserve all the anatomy. This is without open any cistern, just using the dura as the cover of the brain. And you can get good results. And again, you need young people to arrange the things properly. And we're going to publish this month in the, in the master series of neurosurgery, the MIPLATA approach with two videos. And thank you very much for your attention. Thank you, Jorge. Your passion comes through and I'm sure you will infect the young people with it, which is a good thing. Unfortunately, Jean de Oliveira is stuck in midair, so I will try to accommodate his talk later. Are there any questions for Professor Tu or Professor Moura before we hand over to the next session? Hi, I'm Nimsiz Ghali from Chicago. I have a question about the indirect vascularization. Professor Tu, come over just for a quick. Thank you for your, thank you for your talk. Do you know how soon the vascularization occurs in the indirect vascularization? And in my times, we used to use, it was Dr. Osman, the omentum. Are you using any of those? Are you using the omentum? Omentum? No, we never use omentum. It's so difficult to pass omentum from abdomen to, to the, to the brain. So you need to make a very long tunnel. I think it's too aggressive. And how soon the revascularization occurs after indirect revascularization? So for direct, you'll have an immediate revascularization. What about for indirect? How soon does, do you see? Well, there's, usually we follow the angiogram after three months of the surgery. But in one patient, we perform it in one month, four weeks later, the patient has a very, very good collateral from that indirect procedure. So I don't, I don't have the answer for you, but I think that will not take very long. Just few weeks, the patient can develop. But I'm talking about the condition in pediatric patient. For adults, maybe take a much longer time. Ian Ross, I'm from Southern California. I have a question also about indirect revascularization. You described dural inversion. Can you explain that in a little more detail what you do exactly? Because dural has two layers. The outer layer is very rich in vascularity. The inner layer has no vascularity. That's why we want the outer layer to have close contact with the peer. That's why we invert the dural after we cut it. Yeah, just like this. Question here. So it seems the equal long-term outcome between indirect and adult. So how do you choose in your practice that certain patient, from get-go, go in for the indirect? For myself, I think I prefer to use anastomosis bypass, because the patient can be protected immediately after the surgery. For indirect procedure, you need to wait for at least a few weeks, as I mentioned. So if the patient has a very frequent attack of TIAs, I think direct surgery would be much better. I just want to comment about the omentum thing, which was actually done in late 1960s in my country from Bellore by a professor in the chair. And the professor, they tried to do ischemia for cerebral ischemia, the omentum transposition. So it's a very old thing, but it never took off because of the difficulty of, as you said, of this thing, transferring the time taken to do that. The procedure became very much a problem. Yankuan, if I can add, I only use exclusively direct in adults. I agree in pediatrics, there is no controversy. Good work from Peter Vascozzi in Berlin, and it's my experience. I just published 162 cases. It's so unpredictable which adult an indirect procedure will give them enough flow. Peter has some nice work on it. I actually had to do two cases that had had indirect, got no revascularization. They stroked, I had to do direct on and somebody else had done indirect. So, I mean, I wish it worked on all adults, but I don't know how to differentiate or predict who it will work on. That's, that's a problem. Well, when we are talking about adult patient, I think there's a very wide spectrum of age. If you are talking about a patient with age of 60, it should be different from the patient with age of 20. So this group of the patient I presented, they are much younger compared with the other group. They are at the age of 20, 30 years old. The other group is about 40 years old. So that may make a major difference. Yeah, I think you're right. We'd love to keep talking, but thank you for our speakers. And we want, did you say something? Good question. So one of the arguments from other surgeons about you said many opening is that will happen in CV cases that have a hemorrhage, premature hemorrhage in aneurysms. In tumors, a large, very large tumor with pressure, how do you access to the tumor? So that's the argument. What can I tell you? I did the classic for 15 years. And now, for example, we review the last seven years, we only use the general in five cases, really huge things. MCA six centimeters or whatever is impossible. Of course, we are talking about a skull base and vascular pathology. If you have a glioma or meningioma in the convexity, you're going to do the surgery with the size of the lesion, of course. Okay. But I, if you use the extradular corridor, you don't need to expose much brain. You see, you use the tumor and the extradular route to expose the lesion. Okay. We don't have time to show here the surgery, but this is the typical concern that everybody have. And of course, my advice for the young guys is you need to be first for the classic route. And after that, you can, you can start to do this a smaller and a smaller surgery. Why? It's not for a, it's not for a, for a style, you know, it's not to be, I don't know, a fancy thing. It's because the patient complain and they ask in Chile, for example, how big is the incision? I will have atrophy of the, of the temporal muscle. Why I cannot do much better in the vascular? Why can I do a radiosurgery? You know, I have this kind of discussion with the patients and the patients, they ask for results and then you need to offer better results. If you can do a less invasive approach that offer the same results, you must do this. You need to train, but you can do this. Thank you very much. We hand over to Kenan and Dr. Asher is a little late, but he will come and co-moderate with Kenan. Thank you for our speakers. Well, good morning again. We'll move on. Again, I'm Kenan Arnautovic. I'm from Memphis, Tennessee and we will start our subs, subspecialty session on, on brain tumors and I'm honored to present Dr. Kate Drummond. Dr. Drummond is coming from Australia. She has many hats. She's a president of Asian, Australasian Neurosurgical Society, second vice president of WFNS and to list all her accomplishments and accolades, it probably take the rest of the day, but she'll, she'll have two presentations today. She'll talk about technology enhanced brain tumor survivorship and just to follow global neurosurgery, its meaning, current state and implication for our future. So please, Kate. Thanks for the introduction. I'm very sorry that for your sins, you have to listen to me two talks in a row. Feel free to get up, move around, have a cup of coffee. So my first talk's about some digital solution that we have for brain tumor survivorship, which, okay, how am I gonna, maybe down here, that, that we have developed at Royal Melbourne Hospital in partnership with some of our local hospitals. I've got no disclosures for this. I think it's really important to think about our patients with their quality of life after surgeries. We see a lot of beautiful surgery in these talks, but we don't really think about what, what's the patient like in 6, 12, 18 months. And, you know, we, to do that, we need to understand what it is to be healthy. The WHO definition of health is, of course, it's not just going straight ahead for me. What am I doing wrong? Okay. WHO definition of health, a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity. Who in the room here is completely healthy today? Nobody. Everyone's got a headache, a hangnail, a cold, feel a bit anxious about your talk, something else. So, so we're all not healthy. But, you know, this idea of quality of life has become an important end point of health, of good health, of quality of life in our brain tumor surgery. Now, of course, quality of life is related to a lot of things, tumor factors, treatment factors, patient factors, and it's really become an important end point in many trials, whether it be chemotherapy trials, whether it be comparing a couple of different types of treatment. So we really need to, to be thinking about quality of life in our patients. And so here we've got an end point in, you know, a chemotherapy trial for low grade glioma, an end point comparing different surgical strategies, and an end point, perhaps for different, different ways of managing vestibular schwannoma. So it's become an important end point that we really need to, really need to be thinking about with these three factors. But what is health related quality of life? The really important thing is it's self assessed. So it's not what we think. And we often think we've got a pretty low bar for quality of life. Oh, goodness, the patient can walk and talk and they can hear. So clearly they have excellent quality of life. That's not actually, not actually true. But it encompasses physical, emotional and social components of quality of life and illness and its treatment. So I've been studying this for a while. We've got a database of over 1000 patients who, who with meningioma, acoustic neuroma and low grade glioma. And the questions that we've asked over eight years now, is in post operative patients. So it's all an operative series. What are the determinants of impaired health related quality of life? What are their longitudinal changes in health related quality of life? Does it get better? Does it get worse? And what interventions could improve it? And I'm looking at actionable determinants. I'm not interested in whether left sided or right sided or, you know, old or young people have better or worse quality of life because I can't change that. What can I actually change? And we've found some really interesting determinants. We found that poor global health related quality of life is very much related to your subjective cognition, how you feel your brain is working, not how your brain's actually working, but how you feel your brain is working. And many of our patients feel that their brain is not working that well after the operations that we do, even when we test objectively, and it's not too bad. The poor global health related quality of life is particularly related to unemployment. Do we ever look at that as neurosurgeons? The inability to drive, being single, having seizures, being female, having younger, being younger for your social quality of life and older for your physical quality of life and using anti-epileptics. And your subjective cognition is related to these things, communication, fatigue, future uncertainty, which is basically anxiety about the tumor coming back, motor deficit, pain, headache, visual disturbance, sleep disturbance, radiotherapy, seizures and anti-epileptic use. The ones in red are the ones that realistically we might be able to influence for our patients. I didn't put single there because I'm not going to start a dating agency, a marriage agency in my clinic, but everything else we could realistically help our patients with. So we've studied this and we've looked at our patients long-term. So this is for low-grade glioma. You can see on this graph the light grey is what a normal European population would say their health related quality of life is for global. Do we have a pointer? No, not really. So from furthest across, global, role, emotional, cognitive, social and physical quality of life. So the light grey is what a normal European population says, so not a hundred percent, but the black is for the low-grade glioma patients. So obviously quality of life reduced in all domains. All of them are statistically significant, but the ones that are clinically important are the ones with the two asterisks. So they're decreased enough that the patients feel that they notice a difference. And this is over quite some time and you'll find out, you'll be able to see, that actually these impairments sustained over a hundred and twenty months. So over many years our patients feel that their cognitive function, their social function, it's all deteriorated. It doesn't get better, it stays the same. Now you might think that's not too exciting, that's not too, we can understand that for low-grade glioma. It's a pretty bad disease. The results are the same for meningioma and most of the patients in this group have surgically, what we would consider to be surgically cured meningiomas. They have, they feel that their cognitive function is reduced and they have prolonged deficits of a subjective feeling of reduced cognitive function, of fatigue, of sleep disturbance. And then you think, well at least the acoustic neuromas, they must be cured because we're all fantastic skull based surgeons, right? They must be fixed. Vestibular schwannoma patients all felt that they had, you know, reductions in their cognitive function for up to a hundred and twenty months in their social function and bad fatigue. So clearly there's a problem that perhaps we're not dealing with. So I thought, well maybe we'll just sort of start a bit of a support group for these patients. You know, they need some supportive care, we'll get some social workers in, we'll get the physios in, we'll get everyone in. Actually that kind of doesn't work. The patients can't all get there, you know, it's very difficult to have in a small, a country like Australia, big distances, small population, you know, you know it doesn't work if you've got a glioblastoma patient and an acoustic neuroma patient in the same support group, they're a completely different group. So we thought, well this is not going to work. So we thought maybe something online, maybe a technology solution would be able to help the supportive care of our patients. So this is Heidi McAlpine, PhD student of mine and also neurosurgery trainee. And so we thought, well maybe we'll just have a go with this online thing, but we'd better do a bit of a literature search first, which we had a look at. Then we'll survey our patients and we'll see what they want and then we'll develop this special online thing that we're going to develop. So the literature search was really interesting. So we looked for all of the online interventions that had been made to improve supportive care or quality of life of patients, not with just brain tumours, with cancer in general, because there was not one for brain tumours. So we found hundreds of them and usually it was like, we built this beautiful website. And then we evaluated it by asking everyone, did they like it, and they said yes, which isn't really an evaluation. Of all of the ones that we saw and we found published, only 13 had actually been rigorously evaluated with a control group, a before or after, some sort of measurement of quality of life. And of those 13, most didn't make any difference, and one was actively harmful. The patients were worse after using the online intervention. So we thought, okay, maybe we need to do maybe a little bit more research. So we looked at our own patients and said, well, what would you like in some sort of an online intervention? 200 patients in the waiting room of my brain tumour clinic on an iPad answering questions. And they said this, they'd like to control the amount and type of information others know about them when they're online, that makes sense. It's interesting, they wanted to know everything about everyone else, but they didn't want anyone to know anything about them. They wanted to use it any time or location, which is great, because we've got patients who live, you know, nine hours from our hospital. Oh, great, thank you. They wanted to be able to use it as a guide or filter for useful information, because there's a lot of stuff there on the internet telling you that, you know, special mushrooms are going to cure your brain tumour. So they wanted a guide to filter that information. They wanted a health professional to contribute and moderate. And they really wanted to be able to share their experiences and know that they were not alone and that what they were experiencing was what everyone else experienced. So from those things, we got a $2.6 million grant from our government to build a co-designed, that means basically designed by our patients. So they've come up with the name, they've come up with the format, they've come up with the colours, they've gone through the whole thing. And we've come up with something that's a brain cancer online survivorship platform. And it's for patients' carers, the most underserved group in our brain tumour clinic, so carers and clinicians. And really it has the idea that they can connect with their treating team, that they have peer support and that they can manage these symptoms, fatigue, sleep, et cetera, using the platform. So it's through this process of co-design, which I've had to learn a lot about, but we're in the middle of this at the moment. Two Bulls is a digital production company, so we've got industry partner, we've got clinicians, we've got patients, and we've got a continuous circle of refinement until we're right here now at the integrated platform, which is just enrolling 200 patients for a two-year evaluation period to actually see if it makes a difference. And this is important, this evaluation, because we know in drug development, we know that we need to go through this process, phase one, blah, blah, blah, blah, blah, blah, to get down. But for something that's digital or something that's any other sort of intervention, we've got a black box as to whether this actually makes a difference and whether it helps our patients. So I think this will be important for that. And so we've got the platform. It looks a bit like this. It has three pillars. It has a learn pillar. The learn pillar is curated information. It's not going on the internet and typing in glioblastoma and finding that a special copper bracelet's going to cure it. You can type in your age, your tumour type, where you live, you know, all sorts of things to be able to get curated and guided information for your tumour type in your situation. The other one's community. So we have a number of moderated online groups with healthcare professional moderating, so that if you're a 35-year-old woman with children and a low-grade glioma, you can connect with other people in your situation. And if you're a 65-year-old person who's just retired and found that you've got a glioblastoma, you can connect with people who are in your situation. And so we can build that across the vast distances of Australia and yet connect people online. But also make sure that it's safe, that we don't have crazy people coming in trying to sell their special treatment. And so it's very highly moderated. And we're learning something about how to build these communities and to keep them going so they're useful. And then the last one is the toolbox. We decided to only put two things in the toolbox to start with so that we could see if it really made a difference. The first is a cognitive behavioural program for managing sleep disturbance that patients can do at their own stage over a couple of months. And the second is a carer training program for how to manage your relative with a brain tumour. So then we will evaluate those. So I hope that in about six months we'll have the early information about our first evaluation. And we're not going to keep any proprietary stuff over this. I hope that we'll be able to make it available for people to modify for their own circumstances and use for the future. So thank you. And for my next trick. So this is probably a talk that might even get me into trouble because there's a lot of talk about global neurosurgery over the next few days. And quite often as surgeons, of course, we make that about teaching a procedure, which I'm not sure is exactly what global neurosurgery should be about. So I thought that I would give a little bit of my perspective on that. I have a massive conflict of interest because I'm the chair of a group called Pangea Global Health Education. It's not a neurosurgical group. It's a multidisciplinary surgical and critical care education group. So sorry, that's my massive conflict. And my disclaimer is I am not criticising any person, one person's program, this, that or anything else. So I got interested in global health a long time ago. You'll be very pleased to see me here in 1986 in Bangalore in my very culturally sensitive T-shirt with an Australian beer logo on it, where I went as a medical student and I had a great time. I learnt a lot and I learnt very much very quickly that if you're not qualified to do something in your own country, you shouldn't go to another country to do the same thing. And very generously, it was supported by the people who I worked with there, but I don't think that really I made any difference other than made some friends. I've done a lot of work in other places. This is another part of India, right up northeast in Nagaland. And I did this hump and depressed skull fracture, obviously, and realised later that I had used up all of the mini plates that that hospital could have had for the next however many years trying to put this whole thing together, and felt very embarrassed that I'd been sort of so ridiculous in the way that I'd done it, so learning a lot of things. And then I got involved in the predecessor of my current organisation, they used to be called Specialists Without Borders. This was Rwanda in 2010 and we went and did a lecture series. And I sort of afterwards, and having thought about it on multiple times since, I think here we are with my terrible Australian English accent that even some of you guys don't understand in a French speaking country, talking very quickly in the way that I normally do, and a whole bunch of other Australians giving a talk often on topics that are not even relevant in this situation, because we go and give our famous professor talk. And so just thinking exactly how sort of that wasn't that useful, but I did learn some things there that small group teaching is incredibly useful, where people can really interact and where it's a two way street. But I learnt some other things that are really, I've learnt a lot of things in various places in Africa that are not great about our global neurosurgery. One of them is doing procedures that create a disabled person, and this little girl with her tracheostomy had to live in the grounds of the hospital, because there was of course no tracheostomy care, so that meant her mother had to live in the grounds of the hospital as well, which really disadvantaged the whole family. And then this, the place where donated equipment goes to die, because we all love to donate equipment, but we think nothing about the maintenance, whether it will even work in that institution, whether there's even lightning shielding in that institution for very sensitive electrical equipment, whether there's a place to put it, someone to look after it. And I spend a lot of time in Malawi, this is the great biomedical engineering department in Lelongwe Hospital in Malawi, and realistically they would love to be able to have all of this equipment working, but the resources are just not there. So why should we have global neurosurgery? Well, you know, it's about an accident of birth. So this is Pangaea, that's why we call Pangaea the original continent, and let's see, is this going to work? I hope so. So this original continent, Miami, Jacques, and Freetown in Sierra Leone were right next to each other, continents split. So by an accident of whether you're on one side of the divide or another, if you're in Miami you get to live there and you get healthcare that looks like that, and if you're in Freetown you live here and you get healthcare that looks like that. So our aim really should be to be moving that closer together. So how have we looked at it? We've looked at it in small groups, case-based, practical skills, relevant and flexible, and we've also looked at it particularly as multidisciplinary, and this is something that we often miss in global neurosurgery. We don't think about nursing staff, we don't think about first responders, we don't think about infrastructure, we don't think about whether what we're doing is going to fit within the structure that's there and whether the support staff are there. And so I really think, you know, our program involves a big nursing program, it's our most popular program in fact is the nursing program, but I think if we're going to think about global neurosurgery we really need to be thinking about the whole package that makes what we do work to make it work elsewhere. Things I've learned from doing all of this is that surgical aid is often more about the person delivering than the person receiving. You know, lots