This educational video provides a comprehensive endoscopic overview of the parasellar region, focusing on the cavernous sinus compartments, especially to the most difficult to explore - the lateral cavernous sinus compartment. It is designed for neurosurgeons and medical professionals seeking to enhance their understanding of the complex anatomical structures involved in this area. The presentation includes detailed visual aids and expert commentary to facilitate learning. Key topics covered in this video include the endoscopic neurovascular anatomy of the parasellar region, the significance of the lateral cavernous sinus compartment in neurosurgical interventions, and relevant surgical techniques for navigating this intricate area. Viewers will gain valuable insights into the implications of anatomical variations and their impact on surgical approaches, aiming to improve patient outcomes in neurosurgical procedures involving this critical region. Original technique of prof. Bosnjak (2011) to resect proximal dural ring to unlock lateral cavernous sinus by medialisation of intracavernous ICA is presented.

Bosnjak R, Benedicic M. Endoscopic endonasal approach to pituitary adenoma with invasion to the cavernous sinus. Endosk rev [Internet]; Endoskopska revija /Endoscopic review. 2011;16(33):3–11. ISSN 1318-8941. Available online: http://www.dlib.si/details/URN:NBN:SI:doc-AXH0BGUN

AI will have a significant impact but in a longer time frame that we think. AI is math which deals with data and numbers. LLM (Large Language Models) are language based deals with words. AI is excellent in dealing with data. “Large Language Model (LLM) is an advanced AI trained on massive amounts of text data to understand, generate, and process human language, acting like a super-powered autocomplete that predicts the next most likely word or sequence of words in response to a prompt, enabling tasks like answering questions, summarizing, translating, and writing…” (Google search)  Clinic notes can now be summarized at high level. Scribe jobs lost to AI.  AI will replace jobs; Recently 11% of jobs now in the USA can be done by AI. 

Parts of AI are over hyped. Medicine deals with massive data sets: EEG, EKG which need detailed analysis. The use of AI can predict how a protein will fold and what will be its active sites and then used to design drugs to fit that configuration. “MatterGen successfully generates stable, novel materials with desired chemistry, symmetry, as well as mechanical, electronic and magnetic properties…We believe that the quality of generated materials and the breadth of MatterGen's capabilities represent a major advancement towards creating a universal generative model for materials design.”  (Zeni et al Material Science; https://doi.org/10.48550/arXiv.2312.03687)) ;  (https://arxiv.org/abs/2312.03687

Mattergen will allow the creation of drugs and agents to make better products to solve different diseases, We are moving toward a molecular future in Medicine. Trauma, stroke, spinal cord injury, GBM, regenerative medicine; AI will be one of the solutions.Team medicine is the future involving multiple disciplines from basic research to clinical specialization

A major concern for the future is the amount of time spent residency and student debt. 40% of students before medical school and residency are taking “Gap Years” off to pay debts making training longer. Some graduate with $500,000 debt, then, get jobs that take a long time to pay debts. All of this results in a financial incentive to make medicine pay and do more procedures than needed. Need to make residency shorter rather than longer.  

 Good for Video and Podcast,  (27 minutes discussion). 

SUMMARY: This is the recording of the 1st Latin American International Grand Rounds with SNI Digital® and the Latin American Neurosurgeons exchanging their experiences with a world audience. This meeting was organized by Joham Choque-Velasquez, MD, PhD of Cuzco, Peru. The title of the presentations were “Management of Middle Cerebral Aneurysms: Microsurgery vs Interventional Neurosurgery.”  

The first lecture discussion was given by Dr. Kléber Eduardo González Echiverria of Ecuador.  Dr Gonzales-Echiverria discussed the anatomy of the Middle Cerebral vessels and his use of a Pterional or a Supra-orbital approaches related to cerebral swelling.He mentioned he uses intra-operative neuronal monitoring-evoked potentials, to help him determine the length of temporary clipping. There was a wide discussion of the use of brain protection measures for temporary clipping from none, to intermittent clip release, to chemical cardiac arrest, which Professor Hernesniemi used frequently with success. Joham describe this technique in detail and Ramisis Ghaly, a boarded neurosurgeon, anesthesiologist and Critical care and Pain specialist, commented on the use of Cardiac Arrest during aneurysm surgery. Also discussed was how to treat SAH with an aneurym and AVM.  

The second lecture was given by Dr. Giancarlo Saal Zapata MD, of Lima, Peru who has a very large experience with interventional neurosurgery techniques. He presented a series of cases of MCA aneurysms and reviewed his experience with coiling , etc, which was very good. There is some selection in his series because of referrals. Yet his experience is very good.  There was a wide discussion with the international audience on how each approached Middle Cerebral Aneurysm Management. Each neurosurgeon has to do what his/her environment and resources will allow, anywhere. Given the best surgeon and interventional doctor's approaches, coiling appears to be  the first choice, but many factors have to be considered in each case separately. There is no consensus because there are too many variables to consider. Like for basilar tip aneurysms, intervention is the preferred choice and each aneurysm location may have a preferred choice; See SNI Digital discussion among neurosurgeons on this subject: https://snidigital.org/video/243/Clipping-vs-Endovascular-Treatment-of-Intracranial-Aneurysms-Retreatment-failures-20-in-endovascular

 Excellent Discussion of a controversial topic everywhere. Best for Video; Images needed for podcast but Discussion is valuable. In two parts 60 minutes each for 120 minutes total. Need to be seen together to benefit from the Discussion.  (JIA)

SUMMARY Dr. Marvin Bergsneider, who Co-Head of the Pituitary and Skull Base Surgery Section of Neurosurgery at UCLA discusses Pituitary tumors. For those of us who have forgotten pituitary physiology, all the 8 hormones related to the pituitary, come from control centers in the hypothalamus around the third ventricle. For the posterior pituitary, there are direct neural connections from the hypothalamus to the posterior pituitary for production of ADH (antidiuretic hormone) and oxytocin for lactation and uterine contractions. The Anterior pituitary is a collection of cells wrapped around the Posterior lobe embryologically from Rathke’s pouch. 5 different protein releasing factors originate from hypothalamus which stimulate the anterior lobe pituitary cells. The hormones produced by the 5 cell types in the pituitary gland control the thyroid, bone growth, liver and insulin production, adrenal and reproductive glands. The last hormone produced inhibits the production of Prolactin from the cells in the anterior lobe of the pituitary.

