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Operating on the “Inoperable” Gliomas

Mustafa Baskaya

June 07, 2021


- Colleagues and friends. Thank you for joining us for another session of the Virtual Operating Room. Our guest today's Doctor Mustafa Baskaya, from University of Wisconsin. He is truly one of the most gifted, technically micro neurosurgeons I've ever met. He's attention to detail, surgical results and micro neurosurgical teachings are on parallel. He is the director of Skull Base Surgery at University of Wisconsin. Today, he's going to talk to us about the so-called inoperable gliomas Mustafa, sincerely appreciate your friendship. I really have so much respect for your technical skills, for what you have done for micro neurosurgery. And it's an honor to have you with us today. Please go ahead.

- Thank you, thank you, Aaron. It's my honor. And as I echo the same thing for you, I admire your skills, work ethics, and hardworking. And again, it's so appreciated that you continue doing these teaching activities. And I think worldwide is well received and recognized, and thank you, thank you, thank you. So today I'll talk about the operating on so-called inoperable gliomas. And I have no disclosures. This is our lobbyist to medicine, as we welcome everybody after pandemics. And what are the treatment options for gliomas in general, is surgery is if possible? It's doing the gross total resection or near total resection, radiation. We have different types of radiation, chemotherapy, and some targeted therapies and alternating electric field therapy. And there are so many experimental studies going on on this subject. The goal of the microsurgery for gliomas in general, is gross total resection. If you can involve great gliomas, removing entire T2 flare changes, if it is contrast enhancing gliomas, high-grade gliomas, it is removing the contrast enhancing area gross totally. And also if possible, removing some surrounding T2 flare changes. And while you are doing this, you should not cause any significant morbidity if possible. And ideally no neurological deficits. We know that sometimes that's not possible. We have adjuncts to achieve these goals in the glioma surgery. Preoperatively, we have functional MRI. We can use deficient track topography, WADA tests. Intra-operatively, we use awake craniotomy for mapping of neurological functions, such as motor function, speech and other functions are not very, if you cannot do that in the OR, but it's getting better and better. Motor and speech mapping, cortical/sub-cortical stimulation, everybody has frameless neuro navigation right now. Intraoperative MRI, it increases the safety and extent of resection and all kinds of neurophysiological monitoring, and microscope aided like 5-ALA or Fluroscein and Aaron is one of the leaders in this field, as we know. And these are the cases that I use to. One adjuncts, in this case is the awake craniotomy for motor and speech mapping and intraoperative MRI suite with the 1.5 MRI. So if I perform my craniotomy and map the speech and the motor area. And I finish my resection and put the patient on the magnet, MRI looks good, very satisfying, good gross total resection of the entirety T2 area, I am done, now I can close it. If I see anything left behind and in reasonable location without causing the neurological morbidity, I'll go back and clean that area. And in this case, I don't need any adjuncts, no airway craniotomy, no intraoperative MRI, because I know that this tumor will be very distinct from the rest of the brain and I can achieve gross total resection, more than that, even supra total resection without any adjuncts. So what I use also as an adjunct to the oldies, the old friends' neuro-anatomy, right? These all are something we start forgetting topographical anatomy and neuro-anatomy, function neuro-anatomy, surgical, microsurgical anatomy. Unfortunately the progress made in the neuro-anatomy by these giants in neuro-anatomy and somebody rejuvenated the neuro-anatomy and microsurgical anatomy Yasargil. We forget these and these drawings, from the late 1800's, it's beautiful. And it's not different from Yasargil arachnoid drawings. It's the same knowledge a hundred years later, and about we are forgetting these. And that's what I will emphasize in my talk, why anatomy is so important as an adjunct, so we can make some of these so-called inoperable tumors, operable. And this is an example, two-case example, is using the wrong known anatomical knowledge or not having an anatomical knowledge. This is a temporal lesion in a one year old boy and correct localization of the lesion, but the wrong approach going transcortical instead of doing transsylvian like doing the amygdalohippocompectomy going transinsula or transuncus, and getting this without transecting the entire neurocortex of the temporal lobe in one year old boy. This is a wrong