of people, great cases, great adventure, feel great after doing all this great work, but not often evaluated for value or for what it leaves behind. But also we have a – surgeons have a real way of wanting to make the world better one patient at a time. We really have a contract between us and the patient. But often this patient centred approach which we so value in high income countries is actually not so useful and does little to improve medical care for the whole population and it may actually be harmful at times because we get so hell bent on the single patient without seeing the big picture. So how do we do global neurosurgery well? Well the programs need to be designed around the trainees, not the trainers. Doesn't matter what your specialty is, going over to give you a very important professor talk and teaching a very important professor procedure may not be what's needed and you may need to – I mostly teach trauma in Africa. It's about much more than a procedure. We can't just concentrate on that. A needs assessment needs to become before anything and relationships and partnerships are critical. Going once is not going to teach you how to do it well. You need a long term investment in an area. Infrastructure and workforce are most important. There must be capacity building and there must be a culture of mutual learning and continuous feedback and we need to avoid racist stereotypes of rich people from the west coming in and helping people in low and middle income countries and if you've not gone on YouTube and looked at the Médecins Sans Frontières ad about avoiding racist stereotypes, it's a real investment I think in watching for you to just go on and have a look. So we need to do this well in a situation where, you know, this is outpatients, this is ED and this is the operating room. We need to know how to get the great health professionals because as we've heard earlier, the people who work there are fantastic. It's just the infrastructure they have. We need to make sure that the aid that we're giving is useful in their situation. As I said, partnerships are critical and the only reason that I'm in the countries that I am is because we've been invited and we have contacts that give us long term feedback about what we're doing. Godfrey Maguti in Zimbabwe and Nieng'o Mkandawai in the long way. We need to make sure that we're leaving capacity behind and, you know, we're very pleased that this year we had our own Malawian teachers in our group and we'll have more next year so that eventually we don't have to teach our program anymore. We can go somewhere else because the Malawians will be teaching it themselves. And I think in the end, my message is education should be the primary focus of global neurosurgery. It reduces ethical conflicts, it avoids local disempowerment, which I think is really important that people shouldn't be waiting for the group from somewhere else to come and do something. It should be locally empowering. It reduces inappropriate treatment of individuals. It reduces wasteful efforts because we understand what's happening and we can use our aid appropriately. It can promote a local culture, local culture-driven healthcare and it's about more than a procedure. Thank you very much. Thank you very much, Kate, for leading this beautiful effort and teaching us what global neurosurgery should look like and opening our eyes to, hey, and opening our eyes regarding discrepancies in treatment in our profession in the world. Before we move, I think we have a few minutes, just if anybody wants to make any comments on global neurosurgery part of your talk, we'll talk about tumors a little bit later in the discussion. Dr. Ramses. Yeah. So, this topic that we started in the morning by the World Federation and all of that, I'm very passionate into this and here is the issue. You teach, but actually the people you teach, they're actually abusing their own people because in order for the people that you taught to do something, they ask for money from the public. Now, the model of in the past when Britain came to Egypt and occupied Egypt, they did a few things very good. They built a university medical. They actually built a hospital, it's called American Hospital, in Cairo, Egypt, and I got sick and I went and was for free. I hear a lot of talks about teaching, about this, about this. The bottom line is probably 95% of the injured people in each country, they're not getting treatment. So, the question is for the Australian help, for the World Federation help, have you actually built the hospital to actually care for the people, not to teach the people to be teachers and then not serving their own people? Thank you very much, Ramses. I would like just to recognize Dr. Professor Anthony Asher, president elect still or still elect for another day and he's our new president of AANS. Do you want Tony to make a comment? I don't know that I have a specific comment for that. Obviously, the needs are so great and I will tell you that this particular area is outside of my expertise, that is to say, those global economic considerations and so I'll defer to the experts in the room. Dr. Misra. Yeah, Kate, very, very nice talks, very, very impressive data. Is there a difference in the quality of life parameters in different countries? Have you gone to that, you know, country where the expectations are different than the country where the expectations, for example, in America, with the expectation, the outcome and the patient becomes happy is probably completely different than a guy in, for example, in my country. So, Basant, I'll direct you to my latest publication in PLOS One where we've got an Indian cohort of meningiomas compared to an Australian cohort of meningiomas with Dilip Sandika, which we actually had the same, we had the same data set which we compared and there are differences. Indian people are much more robust than Australians in terms of their return to global health-related quality of life, but they complain of more physical symptoms for the first year. Some of the interesting things that really came out of it was, of course, the different funding of the health systems. In India, if you, you know, complain of a symptom or whatever, someone might order a test and that probably costs you some money. In Australia, it doesn't cost you anything, I mean, you can have as many tests as you like because it's all government healthcare. So there's probably some differences in that as well. So I think, I think the basic tenets are the same, but actually there are some very important local differences. Hi, I'm Jeff Clown, I'm from UAB in Birmingham, Alabama, but my comment comes from my context as the co-chair of education committee for the ISP and the International Society of Pediatric Neurosurgery. Kate's talk focused on really two things. One was partnerships and the other is education. And I think we all agree those are absolutely central to this. With regard to partnerships, I just wanted to give a brief shout out to the notion of inter-surgeon as a very useful tool. I hope everybody in the audience has heard that term. Inter-surgeon is, the shortest description is it's like a dating service. Kate doesn't run one through her clinic, so the ISPN will take it on. It's basically like a dating service for places that have a need for a Western partnership and Western partnerships that want to partner. I'll leave it at that. Look it up. Inter-surgeon, it's a supportive thing by the ISPN. And the second is to just make the point that when one looks at LMICs, the average age of people in those societies is much younger. So there is a very disproportionate burden of care for young people and certain diagnoses really percolate to the top. Trauma, dis-raphism, things of this nature really occupy a very high percent. And ISPN is very grateful to WFNS for the partnership and is very, very dedicated to trying to provide meaningful educational experiences for those partnerships. And the second part of my comment is to draw your attention to the series of webinars that are done monthly between the ISPN, again very searchable, Google it, International Society. There's a monthly webinar and there's a quarterly Clash of the Titan, which is just a discussion about controversial topics. So thank you for those comments. I think partnerships and education are the key and ISPN really values the partnership with WFNS to try and help move this needle. Thank you very much. This great conversation illustrates the passion that the American Association of Neurosurgery has for global neurosurgery and partnering with its sisters associations, continental associations around the world. I will move on with announcements now. It's time for our next speaker. This is Professor Antonio Aversa de Souto. He's coming from beautiful Rio de Janeiro, Brazil. He will talk to us about a micro neurosurgical keyhole approach to invasive lesions of anterior fossa and tell why all endoscopic neurosurgeons are wrong for doing their approaches. Thank you, Professor Notovitch and Professor Malkus for inviting me to be here. It's a great honor to be here again in the BNS. Congratulations, Professor Dumont, for your outstanding work. And I'm going to share with you our experience in this approach that is very few now for the neurosurgeons is the subcranial approach for the anterior fossil lesions. As you know, most of the benign tumors, they are the most options for those kind of lesions. And for malignant tumors, the craniofacial approach was used very frequently in the past. And now it's moving to the endoscope. So our experience started more than 25 years ago for dealing with tumors like this. It's a huge stesileoblastoma. We use it to do a mid-facial translocation and then treat with radical resection those lesions. And we could realize doing this approach that we don't need a regular craniotomy for achieving a total resection of large tumors in the anterior fossa when you go through the frontal and ethmoid of sinus. So this is reconstruction. This is the facial reconstruction also. And with a very good long-term result in terms of oncology, you see many years later with cure of the patient. But the problem is the facial scars from malignant tumors. So we start to do this. We change our mind and start to do this subcranial approach that we can have almost the same exposure without a facial scar with that keyhole craniotomy through the frontal sinus and ethmoid with the osteotomy of the frontal and nasal bone. So we are used to perform the osteotomy just above the ligament, canthal ligaments. And then we can expose it as in this beautiful work of Professor Otto of the nasal cavity and the ethmoid anterior fossa, both orbited sphenoid sinus, even the nasopharynx through this way. So we are used to do a bicolonal incision with the pericranial flap. And with transillumination, we can see the boundaries of the frontal sinus and then making the osteotomy with reciprocity in sole. And then this is the nasal bone. It's a keyhole, a small craniotomy, but it's enough space that you need. So after stripping the mucosa and drilling the posterior frontal sinus, we can coagulate the ethmoidal arteries, cutting the olfactory grooves, and then dealing with the nasal portion of the tumors, as you see. So we can take from above, we can reach the whole nasal cavity. It can make sometimes a total resection in a single block. And then with the endoscopy is very useful in this approach also, because we can do a resection, a video assistant. So taking the tumors and taking the infiltration of the nasal septum, you can reach the whole nasal cavity through this approach. And then open the dura, like getting this cytosinus, cutting the falx. We can approach the even larger tumors, because you create the space. Then we can push the tumor downwardly, so we can dissect without any kind of retraction of the frontal lobes. So you have space, then you can do a subarachnoid dissection, arachnoid plane dissection. This is the big cavity, cutting the dura infiltrator of the anterior fossa. This is planus sphenoidali, taking the tumor, infiltrating the planus sphenoidali, so we can achieve a total resection. And this is the big difference between the endoscopy. We can close very well at the end with watertight sutures of the anterior fossa, even if you have only a small part of the dura in the planus sphenoidal. So this is video assistance. Another case of stesionearblastoma, that we can resect the tumor in one olfactory groove and preserve the other side, because it was not infiltrated. This is with video assistance. We are cutting through the frontal sinus from above and assisting from below. This is the gap in the dura. So this is another case, a small stesionearblastoma with post-op. This is another case. This was a doctor with this neuroendocrine carcinoma with infiltrator of anterior fossa. This is how we perform the approach, the bicoronal flap, and preserving the pericoronal flap and detaching the supraorbital nerves with the chisels. And then we can also perform the osteotomy using the bone scapel. And it's a very useful machine that we can do this. It heats a little bit, but we can irrigate a lot. Then it's very safe, very easy. It's much easier to do this kind of approach than a large bifrontal craniotomy that I'm not using anymore for any kind of tumors. So we drill the posterior wall of the frontal sinus, and then we have, this is enough space that we need for dealing with any kind of anterior fossa tumors, taking the crystal guide from outside, extradurally. Then after taking the tumor from the nasal cavity, we open the dura, like get the sinus. And you see, it's almost the same direction that you have when you go through endoscope. You came from below for dealing with the kind of, with these tumors in this subcranial approach. So cutting the folks and taking all the infiltrated dura in the brain around, taking the dura almost in the planus senoidale, and then using the temporal fascia, we are going to perform a closure of this anterior defect in the dura of the anterior fossa in a watertight way, very different from the endoscope that we can do with endoscope. So, and then we can put also the vascularized flap for reinforcing the closure. We have a very, very low CSF leak, as I'm gonna show you. Next one. So this is pre and post, pre and post MRI with the PET. And this is another case, the largest is in the blastomas, the same. This was probably diagnosed as carcinoma, but was a lymphoma, the same. We can achieve with a very good cosmetic result. This is a recurrent tumor, adenocarcinoma. We prefer to do this in block resection of the ethmoid, and then reconstruction. There is no pericranial from here, then we pericranial in the temporal muscle, and opening a small window for performing the reconstruction of the anterior fossa. This is another case. Even larger tumors like this, with infiltrating of the nasal skeletal and nasal bone, we can perform a harvesting bone from the parietal bone for reconstructing the nasal bone, and then we can perform a total resection of this kind of tumors. This is another stesoneural, large one, as you can see, with a very good cosmetic result. This is an interesting case, it's an olfactory shivanoma, very, very rare, that we can do in the same way without any kind of retraction of the frontal lobes. And then I start to do this more than 10 years ago for the olfactory groove meningiomas. Why not to do the same? As you know, many of those olfactory groove meningiomas do infiltrate the ethmoid, so we can perform a larger resection, and more effective in terms of long-term results. So we started with smaller ones, and then moved it to infiltrative cases like this one. This is a perfect case for this kind of approach, with a huge infiltration of the ethmoid bone, and then even larger tumors with calcification, we can do the same with this small, and a keyhole craniotomy. This is another case, and translumination foreseeing the boundaries of the frontal sinus, performing the stripping of the mucosa, drilling the posterior wall, and you can finish and fix the bone, even in poor countries, we can fix this only with the nylon sutures, and with a very good cosmetic result. And this is the biggest difference, we don't have any kind of retraction of the frontal bones. You are dealing with the kind of tumors that we are operating a convex meningioma. And this is the last case I'm gonna share with you. This was a previous radiated gentleman, which was treated in the childhood of a retinoblastoma, and was lost his vision of the right side. He was losing the vision now in the left side, because of this huge radio-induced meningioma, that was invaded the ethmoid and orbit. And then, this is a perfect case for doing this approach, drilling the posterior wall of the frontal sinus, this infiltration of the ethmoid, infiltration of crystal galley. We take first the tumor outside, and another cavity in an ethmoid, creating space. And then, we are going to open the dura, and resect the tumors in a piecemeal way. And we devascularize the tumor, coagulating the ethmoidal arteries. So, you see there is no blooding, during the resection of this kind of tumor, when you do in this way. So, this is using the KUSA, internal decompression. You see, it is like you are operating in a convex meningioma, when you do this way. And you don't need to take the whole orbital rings, because you don't, you need only the medial orbital rings. So, pushing the tumor downwardly, and dissecting the arachnoidal plane, as you can see from the frontal lobes, with any kind of retraction of the frontal lobes. This, as you can see, and taking the lamina papyrus infiltrated, this is left orbit. And the biggest difference, as I showed you, is after that, we can perform a watertight closure of the dura. So, this is pre and post, without any retraction of the frontal lobes, more than six years following this patient, without recovery. Those are my numbers. I have been in this, with this approach, about 73 cases in more than 15 years. I have complications, I had three CSF leaks, all of those cases was preoperative irradiated, this is a dangerous situation. And we had a partial reabsorption of the bone flap, associated also with irradiation, in two telecantals. If you cannot be able to fix the cantal ligaments, you can have this kind of fixed problem. We have two mortalities, with clinical problems associated with this patient. So, in summary, I think this is the biggest advantage of the subcranial approach. We can take the advantages of the craniotomies, large exposures of any kind of tumor of the anterior fossa, possibility of infection preservation, watertight reconstruction, pericranial flaps, and subcranial approach you can take all of these advantages, and the advantages also of endoscopy, with inferior angle of view, no frontal lobes retraction, but with a very, very few risk of CSF leak. So, in summary, it allows a more inferior approach, with a more favorable angle, it allows a wide exposure of parenthesal sizes and nasocavity, and a broad exposure with watertight reconstruction, and we don't need any more facial skin incisions, in many cases, in many malignant cases. So, thank you very much for your attention. Thank you very much, Antonio. I think we have a couple of minutes for comments. I would like to ask you, would tuberculum salaminae-jeoma be a limitation for your approach? Would you change your approach, or it would still stay within this subfrontal? Actually, I love this kind of approach, but I think most of the tuberculum salaminae-jeomas, you do better when you do laterally, with Therion or COZ, because of the, Therion or COZ, because of the relations with the anterior cerebral artery complex. So, I'm using to do this only to the planus phenoidal meningiomas, but tuberculum salaminae, I prefer to go laterally. I think Basant has a comment. Yeah, it was a very nice demonstration. I just have one question and comment about this extensive STCO neuroblastoma, which you showed, and doing both the nasal part and the transcranial extension at the same setting, would it be safer to do in two stages so that the risk of CSF leak is less? Yeah, I don't have this kind of experience. I think it's not a so long procedure, and we minimize the opening of the dura when you do first the nasal cavity, and then we open the dura for as small a time as possible so as you can minimize the contamination, because it's a very contaminated surgery with this malignancy. You see mucopiocelles in the frontal sinus, but I'm used to doing the single, in a single way. Thank you very much. Our next speaker is Dr. Touré, who will be talking to us about management of midbrain gliomas. Please show. Thank you very much. It's a great honor for me to be part of this special symposium, and I thank the organizing committee for the kind invitation. May I have my slides? Yes. Yes. So my talk is the microsurgical resection of midbrain gliomas. I would like to share my experience with large series of midbrain gliomas. So how can I forward from here? How can I go? Next slide. No? Yeah, okay. So the midbrain, or mesencephalon, is the rostral portion of the brainstem and located between the pons and the deencephalon, and there are several nuclei and the major pathways in midbrain. I'm not going to repeat this complex anatomy. Very small area, but very important structures are there. Why I talk about only midbrain gliomas? First of all, generally the topic is brainstem surgery. Brainstem surgery is too much. First of all, we have to separate gliomas with cavernomas. They are totally different story. And then about the gliomas, also we have to separate midbrain, pons, and medulloblongata. They are different structures. And also tumor types are different. Midbrain gliomas, mostly low-grade tumors. Pontine gliomas, mostly malignant tumors. And medulloblongata, mostly low-grade also. So I like to separate them and I like to have my experience with the midbrain and then pons and medulloblongata is coming. I have enough cases to discuss, I think. Okay, in every case, we perform preoperative and three months later, postoperative fiber tractography. We saw the medial lemniscus in every case and we demonstrate the corticospinal tract in every case before surgery and also superior cerebellar peduncle in every case. And then this information give me idea to choosing my approach. And then three months later, I see my results. So finally, in my series, I use seven different approaches for midbrain gliomas. And I like to put one sample of each of them because we have very limited time and how I choose the approach. First case, four years old boy, one year history of progressive left-sided hemiparesis. Please note that left is left in my MRI. So, where is this tumor? First, I have to understand which part of the midbrain. It's crucerebri, tegmentum, periaqueductal or tectal. So this looks like a crucerebri tumor to me. But we have to be careful, it's interesting. Bricollo doesn't have crucerebri tumor and Yaşargil doesn't have crucerebri tumor. It is interesting. And when we perform this tractography, shows that the crucerebri moved laterally. So, and then, in our surgical approach, but tumor came to the anterior. This is, in my opinion, transilvian approach. It's the most suitable approach. And this is postoperative MRI. And in the intraoperative findings and postoperative MRI and postoperative tractography, that this tumor was originating from tegmentum, not from crucerebri. So tegmentum tumor opened the fibers and came to the surface. And so we were able to remove this tumor. And this is postoperative picture. His third nerve is also intact. Another case. Pure aqueductal tumor. Well circumscribed pure aqueductal tumor. This is different. This is not periaqueductal tumor. This is well circumscribed pure aqueductal tumor. And mostly you can perform third ventriculostomy. Patient has a hydrocephalus. But if you look at it, there is a hydrocephalus. And if you come from this direction, foramenol monro is open. Why not remove it through the extreme anterior transcallozal approach? If you get correct angle through the foramenol monro without cutting any foramenol monro structures, you can reach there. And this was the postoperative. So I came from here and through the foramenol monro and removed the pylostic astrocytoma. We published this technique. I have now six cases. Pure, well circumscribed aqueductal tumor. They are all low grade. And it's well removed. And with very small callosal incision. This is less invasive than endoscope. I know endoscope. I use endoscope. And it was pylostic. It was the second approach. What about this one? This is tectal glioma. Patient against children. So tectal glioma. How can I approach this case? You can use supracerebellar approach. But it's going down. It's difficult to get from supracerebellar. For me, from here is the best. And superior cerebellar peduncle is put anteriorly. In any case, all of my cases, paramedial tractus is intact. Preoperatively. And superior cerebellar peduncle was intact. Tumor never invade superior cerebellar peduncle or paramedial tractus. And so for me, posterior interhemispheric, transcentorial approach is suitable for this case. And I use in pronoblic position. I don't see the pointer. Oh, sorry. They don't see it. Use this on the screen. So I use this position. I prefer lateral position. But because of the interoperative MRI, I use pronoblic position. and this is intraoperative MRI. It's very useful. I routinely use intraoperative MRI. So I came from here to cut the tentorium and remove the tactile tumor. And this is three months post-operative MRI and using posterior intramuscular trans-tentorial approach and you see superior cerebellar peduncle is intact. It was intact before surgery, it's always intact before surgery and it should be intact after surgery. It was pilostigastrocytoma. Another case, again, pediatric case. This is, where is the location? This is tegmentum tumor. Most of the cases, tegmentum tumor. This is four years old boy, right-sided tegmentum tumor. How we can approach? Let's look to tractography. You see, sensory and motor fiber separated by tumor and lateral is free. So for me, this case is very suitable case for paramedium supracerebellar trans-tentorial approach. I prefer this approach in semi-sitting position. I love it. But now, because of the intraoperative MRI, I use in chronoblick position. And this is postoperative MRI. Tegmentum tumor, I go through the tumor when the tumor came to the surface. Otherwise, the lateral mesencephalic sulcus is not safe. So that safe entry zone is a little exaggerated. There is no safe entry zone in brainstem. So we have to follow the tumor or lesion. And this was after surgery. And this was sensory and motor fibers after surgery. It was pilostic astrocytoma again. What about this case? This is 11 years old, and she had a shunt surgery in another institution. So she had hydrocephalus, sure. This is tactile glioma. But we have to be careful. Tactile gliomas mostly arise from one colliculus. Left superior colliculus or right inferior colliculus. So it's very rarely took entire. So this is left colliculus. So left inferior colliculus, I can tell. So in this case, you can use supracerebellar approach. Even you can use posterior intermyspheric. But in this case, again, superior cerebellar peduncle, not invaded, pushed by the tumor before surgery. So perimedian supracerebellar infratentorial. Why I call it perimedian? It's not midline. Incision is midline. But I go a little lateral in semi-sitting position. 