Main application of radio surgery is small AVMs considered difficult by Neurosurgeons-Prof. Johannes Schramm

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Clinical proceedings of Neurosurgery Conference

Main application of radio surgery is
small AVMs considered difficult by
Neurosurgeons-Prof. Johannes Schramm

KARACHI: Pakistan Society of Neurosurgeons organized its 26th National Conference here from November 29th to 30th 2013 which attracted a large number of neurosurgeons from all over the country besides many delegates and invites guest speakers from overseas. Prof. A. Sattar Hashim Prof.of Neurosurgery at JPMC was the chairperson of the organizing committee. The conference was preceded by courses and workshops on Skull Base Surgery: From open to endoscopic- the transition and evolution, Nasal/sinus anatomy for the neurosurgeons- the intranasal landmarks, antrostomy, ethmoidectomy, Endoscopic approaches to the pituitary and the skull base-Tips and the techniques, anatomical dissection besides indications and limitations of endoscopic approach to anterior skull base. Complications of endoscopic approaches to anterior skull base also figured prominently.


Dr. Naveed Ashraf and Prof. Tariq Salahuddin presenting a mementoe
to one of the guest speakers from Germany Dr. Rainov Nikilai
at the neurosurgery conference held at Karachi recently.

Prof. OV Jooma Memorial Lecture

Second day of the conference started with O. V. Jooma Memorial lecture to pay tributes the legendary great neurosurgeon who played an important role in providing neurosurgery services in this region for many years. Earlier Prof. A. Sattar M. Hashim chairman of the organizing committee welcomed the guest speakers, moderators as well as the participants to the meeting.
In the next session Dr. Hasnain Haider Shah from UAE discussed Neuro endovascular management of vein of Galen Malformations. He discussed in detail the clinical presentations of neonatal an infantile VOGM, different interventional approaches with various steps.
Dr. Asif Mateen made a presentation on advancement in neuroradiology and applications of PET and CT Scan in neurology, neurosurgery. CT, he said, gives high spatial resolution. He then showed some slides of low grade primary tumours. CT images also showed some calcifications, high-grade brain primary and brain stem tumours. He also talked about GB recurrence, metastic melanoma and Gama knife treatment. These sophisticated diagnostic modalities are also quite useful for diagnosis of epilepsy. Application of PET scan in neurology and neurosurgery was also discussed in detail. Prof. Khaleequz Zaman asked about the indications for combined CT and PET scan as it does increases the cost.
Dr. Imtiaz from Saudi Arabia discussed intra operative neurophysiology in intra and extra dural spinal tumours. He was of the view that a fool with tools is sill a fool. The aim of my presentation, he said was education and not research. He discussed in detail intra operative neurophysiology, maximizing tumour dissection with minimizing neurological deficit. Some techniques have failed in GA. He pointed out that despite the fact that muscle MEP dropped but the surgeon continued surgery because D waves were there. D waves are continuous monitoring and it is minimal stimulation.
Dr. Ikram Alam from Peshawar talked about epidemiology of Road Traffic Accidents. His presentation was based on 336 cases of which 225 (88%) were managed with conservative treatment and the remaining (12%) were referred for surgery. Almost 90% of the patients were discharged in satisfactory condition while 22.9% were referred for neuro rehabilitation. Majority of the Road Traffic Accidents cases, he said, did not require neurosurgical treatment. Prof. Aizaz Ali Shah who was chairing the session remarked that we have not won the battle against head injury for various reasons. We have not implemented international standards. We have national standards and guidelines but we did not make much progress on regulatory and legislative side. Prof.Tariq Salahuddin remarked that in this study extra dural hematoma was more as compared to compound fracture of the skull. Most of our patients at Lahore General Hospital are fracture of skull and they are treated conservatively. Prof. Schramm from Germany remarked that even after unification of Germany when the population of the country has increased, the number of RTA has decreased to three thousand five hundred from eighty million because of the steps taken. But in most of the developing low income countries, people do not wear seat belts or wear helmets while driving was also very bad which results in increased road traffic accidents. Passive safety of car and behaviour of drivers was also responsible for the present state of affairs to a great extent. It was also pointed out that the neurosurgeons have achieved very little even after the formation of neuro trauma chapter. It is only the Motorway and Highways Police which was implementing road safety measures like wearing of seat belts and use of helmets.