 Tumors of these cells are called PitNET (Pituitary NeuroEndocrineTumors).  All these target cells in the pituitary can form tumors, but the most common tumor site is from the prolactin producing cells. Prolactin producing cells make up 30% of pituitary tumors. Another 30% are clinically non-functional (CNF) tumors, all of which represent 20% of all the brain tumors. His talk and the discussion center on the prolactin producing cells which relate to lactation in the female and have limited clinical expression in the male, and how to distinguish them from CNF tumors.  

 There are many causes of hyperprolactinemia making the symptoms non-specific. In the male hyper-function of prolactin from tumors can present with erectile dysfunction or gynecomastia or from mass effect on the other hormone producing cells in the pituitary. Males usually are asymptomatic but can present late with symptoms. Females present with disturbed or absent menstruation, low libido, and/or abnormal lactation. Physicians have measured prolactin blood levels which in males can reach a high of 60 ng/ml, while in females it can be variable but is abnormal over 400 ng/ml.  High levels of Prolactin are usually diagnostic of prolactinoma. The diagnostic difficulty comes with lower levels of prolactin. Dr. Bergsneider discusses the prolactin levels and sex differences in detail. 

 Cabergoline, a dopamine like agonist, is given to suppress the prolactin production in the pituitary cells and can shrink the tumor in 75% of patients.  One third are cured with this biochemical treatment after a year. Persistence of hyper-prolactin levels occurs in the rest of the cases. Those who cannot tolerate the drug, should have surgery. In cases where the female wants pregnancy, Cabergoline must be stopped. Other reasons for surgery are mass effect and disruption of other pituitary function cells. 

 The explanation for the elevated prolactin levels in the past was attributed to the “Stalk Effect” or compression of the pituitary stalk. This compression prevented the hypothalamus produced Prolactin inhibiting factor (PIF) from traveling down the stalk to inhibit prolactin production at the cellular level. As a result, the uninhibited cells produce more Prolactin, leading to elevated Prolactin levels. This idea has now been replaced by the research that finds rising intra-sellar pressure from unrestricted tumor growth eventually causes other pituitary cells to dysfunction and failing pituitary hormonal production later in 85% of cases as the tumor enlarges. This is called the “Triphasic effect “ from Dr. Bergsneider’s research.  

The tumor is grossly removed, endoscopically, with a high percentage of cure. Remnants can regrow; so complete removal is necessary. He shows an intra-operative video of his procedure and discusses the details of his surgery. Most places in the world can measure prolactin levels, but if that is not possible, treatment then relates to mass effect. Radiation can be used for resistant tumors.  So, prolactin becomes a key to measuring the function of a large percentage of pituitary tumors. Tumors of the other pituitary gland cells can be tested for specific physiologic functions with their own specific treatments. After 100 years of work on pituitary tumors, little is still known about the origin of tumors in this small special area of the body with such a concentration of active cells at the base of the skull.  How can we strop the growth of tumors in one cell line without effecting the others?  Getting the specific tumor growth to stabilize metabolically or to regress by molecular treatment seems to be the most likely avenue of research to cure this disease without surgery. Does surgery make sense in the long term?   From the SubSaharan African Grand Rounds. Excellent Talk; Common Problem; Video Excellent; Podcast Good but imaging helps.  (Lecture 35 min Discussion 15 min).  (JIA)

SUMMARY: 

Dr. RIch Byrne discusses the challenges faced by those in medical school, residency, and postgraduate training and in practice. In Medical school the application process for residency consumes hours and days of time applying to a large number of programs, travel expenses, interviewing either in person or by Zoom, or in some selection mode, and the match. What are the flaws in this process and how can it be improved?  How do we select the best people for Neurosurgery? Is it scores, recommendations, externships? How can programs pre-screen applicants? Even then, 1 in 5 residents do not complete the training which becomes a loss for all involved. How is that fixed? 

How are the residents evaluated in their training? How do you measure character, soul, and  personality in the computer age?  You cannot. Are letters of recommendation reliable? Is the personal visit valuable? How can that time be used to determine more about the applicants? What about mentorship in training? Is there enough and is it quality? How do you solve that concern?

What about their performance after residency in practice? How is that evaluated. What place does the American Board of Neurosurgery have? It does not look like they know except for the data submitted and the interview process. Too late!  Are we lowering the bar to accept people into neurosurgery at Board examination time?  Some say yes! What is done about the neurosurgeon who is not well trained?  Why does this happen? Are the choices for practice uniformed? Are the residents under stresses? Is there mentorship in the practice? Does huge debt force residents to make surgical choices for money?  Is it a bad job choice?  We will have a deficit of 10,000 physicians a year in the USA? How is that problem solved?  Lots of questions that are discussed and answered. What are yours?  

55 minutes of Discussion. Good for Video and Podcast. (JIA)