20 degree is enough. But of course, you have to have trans-oesophageal Doppler. And this is the craniotomy. I never go through midline because of the veins. All veins are here, so I have to preserve the veins. Another trick is the very steep angle of the tentorium, especially in Turkish population. So I have to go a little lateral. So and then preserve all this tentorial bridging vein. I am crazy with tentorial bridging vein. And we are going to publish some trick to preserve them. I preserve all of them. So this is beauty of semi-sitting position. You see, this is tumor here. And this is the one tentorial bridging vein. And tumor is here. And this is after resection of the tumor. And after resection, again, you can see that this tumor was, you see, left-sided inferior colliculus tumor. It's from one corner. So it was pylostic astrocytoma again. A little more complicated case. Again, four years old, three times operated in another institution. Right-sided third nerve palsy, left-sided hemiparesis. I don't know how can I approach this. I have to see the tractography, can give some idea. And you see, I cannot come from lateral. A paramedian supracerebellar is not suitable. I cannot come from transsylvia because there are intact midbrain tissue. I cannot come from supracerebellar. And because also there is a tumor in almost in the fourth ventricle. So this is the only case. I did contralateral paramedian supracerebellar. This is the only case I use this approach for this case. And this is the, you see, same craniotomy, but I have to go other colliculus, other direction to have better angle to see because I have to go to anterior. I have to see the basilar from here. So because tumor was in the surface here. So this is intraoperative endoscopy. So tumor was in the surface here. So I come from here and I go inside of the midbrain and this is basilar tip. This is superior cerebellar artery. I left a little piece of tumor because I had to increase the power of the acusa and then I can get the perforator. So I left a little piece in the tip of the basilar artery. And this is, you see, my angle was this one and I left a little tumor here, but otherwise I had excellent view of a whole cavity and I had to remove the inferior part also. So this was pilostic astrocytoma also and sensory and motor fibers after surgery. It's better. So this is early postoperative and then later on her third nerve is also improved. It was pilostic astrocytoma. That tumor I am just following, it doesn't grow. I operated 13 years ago in this case. Last case, this is again well circumscribed aqueduct tumor, but it's in the inferior part. So to come from here is too much. So come from here, because it's in the inferior part of the aqueduct. If it's in the inferior part of aqueduct, I go through the transovulotonsillary fissure approach described by Yashargil and go through from here to here and remove the pilostic astrocytoma and solve the hydrocephalus problem. So diffuse periaqueductal tumor. It's another entity. Many times it can confuse with tactile tumor with diffuse periaqueductal tumor. Diffuse periaqueductal tumor is another entity. They are mostly benign and I just performed third ventriculostomy. But one case, diffuse periaqueductal tumor start to grow and start to have a contrast enhancement, I operated. But generally, I just performed third ventriculostomy. Am I operating every case? No, there are some cases the tumor is everywhere. If the tumor is midbrain, pons and go up, I don't touch it. This is not my surgical cases and I am not sure that I can help them. Now 300 cases, brainstem surgery in my series. And midbrain glioma, 57. And half of, most of them pediatric cases, fortunately, and they all love great tumors. No case with cerebral peduncle. Somehow it doesn't exist, but if the tumor is everywhere, it's in the cerebral peduncle also, but not surgical case. Tegmentum and central mesencephalic structures and tectum, so most of them tectum tumor and then tegmentum and then central mesencephalic. And 54 cases, surgical cases. These are the cases, I used seven approaches. And then these are the histopathology. I have some high-grade tumors. I have glioblastoma even. And mostly pylostic astrocytoma. And mostly macroscopic total resection. And important, hydrocephalus is the critical issue before surgery and after surgery also. In 74 patients, percent patient had the hydrocephalus when the tumor came out. But 12 of them was treated in another institution. They put a shunt or ventricular drainage. Anyway, but my philosophy, I don't do third ventriculostomy or shunt. I just go directly to tumor. When I remove the tumor, in most of the cases, there were no need for any other. Only two cases I had to operate third ventriculostomy in early postoperative period. Because third ventriculostomy or shunt is another risk, another complication. And then, so no mortality. One patient, I have major surgical morbidity because of bilateral pericardial infarction. I don't know the reason. I don't have time to tell about this. This case really disturbed me. And then one patient slightly worse, three months following surgery. But most of them, same or better than preoperative period. Four patient dies in the follow-up period. They are globulastoma and high-grade tumor. So micro neurosurgical removal of the midbrain glomas is feasible with good resection and clinical results. To be honest with you, my glomas series, I have better result than cavernomas. Glomas are very nice to remove. But of course, we have to understand first the origin of the tumor. This is the most important point and then choose the correct approach. Of course, this is not my work alone. I am working with great team and Professor Yashargil is with us. And I thank you so much for your attention. And I look forward to see you in Istanbul in Roton Society meeting in end of August. Thank you for your attention. Thank you. Professor, you're a genius, but we're not geniuses as you are, so two questions. Sorry, sorry. I am an average person. I am not smart, I am not stupid. I am not stupid, but I am not very smart. Because where I am, nobody touches these things. So two things. First, you depend a lot on the fiber tracks. Do you actually depend also on the neuro-monitoring, especially in the SSAP and motor tracks? And the second, when you go there, do you really see a good capsule or some sort of something tell you you're in a tumor, you're in a brain? What is it, other than the fiber track? First of all, I use routinely monitoring, but to be honest with you, monitoring doesn't help me. Subcortical stimulation, sometimes it's working, sometimes not working, I cannot trust. But if the monitoring people say that in the post-operative MEP is intact, I feel okay. But if they say that MEP is not working well, forget it. We will see one hour later when the patient wakes up. So monitoring is okay. I routinely use it, but it doesn't change my strategy or it doesn't change my surgery. But if they say that the patient is doing well, I feel better. That's the point. It's important, very important that I feel better. Most of the cases, pilostic astrocytomas, they are very nice tumors. You can differentiate them. Diffuse astrocytoma is more difficult. And now I routinely use intraoperative MRI. And my neuroradiologist is very picky. Always he saw something in the intraoperative MRI and I have to look again. But it's not the critical issue. In the first part of my surgeries, I didn't have intraoperative MRI. I had intraoperative MRI six years ago, I got it. So you don't use the LAA injection of something that lights up the tumor under the microscope? Okay. LAA, I am one of the first ones in the world to use it. And I stopped it. I didn't understand anything. And now the patient's asking me, do you have LAA? Yes, I have LAA. If you want, I can, but it's not my choice. Professor, fantastic lecture as always. Two questions. Well, firstly, similar comment on 5-ALA, you know, especially in deep, dark holes. You can see nothing. Almost invisible. Lots of imagination and hand waving. You can see a lot, but otherwise I can't see anything. So where do you see a value to combining laser ablation with resection in some of these cases? So, for example, if the angle is very steep from a given approach, do you think there's value in resecting as much as you can and then doing an ablation with LIT for the remainder? I don't have experience with laser ablation. I follow the literature. Even I have a comment for one paper. I look forward to see them. Not one, two cases. I have to see. And I have to see long term follow up. I have 15 years follow up of these cases. All right, everybody, we're going to get started. My name is Nathan Tandon and I'm moderating this session. Our first speaker is Fernando Castro Prado, who's from, I guess, what I could just mostly loosely translate as the Specialty Hospital of Central Mexico. Yes. And he's going to speak to us about an update in SDN and GPI targeting for DBS. Thank you. Thank you, Dr. Tandon. Thank you for the opportunity to present our experience in Mexico City. I came from the biggest hospital in Mexico City that has the most robust program of functional neurosurgery. We do like almost 100 DBS a year. Then we are going to present you about a bit of our experience. How do I project? It's not. Click on 730. OK, and then find your name here. Start. Start. And you should be ready to go. All right, just give it a couple of seconds. It'll go up. Thank you. OK, thank you. I divided my talking in these points, then I am going to start with the introduction and saying that in a placement of the DBS electrode is a surgical procedure that is surgically demanding and it requires a high quality surgery. Nowadays, for example, there is a tendency to do a sleep DBS surgery. Then goes the presumption that the functional neurosurgeon can identify in the MRI the ideal area or as we call the sweet spot where to place the electrode. Then the targeting must be perfect, right? There is a few scales that measure a DBS surgery. One of the most common use is this TAUS, the DBS surgery scale. It goes from 0 to 100 and 60 points are related to the error between targeting and the actual placement of the electrode. Then we can say that the most important part of this is how we place the electrode, the accuracy of our technique. Then targeting is really important. In the past, I had the... so lucky to see this still in the 40s, almost 50s. They used to do x-ray, neumo, encephalography in order to place the electrodes. After that it came the atlases, like the most common ones we use, Schaltebrand, Warren and Tallerach. In the 60s, the microelectrode recording introduced by Fessar and Giot helped us to localize better the nucleus that we are going to stimulate. In the 70s, when it came the tomography and MRI, it gave us a big advantage in order to see some structures. But still, some nucleus are still hard to see as we are going to see in the next parts of my lecture. And in the 80s, the surgical planning was based in softwares. The ones of the first were the metronic frame link that we used in the past. We have more than that actually. Then I'm going to talk to you about how we do nowadays the targeting. We can divide the type of targeting in indirect, direct and other techniques. I'm going to describe everything in detail for you. In the indirect targeting, we use the coordinates that we study in the laboratory and in the atlases. This is actually extracted from the manual of neurosurgery of Dr. Michael Schroeder. This also we can have it preloaded in all the softwares for planning in metronics in brain lab also. This is known for every function of neurosurgery. Another type of planning is integrated in the atlases. This also came available in every software that we use for planning. You see here, we are planning and we superimpose the atlases that was of this type. We can measure or have an idea how is the nucleus and what the structures are around it. Nowadays, they are doing strategies for improving the atlas patient registration. Doing with automated algorithms. In this case, we can customize the nucleus and the atlases for the patient. There is this article where they show the differences in using this type of algorithms. Another way of doing the planning is also using internal institutions. For example, there is one described by the group of Toronto. Where they use the red nucleus in order to plan the targeting of STN. They found out that usually the sweet spot of the STN is 3 mm lateral to the border. The same distance of the anterior border and 2 mm in depth of the superior part of the red nucleus. This is also helpful, especially when you don't use the MRI that can actually see the STN perfectly. You can use also for the GPI, there is another solution. This is called the PUT based method. It is using the PUTAMIN. Where the sweet spot is supposed to be localized in the intersection of two planes. The plane A is going to pass for the top of the PUTAMIN. the plane B is dividing the Putamen in thirds and in the union of the posterior third and the middle third that's the plane and it's supposed to be there, the sweet spot. Then this is another indirect method. But nowadays as the imaging progress and is developed already we can see actually the nucleus. For example, we see the STN like a hypointensity in T2 because the presence of iron is what we are seeing. But we need to consider that most of the posterior third of the STN is not visible because there is no presence of iron there. Then it's illogical to think that some sequence that we are going to see the iron perfectly we are going to see better the STN. This sequence we are using nowadays, like for example the F-gater. F-gater is, we have here an article where they compare the visualization between T1 flare and F-gater and you can see here even we can see the lamina medullaris internal separating the GPI to the GPE. If we use this kind of advanced imaging we can do a better direct targeting. Also with the QSM we can see here in hyperintensity the STN perfectly and other structures. And this is a common sequence usually nowadays also, the SWE-I. But we have to have some careful with this because there is a study where they compare T2 with SWE in 7 Tesla MRI and we see that SWE doesn't display the lateral part of the STN then we have the risk to put the electrode a bit to medial. Then we need to double confirm with the other strategies that are going to detail after this. The direct targeting of the GPI also has progressed with the time with the improvement of the sequence of the MRI. We have all the sequences, being this T2 flash H2D and SWE the best we have here a beautiful show of the different sequence in every sequence and we see here that the border is perfectly shown in SWE T2 flash. Then we also to improve our targeting we are using another techniques in order to know that we are in the right spot. This as I described at first was introduced in the 60s but it has progressed a lot. This example is the microelectrode recording that all of us has. We can have this kind of configuration and this is STN and this is GPI and know that we are in the right position of the electrodes. But nowadays also we are progressing that to the next step and now we are doing like local field potentials where it is proved that the beta oscillating units in the STN can serve like a biomarker in order to do closed loop stimulation and also it can predict what is going to be the better contact of our electrode. Then this we can improve our targeting. Even there are studies where some types of Parkinson's disease like tremor dominant or postural impairment or gait disturbances have a different distribution of this beta oscillating activity. Then we have a type of neurophysiology now that we can predict where in the STN is the best part where we are going to stimulate. Then this is the next steps in order to find our targeting. Also we heard about the connectome, these areas of the brain that are connected with another and that we are mapping all the brain with the connection that does to the different parts of the brain. Then we can do a connectomic targeting too. Also this combining a model that predicts what is the effect of the stimulation based in the pulse width or in the rate of our stimulation. Also with neuroimaging based in connectivity. We do that with diffusion tensor imaging and functional MRI. Then we can now stimulate not only the nucleus but also the collection of the nucleus. This first was very useful for BIM-DBS actually but nowadays we are using also for GPIE and for STN. Then another collaborative technique that we are using for improving our targeting is using the robot. As you see so far all the techniques for evaluating the accuracy is based in how is our vector error or our radial error. This error that is related to many factors that it could be the imaging itself because if we have more power in the MRI then there is more distortion. Also factors related to the frame. That's why we intended before using techniques we did use a frame but it showed no improvement. It was the same like that. Then the two techniques that improve our targeting actually this was the interpretive imaging control. This kind of combine CTs like the OR, like the X-loop of BrainLab. Then we can compare with our planning interoperatively if we are in the right track where we predicted that is going to be the nucleus. Also using a robot in order to assist our implantation show like in this table that the error is reduced in less than one millimeter. Then we are talking about some millimeter error. Then the robot also when you are used to do this and you have your way to do it faster it is going to improve your targeting. What's in the future then for targeting? Then obviously it's going to improve the MRI and other sequences. Segmentation, techniques of segmentation of the nucleus there are some software of electronic that is doing that already. Identification of the sweet spots, this is so common. I didn't have examples but we know almost many groups has published already based in the analysis of the electrodes that implanted where is supposed to be the sweet spot for the nucleus. But we can help that with the software. For example, using the local feed potentials. Also we can help us in the future with the artificial intelligence. Also, for example, for the microelectrode recording is proved that already is better to pass that for a software in order to don't be like something subjective to the appreciation of the neurophysiologist or of the neurosurgeon. In the future I think we are going to standardize some software and the artificial intelligence is going to help us with that. As a conclusion I can say that targeting is the most important part of DBS surgery as you see in the scale that I show you. Targeting can be many types of targeting. Anatomical, imaginological, neurophysiological, connectomic or robotic. But it doesn't matter what combination of these techniques you use but I think the most important is that every method leads you to accuracy. That where you plant your electrode you can deliver the electrode. But the accuracy depends on many factors and stages that are susceptible to improvement. Then the constant improvement in quality control of our vector error is what can lead us to improvement. As Lord Kelvin said, to measure is to know. If you cannot measure it, you cannot improve it. And also say that you cannot improve it, it eventually impairs. Then everything is about quality control and I think this applies to every field of neurosurgery that you have to have high quality control and you have to always think in constant improvement of your technique. Thank you. This is a picture of my hospital. The movie Roma, that almost won the Oscar three or four years ago, was filmed here. This is of the movie. This is my actual hospital. This is my department. You know, as all of you, I am a small part of my department. There's a lot of people behind me. Some are in the audience with me. Thank you so much. Thank you so much, Fernando. We'll take questions at the end of the session. You're right on time, so we'll keep moving. I just want to maybe provoke the audience a little bit. How many folks here do sleep DBS routinely? Routinely would mean at least 10 to 15 times a year. How many do awake DBS routinely? How many think that the future is going to be a sleep DBS? Almost everybody, or two-thirds. Okay, good. We'll continue this discussion in a bit. Our next speaker has traveled really far to join us from Australia. Please welcome Sarah Olsen from Brisbane. She's going to speak to us about, interestingly, the death of a blade of surgery. So I'm really interested in this. Thank you so much for the opportunity to talk about this controversial topic. I'm honored to follow such amazing talks this morning. This is one side of a debate I did with Aviva Abosh in Jerusalem. It is very one-sided, it's very contentious, controversial, but I have also a little thought-provoking. So why am I interested in this? Well, I'm a neurosurgeon who's actually trained in radiofrequency lesioning. DBS was in the private sector in Australia, but it was very late coming to the public sector. And in 2006 we campaigned with our local government and was very happy to be the first unit to get public funding. I also do gamma knife thalamotomies. I have no experience with focused ultrasound, but I hope to later this year. This is where I'm from in Brisbane, Australia. So what is the death of a blade of surgery? Is it progress? Could be. Or is it a cautionary tale more about this? Could be too. So when DBS arrived it came with a lot of pomp and ceremony and fanfare. It was like drink the Kool-Aid. And those who weren't doing it or challenged it were suddenly old-fashioned and perhaps should be put out to pasture. Even if you didn't want, you really had to drink the Kool-Aid, otherwise there's going to be no money for your meetings, none for your fellows, and none for your research. But rapidly DBS became the gold standard, but there haven't been any randomized published control trials demonstrating the superiority over any types of lesioning. It's more expensive than focused ultrasound, the most expensive of the lesioning procedures, and there are studies suggesting radiofrequency lesioning is more effective than DBS in certain circumstances. So you