localization, correct approach. Transsylvian approach, The surgeons in this case thought this is a basal frontal actually. It is not basal frontal and left the tumor behind. So anatomy can be our guide and what affects, the inoperability, location, okay. If it is eloquent, deep, and also surgeon, surgeon related factors. If surgeon is not familiar with the surrounding anatomy or marking surgical anatomy. If the surgeon thinks that this is inoperable or diffuse or advanced disease. Yes in diffuse disease, advanced disease, they are truly inoperable cases. Eloquent cortex we describe as we remove it, the surgery will result in loss of sensory processing, linguistic ability, minor paralyzes, or complete paralyzes. So these are the important areas we operate in, in neurosurgery and the cortical areas. I'll just touched base on this. This is not my topic for today. Those areas mapping awake craniotomy with other adjuncts monitoring. You can turn these cases to operable cases, but the other deeper areas, cingulate, medio-basal temporal lobe, trigone insula and the basal ganglia, thalamus, brainstem still considered by many inoperable surgical areas. So I'll show a couple of cases in the cingulate gyrus. And this is a middle-aged man with this large tumor involving the cingular gyrus extending towards the, into the lateral ventricle. And in this case is the approach is simple interhemispheric approach and the supramarginal resection. This patient survive six and a half years without any life limiting neurological morbidity. So, and other fresh case middle-aged man, again, this is more posterial right under the motor cortex, same approach, not going through the eloquent area, using the accessible area interhemispheric fissure which is our friend like Sylvian fissure getting through these lesions. And we did that again interhemispheric ipsilateral side down frontal lobe, entire medial hemisphere falls away. And you do the safe approach without manipulating going through. And in this case, you don't need mapping because we know where the motor cortex is, your job just staying away from it. Medio-basal temporal region, okay. One or two regions that many neurosurgeons struggled to get. And we like to divide this into three. This region it's includes two very tip off the uncus all the way back to the lingual gyrus and posterior part of the cingulate gyrus. So if you divide this into three, it is not my classification as many people use this, anterial or middle or toward, or sometimes you have tumors involving more than one segment. And this is a case anterior segment case 77 year old as approaches in my mind unlike that one year old boy is very straightforward transsylvian if Luke, can you play the video? So it's like wide transsylvian dissection. This is one of the old videos, but it demonstrates the technique well. You expose like you are doing a middle cerebral artery aneurysm. Find the inferior trunk, mobilize the anterior temporal artery, and make entrance parallel to do inferior trunk in the insula. And you are right in the ventricle. That's the inferior horn and that's the tumor you see here. So if we can go back to slides, Luke, and result is as good and no neurological deficits. So we avoid two visual pathway. We avoid to speech centers, area and patient had perfect neurological outcome. So now we are going to do middle segment. Again, I'm showing cases just located in the one segment. And this is fusiform gyrus, correct localization. And you know, coming on anteriorly you go through the normal brain. Coming posteriorly very long reach. I chose although I don't like subtemporal approach. In this case, I select the go out with the subtemporal approach because it's not very deep is fusiform gyrus and limited approach, but can be used in this, this small cases. And we don't have video for this, but it's result is gross total resection, anaplastic astrocytoma. Perfect outcome patient had the recurrence free survival five years then they came back with the great recurrence, which was consistent with the great for. So we go to the next slide now. So this is in the posterial segment and this is the perfect case. Aaron loves these cases so perfect for the supracerebellar transcentral case. Aaron has an excessive experience with this approach as well. So it's straightforward. I'll show a couple of one video short video and his position is sitting or prone depends on the patient habitus. If skinny patients long neck, I can flex. I like to go prone. As short neck, big neck, I like to do sitting. So detaching the old arachnoid adhesions and cutting the tentorium. And then you'll get to the area of the hippocampal, a post parahippocampal region. And then you do your own regular dissection, finding the tumor borders with the navigation and then piecemeal resection. It is very nice approach. You avoid visual pathways, you avoid excessive retraction, and potential aversion of the vein of labbe. So thing is I removed gross totally. You see there's no problem with the retraction. So if you come subtemporal is long way, and you are retracting contusion the temporal lobe. Just come from the infer tentorial highway to the supratental region as described by Yasargil and used by many, many neurosurgeons like Dr.