Good morning, everyone. I will try to explain you just a little bit my philosophy before to show you the technical considerations and especially to show you movies. More and more, what I would like is to see patients early in order to remove more tumor and preserving the quality of life, knowing that 90 percent of patients I can see have a low gray glioma or just intermediate glioma, so enjoy a normal life. And this is very important because what I have in mind when you will see movies is that I can change radically natural history of the tumor by performing a complete or supra-total resection and then to increase significantly the median survival more than to double them. But I know also, thanks to George Hochman, that there is a very important anatomal function on variability. So I should do mapping in all cases. Explaining why, this afternoon I will show you some talks with other typical considerations and neuroplasticity explaining why even in the right non-dominant hemisphere I will perform weight mapping with cortical and subcortical mapping. So it means that thanks to this individual functional anatomy, first of all, I do not perform biopsy. Before, I will go directly to the OR in order to increase the extent of resection, even in so-called eloquent areas because you will see that it does not exist. It's a network with the possibility to see reorganization within this network if you deal with the brain in this patient at this moment. Now technically speaking, this is the reason why I perform a sleep-awake, a sleep mapping in all cases with very strange parameters because 60 hertz, but in all cases from one to four milliamps, maximally, most of the time, between 2 and 2.5. It's enough in order to obtain a positive mapping in 100 percent of cases. Of course, it's very important to have a very good team. And neuropsychologists and speech therapists are absolutely crucial in order to give you a real feedback online every four seconds and not just yes, no, but to have a real cognitive assessment online. Of course, we have the habit to adapt the tasks according to the quality of life of each patient because more or less you can do what you want in 2D or not only to map movement, some other sensory function, visual function, language, but also executive function, high-level cognitive function, emotional process, and so on. So we should deal with the patient before surgery. And the first goal is, of course, to avoid hemiplegia and aphasia. And really, I touch wood, but the rate of hemiplegia I had these past 10 years is zero. But what I want is more because most of patients are pushing me in order to increase their quality of life because once again, they are coming while they had just one seizure or more and more incidental discovery. So what they want is really to continue to enjoy a perfect normal life, including working full-time. Otherwise, it's a chess. Very frequently, people coming to Ompollier are asking, have you a battery? We should administrate in 2D or according to the location of the tumor. Then we publish this paper, and according to the lab, we say we can use this battery of tasks. No, you should forget that. Most important is to say that the battery should be adapted according to the functional boundaries you will encounter into the depth, namely the pathways, because you can see that if you remove a frontal tumor, an insular tumor, a temporal tumor, an occipital tumor, in all cases, you will be into the contact of the inferior frontal occipital fascicle. You should imagine that in your mental imagery in order to have the good task at the good moment, not related to the location, low-barrel location, but related to the subcutaneal connectivity. Because if you cut it at the end, the patient will not completely recover. I know it's a technical speech. Nonetheless, now you will see movies. It's exactly what I have in my mental imagery in order to avoid to use neuro-navigation or intraoperative MRI. I mean the goal is to know the functional anatomy and, of course, to adapt this knowledge at the individual level. And, of course, I will explain this diagram this afternoon during the talk about hydrotherapy. But it's exactly what I see in the morning when I come into the world. So it explains why I try to do every day resection of a part of the brain according to functional boundaries at the individual level, both cortically and subcortically. So it explains why I don't use microscope. Otherwise, I will lose the 3D representation in my mental imagery. I do not use intraoperative MRI. I have no, but I don't want, except for maybe research, but I would like something more exciting. I don't use neuro-navigation because the shift and because I know where are the fibers. I don't use electrocorticography because I have no seizures. Definitely, we published recently in World Neurosurgery, a prospective studies based on 400 cases just performed the past five years, and the rate of seizures is 3% just partial seizures, 10 seconds, no aborted surgery. So you can do that with nothing except knowledge of the functional anatomy and a dream team. This is probably the most important. So now the methodological considerations. And how I do it, I will show you an example and then movies. 