Prof. A. Sattar Hashim, Dr.Asim from USA and Dr. Rainov Nikilai from Germany speaking
at the neurosurgery  conference held at Karachi recently.

Dr. Yasiruddin spoke about traumatic brain injury and management of intra cranial hypertension. His presentation was based on a study of thirty patients and most of the patients were between 20-40 years of age. Inclusion criteria were injury within seventy two hours. He then showed video of the various procedures and discussed patient case history and treatment protocol. ICP monitoring he said provides an effective way for conservative treatment or surgical ICP management in traumatic vein injury. One of the participants remarked that ICP measurement has no advantage but at the same time there are studies showing benefits with ICP management. Prof. Tariq Salahuddin remarked that this has remained under debate and we should treat patients as per raised pressure. He further stated that we need to have proper protocol for severe head injury. We have started monitoring on selected patients and they have to be ventilated. It is e expensive but we are working on that. Prof. Khaleequz Zaman asked about the morbidity and mortality in craniotomy and decompression. Selection of patients for these procedures, he said, has to be appropriate and it all depends on how you select your patients.
Dr. Hameedullah Buzdar along with Dr. S. A. Siddiqui chaired the next session. The speakers included DR. Erum Bukhari and Dr. M. Usman.

Prof. Iftikhar Ali Raja Memorial Lecture

Prof. Khaleequz Zaman along with Dr. Naveed Ashraf chaired Prof. Iftikhar Ali Raja Memorial lecture. In his introductory remarks Prof. Khaleequz Zaman paid rich tributes to late Prof. Iftikhar Ali Raja who he said was a King among the eminent neurosurgeons. He contributed a great deal in promoting the discipline of neurosurgery in Pakistan and organized many conferences. He was so popular even overseas that at some of the conferences he organized in Pakistan, we used to have more overseas speakers and participants than from Pakistan. He met a tragic death in airplane crash at the age of sixty four years.
The guest speaker in this session was Prof. Johannes Schramm from Germany who delivered lecture on microsurgical results and differential treatment modalities of small AVMs. He pointed out that since 1966, they have managed 292 cases of AVMS of which 231 were managed with microsurgery alone and forty five had remobilization. Small AVMs, he said, should be small enough to be good for radio surgery. They had eighty cases of small AVMs in their series. He then talked about surgical indications for small AVMs, brainstem AVM, difficult AVMs rejected by Gamma Knife. Standard surgical technique was also discussed in detail. He laid emphasis on careful dissection of arteries. They observed increased early deficit in forty seven cases and 14.3% morbidity. There was total occlusion in 98.7% of cases. Comparison from various remobilization series was also discussed. There was 10-15% morbidity and mortality was 1.5% high in some cases. Talking about results of remobilization, Prof. Schramm remarked that it was still helping neurosurgery. Main application of radio surgery is small AVMs considered difficult by Neurosurgeons. Combined multimodal treatment offers many advantages. Prof. Schramm was of the view that remobilization before radio surgery significantly decreases the obliteration rate. He then referred to palliative AVM treatment and pointed out that incomplete treatment worsens patient outcome. Microsurgery has high exclusion rate while radio surgery was 20% less effective whereas remobilization was 60% less effective. Responding to a question Prof. Schramm remarked that 17% of their cases had remobilization.
Dr. Bilal from Peshawar was the next speaker who talked about clinical audit of intracranial haemorrhage. This presentation was based on fifty nine cases of which sixteen died. ICH, he said increases mortality. They had 27% mortality in their series. Dr. Asim Mahmood talked about dural arteriovenous malformations of the skull base. This presentation was based on six hundred cases series. DAVMs, he said, has stroke like symptoms like headache by high blood flow. Conservative treatment is advocated for managing AVMs and many believe that AVMs should not be treated surgically unless they are symptomatic. However, surgery has a definite role and radiation therapy has its own benefits. He opined that endovascular management is the first line of treatment for DAVMS. He then talked about skull base approaches with different modifications and said that less invasive treatment at times is not so less invasive. AVMs may carry a high risk for neurological sequlae or death.