* Dr. Tray, myself. So if you go to the lab, this is all you're gonna do. I mean, this is the section. This is the lab. You can be paramedian. You can expose the midline depends on your preferences and depends on the case. And you don't have to open the dura of brain deep, shallow, and the tentorial retract sutures retracting opening with the gravity. This patient is in the sitting position with the gravity cerebellum falls. You go supracerebellar and cut the tentorium like demonstrated in this case. And you expose the entire posterior medial basal region from lingual gyrus, parahippocampus, cingulate gyrus. And you can even reach the atrium through this. And we publish papers on this. So what about this case? This is very complex case it's involving entire limbic lobe from uncus to the posterior hipppocampus, to the posterior cingulate gyrus all the way high and up. You know, I think about a lot from this case, and I couldn't find a good solution to tackle this case in one or two stages. So initially my thought was I can come anterial and then the posteriol and two stages, but I also close to the coming as a stage from the occipital interhemispheric. So this was a tough case first I come transsylvian and then you can go back to the slides probably. Yes, you can play this. These are all potential approaches. So I said, this patient was quite symptomatic from it, including visual, field speech and lethargy. So I went anterial interhemispheric, I'm sorry, transsylvian for temporal first. You can go back to slides. You can skip the video actually. And this is the first I come transsylvian and then I wasn't able to reach the posterior part. I came supracerebelar transtentorial that left it some residual in the posterior cingulate area. I came as a torch stage occipital interhemspheric So yes, it's sometimes necessary, but it's worth it because these are, if you don't do this surgery, you know, this patient, you are turning a issue to the more chronic problem and little residual. And there's a good data extent of resection makes the big differences in outcome correct. So this is the way I did. I actually, he is more than seven years now. Grade 2 astrocytoma, no recurrent disease. Next slide please. So when we do these things, anatomical considerations, yes a hundred percent. Pathological anatomy yes a hundred percent. Anatomy changes with the pathology. Personal preference, you should not have any personal preference. We should be versatile and have a full understanding of the neurosurgical microsurgical topographical anatomy. So this is what happens if you don't do that. So now next region is the insula. Insula is the Island of Reil. So you need to have a perfect understanding of the vascular anatomy, including venous and arterial and the sulci and gyrus anatomy when you are dealing with the insula tumors. So it's tricky surgery and requires a wild Sylvian fissure. And you can watch a neurosurgical videos on that. You know, Dr. Kwan Godel performs those beautiful surgeries, and you need to start from the beginning of the proximal, go all the way distal, expose entire opercular, including temporal frontal and parietal. Unlock the Sylvian fissure completely. Have a full control over the vascular anatomy. And while you are doing this, you should minimize the venous injury or taking the veins sacrifying the veins. I know some people autos prefer mapping and then going to chance transcortical, in my opinion, transsylvian is much more elegant and better dissection. And you preserve the opercular, you don't need to deal with the no cortical problems. So this is before, and this is after you skeletonized all this candelabra and MCA branches. And after the resurrection, it looks, it should look like this. And this is a one off the case example. Middle-age person. We can play the video now. So this is regular frontal temporal craniotomy and opening the fissure widely and preserving all these major, major veins causing the Sylvian fissure. Some of them will be on the site. And the idea is wide arachnoid dissection, very total skeletonization of these veins. You can retract them and using sharp dissection or spreading motions or peeling motions or combinations, whichever one your field comp I'll use all three. And you see, I'm doing everything to maximize my Sylvian fissure exposure. Same time, less tension on these veins. So I'm going all around these veins so I can retract them and don't cause avulsion injury. And I also use this kind of suture technique and initial dissection it helps a releasing one of them suction hands specially. See