32-year-old, generalized seizures. If you perform the preoperative cognitive examination in 80% cases, you will find some deficits. The patients are not well, should be objective. This is the classical location in the temporal occipital left dominant in this right-handed patient. And the patient told me, I don't want to have amyopnea. I don't want to be amyoplegic, of course. I don't want to be aphasic, but I don't want amyopnea because I like to drive and I would continue after surgery. So normally, you don't need DTI in order to know what you will live because you will adapt, of course, according to the willingness of the patient. He decides. It's his quality of life. In all cases, I have a very poor mental imagery. I perform lateral position, right, left. I have two brain imaging in my mental imagery. That's it. So it means that the patient will help us in order to have a good positioning and we will put laryngeal mask in all cases because when I was in Paris for 10 years, I did not use LMA and it was not so comfortable, not for me, not for the anesthesiologist, and not for the patient. Sometimes he waked just a little bit more bleeding and so on and so on. Now, no problem. But I have very good anesthesiologist. When I perform the bone flap, they know that, they decrease the propofol and the median time before awakening, complete awakening in our experience is seven minutes. That's it. So it means that when I sometimes hurt for the fact that we should wait 30 minutes, one hour, no, no, no, seven minutes, 10 minutes after we can perform the task, including very high level cognitive task if you have good anesthesiologist. And of course, we have the same anesthesiologist every day within the same team. I use Mephild. I don't shave. The rate of infection is 1% in my experience, so it's not very important in this guy. But for young ladies with hair, in order to preserve their quality of life, it's very important. I perform wider bone flap, not a complete, of course, hemicraniotomy, but just in order to expose the ventral premotor cortex in all cases, as you will see, namely the lateral part of the precentral gyrus, as demonstrated yesterday by Guillaume Ribas. If you stimulate in the left or right side, in all cases, 100% cases, you will induce speech apraxia. It's not, of course, related to language. It's just articulatory processing, the SLF3 loop and entredo. And it works. In 100% cases, explaining why I don't need electrocorticography, because when I induce this kind of speech arrest, then I know. And you will identify it with less than 3 milliamps in 95% cases. So after that, you can do mapping. Of course, with the speech therapist or neuropsychologist, I don't accept negative mapping, because I should know exactly where I am in this patient at this moment. And I should be sure about the intensity. After that, I will perform the cortical resection, as you will see in movies, according to the functional boundaries, sub-bial resection. And then I will never, never, never use, again, the coagulation in surgery. So it means just the cortical surface, and that's it. If you perform sub-bial resection, you will not have any bleeding. The rate of transfusion we did in 10 years is 2. The rate of intraoperative bleeding, hematoma, postoperatively, is 0. So it's not a problem. But I have no vascular problem, because I do not coagulate. So now, the most important is to identify this connectivity, explaining why I have this model in my mental imagery. And in this case, of course, you will identify the inferior frontal occipital fascicle with some semantic disorders and the optic radiation, because remember, patient told me, I don't want to have any amylopia. Okay. Of course, preservation of vessels in all cases, especially a vein, in all cases, 100 percent cases. And at the end, you have something very clear for me. You have the cortical mapping. You have the sub-cortical mapping with the I4, the RQ8, the optic radiation, and so on. So you should know perfectly, of course, the stratum sagittale. And you cannot remove more. And if a colleague told me, now you should perform intraoperative MRI. But I know where is the residue. The residue is at the level of the optic radiation, because the patient told me, I don't want amylopia in order to continue to drive. So I don't need intraoperative MRI. Four hours. It's not long to do that. Eight o'clock in the morning, at noon, it's finished for a very big tumor, whatever the location. Sometimes, of course, you can leave the operating theater around 10 to 11. Never beyond noon. No clinical worsening in this case, of course, because there was mass effect also, so I don't speak only about pure low-grade glioma. And three days before discharge in this guy, we decided to keep a little bit more in order to adapt the rehabilitation at home. And you can see the postoperative MRI, of course, with the vein, the T1, the T2, and the flare, and the residue expected exactly at this level. You don't need ETI in order to imagine the optic radiations. Not before. Not after. Not during surgery. Of course, you can do that if you want. The great advantage of this methodology, if you want to add around you every methodology like in Star Wars, eight, then you can do that. And I'm sure that Lorenzo will demonstrate that you can add, but because Lorenzo knows the functional anatomy. So please be careful between to use something very high level, speaking about the methodology, in order to continue to progress in technology, rather than to use it in order to compensate the lack of knowledge of the functional anatomy, otherwise you will not obtain 99 percent of good results. This is the message. So the message that, first of all, know the anatomy, second, the function, third, validate into the or, fourth, no problem. And that, at this moment, you can use what you want intraoperative MRI, and so on. So you will see just movies now. I have probably seven minutes approximately. More? Five? Ten? Five. Okay. So quickly. Okay. A classical left frontal temporal insular tumor, young people, just a seizure, nothing very special. I will go fast in order to show you that patient is in lateral position. So a big scar, but not too big, finally. And of course, in hair, so I don't shave, I put result, bay bone suture, no problem, nothing very special to do after surgery. So wide bone