think, how did this happen? So perhaps this was the reason for this consensus, with others concerned with the way it was rapidly expanding radiofrequency lesioning rapidly being retired. So in this paper GPI radiofrequency pallidotomy should remain in the surgical armamentarium. Lesioning doesn't carry any more complications than DBS, and unilateral pallidotomy is better than DBS for dyskinesias. So these were the experts, they all agreed, so we all listened. Of course we did, no we didn't. We threw the baby out with the bathwater. And so while DBS has been life-changing therapy for hundreds of thousands of patients, there are problems that have become apparent. It's very expensive, as I mentioned before. And we all know there's a lot of work and follow-up with DBS, particularly for the neurologists and psychiatrists, as opposed to lesioning, where there was just one follow-up, usually particular, and even more so when you introduce multi-directional leads. This could be likened, I think, to clipping and coiling of aneurysms. One good clip, you saw them once, and now you've got them for life with the coiling. So with lesioning, you really had to have refined surgical targeting skills. And I worry that with multi-directional leads, not only are they a great deal more work for our neurology colleagues, I think we accept potentially sloppy surgery, expecting those electrodes to mop up the problem. So this is a patient of mine. In fact, she was the reason I really wanted to get DBS. I'd done a radiofrequency lesion on her right side 20 years ago, but we all knew bilateral thalamotomies weren't great. In fact, in some cases, terrible. And we know that longevity may not be great in DBS, either, with habituation occurring somehow with stimulation. We see the emergence of new tremors, presumably through new pathways, which we didn't see with lesioning. So this lady, I did a radiofrequency lesion on this side, and she has DBS on this side. 20 years later, this is still really good, and this side fell apart within three years. So bilateral lesions. Well, if you've ever seen someone with a bilateral thalamotomy, and I have a young person in a nursing home, it is pretty confronting. But then, you know, gamma knife and also focused ultrasounds are showing you can do staged thalamotomy. So I'm really not sure about that. And of course, with the lesioning, we didn't have infections, erosions, fractures, migrations, or device malfunctions. And I don't know about you, but when I've got a patient with a DBS, and it's really hard to get an MRI, and I can only get a 1.5 tester, and they'll put up every excuse now on demand not to do it. But 80% of patients with DBS are likely to need an MRI in their lifetime, and not accessing one may delay treatment for life-threatening disorders leading to death. And of course, there are patients. Patients, they don't want follow-up repeat programming or periodic replacement. If they're like me, they just want one operation and then be gone, get on with my life, not tied to my neurologist or psychiatrist for the rest of my life. So there are different patient factors playing now, and I think we've got to all be aware of what we can offer. Now the big bogey, I guess, is psychiatric surgery. So DBS's market is non-destructive, reversible, lenient, and somehow more legitimate. That's its ethical argument, which is a little bit sinister to me, but anyway. But DBS has not been shown to be more effective or safer than ablation. Radiofrequency ablation is more effective than DBS for OCD in a meta-analysis, and people in the audience might also remember that the DBS patients in the depression trials, many of those patients went on to radiofrequency lesioning. And of course, once you've got DBS in, it's for life. It needs life maintenance. Why would you have someone with OCD with some of the new obsession? You're chained to a neurologist or a psychiatrist for the rest of your life. So is DBS more ethical than ablation? I think there are definite ethical issues regarding the world population I'll come to, and we all know patients that get these put in, but really don't receive very good post-operative care at all. And there is a delegitimization of lesioning, particularly by those who didn't actually have an experience in the ablated procedures, but now the wheel is turning back. So radiofrequency lesioning, this is a particular gripe of mine, could probably treat all of the world's population instead of the 20% of the developed world who can afford DBS, focus ultrasound, or gamma knife. So how do we let it die out? Acute failure doesn't happen with lesioning, but it certainly happens and can be life-threatening in patients with severe dystonia or psychiatric illness. Now this is also a patient of mine I'm somewhat confronting. They had DBS with me, with a great result for Parkinson's disease. I was very, very happy with him. A few years later he had a long-segment thoracolumbar fusion with a spine surgeon with a monopolar on 40-quartery the entire time. This is how he woke up and this has been reproduced with permission from his family. His course following this was tragic and I'm sure you all can see what's happened there. So it is one big old calf-grass maze somewhat and I think gaslighting's gone on. It's certainly not just an ablative surgery, I think also you probably could think about medical cannabis, complete surgery for back pain, interventional neurovascular treatments in some cases to name a few. So is it progress or is it a cautionary tale? I think it's probably a bit of both. So in conclusion, lesioning I think, to quote someone else, is a noble art that must be taught. I think we are a bit vulnerable to gaslighting and people are best served when they have access to all therapies. Thank you. We do have a few minutes for questions for you if anyone would like to ask any. If not then maybe I can ask you one or two. So do you think there's an impact of age in who you lesion and who you do DBS in? Would you make that a factor in determining a preference? And then a follow-on question to that is which of your movement disorder patients do you feel lesioning is really just not an option for? Would you do paludotomies routinely as well or do you think that GPI stim is better than paludotomy? Look, I very rarely do lesioning now. I've only had one case in the last few years and this was a girl who really needed repeated MRIs. I do do gamma knife, thalamotomies, but they're usually reserved for people who aren't eligible for DBS. So this was really just to talk, to think about it I suppose. But I haven't done them in a long time. I can do them, I was trained in them, but I do wonder how on earth that that happened, that it just sort of phased right out. Certainly I think everyone would say bilateral thalamotomies, radiofrequency thalamotomies was a problem. But we see people do it and with focused ultrasound and stage way and same with gamma knife. So overall though, I see what other people think. How about another sort of maybe, there's a third party in this room which is a vendor that has something to sell as well, right, who then channels patients into movement disorder programs. So absolutely there's value to lesioning, there's value to ablations, but I think what hasn't happened and I think maybe that's the take-home message here, is we've never systematically compared these two modalities. And in many, many countries where there aren't enough resources, and this is exactly the right audience for that, this would be so easy to do. Where you could take 50 patients and do lesions and 50 and do DBS and compare them up to five years out and I think it'd be really a huge contribution. Very hard to do in the US. Yeah. Or maybe even in Australia. You wonder why that happened, don't you? How did that come about? Thank you so much. Thank you very much. of this session is Dr. also a world traveler, Takashi Morishita, who's joining us from Fukuoka University Hospital, still going to speak about connectomic analysis of DBS effects. Thank you very much for this wonderful opportunity. I'm very humbled to be here. I would like to talk about my research projects about connectomic analysis of DBS effects, especially focusing on the sweet spot in the thalamus. I have no disclosures related to this talk. And most people do the direct targeting for movement disorders in DBS or lesioning. These are very nice articles showing the results of analysis of sweet spots on the 2D atlas. And they use the ACPC coordinate system and indirectly address where is the sweet spot for stimulation. However, the problem is that these techniques have not considered anatomical variations among patients. So it's really, we need a high quality image to directly identify the target for DBS or lesioning. So this paper was published from University of Florida showing a nice illustration of the basal ganglia structures. And they used deformable atlas on these images to delineate the structures. And when I was a fellow under Dr. Foote, he said he may be hallucinated because he can see the lamina in the thalamus. But I thought what he was saying was true. So I tried to find out the borderlines in the thalamus or basal ganglia structures. And I published this paper in 2019. To further make sure that my finding would be right, I chose the VIM thalamic nucleus as the region of interest. And I looked at if I can see the fiber tract passing through the motor and cerebellum. And it was quite successful. But in this paper, the relationship between the electrode positions or volume of texture activated and the fiber tract was not analyzed. At that time, I did not have the technology to make sure. So recently, the neuroimaging technology, technological development is really remarkable, especially the advent of lead DBS changed our world. The patient, this enabled us to analyze the lead location, VTA, and various analysis. But the problem is we don't have our, we need some neuroimaging specialists to analyze the fancy things. So I was lucky enough to have my collaborator, Dr. Yuki Sakai from ATL, and he's really genius to analyze various neuroimaging. And so the first, next part, in the next part, I would like to talk about the thalamic DBS for tremor. There are several approaches to address the tremor, and especially in the thalamic targeting, like dual-lead technique and 45-angle approach, and also posterior subthalamic area could be a great target for tremor suppression. But we don't know where is the best sweet spot for tremor. So from my series of 11 DBS electrodes, Dr. Sakai analyzed where is the sweet spot. And first, we made the heat map of VTA overlaps, and we can see the stimulation point was focused in the ventral lateral part area of the VIM nucleus. Then we incorporate the improvement, I mean, clinical outcomes with these areas. And interestingly, the treatment, I mean, improvement-related area was focused in the VIM thalamus specifically. And then we depicted the normative connectomes. And improvement-related fibers are more specific to the cerebral thalamic fibers. So it was very consistent with our expectations, and this is a circular plot. So in the next part, I would like to talk about the Tourette syndrome. So from the first study from in 1999, there are many papers showing the clinical effects of the thalamic DBS for Tourette syndrome, but the problem is that there are responders and non-responders. I hypothesize that there may be a sweet spot in the thalamus for tick suppression, and also sweet spot may be missed in some non-responders. So last year, we published this paper in Journal of Neurosurgery, and we analyzed the lead locations and the volume of tissue activated in this paper. The interesting finding was the therapeutic effect was more likely to be induced when we stimulate the dorsal area, including the ventrolateral nucleus and the posterior, more dorsal area of the central median nucleus. And depressed mood was likely to be induced when we stimulate the medial part, especially when the stimulation spreads to the medial dorsal nucleus. And further, we analyzed the normative connectomics. The therapeutic effect VTA was connected to motor networks, and interestingly, the normative connectome associated with depressed mood was more likely to be associated with limbic circuit, especially inferior thalamic peduncles and some fibers going to the dorsal front basal area, front orbital area. In my practice, I found some interesting phenomenon in TRET syndrome. It's a micro-region effect. You can see the clear tick on the left side, but on the POD1, without stimulation, he was very happy with that tick. Then I — this phenomenon reminded me of micro-region effect when — especially the publications from University of Florida when I was a fellow. So right after implantation of micro-electrodes and DBS electrodes, we can see some clinical improvement. Then, even after six months with off-stimulation, sometimes the improvement could be maintained. So I did a similar study in the TRET cohort, and then both motor and phonic ticks could be improved right after surgery and even after six months off-stimulation. So to analyze where is a sweet spot in TRET syndrome, we analyzed the presumed micro-region area. In this study, we looked at the overlaps in the DBS electrode positions, and this is a heat map. Then we colorated the tick suppression effect with the lead location, and we assumed — we considered the sweet spot would be the middle — intermedial area of the central median nucleus to the ventral area of ventral lateral nucleus. Again, we analyzed the normative connectome associated with the tick improvement or micro-region effect. Then, this finding was very similar to the previous publication last year. So why identification of sweet spot is important. Surgical procedure will be more precise. Well, improvement may be obtained with the minimum stimulation intensity, and stimulation in this side effect may be avoided. But sometimes I have some critiques like the — my, our normative connectome don't look like real. I'm very humbled, but — and I think the normative connectomic analysis is not perfect at this point because it only provides what pathways are related with the depicted VTA and do not provide neurophysiological information. But I believe the technology will develop and further address these problems. So, the left side is my 11-year-old son doing surfing. L.A. is a huge city for surfing, so I'm very happy to be here, but, you know, technology is always developing, and I believe my son will be like Kelly Slater, like this. Oops. Oops. And, at last, I would like to thank my colleagues, and Fukuoka is also a beautiful city, and I always welcome you to come here. Thank you very much. Any questions or comments? If not, then maybe I can just propose a theme for discussion, and we have a few minutes. You know, it seems to me, and this is true in many, many areas of neurosurgery, but especially in functional and surgical neurosurgery, that much of what happens at one center depends on a small cohort of 30, 40, 50 patients, and a, you know, either a collaborative research or an industry-sponsored way of sharing these data to gauge outcomes based on tract information and on anatomical localization is almost a critical first step to enabling machine learning. Because what we are doing here is measuring distances from one point to another, looking at one fiber pathway. These are all important and correlative ways of measuring efficacy, but they are univariate estimates, and we tend to find the one thing that works best with our data. We've all done this, right? We're doing the same thing for central median targeting for epilepsy. And I was just wondering if anyone in the room, you know, feels like there is a venue or a room, a way to share anonymized data with both movement disorder outcomes as well as patient-specific imaging information. Please. Can we activate that mic, please? Thank you. Male Speaker 1 The first one, the first one is that in this case, it changes from one person to another. It does. Male Speaker 2 I assume it could be true. Male Speaker 1 Like, are we doing that now? I don't do DBS, but I'm just asking. Are we doing it now? Like... Male Speaker 2 I assume basically the same. So that's why I used, we analyzed the data in the normalized brain space to get the uniformed results. So probably you mentioned, so sweet spot could be like in one person, 14 millimeter lateral to the midline, and another one could be 12. So it's a different, it depends on the anatomical variations. But in the same normalized brain space, we believe the sweet spot could be one place. Male Speaker 3 The other is the three speakers, I was interested to see if the deep brain stimulation found more indications. Because at some point, we thought that it's good for obsession, for societal, for this and this, and I did not hear any new indications yet. Male Speaker 2 Okay. The threat is relatively new indication, and it's really exciting to see the development of the psychiatric DBS, and I believe it's certainly the surgery for neuropsychiatric disorders is not basically performed except for threat in Japan, but we are going to find out the way. Male Speaker 3 And just maybe to add to that point, there's several ongoing small scale NIH sponsored trials for OCD, for depression, and for epilepsy. So the space is rapidly expanding, of course, I think, and we've been saying this, I think, for about a decade that, you know, functional neurosurgery is going to become more and more important and relevant. But I think, you know, there is a certain activation energy and a certain amount of new knowledge that has to be gained to drive new therapies. And I would just say, for the longest time, what we did was do 130, 140, 120 hertz stimulation duty cycle in every target we went into, and nothing in the brain operates that way. There's nothing that goes off, you know, 30 times a second. So targeting is certainly one thing, but the way we stimulate is a huge question, and it's a very big space. So I think these trials, many of which have published some of the early results, are very, very encouraging. And I have, you know, certainly not enough room today to talk about that. Thank you. That concludes our session. Jacques, we give you four extra minutes. Male Speaker 4 Thank you, Michael. So now for the neurotrauma session, I invite Brian Kitagawa and Jacob Joseph. And after the neurotrauma session, we will squeeze in John DeOliveira, who made it without the mic, and then we'll have a Q&A session in the brain, and before the pediatrics session, we'll talk on AVM. Hi, good afternoon, everyone. We're going to start the neurotrauma session. As you can see, I'm wearing a mask. I'm wearing a mask. He said, my name is Ryan Kitagawa. I'm a neurosurgeon from Houston, Texas. I'm Jacob Joseph, a neurosurgeon from the University of Michigan. So we'll go ahead and start off our first talk with Lynn Lucena from the Philippines to talk to us about task sharing in neurotrauma. Okay, a pleasant good noon to everyone. So I'm here to talk about task sharing in neurotrauma. Disclosures none. But first of all, I would like to thank the organizers, the AANS, and of course, Professor Jacques Marcos for inviting me here. It's a pleasure. This is where I do my work. This is Bicol region in the Philippines. And this is my hospital. It's a provincial hospital. And it caters to like half of the region, like 3 million people. So this is where I do my work. So despite the advances of neurosurgery, we have been talking about like the previous lectures, connectomics to endovascular to microturional approaches. And yet for the past decades, neurotrauma has been lagging behind. And we seem to take it for granted because sort of the very basic, when you do neurosurgery, you learn it. It's one of the first things that you actually learn is to address neurotrauma cases. So coming from my country, which is classified as part of the LMIC, you still have a lot of things that we need to do, like from the acute treatment of neurotrauma, which means from the recovery to the critical care units, and then to the cognitive treatments and rehabilitative treatment of neurotrauma, there's still a lot of things to be done. So this is a very familiar global neurosurgery workforce map from the WFNS, which sees that there's a lot of deficit and gap, especially in the Southeast Asia and Sub-Saharan Africa. So with this, there's 23,000 neurosurgical needed in the LMICs with 5 million essential neurosurgical cases and treated each year. So from these studies, it says here that the Sub-Saharan Africa and Southeast Asia regions actually very much have a deficit of neurosurgeons, with an expected ratio of 1 is to 100,000. The Philippines right now, this is in a published paper of which I'm part author, it's 1 is to 620,000. But where I actually work, it's 0.116 per 100,000. The first time I started my practice 20 years ago, it was like 1 in 5 million. So I started the practice there. So now with the global burden of disease in 2017, it's 195 million new cases of road injuries worldwide, majority of which was due to motor vehicle and motorcycle accidents. In the Philippines, from 2005, there's 65,000 cases to 110,000 cases in 2017, all occurring in Metro Manila alone, which is the capital city. So the injuries were among 15 to 29 years of age, and it's considered to be the leading cause of death globally, even higher than HIV and other infectious diseases. So now with the Philippines, with 109 million people, estimated in February 2020 to an archipelago of more than 7,000 islands, we had an increase of around 45.76% from 2006 to 2015 of deaths from road crashes. So now in 2019, I did an informal survey of the 10 training institutions of neurosurgery in the Philippines, and there was an average of 80 to 100 cases of traumatic brain injury per month, with a mortality from severe traumatic brain injury of 80 to 90%, with disability including post-concussive syndrome in mild traumatic brain injury in 20 to 30%. This is the demographic of the Academy of Filipino Neurosurgeons, which is the sole neurosurgical society in the Philippines, and this is this distribution. Surround, around 142 fellows of the Academy right now, and more than 50% is in Metro Manila, which is only like 14 million. And there are 11 training institutions, and nine of these are in the capital city. So where I serve, the population are around almost six million. There's 1,200 cases of traumatic brain injury, of 6% of which is surgical. There are two tertiary government hospitals with 250 to 300. Now it has increased to 600 bed to 800 bed capacity with an ICU and a scan, and with some private hospitals also. So with this gap, what is the solution? So we were looking at short-term missions, training camps, training, task-shifting, or task-sharing, of which is my topic. So what the difference between task-shifting and task-sharing actually is that when task-shifting, you delegate the task to the existing or new groups with less or narrowly tailored training. When task-sharing, the workplace strategies are actually built upon the collective input of the health team. So you share these responsibilities ultimately. So the theoretical model is this. You should have a structured training curriculum with oversight, competence-based evaluation, integration into the workforce with appropriate referral networks. There should be some amount of financial compensation and hopefully recognition of the health system with advancement and professional development. So this is actually a paper of my co-author, Faith Robertson, and this is the first of its kind, Task-Shifting, Task-Sharing in Neurosurgery, an International Survey of Client Practices in Low- and Middle-Income Countries. So with her, this is the ideal task-sharing model, which is divided into three phases. First, you need to undergo training, and then practice and maintenance of the providers. So this is the result, where those task-sharers were located. So with this, it says here that the complexity of procedures performed by neurosurgeons and task-shifting, task-sharing providers. There are more neurosurgeons actually still providing these procedures, but as you can see, the task-shifting and task-sharing providers are actually performing also the burr holes and the craniotomies for hematoma evacuations, and even the compressive hemicraniectomy for strokes, and even spinal fixation in some areas. So down the line, okay. So I saw these papers in some of my researches. Should trauma surgeons perform neurosurgery in emergencies? Actually, in some areas in Europe, they have trauma surgeons coming in, when you have neurotrauma, which is a polytrauma, the trauma surgeons actually address this and then stabilize the patient or do some evacuation and then transfer it to a higher neurosurgical facility. And also this paper, Management of Neurotrauma by Surgeons Orthopedists in a Military Operational Setting. So with this, the Philippine model is that