then now I am doing peeling and then the sharp and exchanging these motions. And until I really, really, really dissect and get to see you got the glimpse of the tumor here, and the MCA branches here, insula branches and you'll have a feeders coming directly from these branches. They are short feeders and you have to, you have to coagulate one by one. It's very tedious, but it's sometimes it takes like a 50 60 site feeders taking them coagulating and dividing them, not avulsing them. And that initial tumor sampling. And then will go slowly debulk and dissect. Initially, I like to do as much as I can do dissection, but at one point you have to go debulk the tumor because it's your dissection limited by the tumor mass. So you have to exchange this maneuvers. Now I'm dissecting finding the full two side of the circular sulcus and dissecting these branches, coagulating them, that their vascularized. While you are doing you pay attention, follow these feeders. These branches, if they are going towards the anterial substances, if they are coming from the early proximal part of M2 or M1, this M1, they are likely lenticulostriate arteries. So you have to respect them. You won't take them or try not to manipulate them because the results will be catastrophic injury stroke to the internal capsule or coronary artery. So then low intensity, low intensity, ultrasonic aspirator, again, keep changing your maneuvers, debulking, debulking, and go around that circle of sulcus, from frontal to temporal and the backside, and then turning around. So you complete the isolate that insula entire insula now is the tumor. So you see that was a part of the tumor were so distinct. Part of the tumor was not distinct. Those are the T2 areas. I'm not only removing the cortal sinus area. I am also attempt to remove the T2 flare changes and I do insula gliomas on the motor evoked potential monitoring and with sub-cortical stimulation. It's a sub-cortical stimulation is helpful to identify the motor fibers and the internal capsule, but sometimes over reads, you need to be aware of that, but do whatever you can okay. So I'm using the, this to show that I preserved the veins, I preserved the arteries is just for demonstration purposes. And both opercular is preserved. Immediate post-op Dan, back to the slides. So immediate post-op, actually she did very well as she's been more than three years now. Grade 4 astrocytoma and believe it or not, this is methylated, but you will do your best. Best post surgery done radiation. Then you talk about other adjuncts. But you are doing best for that patient giving best to the desperate patient, okay. Without surgery, unfortunately, and you can apply this same philosophy. And even this gigantic grade 2 astrocytoma achieve gross total or near total resection. And other one, I want to emphasize these tumors can start like a very slow growing lesions. Please do not sit on these tumors because when they are small, it's much easier to remove. And this case is unfortunate case. They waited thinking that this is a limbic encephalitis and patient was on status. They didn't get better. And tumor continues to grow and still sitting and doing the biopsy, needle biopsy. And eventually it turned out to be an inconclusive biopsy possible astrocytoma grade 2 or 3. So that's the problem with stereotactic biopsies. And they came to me, I said, this is an insula glioma with mesial temporal extension, and this needs a surgery. I can skip this actual if, okay. This is the area of the biopsy again, short dissection techniques. And it's the same technique. So if it's is okay, we can skip this video and go to the next. And this is a gross total resection of the aria enhancing a non-nursing arias. And unfortunately turned out to be great for more speech, no visual problems. And other dramatic case is huge insula tumor. And it's grade 4 astrocytoma. Patient receives the biopsy and confirms a grade 4 astrocytoma we commanded the radiation. This patient cannot tolerate the radiation with this. He will be incapacitated in after a few sessions. So we recommended the surgery. And can go to the slides again, okay. It is significant in large tumors. Some of these tumors are soft. The size actually it can be problem in insulagliomas, but if it is solved and easily sanctionable, and you find the feeders early, you can remove these gross totally even this large tumors. Slides please. See this is the pre-op, post-op and very good results. Receive radiation is more than a year now, even with bad molecule biology is been remaining tumor free. So now we go to the basal ganglia frontal basal region. This is, can be tricky. This is all fortunate. Eventually turn out to be okay. His motor vehicle accident, incidentally found legal or not this gigantic tumor. And this tumor was explore at all sides institutes with idea that they can remove just partially and then radiate. And the pathology