flap, but I do that under general anesthesia, under propofol and remifantanil. So no problem for the patient. At this moment, clack, so the anesthesiologist will cut the drugs instantaneously. So I have approximately five to ten minutes in order to do local anesthesia at the level of the muscle, at the level of the dura mater, as I learned from Mitch and George, and to do the opening of the dura mater, even if, to be honest, sometimes I prefer to wait that the patient is awake before to open the dura mater, because sometimes he can cough. And to do the ultrasound, if you want, but to be honest, it's just because I have visitors and in order to demonstrate that we have intraoperative MRI just in 30 seconds and not expensive. And definitely the most important now is to perform the cortical mapping. And of course, the patient will have a speech arrest due to the stimulation at the level of the ventral premolar cortex, because here you have the central sulcus, the sylvian fissure, the precentral sulcus, and here the so-called Broca's area, which does not exist. We will speak about that this afternoon, but you will see that I will remove in front of you just online the Broca's area while the patient is moving and speaking. So at this moment, you see why it's very important conceptually also, especially for young people in this room, to say, okay, I will remove the Broca's area. I am sure that I should do that. Yes, because you have a positive mapping. If you have a negative mapping, you will have an inhibition. And I know that because so many people are doing that. And finally, do not remove the tumor by telling, I don't dare. So it was impossible. Of course, this is the message. No, it's not. And then I have to reoperate after them to perform a wide open flap, positive mapping, and to remove the so-called Broca's area. Now you can see, of course, this is the pars triangularis, this is the pars opercularis, the orbitaris, and I will do a transopercular approach because I am not a very good neurosurgeon and I cannot split the sylvian fissure with 99 percent of reliability without any spasm vascular problem. But I can do a transopercular approach with a 99 percent of reliability. Now I will take the Bakke and to perform this subpial dissection, and you will see just in 30 seconds online, we will be into the contact of the anterosuperior part of the insula here. So no bleeding, of course. You have not to coagulate. Definitely, I will not coagulate until the end of surgery. So you have understood the principle. Now you have seen that we removed completely the pars triangularis, and the patient is, of course, speaking and moving. We removed the pars opercularis, I'm sorry, and we removed the pars orbitaris, so the left inferior frontal gyrus in the right-handed patient, and the patient is continuing to perform the semantic association task, the naming task, the double task. We will speak about that this afternoon. And now I can remove the temporal pool in order to have an access to the inferior part of the insula. And now, of course, you have a beautiful access to the insula, and you perform a subpial dissection with no bleeding. Never, you will see the coagulation now, from now into this movie. And of course, it's not so difficult to do that because we disconnected now the anterior part of the brain invaded by the tumor. The patient is doing movement plus language, and one plus one is not two, but the potentiation within your brain, thanks to the working memory loop. And finally, the most important is, of course, the subcortical connectivity now. So normally, you should see no mental imagery. You can follow my arrow here, the trajectory of the inferior frontal occipital fascicle, and you will induce semantic paraphysion. And here, you should see the SLF3 and the arcuate fascicle. Okay. Now we will check stimulation at the level of the Wymer tract. I should find, okay. The patient is moving now, speaking, and I will perform subcortical stimulation in order to be sure that I was into the contact of the dorsal pathway, first of all. You can see, okay, modification of movement, array of speech, okay, I was into the contact of the crossing fibers between the frontal striatal, the FAT, and the SLF3 anterior part. So I know where I am. I will do exactly the same thing now at the level of the inferior frontal occipital fascicle within the temporal lobe and the temporal stem. And the patient is blocking, okay. You cannot listen, but Sylvie, my speech therapist, is telling me semantic paraphysia, modification of the behavior, blah, blah. We have understood the IFOF. So everything is clear. So it means that you are protected from the anterior perforating substance by the temporal stem because in this temporal stem, the IFOF is running laterally to the perforating atrius. So at this moment, you can put the patient under general anesthesia, and you can finish, if you want, the resection because this part of the brain is totally disconnected. So nothing very special. I will just show you now the postoperative MRI. And you can see, of course, that we remove completely the left inferior frontal gyrus because Broca's area does not exist. We remove completely the temporal part, the insular part, except the anterior perforating substance, and it was expected because I say to the patient before surgery, without DTI, we will leave exactly three to four cc, and it's exactly what happened. So once again, if we can do that with a high level of reliability without any methodology around you except a grim team and this knowledge of the brain, you can do that. And I know that because many of you came and reproduced exactly the same results. Thank you very much. Thank you.

philosophy

approach

treating patients

brain tumors

complete resections

quality of life