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innovations in learning. A new video journal, Interactive with Discussion.
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Now offering this program and all of its program, other programs on podcasts, on Apple, Amazon, and Spotify for your listening pleasure
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In association with SNI, Surgical Neurology International, an Internet Journal with Nancy Epstein as its editor-in-chief,
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is pleased to present another in the SNI Digital series, Interviews with Clinical Neuroscience Leaders.
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This interview is with Gary Steinberg
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on the topic of how I manage brainstem cavernous malformations in deep locations
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Dr. Steinberg is the Bernard and Ronnie Lakutra, and William Randolph, her professor of neurosurgery, and the neurosurgery William Randolph, her professor of neurosurgery, and the neurosurgery.
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Sciences, and the founder and co-director of the Stanford Stroke Center, a former chair of the Department of Neurosurgery at Stanford. At Stanford, his university school of medicine is located in
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Palomalto, California. Along with Dr. Steinberg is Eric Nussbaum, who will be discussing the topic for this program He's the chair of the National Brain Aneurysm and Tumor Center and the Director
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of Complex Cranial Neurosurgery at the Midwest Spine and Brain Center in Minneapolis and St. Paul, Minnesota. He's an associate editor-in-chief of SNI and also SNI-digital. He's published numerous
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papers and books on intracranial aneurysm surgery and brain an aneurysms and vascular malformations on amazoncom.
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and on cerebral revascularization,
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available from themecom. With Dr. Nussbaum is Dr. Osmond, who's the creator, CEO of SNI and SNI Digital, former professor of the University of Michigan, Minnesota, Illinois, UCLA, former
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head of neurosurgery at Henry Ford Health System at the University of Illinois, Chicago It's a futurist, an entrepreneur, healthcare consultant. It has written many scientific papers and books.
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Can you see this? Yeah. Yes. It's terrific. Okay, so, and of course, you know, you have to, and I know Eric knows this, and you know this, Jim, that you need to apply different skull-based
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approaches to access the brainstem calf mails depending on where they come closest to, a peel or a pendable surface. This guy presented, he's a 40 year old with migraine headaches. And you can see
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the bleed here. With headaches alone, I did nothing. It does not come to a surface. But then he came back
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and you can see now he's,
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This is not navigating well, City. It's okay, so we read blood and it's bigger. And now we symptomatic and so this was one of the first case I did many years ago where I approached a deep brain
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stem cab mal where it did not come to appeal or penimal surfaces. And the idea is you can work through safe planes to access the brain stem and this is a safe one, the sign of the ponds here is key.
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And, um,
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So, you can see I'm now under the right temporal lobe, here's the tent, here's the stem, looks normal, superior cerebral artery, fourth nerve, fifth nerve is over here, so
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I'm going through the right matter, there's the cab mal, and here I'm using forceps, and I'll show you the difference, and there I'm taking it out Now, what do you think happened to us evoke
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potentials, it was about four millimeter opening, so his evoke potentials actually temporarily were lost for
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the SCPs, they came back, but the monitors were lost and did not come back, and he woke up not unexpected with a hemiparasus on the left side, complete hemiparesis, and within eight hours, he
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was moving his left side. Within a week, he had only some left ankle weakness, and four months later, his neurologic, he normal, and he's shooting his golf handicap in single digits. So that's
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one thing I learned early on, is you have to prepare the patients and the families for a temporary deficit. And it could take several months to get back to baseline. And that could be a difficult
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period, obviously.
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Either your choice is either re-bleeding or take the chance, take the risk. Exactly. So let me show you, let me move this
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thing to the side of I can.
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Let me show you another case. Here's a case of an anterior
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midbrain, cab mal. Eric, how would you do this if you were going to approach it? She had bled several twice, had a
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hemiparesis and numbness on her left side.
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So it really doesn't come to the surface laterally, just in the midline Exactly, just in the midline. And is there a third nerve palsy pre-up? He does not have a third nerve palsy pre-up. That's
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the painful probably part about it. Yeah.