we have general surgery residents rotating under my mentorship, a three-month rotation, when they are already in their residency year of general surgery from second to the fifth year. Then they go to all the possible neurosurgical cases with consults with the neurosurgeons on phone or text and Viber. Then there's progression of autonomy, in which they are able to operate specially before with me, teaching them, and then later on, gaining more autonomy as they become more senior. So this is me with my residents in general surgery, doing some evacuation of hematoma. So the study design was actually a retrospective logbook review of all these patients with admitting diagnosis of traumatic brain injury and elevated intracranial pressure. The outcomes were mortality, with the secondary outcomes of infections and length of hospital stay and Delta GCS from the lowest inpatient score. So these were the results. There were 3,241 cases, with 2,232 at the government hospital and 1,008 at the private hospitals. Demographic of patients is as shown. The neurosurgeons were more, of course, the private patients and the task shares were in the public or in the government hospitals, meaning these were my general surgery residents. And those who were treated by the neurosurgeon were more of the older age and the ones with the task shares are the ones who were vehicular accident victims. So you can see here that what was remained significant after the multivariable regression was that the year, the mechanism of injury and the TBI severity. The outcome showed that there was no difference, significant difference, there was no significant difference in the surgical mortality rates between the groups with an overall 19.1% in the neurosurgeons and 20.2% in the task shares and task sharers. So overall, down the line, pneumonia was almost the same. All this, the change in Glasgow Coma score and even the length of stay had no difference. In conclusion, this retrospective cohort study is one of the first to thoroughly examine the quality of task sharing and task shifting care provision in neurosurgery. It demonstrates that emergency neurosurgical care can be delivered safely using a carefully designed task sharing, task shifting model. More data needs to be collected, however, and for it to be practiced, there should be really, the lesson there is oversight and possibly recognition from the Ministry of Health. So I would like to acknowledge these people. And these are the publications already of the paper. And I would like to invite everyone to come and be with us in 2026 for the 18th Asian-Austral Asian Conference in Manila, Philippines. If you're interested, kindly email me. And we have a hybrid online first Philippine Neurotrauma Boot Camp, which means it's a three-day thing with physical presence, but still we will be available online from injury to recovery. So we will not, this will emphasize the multidisciplinary care of neurotrauma from the EMS, nursing care, and even advocacy with the lay people and the local government. With that, I would like to thank everyone. Jos Mabalos, thank you. Yes, we invite any questions. I never, thank you very much for your efforts. I never been in the Philippine, but I just have two questions for you. Are you intermediaries, middleman? Are you guys encouraging that? Like in America here, one primary physician works with 16 nurse practitioners. They can handle the clinic. And the primary physician can do the few little things. Are you doing intermediaries? Instead of having a neurosurgeon do everything, you can just let the neurosurgeon do the most critical and you teach and you have medals. And number two, is your orthopedic doing spine surgery in Manila? First of all, for the first question, yeah, if you have primary physicians doing these things, it's more of, we had to sort of divide ourselves. So since I am part of the department, so I have this residence under my care and mentorship. So they rotate with me. So they are the ones who actually take care of the emergency life-saving procedures of neurotrauma. I'm talking about nursing, non-MDs. Oh, non-MDs. Okay, so non-MDs right now, yeah, we do not do that. It's more of the ones who are training to become surgeons also. But there are actually papers already with non-MDs doing that, especially in Africa. So there are published papers. So the second is in Manila. Yeah, they're still doing this task sharing in Manila also. Was that the question? Yeah, orthopedics are sharing part of the spine. Oh, orthopedic surgery? Yeah, no, orthopedic surgeon doing spine surgery. Oh, yeah, well, yeah, they do, yeah. So. Because, well, the history is that we were so few, the neurosurgeons, and I think they focused, my mentors, the people who were ahead of me, they focused more on the cranial surgeries, the more life-threatening ones, such that the orthopedist, they started doing the spine surgery. But now we have a joint society where there's now the neurosurgeons doing the fixation and everything, and also the orthopods. So there's the Philippine Society for Spine Surgery, something like that. So thank you again. Thank you so much. So for our next speaker, we invite up Wellington Paiva from Brazil, who's going to be talking to us about machine learning and prognosis in severe traumatic brain injury. I would like to thank, I would like to thank the organized committee for this invitation to speak in this very impressive symposium. Thank you. I will speak about a very important issue in neurosurgery, especially in neurotrauma, the data aspects involving prognosis in severe traumatic brain injury. So, to talk about the clinical relevance of traumatic brain injury is not necessary because we, it's well known about the importance of disability and death involving these patients, especially in low to middle income country. It's reality in United States and Europe, but in country like Brazil, like continents like Africa and Asia, it's epidemic problem with socioeconomic quality of life and psychological aspects for the patients and families. I will present a regular case in our service, a patient with, patient 34 years old that suffer a traffic accident with three points in Glasgow Common Score in trauma CEN, hemodynamic unstable with this wound in the emergency department, and in tomography CT scan show with diffuse injury and fractured fabrication of frontal bone. We had operated this patient in the post-operative CT showing hospital lobe ischemia, indicating a uncal herniation. Then the problem in this point for this regimen of these patients is about to predict the evolution of these patients six, 12 months after the trauma, about disability and the risk of death for these patients. Then to understand about prognosis of patients with severe traumatic brain injury, it's a central part of management of these patients to know about the neurological outcomes is essential and involve three main players. And it's very important in the past, this hypocritical aphorism, no head injury is so serious that it should be hopeless, and no so trivial that it can be ignored. It's a truth in the past and it's still truth now. And the definition of prognosis is important to use prognostic model. It's not a new aspect of the study in traumatic brain injury and in neurosurgery, but it still is a central part of the management of these patients and involve three players, involve family members to information about the evolution, the possibility of evolution of these patients, involve doctors, emergency department doctors, neurosurgeons and neurointensivists to define about the extent of intensive treatments for these patients and involve healthcare, health insurance companies and government that pay for these patients and socioeconomic impact is a very important aspect for these patients. To use of these prognosis models, it's important for research in neurotrauma and in neurosurgery, but in clinical practice as well. And to build a specific model, a prognostic model of quality, it's important to have reliable, to have feasible to use and the value for specific populations. And this is a important problem because the major part of scientific production and prognostic model was built in high income countries in the United States and in Western Europe, but the major part of patients with severe traumatic brain injury are in Latin America, Africa and parts of Asia. And it's important to have a prognostic model with applicable for all patients. And it's necessary basic requirement about the high number of patients to analyze the statistical analysis appropriate. Here's the protocol to insert information in database and the possibility of generalization of this information. The two main prognostic model that we have is IMPACT and CRASH. IMPACT, it's a model for prognosis prediction model six months after trauma and use information about clinical CT scan findings and labs to calculate and to have information about risk of death and the outcomes six months after the trauma. The CRASH model, it's based on clinical aspects and CT information and was built with information from 10,000 patients in the CRASH-1 study. It's possible to use CT scan scores to prognosis, very common in clinical practice. For example, the use of martial classification for diffuse injury. There is some interesting correlation with results and outcomes of the patients. It's possible to use Rotterdam score and Helsing score. But for us in our center, we have not with satisfaction use of these models for our specific population. Then we decided to build our prognosis model in our hospital. It's a large hospital in Brazil, in Sao Paulo, Brazil. A large city in Brazil, level one trauma center. There, we treat around 300 CFRTBI per year. And we beginning with more than 500 patients. Now we have around 1,200 patients in this registry. And we apply it in some studies. For example, in these studies, we compare CRASH score traditional with a new score that it's a CRASH plus information about the coagulopathy. And we found results of better accuracy using this technique. You compare tomographic findings as well. In this study, we analyze in our database comparing the three CT score, Marshall, Rotterdam and Helsing. But the accuracy was not good in the three system. Then we conclude that's necessary to improve the quality of statistical analysis. And it's possible to use advanced statistical model. And in this kind of analysis, the machine learning is a better option because it's more valuable. But one more question, important question, it was this machine learning. It's a kind of artificial intelligence and it's possible for the software to use specific algorithms to identify pattern, to make prediction of deaths and outcomes in these patients. And it's possible to use a repetition of analysis to improve quality of prediction. Currently, this technique is used for autonomous car and in medicine, in oncology, it's very common to analyze early diagnosis of cancer. But it's possible to use in other areas of healthcare, especially for prognosis and outcome definitions and for image analysis, we think that these two areas is more important for patients with traumatic brain injury. We find increased interest in this area, in the trauma area in the last years. And how can I use machine learning in traumatic brain injury? It's possible to use for prediction of outcomes. It's possible to run this immersion analysis and to personalize the management of these patients who have used it, supervised and learned. But there are other options like unsupervised learn and reinforcement learning. There is some comparations in between classical statistics with this new techniques and possible to analyze techniques from naive Bayes compared with logistical regression with difference between it's better use of machine learning compared with classical statistics. Our team published this paper some years ago about the use of this technique for TBI mortality prediction and possible to use clinical and CT scan aspects of these patients to build a prognosis by using Bayesian approach and possible to identify in our population what the better prognosis factors for our population because we have difference between patients treated in high income countries, our pre-hospital our assistance is different, our access to use of technology and ICU techniques is different. The group, the central TBI group has published last week this paper in person paper showing as well better results using machine learning compared with conventional statistic analysis. Then I think that use of this technique is very interesting. It's better than use of classical tests. However, it's important because it's a large database with large mathematical analysis, but it's important that in trauma we have test to question involving biological and physiological mechanisms and important to understand this participation of these questions and not only about the data owns data. Now a few important participation of machine learning is about image analysis. The literature has discussing about this, but it's available use of soft when it's possible to analyze information about CT scan in acute phase is important in some centers in secondary centers without neurosurgeons or even hydrologists and possible to use this kind of analysis to detect information in CT scan and in MRI for super acute phase of traumatic brain injury as well. It's important to have large databases with more diverse datasets, and we have three important databases, TRAC-TBI, Central TBI, and TBI Latino. It's a new database that's built for Andrés Rubián in Colombia and other countries in Latin America. But it's important, more than large datasets, it's important the quality of data inserted in this database and the aspects involving the capacity of generalization of this information to predict outcomes in traumatic brain injury. Then we believe that machine learning is important to predict outcomes in TBI, however it still challenges and limitations, it's not so different to what we have now. For image recognition, I think that it will be soon incorporated into the clinical practice. Thank you. Do you have any questions from the audience? I hate to be the only one asking questions, but I cannot help it. I wanted to ask you, is Brazil now becoming a lab for the AI? Is it? Yes, we have invested in this possibility to use, but it's not like when we think about artificial intelligence, we think about super structure, but it's possible to use with good computers, the use of this software to application in this kind of system. No, I'm talking about, is it becoming a foreign lab for foreigners, for other countries to make Brazil an AI center? Is it? Yes, yes. So, there is a fear that the AI, because one of your slides is medical decisions, so there's a fear in America, especially, and all of us, that AI is going to decide for you what to do. Is this what you're going to look forward five years from now then? Yes, I think that it's possible to use this technique in the decision tree involving management for the patients. This moment we're working only with outcomes prediction, but I think that it's possible to improve quality of use of these techniques for neurosurgeon, not only for neurotrauma, but the other specificities. Do we have any other questions from the audience? Okay, thank you so much. With that, we'll move on to our next speaker. Our next speaker is Andres Rubiana from Colombia, who's going to be speaking to us about the cranial compartment syndrome and TBI insights and management strategies. Which side? Either one works. Okay, thanks. Thank you for the invitation also to Professor Marcos and for this opportunity to discuss some of the work that we have been doing locally. So we're going to speak about the cranial compartment syndrome, TBI. It's something that we have been working on with some of the groups. We don't have any conflict of interest other than the groups that are working actually with us in this project. We all know the traditional Monroe-Kelly hypothesis that was stated in 1783. And they have these very described concepts about that the brain is inside an unexpandable box of bone. The brain parenchyma is practically almost incompressible. The volume of blood in the cranial cavity is almost always constant. And a continuous outflow of venous flow from the cranial cavity is required, which makes room for continuous inflow of arterial flow. So many of these concepts were used. And then we are all aware of all the work from Niels Lombard with the WAIP analysis, but also related to a specific value of ICP. And then how many of these learning processes come to a vault. And then we have the Richmond crew and all the group from VCU working into the pathomechanics of intracranial pressure and also related to some specific thresholds of numbers. And now we are in the modern era of the ICP measurement. And all the treatments and diagnoses that we make for decision-making in these cases are based on that number. So if we go over many of the guidelines that we actually have from different countries, even high-income countries, even low- and middle-income countries, they are always in this threshold of number to decide what to do with the patient. Even the more recent algorithms that have been developed by consensus of experts use these same values in order to define what's the next step for the patient. So we all know that when we talk about intracranial hypertension, we also speak about compliance and how the compartments into the school manage that pressure. And also how the content and the components responds to this pressure. And we have been also aware that the waveform is really important for us in order to understand the relationship with the compliance in the cranial cavity. So working with the patients in many of these projects that we have developed, the project that we are participating in with the support of many of the international actors, we start looking for conditions in some of these patients that do not follow the same trend that has been described and used. You can see here, for example, some of the specific monitoring parameters for many of these patients. You have seen, for example, a very abnormal curve, a very abnormal wave with loss of compliance with an ICP of 12. You see here something similar with an ICP of 16. And you have a normal pattern of the waveform with an ICP of 25. So how are you going to start treatment for intracranial hypertension in a patient that does not have intracranial hypertension? And correlating this with many of the non-invasive techniques that we have been working on, specifically for how to manage this patient in less-resourced areas, we use a lot, many of the non-invasive monitoring systems like the optic nerve ultrasound, also the TCD, the pupillometry. What we are starting to see is that the waveform correlates better with these non-invasive techniques than the value per se that we use for many of the monitoring devices. So in this process, we start digging into the basics of many of these traditional concepts. And we found that around the late 70s and 80s, there was some discussions published related to the difference of pressure gradients between the two compartments, the two supratentorial compartments. And many questions arise at that time. Is that what's clinically important or not? But at that time, they were measured mostly with the Richmond screw. And we understand that at the time, they focused too much also into the value. So analyzing also the concept of the compartment syndrome that have been described for other areas of the body, including the abdominal compartment syndrome or the extremity compartment syndrome, we start looking into the comparison of the cranial compartment syndrome. That in some general publications of trauma and surgery, have been some discussions regarding that when you have abdominal compartment syndrome or when you have extremity compartment syndrome, what the tissue that is really in danger is the nervous tissue and also the vascular supply for the compartment. And if you see in the cranial cavity, it's of course the same. So you have some amount of pressure or something that is generating problems with the perfusion, with the vascular areas, and with the soft, the neural tissue there. And you have these located in three different compartments, the two supratentorial and the infratentorial one. So therefore, the intracranial compartment fulfills all the conditions to develop a compartment syndrome. And depending on the degree of tolerance to pressure, that is what we call the compliance of each subcompartment, a change in volume due to brain edema or in pressure of any other contained elements, can progress to a generalized compartment syndrome. So we saw that also monitoring these patients after decompressive craniotomy with change also in the waveform sometimes. And we started also doing some cases bilaterally because we identified early with the non-invasive techniques some areas that were compromised associated to the waveform also after surgery. So recently, last year, we published this article going a little bit deeper into the concept that already had been described, especially by the physics groups at Cambridge University related to how to include the advanced monitoring of every one of the components of the cranial vault, including the content, and how you can correlate, for example, the waveform of the transcranial doppler with the risk of high ICP and also the optic nerve ultrasound as we discussed. So maybe something that we can use in order to understand better this is also add more monitoring. So when we start monitoring also the brain tissue oxygen, we understand that sometimes the changes that you regularly do for improve the oxygen brain tissue, like ventilatory parameters or also hemoglobin thresholds, were not enough in order to improve the oxygenation. And we saw how many ways after the decompression the oxygen improved. So the oxygen problem was correlated more by the loss of the compliance other than the distribution of the oxygen per se. You have this case that we did recently, for example, with a patient where we started with an EVD. This is just to show that the hemodynamic parameters of the patient systemically were well. And also, if you see the correlation between the two sides, you have an ICP waveform here that is almost normal with an abnormal value. And you have here an abnormal ICP waveform with a normal value. So this also didn't correlate with the regular parameters and the regular concept that we really manage since the Monroe-Kelly doctrine. So the idea that we are working on is that maybe we need to understand better that concept of what is happening inside the school in these cases. And maybe if we treat this as a compartment syndrome, focus more on the waveform showing the actual compliance of each one of the compartments, will be a better trigger for defining surgery or more aggressive therapy. And this one, one of those recent cases where you have a CT that is almost normal, but when you do all the monitoring that the waveform was totally abnormal initially in one side and after the first surgery was totally abnormal in the other side. And the oxygen was improving after the second decompression. So if you take into consideration that in around 80% of the globe, the decision of surgery in these patients is taken only based in an image without measuring anything of this. You can understand how many patients are at risk of dying because sometimes the CT looks very well. And you decide, okay, this patient is going to stay even sometimes out of ICU or even in an ICU. And then the patient is doing really bad systemically and the patients die sometimes because you take the decision too late to take that to surgery when the brain already suffered for hypoxia or other issues. So maybe the possibility to include many of this multi-monitoring to decide in a better time fashion where to take this patient for aggressive treatment will be a possibility to decrease the complications that we have. We really see many of these cases in different type of resource settings with the work that we are doing at least in Latin America. And we are full of histories of people that said that in the middle of the night the patient that they considered were not necessary to be taken to surgery because of the initial CT, then it started getting And they decide to do something else and they do a new CT and with the new CT half of the brain is ischemic or there is a big re-bleeding and then decide to do nothing because the patient is already too bad or too sick. So this is something just to bring this into account. We published this paper a couple of weeks ago with this discussion related how to integrate many of these monitoring tools that are not expensive, that are non-invasive and are correlating sometimes better with the ICP waveform other than the number that we use to start triggering the treatment. So as final remarks we can consider the