comes back grade 2 astrocytoma. And then patient found out about these things and requires second opinion for further resection. This is what we did. We have a good video on this we can watch. This is their incision. So we went through the same incision. Craniotomy it wasn't very, I think it wasn't enough. So we extended the craniotomy little bit and the brain's still swollen and the closure and removing the hemostatic agent, which was placed at the first surgery. And then, there's this necrotic area, we sampled for possible infection, but turned out to be nothing. And this, all the hemostatic agents they placed in the resection cavity and the old hematoma. So now we clean that and now we are going to do, this is an insula tumor with anterior frontal basal extension into the basal ganglia and lateral ventricles. So identifying the thing at important things like vasculature is just, anatomy is kind of distort from the previous surgery. We find the MCA branch and then we went to dissect entire Sylvian fissure and take the site feeders, deal with the insula part of the tumors. And tumors exophytic in the Sylvian fissure giving the impression that there's a temporal tumor but it is not, it is actually frontal area pushing the temporal. These areas and we will remove low intensity ultrasonic aspirators. And then slowly, slowly go into basal frontal basal. This is the exophytic area. This is temporal operculum is completely, actually temporal operculum is preserved. They're removing the still frontal tumors and part of it anterior insula. Eventually will go medially towards the frontal basal region and then the basal ganglia, then into the ventricle, then the basal ganglia and remove what we think is the gross total resection. So it takes time, a lot of dissection, but I think this is the good way you have the better control and you don't need any mapping other than motor evoked potential monitoring and sub-cortical stimulation. Now we have the better anatomy we got to the MCA, entire MCA. We got a go to find the ICA, soft tumor removing it. Suction and then that's A1 you can see here. This is A1, ICA and MCA is labeled. This is the optic nerve. Olfactory neuro nerve. Now we are moving towards basal ganglia, frontal basal region ventricular region. I'm using retractor because it rainfalls just to hold it. And I went both ventricles, clean everything and done with it. This is the part going into the ventricular and the basal ganglia. You'll see it looks different. See, all the pathology came back as a great tool, but the molecule biology of it, wasn't good. But you received, the radiation he is been doing fine. I think we can skip the rest of it, the rest of the video. This is the immediate post-op. I'm sorry, this is the post-op two months. No announcing parts seems like we got all the T2 areas as well. They marked that, but these are my contusions from the surgery. There's no residual tumor I know for sure. Slides please. This is a localization issue. So this is hard location. And again, this is a basal substantia illluminata tumor. The approaches is you can come interhemispheric is long reach, and it's not going to work. Or you come transsylvian through the circular sulcus and make your answers here. So I did the transsylvian approach and pathology was a grade 2 astrocytoma and gross total resection. Again, localization is important and the lock you're choosing to access the tumor is very important. And now we go to another, another area thalamus. Thalamic gliomas are luckily rare, mostly affects the children. So why we do the surgery in thalamic gliomas get the true molecule phenotyping and improve trying to improve prognosis and reduce symptomatology, and reduce mass effect. So patients can tolerate radiation. And if we can do safely, why not? We are doing the, gliomal surgery in the frontal lobe, insula why can't we doing in the thalamus? The good data showing that extent of resection evenly improves, survival in thalamic gliomas, how are we going to access there are different classification in this, Yasargil classification, Spetzler classification. And we came up also all our own. And we are in process of writing this and approaches for anterial located lesions anterior interhemispheric transcolossal approach, either neutral position, or if subtle side down or contralateral side down depends on the location and the angle of attack you like to. And if the anterior interhemispheric approach is, you have to cross the sinus small callosotomy not more than one, one and a half centimeters, going into the ventricle. If tumor is coming to the lateral surface of the thalamic lateral ventricle, surface of the thalamus, it's that you don't need to do any further dissection. If tumor is in the third ventricle, then you do more dissections in subchoroidal, transchoroidal, interforniceal, you chose it. And this is a case, I chose to anterior interhemspheric