Dr. Abid Saleem from JPMC discussed AVMs treatment by radio surgery assessing their pros and cons. His presentation was based on 254 AVMs which included 165 male and 89 females. One hundred eighty nine had prior haemorrhage. No acute morbidity was noted in forty eight hours. His conclusions were that Gamma Knife surgery was safe and effective for management of AVMs.
The first session of the conference next day was chaired by Prof.Tariq Salahuddin along with Dr. Naves Ashraf. Dr. Asim from USA was the first speaker who talked about gene therapy and said that life with cancer begins at Henry Ford Hospital. Commenting on the presentation Prof. Schramm from Germany remarked that neurosurgeons in Germany are well qualified to prescribe chemotherapy.
Prof. Rainov Nikolai from Germany was the next speaker who talked about neurosurgical treatment of cancer. He pointed out that because of some serious side effects, appropriate effective dose was essential for successful treatment. Continuing, he said that Tumour Trust Fields are now entering novel types of cancer treatment. He then discussed the safety and efficacy of Alternative Electronic Fields and highlighted the disruption of cancer cell replication by this treatment modality. There are two mechanisms of action of destroying cancer cells. TTF destroys cancer cells in culture and so far no device related adverse effect has been seen. Continuing, he said, that TTF increases progress free survival of primary GBM patients. TTF is a continuous treatment for twenty four hours with disruption. Equipment used is big at present but with the advances being made in technology, its size will be reduced in the days to come. Let us remember that to begin with the size of pace marker used to be suitcase like, he remarked. TTF treatment, he further stated, was better as compared to second line therapy. FDA of United States has approved this treatment for these very reasons and it is also approved and being used in Europe since 2011. However, he cautioned that this device should be used after training. Patients also need to be trained how to use this equipment. This treatment is named as NOVOTTF. This is based on electromagnetic energy. The study still continues as we need at least five hundred cases and hopefully the study will be completed in the next few years. Toxicity and quality of life in current GBM patients, he said, are in favour of TTF treatment. For recurrent GBM it is first ever licensed treatment. TTF is not compromised by development of resistance in cancer cells. This study was now in phase two and phase’s three trials.
The next speaker was from Russia who talked about preventing and treatment of skull brain scars which leads to epilepsy like headache. He emphasized the fact that one needs proper material for neurosurgery. Prof. Schramm from Germany was the next speaker who talked about motor outcome and intra operative monitoring. He discussed in detail the use of MEP monitoring and the surgical technique. Main mechanism of damage in ganglia, he said, is paresis which could be transient. MEP monitoring lead to surgical intervention in 44% of cases. They achieved 90% resection in 42% of cases and 70-90% resection in 51% of cases. Most of these patients, he said, were now seizure free. Based on resection, overall survival was very good. About 10% of patients have risk of hemiparesis and mortality is about 3% in four days in stage-IV. He opined that they no longer operate on stage-IV cases these days because of higher mortality. Clinical condition and outcome of surgery is good. Referring to various series Prof. Schramm remarked that permanent deficit was 11.5% even by Gods of microsurgery like Yasargill in 1992. He did lot of microsurgery. In most cases the permanent deficit is reported to be between 7-9%. Glioma series had complications and morbidity of 25% and mortality between 1.7 to 5% of cases. If age of the patients is young and under forty years of age, survival is better. More extensive resection could lead to high mortality. His advice to his colleagues was that one should be honest to the patients. Prof. Tariq Salahuddin remarked that one should be realistic while operating in difficult areas of the brain.
A young ENT surgeon from India showed various surgical procedures dealing with juvenile angiofibromas. He had modified his technique and was doing surgery with this technique now for many years with excellent results. He opined that the concept has now changed and most of his one hundred forty cases were in stage 3A and 3B. These angiofibromas, he remarked, should be managed in conjunction with neurosurgeons. Dr. Abdullah Yahya talked about complicated skull base surgery. A number of other presentations were also made by various speakers in different sessions in the afternoon and one of the sessions was also dedicated to late Dr. Aftab Qureshi.

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