possibility of defining the cranial compartment syndrome in patients who lose compliance independent of the ICP value and they will require increasing therapy intensity in order to decrease the risk of definitive damage over blood vessels and nervous tissue. And maybe patients with high values of ICP who do not develop a compartment syndrome with a normal ICP waveform, normal optic nerve ultrasound, normal pupillometry or normal transcranial doppler can be at risk of over-treatment. And in an opposite way patients with normal ICP values and abnormal ICP wave, abnormal optic nerve ultrasound, abnormal pupillometry or abnormal transcranial doppler can be at risk of under-treatment. So what maybe does the difference in these cases is the diagnosis of the unilateral or bilateral cranial compartment syndrome other than the regular concept of intracranial hypertension that we have been based for I don't know how many years. So thank you for allowing me to discuss this. And this is something that we have been working with the support of many people internationally. This is the program that we have been managed for the last eight years with support of the Barrow Neurological Institute of the Phoenix Children's Hospital at the University of Cambridge, training physician for LMICs in advanced management and basic management of neurotrauma care, considering this as an important super-specialty. And Dr. Lucena mentioned that sometimes it's taken apart because it's not as fancy as other super-specialties in the areas. And this is our group of trainees with some of the instructors from the program from different regions of the world. Thank you so much. Thank you. Do we have any questions from the audience? Isn't it that compartment syndrome depends on the pressure inside, not the waveform? Like when they say compartment syndrome in the legs or in the belly, it still depends on the pressure rather than the waveform. Yep. Yeah, the idea is to use the waveform as the new surrogate measure in order to understand what is happening inside the school, other than in other areas. Maybe in other areas, for example, if you go over the extremities, now they are using the near-read spectroscopy to understand the oxygenation inside the compartment. But we have, fortunately, a waveform that we can identify early for what is happening inside the compartment. Does your institution currently believe in ICP monitors then? Yeah, we use that. We use invasive ICP monitoring, but we use it combined with these other tools. And what we have been learning is that if we base only on the number, maybe we are over-treating or sub-treating patients. Do you guys need to stop asking questions? Do we have any other questions from the audience? We'll have a quick question for you. So if you have a patient who has a normal ICP, but an abnormal waveform indicative of poor compliance, do you find that traditional medical management is effective in treating that? Or are we looking at the surgical? We use regularly the traditional medical management to understand that the systemic conditions of the patient are not causing that. But if you give, say, for example, a hypertonic saline bolus, 23.4%, is that effective in changing the waveform around? Not really all the time. Sometimes it happens transitorily, and they didn't respond. It's like the same concept for fluid response, if it's a transitory response or not. It's almost the same concept. And along with that, when do you determine their medical therapies are ineffective, and therefore you're triggered to actually decompress the patient? When all the other monitoring goes into the same direction. For example, if you have the optic neural ultrasound more than 6 millimeters permanent, independent of the response with the fluid, or is going near to 7, and if what we are doing with the pupillometry is actually not using the MPI, what we are using is the difference between both sides for the maximum contraction velocity. And when we saw a reduction in the velocity in the side that is also correlated with the optic neural ultrasound increases in that side, you know, and also correlated with the abnormal waveform in that side, is something that is showing to us you need to go more aggressive with this patient other than just wait for, you know. All right. Thank you very much. Okay. Great. Thank you. Thanks for the wonderful neurotrauma session. And we'll squeeze in Dr. Jean de Oliveira just before the break to talk to us about microsurgery for AVMs. Okay. Thank you very much. Good afternoon, everybody. First of all, I would like to congratulate the organization committee, especially our dear friend, Professor Jack Smolkin, for joining such a great group of excellent neurosurgeons all around the world in this meeting, which they call Global Symposium. So, congrats, and thank you for having, and also thank you for the patient waiting for me up to the end. So, to talk about AVMs, we go back to the pathophysiology to understand that when you don't have a capillary, normal capillary formation, so you have a direct connection between arteries and veins, which explains the main presentation, which is the hemorrhages, seizures, and progressive neurological deficits. So, when you understand that, it's important also to understand the natural history. If you see this meta-analysis and systematic review, you're going to see that most of the case is going to bleed in an annual rate around 2 and 4 percent, but there is some difference between those AVMs, which already had some blood, when you compare with those that never bled before. so when you see one-year risk and then we follow those patients five years and they never bled, so in fact it decreased the incidence. On the other hand, when you have AVM that had bled in the past, it can, after five years, it can reach 26.5 percent annual rate, which is not a good natural history. So when we follow those patients in the long-term, we're going to see that in this beautiful old paper, but still beautiful because it's the largest long-term follow-up that you have in the literature, we're going to see that one among four patients will die, will die because of the hemorrhage arising from the AVM. So the natural history of the AVM is not so good as some papers that have followed the patient for a short-term follow-up has published before. Based on that, we have to remember the risk factors that we have, the angioarchitecture when you have the presence of aneurysms, venous stenosis, sometimes the ectasy venosa, exclusively deep drainage and a single drainage vein, all those features can turn the risk higher. It's an old classification dispatched from Martin in 1986, but still working because it's simple and every one of you know this classification, which is based on the size, the venous drainage, the eloquence. I have the privilege to work with the BNI group and since 2011, when they published this updated of the Spetzler-Martin, which now it's called Spetzler-Pons classification, you're going to see that the group one and two was classified as class A, the group three as class B, and the four and five as class C. More than classified is important is to recommend the treatment for each class, which is the resection, microsurgical resection for class A, the multimodality treatment for class B. For most of the class C patients, probably the natural history can be better than any kind of treatment. Of course, there is some exceptions like recurrent hemorrhage, progressive neurological deficit, still-related symptoms, and also when you have AVM with aneurysm also. When you have situations like that, we have to consider treatment and of course, the treatment should be focused on the microsurgery because the microsurgery is the technique that provide the highest rate of cure when you decide to treat the patient. So embolization for class B or class C and radiosurgery for some small and deep AVMs. I'm going to show a couple of cases to you to illustrate how we do with this kind of lesions. You see a male, 39 years old, a sudden headache, sorry about its written in Portuguese here. The patient has hemiparesis, but look at a small nidus right here, but it's a huge hematoma. So for this patient, which became almost hemiplegic after a couple of weeks, we see that it's a small AVM, but the natural history was not good for the patient. It's a small AVM fitted by MCA branches, a single venous drainage, and I would like to show you, when we have AVMs placed in an eloquent area like the sensitive motor area, we like to start the surgery doing a brain mapping to understand the whole anatomy, to understand the function before you start to dissect the nidus. And after you dissect the nidus, you can compare not only that the blood flow now is changed, you see everything's here, it's arterialized, but after you dissect the nidus, you're going to see the venous color again in the normal venous drainage. This is very important, to compare how the function was before you start to dissect and after you dissect the nidus, and then also you can have not only the anatomy, not only the function pre and post dissection, but also the flow. There is no other technique that provides you so many information when you treat the AVM. So you have the microsurgical anatomy when you do a craniotomy, expose the whole nidus in the whole normal brain around the nidus, so you have the function by the brain monitoring, you have the brain mapping, and also the flow analysis. So this is a lot of information that at the end you can achieve a very good result when you perform a postoperative angiography, which means the cure. When you don't have nidus any longer in the postoperative angiography, that means the cure. So AVM, like any reason, it's a curable lesion. This is very important. Another class A case, I had the privilege to operate this case during a live course in the Siberian department. You see they have a very good facility to perform a pre-interoperative angiocyt. So the images can be acquired in 20, 30 seconds. Those images go directly to the image guidance and their navigation system. And then you have a real image interoperative. Look at part of the nidus was embolized and the part of the nidus still open. So we perform a combined approach, interhemispheric approach. When you do interhemispheric approach, it's very important to preserve the veins, even when you have to sacrifice a piece of the dura over that. So we perform an interhemispheric approach and also a combined approach with the transsucral approach. So through the interhemispheric, we remove that part which was embolized. And then through the transsucral approach, we could dissect the whole nidus that is still open and then remove this AVM completely. Because we had the facility to perform interoperative angiography again, CT angiography, we did that which confirmed that the whole nidus was dissected. And the day after, we perform angiography that was consistent with the interoperative. So when you have the technology, the technology can help you to achieve a very good result. This is another example that we have in mind to master the whole technique, the whole approach that you have in the armamentarium of the neurosurgery. Look at this AVM which is laid down over the tentorium in the male, 32 years old, hemorrhagic stroke, memory death, epilepsy. Feeders from PCA. And I have the privilege also to learn from Professor Evandro de Oliveira how to deal with lesions located in the medial aspect of the temporal lobe, especially when the lesion is over the tent. We published together this beautiful JNS cover which was called Supracerebellar Transcentorial Approach. When you remove, not only to make a cut in the tent, but when you open the tent, you can expose the whole medial temporal lobe without to any retraction, without to go through the cortical area. So this is very important. What I do nowadays, different from what Dr. Evandro published in the original paper, he used to do it in a semi-seated position. I do it like a concord position. I like to perform for AVMs wide craniotomies, especially when you have to expose the venous. I like to do a lot of bullet holes because I can dissect the dura. I don't mind about several bullet holes. I'm very worried about lesions in the dura, lesions in the sinus. So sinus and the dura is more important than the bone. The bone you can reconstruct easily. So when you perform a craniotomy like that, you have to expose both transversal sinus and also a little bit of the dura of the occipital lobes bilateral. Because when you open the dura, retract the dura upward, you have natural space. Even when you have patients in the prone position, posterior fossa surgery starts always with CSF releasing. It doesn't matter if you go through any space. So look at how the gravity works in favor of you. You expose the whole tentorium. You can sacrifice small veins, cut the arachnoid. I'm going to skip a little bit. So look at the tentorium right here, the free border of the tent. So then we start to coagulate the tent in the border of the transversal sinus, which is right here. When you do that, we can cut. And then when you do the last cut in the free border of the tent, a little bit more of coagulation. We have to perform MRI, the venous MRI, to analyze the venous before you do that. Look at when you do the last cut, how exposed it is, the temporal, the mesial temporal lobe. So because the feeders of this AVM was coming from the PCA, this is the perfect approach because we have the proximal control in the early stage of the surgery. If you go sub-temporal, if you go trans-temporal, the last thing you're going to see is the PCA branches. So when you do a supracerebral or trans-tentorial operation, the first thing that you have is the proximal control in the PCA. So this is very important for your strategy in this surgery. So after you have the whole control of the AVM, you're going to perform the circumferential dissection and then, sorry, I'm going to skip this. So at the end, this AVM will finish inside the temporal horn of the lateral ventricle as you're going to see right here. So this is the nidus, this is the temporal horn, you're going to see the choroidal plexus right here in the ependyma. I hope you can see in the same quality that I'm seeing here. Dural reconstruction is very important, bone reconstruction is very important, and also postoperative angiography to make sure, comparing with the preoperative, that you remove everything. When you consider a low-grade AVM, grade one, grade two, which is now called class A, and you compare the microsurgery, endovascular, and radiosurgery, you're going to see that morbidity mortality is very low for microsurgery when you compare with endovascular and radiosurgery. And also, the cure rate from microneurosurgery is almost 100% against only 30% for endovascular, 75% for radiosurgery. So there is no doubt that for low-grade AVMs, the microsurgery should be considered as the first option. When you go for the class B case, the things start to change a little bit. So usually they have a large nidus. So for cases like that, it's important to have a very good preoperative analysis with tractography, to analyze the presence of aneurysms inside the nidus, deep venous drainage like this, sorry, it's a basilar vein of Rosenthal. To compare the images from the angiography with the anatomy, this is very important to understand the anatomy when you see the angiography. This is a contralateral stilling of flow. For cases like that, most of the case, we perform a preoperative embolization and look at how the preoperative makes the surgery sometimes easier, no bleed. This is not the eye, this is aneurysms inside, thrombosis inside the AVM. But still, for those small vessels, perforating vessels that come from the deepest part of the AVM, the embolization cannot occlude these vessels, unfortunately. Look at these very small vessels right here. So this is the problem. So this is the falx, this is the anterior fossa. Look at how you can dissect it, and a very important principle is to occlude the main drainage vein as the last vessel in the surgery. You just occlude the main drainage vein after you occlude the whole complex of arterial feeders. This is the postoperative angiography, and this is the patient. It's a very good discussion when you have an AVM in the very eloquent area like you have in this case. We do what we show in the first case. We start with the brain mapping. The tractography in cases like that is very important because inside the AVM, there is no brain, especially when you have very, very compact nidus. So there is no brain inside. So the tractography is important because the nidus is displacing the fibers tract for some direction. So the tractography can show us where the fibers are, especially the motor fiber, the sensitive fiber. So this is very important for our surgery. This is an AVM feeded by MCA, ACA, a single drainage vein, which is a risk for bleeding. That patient was referred for embolization three times, and she had a large hemorrhage after the third embolization. Again, another very important principle, large craniotomy to have the normal brain around the nidus. So you can dissect the whole nidus and then occlude the main drainage vein after you dissect the whole nidus and remove the nidus. The hemostasis in the bed of the AVM, also it's very important, especially when you have bleeding coming from the deepest part. I'm finished. I'm going to skip this. I'm going to finish with this case. Look at a small hemorrhage inside the third ventricle. It's a young boy, 13 years old, sudden headache, and he was in coma, comatosis, and the MRI showed this AVM in the posterior aspect of the splenium of the corpus callosum. Feeders come from ACA, but also from PCA, as you can see here. In cases like that, we have to analyze the MRI, especially the venous part, because when you have lesions located in this area, sometimes you have difficulty to have access to the most lateral aspect because of the sinus. When you go interhemispheric, transfalsine, contralateral approach, you have the whole control, you work in front of the lesion, and again, the pre-op MRI, the venous to analyze where you're going to enter, it's important. The positions like this, to have the gravity working for you, those are the residents helping me. Again, a lot of blue holes crossing a little bit the midline, and then you have this situation. Interhemispheric approach, we're going to open the faults. First of all, we're going to find the both feeders that come from ACA, the both ACA, one right here, another one right here. Before I start to dissect the nidus, I have the control of the ACA. The only thing that I don't have is the feeders that come from the most deepest part, from the PCA, so that was the last thing that you're going to see. In this case, we have some venous lakes in the faults. We have to avoid that. This is the inferior sinus, sagittal sinus. We coagulate and open. After you open, look at, you don't need to make a retraction, the gravity does it for you, and now we're going to work in the front of the lesion. Now it's more about the same, so the approach here is the most important thing, because I don't have to make any retraction, and I have the control of everything. This lesion enters into the atrium of the ventricle, as you can see right here. This is the choroidal plexus, which you also send some feeders, and at the end, this is the callosal drainage veins, the unique drainage vein, and so this is the final aspect. I'm going to skip that and finish saying that this is a very good also meta-analysis showing that when you analyze the whole data in the literature, you're going to see that intracranial hemorrhage after microsurgery, it's very low when you compare it with stereotactic radiosurgery embolization. The complication, seven, five, six, is the same, there's no difference, but the chance of cure is 96% for microsurgery against 38% stereotactic radiosurgery, only 13% after embolization. I think the most important information here is you don't need to use those techniques separate. You have to have all of them to help the patients to achieve the cure. Most of what we talk about is publishing this very good book that I published with my dear friend Luis Borba, and this is the beautiful building of Santa Casa of Sao Paulo, and any one of you is most welcome to visit us any time. Thank you very much for your attention. Thank you, Jean, we're short on time. If you have burning questions to Jean, you can ask him during the break. Let's be back at five past two, please, for the finale pediatric session. Welcome to the pediatric section of the Global Symposium. We'll go with our first speaker, since we're right on time, Preliminary Study on the Reproducibility of Triggered EMG During Selective Dorsal Rhizotomy, Professor Zhao Bo, from China. Thank you. And good afternoon, everyone. It's with great honor and excitement for me to stand behind you today. And actually, I'm from Shanghai Pediatric Neurosurgeon. I'm so humbled to share what we have learned from our past in SDR procedures. And hope today's, my presentation, would be informative and thought-provoking. And my presentation's name is A Preliminary Assessment on Reproducibility of Triggered EMG During Selective Dorsal Rhizotomy. Actually, we all know that intra-op physiology have been applied in SDR surgery to help us to finish, to complete the rootlet selection for long. Multiple schemes have been developed. The most popular one is using trans-stimulations trying to find the rootlet which we thought to be more associated with spasticity in the lower limbs in patients with spastic cerebral palsy. The scheme, we call it EMG Response Grading System, which divides the EMG responses into five categories. The first, from zero, one plus, two plus, three plus, four plus. We only cut those with EMG responses from category two plus to four plus and leave zero and one plus intact. And I would like to show you a few examples how it works and how we interpret during surgery. And this is the imaging we got from the screenshot showing there is two columns from the right and the left showing, shows the left side of the lower limb and the right side. The first one here is adductor, femoris, hamstring, anterior tibialis, gastrocnemius, external one. This is the muscles inside and also this is gastrocnemius and internal. This is endosphincter. So based on this interpretation, we know this is a four plus because we, okay, and this is a four plus. Actually, this is the stimulation on this side. We see both EMG responses on both sides. So based on EMG responses grading system, it belongs to four plus. And the interesting thing is when we stimulate the same rootlet using the same stimulation parameters, in two minutes apart, we got this. It still belongs to the EMG response grading system, four plus, but the pattern's slightly different. So let's go to the second one. And when we give 50 hertz trans-stimulations, we only see some twitches here. In some channels, we monitored, but not much. And we repeat in two minutes, nothing. And let's go to the last example. When we give a certain rootlet of trans-stimulation with 50 hertz, we got four plus, right? It's a four plus. Both sides, we got EMG responses. But interesting things, when we repeat the same stimulation two minutes, nothing. So this actually, this situation, we happened a lot during our daily practices. It's much, much more than we could imagine. These things make us in a dilemma of decision making, whether we need to cut it or leave it intact. So we change the trans-stimulations to single-pulse stimulations. This is a single-pulse stimulation. In one second, we give one single pulse. And this is the EMG responses we got from the channels we monitored. Usually, we monitor 15 channels, including one channels for sphincter. Last one is sphincter. Actually, we start to perform the single-pulse stimulation since six, seven years back. We're using a single-level approach. At L2 level, we wrap ore, a cauda equinor, tested one by one, and trying to find out the rootlet for cutting solely based on the interpretation of EMG. This is a protocol we use during our single-pulse stimulations. We start from zero and gradually increase the stimulus until the endpoint. We define endpoint as any evoked CMEP, more than 200 microvolts, appeared in any of the channels we monitored. This is endpoint. This is a protocol we use to monitor and complete our rootlet based on that setup. I think we could find this protocol in the CNS. And that was four years ago we made that publication. So before we start, I would like to show you a few examples of cases undergone such SDR guided by the scheme. This is the first case from Japan. Actually, the surgery was done like two years back. And after 18 months, a very intensive rehabilitation program, the kid getting improvement was dramatic. And this is a second case before surgery, nine months after surgery, and almost