transcallosal appproach. I dissected the colloidal fissure to gain more space, but in reality, I didn't need to. So it's lateral side done, respect to veins again and skeletonized them. So you don't avulse them. You go to the Corpus callosum and between two callosal arteries you see here, pericallosal artery here, and other pericallosal artery on this side, you put the cotton, you separate them. You go into the ventricle. You see the format of Monroe right now. Hemorrhagic tumors. Now I am dissecting the choroidal fissure to gain space and define the, that's the thalamostriate vein. Okay, very large got to respect that. Removing the hemorrhagic part of the tumors. Then going around and removing the rest of it piece by piece, defining the anatomy as you remove. And again, this surgery is done on the motor evoked potential monitoring and sub-cortical stimulation. Sub-cortical stimulation is good to orient you for the position of the internal capsule. If you know, the anatomy told me you don't need it, but it gives you a confidence, although it's sometimes it's over reads. And I'm still, also the I'm learning the subcortical stimulation. Although I have been using years every, every time we learned something new. So going slowly debulking with the ultrasonic aspirator and the microsurgical tools to see that. Now we are about to see the floor of the third ventricle mammillary bodies just came to view and removing the tumors. Anterior part is well controlled right now. We are gonna move to the posterior part. This is anterial and floor of the third ventricle and you remove piece by piece, slowly don't rush these surgeries okay. These are like an AVM surgery. If you rush it, you get into trouble. Using dissectors that's aqueduct. Now, we decompress everything. And while you are, perform total ventriculolostomy. These patients may have a significant obstruction CSF obstruction hydrocephaly, and give a chance since you are done you just do fenestration, when you are microsurgically. Okay, so you got it, again, anterial to posterial. This is the final view, floor of the third ventricle. It seems like we remove gross total area everything. Slides please. It's looks like a gross total maybe there's a residual here. Pathology was a grade 4 astrocytoma as we predicted, but patient dominant thalamic tumors, they wake up with aphasia and hemiparesis like clears, aphasia clears in few days. Non-dominant thalamus, they wake up with hemiparesis and it gets better, as long as you didn't injure the internal capsule or you didn't take any important vessels. So this is another one. It's is a pilocytic astrocytoma diagnosed by biopsy 30 years ago. And Ommaya placement into the cyst and shunt placement and radiation. And he was followed 30 years and was fine until recently. And he started having more symptoms and also the expansion of the cyst and the slight growth of the solid part. So again, it's not till side-on. It's just collapsed totally ventricular system. In this case, it's coming to the third ventricle surface. So we have to do transchoroidal approach to get this because in on the surface of the third ventricle. And you will see choroid plexus, fornix I'm dissecting and getting to do, trying to get into the third ventricle through, this is previous shunt. Cut it out. Navigate to the third ventricle. We see the tumor there, is actually, I removed in multiple pieces. Again, preserving the veins. He did extremely well. And this is small tumor. Slides please. He didn't have any deficits from this. What if it is larger tumors dominant thalamus, they'd wake up with the anterior thalamus they wake up with the speech problems. So other locations you can use superior parietal lobule approach. I quit doing this. It's long reach and is too much brain to traverse. This is one case I did years ago, 15, 16 years ago. One of my first thalamic tumor cases, through the superior parietal lobule. If I do it today, I will come different way, but I did superior parietal lobule and it worked well, but it's not preferable. Transsylvian approaches is good in some cases like this. Thalamopendicular tumor, it's coming only to the surface of actually Sylvian fissure and there's no other approach you can reach this. And this patient is pilocytic astrocytoma after the radiation became completely plegic in the arm, face and the paretic in the leg. So I did the surgery with all our pediatric neurosurgery colleague, dear friend, Dr. Iskandar, two stages, transsylvian approach for near total resection. Okay, these are the outcome, post-op and you can play. This is the only part we couldn't get is the part that right in the internal capsule. And this the video six months after our surgery. His hand was completely plegic, now he is playing basketball. Okay, you can go to the next one. And there's another approach is the occipital interhemispheric approach for thalamus. And this is the perfect case for