two years after surgery. Dramatically changed. The family is happy. The kid is happy as well. This is the girl when surgery was done, was five and a half years old. And just nine months after the intensive rehabilitation program, dramatically improvement could be observed. This is the case, actually, when the surgery was done, slightly younger than five years old, hemiplegic on the right side. And let's see how much improvement we got after one and a half years in intensive rehabilitation. So let's go back to the three examples I showed you before. When we give trans-stimulations, we got this. The single post-stimulations, we got this. Let's see what's it going to be in two minutes after repetition. So this is two minutes repetition. Actually, the same things, the trans-stimulation, but even they belong to the category four. But the shapes of such patterns are slightly different. But it's exactly the same, almost more or less the same, when we give single post-stimulations. Take a look at this. OK, let's go to the second example. I said there was only twitches here. But when we give single post-stimulations, we got the responses on the left side. The second repetition, we got more or less the same responses. We call CMAP. CMAP is compound muscle action potential. But there is nothing when the trans-stimulation is given. Let's go to the example three. I said that the first time when a trans-stimulation is given, we got a four plus. But when the second time, we give the same intensity parameters, nothing can be observed here. But the CMAP is very, very, very much stable. So this is the typical CMAP we obtained during our SDR when we stimulate the dorsal rootlet of the spinal cord. Usually, it contains five faces. Some people said it's three faces. But never mind. It's a typical CMAP pattern. So I will show you how CMAP changes when we increase gradually the intensity of stimulations. Actually, this is 0.16 milliampere. There is nothing showing the channels we monitored. But when we increase a bit to 0.17, some CMAP appears on the right side of the hip adductor. A bit more, because I said the endpoint is 20 microvolts. Still not to reach that endpoint yet. So we increase, increase. OK, sorry. That has reached 20 microvolts. So we call this endpoint of this rootlet. So let's see the second root, 0.28 microampere. Nothing. And some CMAP could be seen on the right side. And now, the CMAP more prominent on the rectus femoris. increase a bit more. And this is the endpoint. This is the endpoint. We reached 20 microvolts. And let's go to see the rootlet three, 0.44. And some twitches here. More, a bit more, more. It changed the faces, but the CMAP amplitude increases. A bit more, more, more, more, more to reach the endpoint. That's it. So I said the reproducibility of CMAP is good. It looks very good. But how good it is, so we don't know. So we need to set a criteria to evaluate, to determine whether it's good or bad. That's why we made a retrospective study on our patients. You may ask, why you stimulate twice? Because our procedure 100% relies on the interpretation of such a EMG evoked. So to be on the safe side, usually we stimulate twice to make sure we don't make any mistakes. We collected the patients in 30 patients, 131 rootlets. In our current study, we made a criteria to select patients and rootlets. And the most important thing is this. At least one non-sphincter-related dose or rootlet have been stimulated at least twice within interval one to two minutes. Sphincter-related rootlet means when you stimulate the rootlet in the sphincter monitor channel, it first appeared CMAP. We define it as sphincter-related. So the focus of current study, we compare CMAP patterns at the endpoint between the first trial and the second trial. Thus, we set up two criteria to make sure they are, the reputation is good. The first is whether the greatest EMP amplitude appears all the time at the same channel. The second is whether the channels with the top three greatest evoked EMG amplitude between the first and second channels at the endpoint are mostly the same. So let's see what happens. The results, actually, we found our results matched each other between the first and second was excellent, just excellent. Of course, there are some mismatch, but very few. This table is showing the detailed comparison of two characteristics of the electrophysiology at the endpoint in the first trial and the second trial. Pay attention to the last one. This is the last part to emphasize the distribution of CMAP between the first and second trials, how they match to each other. Oh, shit. Sorry. OK, so let's see. Actually, this is the first one and second. So actually, I just want to see how good the reputation is. And this is the same intensity injection. We got more or less the same. And also, this is the figure. We are finishing our paper, and now it's at the stage of English editing. This is the figure we put on paper. And when we put all the CMAPs from the onset to endpoint of one certain trial together and compare the first trial and second trial, looks like excellent. So we have so many data collected. Actually, at the beginning, we did not realize that the value of the data. Now we start to know, actually, that the pair of the data is important and extremely important. And of course, we can use the data to optimize our surgery. And also, we can find more, understand more what happens in the spinal circuits in this particular population of patients. And I'm Dr. Xiao from Shanghai. This is my email address if you have anything. Do not hesitate to contact me. Thank you. Thank you very much. We'll save questions for the end. Okay, we'll save questions until the end Okay, so the theme of the meeting this year of course is neurosurgeons as advocates and there's probably there's tremendously talented people on this year's Billet, but there's nobody that lives up to the notion of being an advocate More than the next speaker, and I think you'll you'll see why at the end of his talk This is my friend and colleague Kamel Ghatmeh from Colombia Title of the presentation is folic acid fortification to prevent spina bifida a labor of love and a public health mandate Thank You Jeff and David, thank you to dr. Marcos and W and A's and the organizing committee for including this relevant topic during this symposium This is our agenda for today, we're gonna See how we can bridge Chasms in knowledge and we how can we go from knowledge to action through advocacy? Data driven advocacy and why this is a labor of love and how we can make it a public health mandate Did you know that? New knowledge takes 10 to 15 years to be applied in real-life scenarios like in the clinical office or in hospitals Etc. What if I tell you that one particular piece of knowledge? Has had robust evidence for more than three decades and still thousands of children are not getting the benefit from that. I want to tell you a story of Colombian patient Francisco he was born with a large lumbosacral myelomeningocele and The next 24 hours. He underwent a successful surgery because even operated on this prenatally But Francisco's mom didn't go to a consult early enough to be candidate for this procedure and Even though he did perfectly well During his lifetime. He's gonna face multiple interventions and multiple complications such as hydrocephalus Chiari spinal deformities bowel and bladder Problems tethered cord limb deformities walking disabilities and many Re-hospitalizations due to different procedures in addition to that He might have psychosocial issues including poor access to quality education and work Independence are alive with full feeling relationships, etc three of every thousand babies are born every year in the world with one neural tube defect that can go from very severe and lethal cases such as anencephaly or to Less severe cases such as spina bifida occulta and that's just the tip of the iceberg Because as you can see here, we are counting on only living birds, which is 185 Thousand cases per year, but we are not included in the statistical data misclassified neonatal deaths stillbirths elective termination that accounts more or less 60,000 per year and early fetal losses that could be due to this reason We all know that neural tube defects are preventable in a majority of cases and we can do diet diversification for that But the problem in low and middle-income countries is hunger and very poor access to quality food. We can also do as a clinical practice guideline folic acid supplementation that prevents many of the cases However, less than 50% of pregnancies are planned and less than 4% of women in reproductive age actually take oral supplements And that happens when they get to a pre-conceptional clinic and is usually not the case for many many context And as a public Health policy level we have large-scale folic acid fortification of staple foods These three strategies are not exclusive. They are complementary and they we need to continue working in all of them so mandatory food fortification is Practical because it improves the level of folic levels in women of reproductive age Before they get pregnant and they don't have to make Behavior change by start taking pills. It's safe because there are no harms demonstrated with the levels that we use for food fortification It's feasible because countries do not have to invest in Costly machinery or infrastructure. They just have to add a pre-mix of micronutrients to the product and it's cost-effective because fortifying one ton one metric ton of Flour costs only six dollar but saves millions in resources and thousands of lives In addition to that it has social impact because it can help countries to achieve the sustainable development goals goals by 2030 Especially number two zero hunger number three health and well-being and number ten reviews inequities because there is nothing more Inequitable that being born with a disability when this could have been prevented The good news is that in the world 62,000 babies are protected every year with large-scale food fortification The bad news is that is less than a quarter that we could prevent and we can do better The reason is that in the world 92 countries have enacted a policy for Mandatory fortification of staple foods and from those only 62 included folic acid in the in the micronutrient preparation So we know all that and how do we bridge that gap? Because that gap is harming people in the public health Environment but also in the clinical setting so we need to close that and then we have Translational science that allow us to translate knowledge to those key decision makers to make that science Digestible so they can understand it and use it And how do we facilitate or accelerate its use then comes an advanced form of knowledge transfer That is science diplomacy where we can collaborate to address common problems exchange knowledge and build Partnerships I Want to introduce to you kingdoms model is the multiple streams model for policy dissemination. So when a problem such as neural tube defects And the policy which you already know large-scale food fortification merge with the political stream the political will then a window opens and that's where us as Advocates a scientist as knowledge brokers can make an item to enter the agenda of those policymakers and that What we tried with the new advocacy toolkit in 12 in 2006 in Santa Cruz, Bolivia the Latin American Society of neurosurgery with the pediatric chapter make the declaration of Santa Cruz which stated that neural tube defects are a Preventable social problem and the governance of the region should support food fortification policies and During the years they have been working to achieve this So as you can see here in the 20 Latin American countries, they have a mandatory policy in place to fortify wheat flour however, most of the vulnerable people eat different products because of cultural, ethnic reasons, or because it's the only thing that they can get. It should include cassava, which is mandioca in Brazil. It should include rice, corn flour, and other products. And you can see here a positive deviance, which is Costa Rica. You probably don't see the green color here, but Costa Rica has the lowest prevalence of neural tube defects in the world because they have successfully implemented fortification policies. They actually fortify all of the basic staple foods and they always include folic acid in it. During the doctoral research, we found barriers and facilitators of why the countries are not implementing this. And one of those is that policymakers simply don't know that this is a public health problem and it's in their hands to take action to change it. And as facilitators, partnerships between academia, professional societies, such as the one that is gathering us here today, and advocacy and leadership from neurosurgeons and professional organizations that can actually convey the message because we have knowledge of what these patients have to face during their lifetime and because we have a good standing in society in most of our countries. So that's how we can bridge the chasm between all of this knowledge and translate it to populations to actually change public policy. And that's how we developed the Neural Advocacy Toolkit, a toolkit that has different components including pitch deck to make an elevator pitch in less than five minutes to talk with the policymakers, an infographic fact sheet, and evidence brief in a very lay fashion to make it very understandable for those policymakers, which usually don't necessarily have a medical background, and an executive summary of successful legislation. This toolkit was introduced to all of the pediatric neurosurgeons in Latin America through in-person and virtual meeting. And from those, more than 500 pediatric neurosurgeons, we selected 30 key opinion leaders, at least one per country, and they started using, assessing, and disseminating this innovation. They described some attitudes toward using the toolkit, such as motivation, engagement, intention to act, and they also identified potential drawbacks. But I want to emphasize having empathy with those individuals that have to face the scourge of living with congenital disability, and also the awareness of how this can impact even through the adult life. We discovered ideal channels to get to the policymakers. What would be the ideal initial approach, and how would we make a follow-up? We also described challenges and strategies to overcome that, but using a knowledge transfer toolkit was one of the most powerful tools that we could use to make that possible. Then it was disseminated through the countries, and of course I had to start with my home country, Colombia, and this was presented to the Ministry of Health. And Colombia is now working in updating the previous resolution that fortified only one staple food to fortify all of them. It's in the last stage of approval. But then, with the support of multinational organizations and the Colombian government, there was the decision to make it global. We had an ICPA statement in 2021 calling all governments to encourage large-scale food fortification, and, inspired in Godfrey Oatley's work, Dr. Rousseau and Dr. Blount founded GAPSBI. It's the Global Alliance for Prevention of Spina Bifida. In addition to that, they wrote a paper in 2018 that was seminal for my doctoral work in which they explained why we, as neurosurgeons, should be advocating for this. In addition to that, Dr. Rousseau ended up being in my dissertation committee for my PhD in translational science. So Colombia decided, as a member of the Executive Board of WHO, to sponsor the resolution. So they started socializing this last year in May in Geneva, and it got all of the support, endorsement, and scientific advice by GAPSBI. During the World Congress in Bogota, members from the WFNS, WANS, CNS, ISPN, and GAPSBI gathered to start a strategy that was top-down and bottom-up, targeting high-profile government officials from Colombia and also mid-level technical officials at the Ministry of Health to explain the importance of this and how they could take action. We had different meetings with the Foreign Affairs Ministry and the Health Ministry, and we jointly designed a diplomatic route map to move forward the initiative. We had different meetings with WHO officers to refine the language, exchange knowledge, make sure that vulnerable stakeholders would be protected, and identify sensitivities. And we reoriented the focus of the resolution from being only folic acid and neural tube defects to all micronutrient deficiencies and congenital malformations and chronic conditions related to that, and not only folic acid but all the micronutrients. We actually walked the talk in Geneva. During the physical dissemination of the roadmap and the knowledge in different activities in Geneva, we navigated with the roadmap that was established. We had a formal statement made by Priyanka Mathur. She is a Northwestern University medical student, and she represented WFNS, ISPN, G4 Alliance, and GAPSME. I want to tell you the case of Ethiopia. They have 120 million inhabitants, and they have 40,000 cases of neural tube defects per year. Half of them die very early, and 10,000 of them have spina bifida, and they have limited neurosurgical staff, and many patients die or are left without treatment, despite significant efforts by the government or NGOs such as REACH and other foundations. So we actually had a meeting with the Ethiopian Ministry of Health, who happens to be a gynecologist, and they were already working on that resolution, but they ended up that was the final impulse they needed, and they already have promulgated a policy for food fortification. The mathematical model showed that in three to five years, they will have 8,000 cases less of spina bifida than neurosurgeons in the eight university hospitals can actually deal with. So Colombia made some more diplomatic sessions with scientific advice, and this is the final resolution accelerating efforts for preventing micronutrient deficiencies under consequences through safe and effective food fortification, and it was endorsed and presented by 35 countries led by Colombia and by 70 civil society organizations, including WANS. Finally, it was an agenda item in the executive board in January, and it was approved without any objections. So it will be voted this upcoming May in WHA 76, and after that, that's not the end of the process. That's just the start. We need to work on implementation, surveillance, sustainability, knowledge transfer, translation, and use. We need stakeholders' engagement by policymakers, the middle industry, consumers, and, of course, healthcare professionals, and low- and middle-income countries are going to face challenges to implement that, so we need finances as well. So the World Bank cannot be involved at this stage because they have to be neutral with all the shareholders, but they have expressed their intention to help LMICs after the resolution is passed. So as a conclusion, we can transform our role from passive stakeholders to active change agents. We need to identify barriers and facilitators. We can convey strong messages as neurosurgeons to crucial decision-makers, and advocating for primary prevention by no means implies that we decrease all of the efforts to provide quality, humane, and person-centered care to individuals like Francisco that live with neural tube defects. And quite the opposite, they inspire us to find innovative ways of incorporating meaning in our careers, and that's what advocacy does, and we should be inspired to do something beyond the surgical theater or the clinical setting in terms that we can impact more systemically. So this is the call to action. In your country, find who's representing that state in WHA. Seek an in-person meeting with them. Use a knowledge transfer toolkit. We can provide all of those resources in English and Spanish and some other languages, and invite to vote yes to the initiative but also make a statement supporting the resolution and already telling what they are doing right now for food fortification and primary prevention. Have your organization sign the endorsement letter if they haven't done so yet and join us in May in Geneva for multiple events that we're going to organize related to WHA 76 and can analyze effort from multiple stakeholders. And the ultimate goal is to save thousands of children from being born with a devastating condition but a preventable one promoting a healthy and fulfilling start of their lives. Thank you so much. Thank you. We're going to save questions until the end. The next speaker is Amal Abu-Hamdan speaking on pediatric AVMs. Thank you. It's a great honor to be here and amazing tour de force and impactful work there, Camille, to follow. All right. So my talk is on surgical, well, really multimodality treatments of pediatric AVMs. So we're coming back into the wire wearing scrubs from all these policy meetings that Camille referred to and back to dealing with this beast. I'm both pediatric and cerebrovascularly trained, so I'll be comparing our experience with both the pediatric AVMs as well as with the adult population. So what's the difference between an adult and a child in terms of the AVMs? Reported higher incidence of hemorrhage in children, higher mortality rate tend to be deeper in location and more infratentorial locations, slightly higher re-bleeding risk, lower risk of associated AVMs and of seizures. And, of course, from a practical point of view, dealing with the surgical risk of a child with a small blood volume and the risk of bleeding intraoperatively and sometimes with the smaller children, just the challenge with any endovascular work that's associated, for instance, with the preoperative embolization. Why do they bleed more? Theories there about active angiogenesis and remodeling increase VEGF. The greater propensity to recur after excision, of course, that makes it even more critical to have careful follow-up and potentially the deeper locations with the higher pressures. In children, unlike in adults, really, if we see a child with a hemorrhage, intraoperative parenchymal hemorrhage, that's an AVM until proven otherwise. And with a small percentage of patients that have genetic conditions associated, such as HHT, but very high rate of presentation with hemorrhage and less commonly with any seizures, focal deficits. The cardiac failure tends to be more with the vein of gallen malformations, but that's not the topic of this talk. Another aspect to this is, you know, we think of them as congenital lesions, but the anti-congenital hypothesis is the growing number of cases of de novo formation of AVMs that are described. And really, we're doing increasing number of prenatal MRI scans and ultrasounds, and we don't seem to see those as often as we would expect it for the incidence of the AVM. So potentially acquired in a percentage of these. And neonatal AVMs are rare. So looking at our case series in Adelaide in South Australia for the pediatric, start with the neurovascular workload review. So this is retrospective series review of prospectively collected series. So just putting it in context here, of all the vascular, cerebrovascular work, the AVM work really constitutes the majority. And that's both surgical as well as diagnostic and interventional. Again, mainly preoperative embolization rather than pure treatment. In fact, we haven't had a single AVM that we treated purely with EMBO. So from the surgical point of view, again, almost half of our vascular workload in children is for AVM surgery. A very small percentage of interventional INR work, but a lot of diagnostics and assessments of these AVMs. So stepping back now to evidence, unlike the evidence that Kemal presented on the fortification with spina bifida, really we don't have great evidence. If we want to go by a sort of randomized control trials, there's obviously been the ARUBA trial, but that was for adults and multiple problems with that. So not only is it for adults, but very small percentage of patients that had the grade one and two AVMs, which would ordinarily be considered low morbidity surgery. And multiple other issues with it, such as a very small recruitment and no minimum number of AVM surgery or surgical expertise for the sites that were recruited. So since then, there's been a number of centers that have published their series showing safety and efficacy of microsurgical treatment of arteriovenous malformations. This is mainly in the adult world, but also series in children. So here I will review a sort of comparison now between the adult work and the pediatric caseload, looking at, for the adults, certainly patients that would have qualified for ARUBA or were ARUBA eligible. So for the adult population, there were more presentations with ruptured AVM than unruptured for our surgical series, and slight preponderance of males in the hemorrhagic presentation. In the pediatric