that. This is not bithalamic tumor is unilateral thalamic tumor, but this part is cystic expansion. And this is older. I don't like that much. I did occipital interhemispheric approach for this and we can skip the video actually. This is short video and immediate post-op, mild hemiparesis. We can play the video. So it's showing the gross total resection of the tumor. She did very well. 41 months, grade 4 astrocytoma. She just received radiation, a perfect 41 months. And then 44 months, she developed bilateral hemispheric, extensive small, small diseases. She survived more dear patient, dear friend eventually died. Next slide please. So I found staging is very good for thalamic gliomas and in some cases I use that, and this is one of the cases that shows that example. I came, couldn't get everything brain is not pushing the tumors. And I stopped that I came back again, through to transtemporal approach. Showing the entire entire tumor. So I found these cases is hard to get to these interhemispheric posterior approaches. You can argue coming supratentorial but I find the sulcus in these cases and dissect the sulcus and do transcortical in some of these cases. And that's the only time I will do transtemporal approaches in these cases. Otherwise, I like to go using the. We can go next. We can skip this. So, and this is the end product, gross total resection, grade 4 astrocytoma. We gave the patient the best chance. And the brainstem and same story. Not every brainstem glioma is operable, diffuse brainstem gliomas, and advanced brainstem gliomas is operable. But for some reason, mesocephalic gliomas, they are not diffused. Gliomas in the pons are diffuse. Gliomas in medulla, they're just confined to medulla. I don't know why is this, but its always diffuse ones are in the pons. So this is a 23 year old again, college student. So this is a focal disease, okay? Perfect case for supracerebellar approach, transcollicular approach. You can do, if you go to the one collicular or both colliculi on one side, you know, it's safe. And there's a dogma that it can cause gaze paralysis, vertical gaze, it is not. It's only, you cannot follow the fast-moving objects for few weeks and then it gets better. And it's introduced by described by Yonekawa, professorial successor. And I use in many cases, this is one I was able to get the gross total resection of this grade 3 anaplastic astrocytoma. And as you see, no eye issues at all. And this is a very recent case, localized to the medulla. See it is as likely as high grade glioma, patient has significant swallowing issues, eating and nausea, vomiting. So lost weight. So we recommended surgery, but of course, many people said, no, just don't have surgery. This is a trickly location. It is not, and it can be done safely. It is, I'll show you how. Just medium suboccipital craniotomy, just everyday surgery, right? Open the cisterna magna, isolate the tumors and you'll see initial arachnoid dissection exposed dorsal brainstem. There's archery, just stop to, and this is the exophytic part of the tumors coming out, but see this is the PICA. You need to move away that PICA. So you can do remove it safely and more arachnoid dissections, opening these natural corridors have shoots to mobilize the tonsil. I'll ask you to expose the tumor better. And of course preserving the vasculature. So don't be minimalistic when it comes to dissection, okay. Actually, this is, it increases the safety of minimal. Minimally invasive doesn't mean maximum safe. So you have to be maximum safe and these surgeries done by the vascular neurosurgeons, skull base surgeons. I think we have better understanding and skills of dissecting, preserving the vasculature and understanding the anatomy. So this is, again, we are entering the tumors, paying attention to PICA, very low intensity, and the monitoring of the lower cranial nerves and motor evoked potentials during the surgery. This is a dorsal side, so you don't need to do mortal stimulation, but if you do it, I'm not against it. So there's a site feeder that coming directly to the tumor. I'm taking the tumor feeders and preserving the normal. And tumor is not in waiting the cerebellum it just stays in the medulla and is usually these are older they look, bilateral is usually preferred one side, medulla gliomas. Low intensity finding the normal borders. If you use coagulation, it should be very, very low intensity coagulation. Sharp dissections, getting piece by piece slowly but surely. This allows also good sampling of the tumors. And you can get all kinds of molecule biology studies. Removing piece by piece slowly. Now we start seeing the normal tissue here. You cannot do, you cannot do supramarginal resection, supratotal resection in these tumors. You do your best gross total or near total resection. Intensity I use this as a sonopet 5 of 10. I haven't used it for a long time, but it's again, its lowest intensity some possible. Just rushing motions of the ultrasonic aspirator again. Very lowly intensity coagulation or no coagulation at all. Checking vasculature, making sure. And this is optional again, you can close the arachnoid of cisterna magna, it reduces the adhesions and then also is good practice for your a chief resident or fellows. Slides please. This is the immediate post-op. I think this one is delayed postop. Nausea, vomiting got better, right after surgery, very interesting. And she gained weight again and she received the radiation has been doing very well without any obvious recurrence for more than six months. So anatomy allows us to localize the lesion correctly, and that will help us to choose the correct surgical approach. And in surgical, resection of gliomas is possible. And I think it improves outcome even in the difficult locations like brainstem and thalamus. And how we do this, We have to go to the lab. Without the lab, without studying this in the lab, these techniques skills on anatomy, you won't be able to achieve a good results, okay in my opinion. And every neurosurgeon as said, by Professor Yasargil, should spend at least a year in the neuroanatomy skull base anatomy lab and the microsurgical skills lab. So anatomy dictates everything. And, "I hear I forget, "I see I remember, "I do understand." This is the example, okay. You read you, listen, you listen to mentors, masters. That's why we are doing this. That's why Dr. spent days, years to establish this neurosurgical atlas right for you guys. What did he gain? Nothing, other than training you educating you guys okay. And that's the pride we have. So read, listen, watch dissect. Then you go to operating. Then you will understand better. When you understand better, you will perform better. So I'll thank you and thank you for your time and participation. And I thank you, thanks Luke, for your organization and professor, I always appreciate and grateful to you, what you do for a neurosurgical training and education globally, thank you.

- Beautiful work, Mustafa, really a spectacular, gentle manipulations, the patients technique, preservation of normal structures. You have truly been the protege. Something you brought up that was very interesting Mustafa. And that was about approaching these large pre-atrial tumors, you know, the tumor around the large, around the area, the large tumors around the area of atrium. What we have done is use the transversing approach and has worked well. It preserves the meyers loop and the optic radiations as they go around the ventricle as meyers loop. So that's something we have enjoyed doing. You mentioned in that case that you do it differently now. So how do you now approach those large peri atrial tumors?

- These are periatric tumors. If it is exercising meningoma I'll do the way you described a transversing approach. If it is thalamic tumor, that was a purely thalamic tumor. Now, instead of coming superior parietal lobe approach, which is your goal, I mean this long cortex brain tissue, I will have come interhemispheric, either anterior or posterior. I exercise those options, not just jump onto the superior parietal lobe approach. That's also case example that, you know, my training, I did two trainings, right? The last training in University of Miami, I learned superparietal lobular appproach from Dr. Heros. And in my mind, that was the only approach. Not only approach probably, on of the best approaches. So I didn't think about the others. I don't exercise. That's also a good example. You need to be versatile thinking other approaches, be aware of it. That's why I say read, listen. If I didn't read your papers, I wouldn't know anything about approach. If I read it, I'm aware there's such an approach. And if that I find the case fits that approach, why shouldn't I try that if it is better approach, right? it is better approach. I'm trying to reflect the thought process but fortunately in one hour, you cannot put everything in together, but that's a good example. We change over time and we learn from each other. There are many approaches. Other day I was listening Professor Ture. He described the contralateral, supracerebellar approach to the thalamus and is beautiful. I mean, this explains why he told about it. And so that's why this is important. But what you are doing is important. We learn when we are doing these things to listen, read, see, watch, review.

- Very good, well, I wanna thank you again, Mustafa, spectacular lecture, how much you have done for micro neurosurgery and really enjoyed this lecture. I look forward to having you with us in the next one.

- Thank you, thank you. I always appreciate, have a wonderful day and thank you. And all your crew putting all these efforts and thanks to everybody. Thank you very much.

- You're welcome, you're welcome thank you.

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