population, also more presentations with ruptured rather than unruptured, and slight male preponderance in the ruptured series. For the unruptured group, in the adults, the main presentation was headaches and some unusual presentations with trigeminal neuralgias, etc. But for the pediatric unruptured group, it was mainly headache, followed by seizure and incidental finding in a handful where the MRI scan was done for unrelated reason. This is an example of the sort of case that we'd see in adults for two reasons that we don't see in children. So this is a lady who'd had really drug-resistant epilepsy, told this was inoperable. And you can see with, you know, years of presumably microhemorrhages contributing to this massive varices and the contribution to this epilepsy. Anyway, it was thought to be inoperable because it's a grade five, but when you carefully interrogate it with an angiogram, it was really a grade three AVM. And with no preoperative embolization and really the careful microsurgical technique, this was resected and good outcome was achieved. Now, contrast this to a child with this AVM in a parietal lobe that presented with a single seizure, spetzelmartin grade three. And presentation always given to the family for radiosurgery or microsurgery plus or minus preoperative embolization. Didn't think any preoperative embolization was needed here and microsurgical resection was performed. With the standard technique, really this is where the adult and pediatric work is very similar. So this is not tumor surgery. You work in sulci. You identify the feeding arteries in the sulci. You place temporary clips remote to the AVM. And then once you've got control of those, then you start working around the actual nardus in a circumferential manner and not ending up in a deep, dark hole in one particular spot. As you get deeper, there is the more friable vessels. And even more important that you have good exposure and often these don't respond well to standard coagulation and need AVM clips for good control and good resection and good outcome. Another example of presentation with headaches. This is not your average headache. These are recurrent migraines presentations in a young lady. And every time she presented to ED with severe headaches, she would have a scan. And, again, no hemorrhage at any stage. But this pretty much lower occipital AVM. This is the preoperative angiogram showing us Bessel and Martin grade IV. AVM quite diffuse. And some transcalvarial feeding through the external circulation. Now, nothing minimally invasive about AVMs. This is, you know, something where you need wide exposure. And, again, circumferentially working around it and delivering it. She did have a homonymous hemianopia, but migraines completely resolved. And I see her often on my weekly hike at a local mountain. Well, hills compared to what you have here. So just a note on these things. There was a paper from Toronto during my time there of really the high incidence of migraines with occipital AVMs that respond fairly exquisitely to resection. Now, back to the ruptured. So how do they compare the adult and the pediatrics? A good proportion of patients who present with sudden collapse and poor GCS, probably slightly higher in the pediatric population. A handful of focal neurological deficits. But a couple of those really because of lack of awareness that strokes can occur in the pediatric population. Some delay to getting to hospital. Whereas with awareness and education on strokes in adults, you know, coach stroke, you get to hospital stat. But working on awareness of that. So location, there was slight preponderance of frontal location for adults for the hemorrhagic presentation. But really for kids, it was fairly equal distribution frontal, parietal and slightly more temporal. Less aneurysms, both intranodal and proximal aneurysm in the kids compared to the adults. Presumably not enough time for those shear forces to cause those AVMs. And mostly grade 1s and grade 2s. But a small number of 3s and 4s in both. Quick example of, you know, a young man who came in extremist with collapse, GCS3, fixed dilated pupils. This is initially a life-saving surgery. No time for any angiograms. Just a CTA that tells you, yep, sure enough, the odds are there's going to be an underlying AVM there. and taking him to theatre for a decompression and evacuation of the hematoma, enough time to recover, and then in the light of day, coming back for resection of the AVM, and achieving complete resection with prolonged recovery, but ultimately, apart from mild cerebellar symptoms, practically complete recovery and going back to normal life. So this is from coming back from fixed dilated pupils. This is another young man from the adult hospital, just as a dramatic presentation with drop in GCS and pupil fixed and dilated, tiny grade 1 AVM, but no less morbid when they do bleed, and again, hematoma evacuation, we didn't know where the AVM was at the time, it was all just an emergency in the middle of the night, and then Angie Graham later showed it and came back for it. Just a word about preoperative embolisation, we use it very carefully and judiciously, obviously risk with onyx of escape into the veins and risk of hemorrhage, so one has to be very careful with those, and really asking ourselves why do we need the preoperative embolisation, the idea is to reduce the morbidity and the risk of the procedure, not to add to it. There's very high complication rate reported from it, so we really reserve it for cases where it's going to aid with some of the deeper feeders that would be encountered later in the case, so the idea is to. Another example where preoperative embolisation was carefully utilised with complete resection, back to the ruptured about less than half where it was done as an emergency in the middle of the night, so whilst you do need to do life saving procedure, you do need to be prepared for the possibility of the AVM rupturing at the time and therefore having the right exposure to be prepared for complete resection. All of those, whether it's adults or paediatric, we use what we refer to as the Morgan protocol based on his publications of the significant reduction in the delayed hemorrhage following resection of AVMs, particularly the high grades, when that was employed it was significant reduction in the rate of postoperative hemorrhage. This is with complete resection of AVMs, which of course has to be confirmed with DSAs. Just note the superb outcomes for the unruptured and even the ruptured, only one was in a dependent state, so more favourable than the adult population. Follow-up is critical, both adults and kids, but particularly in kids with a much higher follow-up rate, so if we are doing this to improving on the natural history, obviously it's not just a matter of operating but making sure that we check for any recurrence early. So final remarks, whilst optimal management for paediatric AVMs or AVMs in general really remains controversial, given the lifelong risk of bleeding and the significant deficits and mortality, it's critical that we maintain this multidisciplinary approach and the microsurgical skills work within multidisciplinary centres, judicious use of pre-operative embolisation and judicious use of protocols in ICU care, particularly for the ones greater than, for the higher grades. And so this really just adds more to the evidence of the safety of microsurgery for the management of these patients, both paediatric and adults, but the critical importance of long-term follow-up. We've had one so far recur, but obviously you don't want to miss one when you have already achieved cure. So importance of maintaining our surgical series, possibly even in combined prospective registries in the absence of clinical trials to support our practices. Thank you very much for the opportunity to present today. Fantastic talk. Tremendous. Again, in the interest of, because we're giving the speakers, the speakers have run a little over, but these talks have been great, so we're holding questions for the moment. Graeme Feagin will give us our next talk, Global Issues with Paediatric Neurosurgery. Thanks very much, and a special thank you to Dr. Morkos and Dr. Nitevich and Dr. Strunk for the invitation to be here, and a special thank you to the audience. I've been at a number of these international symposia. I've never seen such a big audience, so clearly something got right this time, and fantastic to see this continue in the future. So given the fact that kind of the whole, I guess, ethos of this meeting is really positioning AANS in terms of the new global strategy, I thought it might be helpful to look at paediatric neurosurgery from a bit of a global lens and try to understand what the particular value is of paediatric neurosurgery as a discipline. No particular conflicts of interest, and although I speak from Africa, I certainly did not profess to speak for Africa. So I think we're all familiar with these figures. The bottom line is, as neurosurgeons, our jobs are secure. The world is short of neurosurgeons, and just to make up the 5 million unoperated cases, we need something like 23,000 new neurosurgeons to be trained, and that obviously has tremendous implications in terms of our different training schemes. When you look at paediatric neurosurgery and this work, just to credit Michael Dewan, who really did some phenomenal work four or five years ago trying to quantify these numbers, paediatric neurosurgeons comprise about 4% of all the neurosurgeons in the world. There's a tremendous maldistribution, around 80% of all qualified paediatric neurosurgeons are in high-income countries, and when you look at low-income countries, particularly in Africa, you have a ratio of approximately one trained paediatric neurosurgeon to 30 million children, so that's clearly an unworkable ratio. When you look at distribution of care in terms of emergency care and elective treatment, in many, many countries, children who require elective surgical care for neurosurgical problems have no chance, really, of seeing a paediatric neurosurgeon. Does it matter? Well, certainly if you live in low-income countries, it is most definitely seen as a problem, so that's something we need to pay attention to. So I'm going to just give you a few thoughts from the southern tip of Africa, from South Africa. I'm privileged to work at a children's hospital, Red Cross Children's Hospital, in Cape Town, but as part of a kind of multidisciplinary team, and I think we just saw from Amal's beautiful talk that it's really incredibly important that paediatric neurosurgeons function as part of the ecosystem with the rest of neurosurgery, and I think that's when paediatric neurosurgery really thrives. Just to mention, I really enjoyed Dr. Shah's presentation and the attempt to really refine selective dorsal rhizotomy. One of the really important points that we've learned very profoundly in Cape Town, Warwick Peacock, who was really the person who drove the rediscovery of rhizotomy in the late 70s and early 80s, we have the joy of following up Warwick's patients 40 years later, and these young children who are operated in the 70s and 80s are now aging adults, and it really kind of unlines the fact that what you do in children, you kind of have to factor in that they're going to survive for an awfully long time, and really have to be sure that what you do is as evidence-based as possible. So as neurosurgeons caring for children, I think Dr. Blount spoke very powerfully earlier about the ISPN and the relationship between the ISPN and different global organizations, and really it's about the children. It's not about us as professionals. One of the really, I think, very enticing things about paediatric neurosurgery is, in many respects, it is kind of the last refuge of the general neurosurgeon, and that it covers such a wide spectrum of different conditions, but within paediatric neurosurgery, there are very exciting kind of subspecialties developing, such as paediatric functional neurosurgery. No question, and I think we've seen a few times today already, that there's some really amazing technical challenges, so it's certainly not a field devoid of excitement in the operating theater, but teamwork is really essential. And I think one of the points one has to reflect on, if only 4% of neurosurgeons in the world are actually qualified paediatric neurosurgeons, what is it that distinguishes a paediatric neurosurgeon from a well-trained general neurosurgeon looking after children? I think there are a few things that philosophically are important if you're a paediatric neurosurgeon. One of them is really paying very close attention to clinical assessments and thinking very carefully about whether you're going to do imaging, because it's always more difficult in children. Probably the most important aspect is thinking about development, and it's not just development of the nervous system, but also thinking about development of the musculoskeletal system and all the other organ systems, and really thinking long-term, understanding the goals of treatment. And you can have a baby that's born with a really devastating condition, but you can actually really bring incredible meaning and quality of life to that family in treating that child appropriately. But the reality check for me is that well over 80% of children in the world who undergo neurosurgical procedures are not being operated on by paediatric neurosurgeons, so we need to really kind of make sure that they are getting the best quality treatment. There are a lot of things I've been in practice now for nearly 30 years, and there are a lot of things that have really changed our practice over the last 30 years. I want to touch on just a couple of them. Just to acknowledge my colleague in Cape Town, Tony Fugazi, who has really done an amazing job of pushing forward multimodality monitoring, and this has really changed the face of traumatic brain injury treatment. The calamity, though, is that we have this kind of technology in Cape Town, but throughout most of low-income and middle-income countries, where the vast majority of children, and adults for that matter, sustain traumatic brain injury, we don't have this kind of technology, and that's something we really need to address. Kamal just gave us an absolute masterclass in advocacy and turning advocacy into action. I'm not going to say too much about spina bifida other than this probably is the emblematic condition of paediatric neurosurgery, and we hope that the incidents will plummet following the World Health Association resolution. It's a fascinating condition because the way in which we've approached it and treated it has really changed over the decades, and certainly one of the most powerful impacts of fetal surgery, I think, has been renewing the sort of focus on giving these children the kind of treatment that they require. We've heard about the impact of folic acid fortification. We've heard about the incredible power of advocacy, and I think the most impressive thing about Kamal's presentation is not just advocacy, but really translating that into policy action and really making a difference. Just to touch very, very briefly on closed dysraphism, which is, I think, one of the most fascinating aspects of paediatric neurosurgery, I was incredibly disenchanted as a kind of young consultant operating on these kids. I really thought that our outcomes were terrible, and was a very early adopter when Dachling Pang came along with his approach of radical resecting these lipomas, and it's a beautiful operation if you approach it in the way that he's advocated. It's not a complex operation, but it's certainly an operation that I think is incredibly rewarding, and one that any well-trained neurosurgeon can do with some very basic intraoperative neurophysiological support. The results are very, very rewarding. As you can see, resecting that lipoma, you've got the spinal cord lying free there, and a much better chance of a good long-term outcome. Obviously, that kind of situation is ideal, and I'll just give you another case. Here's another kid with a lipoma, and as you can see, once you've resected the lipoma, the spinal cord lies free in this kind of CSF-filled sac. You've got a very good chance of that child not retethering and not requiring further surgery. So there really are some really interesting technical challenges in paediatric neurosurgery, but I think the most fundamental problem is to make sure that the services we can offer get to where the kids are. So we know where the children are, and that's largely now in Africa and in Asia. Most of the children's hospitals in the world are not in those parts of the world, and it's incredibly salutary to reflect that by 2100, half the children in the world will be African, and there are virtually no dedicated children's hospitals in Africa. And this data is real. I mean, there's no question that the growing population of Africa with the median age of many African countries well under 20 means that as paediatric neurosurgeons, we really need to pay attention to this rapidly growing population. And by 2100, five of the ten most popular cities in the world are going to be in Africa. So we really need to make sure that those cities have the facilities required to look after children. One of the most rewarding parts of my career has been participating in the training of a lot of really wonderful colleagues from across Africa who've gone back to their countries. Probably the best example is in Uganda. We've had a partnership with CURE Children's Hospital in eastern Uganda and Mbali, which is now getting to a point where they're going to be able to offer world-class training within Uganda. So it is about education. Nels Mandela was absolutely correct, but there's a bit more to it than that. And when Kate Drummond spoke earlier today and said that the primary focus of global neurosurgery needs to be education, I'd completely agree with that. But that's not the end point. And I think the real end point is leadership. And I think that is the most powerful tool that global surgery and the whole global surgery movement I think gives us and gives our trainees is understanding of leadership and how we can make a difference in healthcare systems. So the Lancet Commission, we all know this. We all know the impact it's had. We've been very fortunate in Cape Town recruiting Salome Maswimi, an obstetrician who's led global surgery within our Department of Surgery. And the most powerful aspect of the work that Salome has done has been recognizing, and this is working with people the length and breadth of Africa, the incredible impact that leadership has. And I think Kamal's talk once again showed that once you engage with policymakers, once you engage with politicians, once you have agency as a specialist, you can really start to make a difference. So leadership is what it's about. And that's very much kind of the key aspects of the approach that we have to global surgery now in Cape Town. I want to end off with just a couple more comments. So if you look at the current status of global surgery, I think there is a worldwide acceptance of the fact that the kind of center of gravity really needs to shift to the communities in which this really makes a problem. And the notion of kind of decolonizing global surgery, and I think Kate really touched on this quite powerfully earlier today, is a very interesting statement that came out of a Congress on Research Integrity that was held in Cape Town last year, really addressing this in quite a, I think, quite a reflective way that actually there are many ways in which our academic practices reinforce privilege and maybe mitigate against really growing capacity of colleagues in less resourced countries to really have the kind of careers and the recognition that they deserve. And when we have the World Congress in Cape Town later on this year, we're going to look at this in relation to neurosurgery. Just the last couple of comments, I think one of the most powerful messages we need to give the next generation is our opportunities as neurosurgeons to advance research, and it's most definitely the case in Africa. We were part of a really exciting venture with the Wellcome Trust, which is a very big research funding organization, looking at neuroscience in Africa. And when you look at the real strengths, and I think this will obviously apply to all developing countries, the real strengths when you're looking at developing neuroscience research largely relate to the conditions in which children grow up and the different conditions that children are going to develop. And there's some real opportunities to do world-class research that's actually going to make a difference and contribute to science throughout the world. So in summary, I think we're all secure in our jobs. The world certainly needs more of us as neurosurgeons. For anybody considering a career in pediatric neurosurgery, I think those of us who are in pediatric neurosurgery will all attest that it's a dynamic and evolving specialty with a massive unmet need for pediatric neurosurgeons around the world. And I think global surgery, if anything, is just really sharpening our focus on what we can offer. So all of us who are here are only here because we've got colleagues back home who are doing the work, so just acknowledge everybody back in Cape Town looking after things. I just want to end off with a brief message to hopefully encourage all of you to come to the World Congress in Cape Town in December. One of the themes we really want to focus on is something that Archbishop Tutu used to talk a lot about, and that's Ubuntu, the sense in which we're all human beings through our relationship with others, and none of us functions as an individual. And I think that's a very powerful kind of mantra almost for the global surgery movement. So please make a note of the dates. Abstract submission opened a couple of months ago, and registrations opened. If I've got a minute, Jeff, can I just quickly show a video to try and entice you to come to Cape Town? For those of you who have not been to Cape Town, it's quite an attractive place, and we'd love to have you join us. I've had the pleasure of attending every WFNS meeting since the wonderful meeting in Sydney in 2001. Since then we've had fabulous meetings in cities like Marrakesh, Boston, Seoul, Istanbul, and now in Bogota, which really have helped to build the World Federation into the incredible global community it is today. Those dates changed, by the way. The scientific legacy within this Congress and the fact that it's been hosted in Africa is quite significant because neurosurgical research is very underrepresented within our continent. So having this Congress here will allow a lot of young neurosurgeons and older neurosurgeons to be able to come and present their work. So my goal is to develop a platform for neurosurgical research, collaborative research, across centres all over the world. 90% of the disease burden across the world occurs in areas that only account for 10% of the research. And so those results of very, very good clinical trials that get done in high-income countries aren't relevant to where that 90% of the disease burden is. Our goal is to try to change that. And if that could be the one legacy from our meeting, it would be that. One of the most amazing things about Cape Town is the sheer diversity of the scenes and activities that you can engage in in Cape Town in such a compact area. For many people that have not come and seen the African continent, this is a perfect opportunity to firstly attend the Congress, but hopefully also bring your family and then have a holiday afterwards. We are a dynamic, diverse country with 11 official languages and a lot of heterogeneity. So people can enjoy cultural experiences based on the history of South Africa. So we're hoping to be a bit different to other Congresses where you can come and have the scientific experience, but also feel comfortable enough to bring your family along and have an introduction to Africa. So we hope that as much as you learn scientifically, you utilise the opportunity to actually, for many, have their first time in Africa and also just have a true African experience. So I think the single most important thing we would like to achieve this year, and we really need your help in doing this, is to save the date. A successful World Congress is essential for the future health of our profession. And the only way we can achieve a successful Congress is through your help. So please save the date and plan to be here. Thank you.

microsurgery

arteriovenous malformations

AVMs

natural history

risk factors

treatment option

lower-grade AVMs

advanced monitoring techniques

individualized treatment plans

pediatric neurosurgery

global issues

shortage of pediatric neurosurgeons

multidisciplinary teamwork

surgical treatment of children

evidence-based guidelines