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Boy, if it came a little more lateral, you know,
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I mean, I feel pretty comfortable with the midbrain and the pontine calf malts coming at them from the more lateral, you know, the trajectory you showed. I don't, yeah, I don't love coming
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through that interpreduncular sister and it's uncomfortable. I wonder if you couldn't approach this laterally also. Yeah, I worry, 'cause here's the peduncle. Yeah. And this is a little high for
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a sub-temporal also. It's a lot of attraction. I thought I would come around this way through a terraonal trans-servient approach. Yeah. I would have to retract a little bit of this and of course
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a third nurse in the way I came it's a lesionally for this, but
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after I did this case and in the future, and I'll show you how to come contra-leasively 'cause you have a more direct shot, but I'll show you what I did here. So on my website, this is an old
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video. Here's the carotid artery, optic nerve. Here's the basilar, so third nerve. I've retracted the temporal lobe and taken down the onchus off of the third nerve a little What I don't like,
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and as you say, is, is, uh, is the the prophylators which are coming off the basilar and you'll see here
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so taking down a rapinoid here's the stem this is part of the peduncle and this is what I don't not dissecting but you have to but there's the cab mal
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and I was able to get this out from anipsilisional approach and I did give her a third nerve palsy on the right but it recovered after four months and her hemiparasus resolved. I've been using
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tractography because we have a neurosurgical simulation and 3D virtual reality where I can overlay the fiber tracks and the vessels and I can simulate it ahead of time and I can actually inject this
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image into the microscope when I'm operating. And so I have that in the OR2. I started using this laser, which I really like. It has a 05 millimeter outer diameter. I've done - this is an old
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slide, but I've done about 150 cases now in the brainstem using it. And I'm going to show you how I use it. Here is a
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cabinet on this one's on the surface. So this one could be approached laterally here And
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we're on the left side. So anterior is here, again, under the temporal lobe, navigation is key,
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and I'll show you - there's the fourth nerve. Here's the fifth nerve. This is more anterior. Now, see how fine that laser is? And you can use it as a disector. And
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it seals the vessels at low wattage five drops of power.
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and it does not interfere with neurophysiological monitoring, which is a huge advantage.
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Let me show you this because I'll show you how to now this one. How would you approach this one Eric? This is a dorsal Hado Mesence of
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phallic you can see so it goes up to just below the
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inferior peduncle
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Yeah, I mean The question would be if you came over the top of the cerebellum laterally whether you could get to that or whether you have to That's how I did it. I did a far lateral Supercellular
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infra-gentorial approach. Yeah, and there you can see it now. Here's the malformation coming to the surface Here's the the superior cerebellar artery, but you can see how general this is in terms
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of
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So, you put a little pressure on the malformation. What I used to do with a lot of vascular neurosurgeons do, there's the fourth nerve, is to tug on the malformation and actually just pull it out.
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I don't like that because I think it's more traumatic to the brain it's attached to. So, I like to actually dissect it and sever it, the vessels, seal and sever the vessels and use the laser to
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make the plane between the malformation and the hemociderin stained brain. Another pontil medullary one, this was tricky because it is more anterior and so I used a right suboccipital far lateral
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approach. So I came in, took off part of the occipital condyle, here's the stem, this is the medulla, where the
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ventricle is there. And you can see here.
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That's the anterior stem. And you cannot even get four steps in here. And this is why I like the laser also. So I'm very anterior now. And after dissecting it with the laser - and that's about a 3
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millimeter opening.
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This one - I won't show you the video. But this was one, again, inside the pond It doesn't come to a surface. And he had bled a couple of times. But I was able to do this through about a 1 and 12
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millimeter opening. Again, the laser is the smallest opening in the stem.
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And this is what I was saying about these mood brain hypothalamic ones. They're tough to get to. I did another one, controversially. And I was thinking of going controversially with this Here are
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the namalary bodies. But I decided, when I was approaching it, to take this out through the laminar terminalis. Because you see the surface it comes to, is closest to the laminar terminalis?
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Good idea. And I'll show you this, 'cause this was a, I've done two, two, I think, two or three this way. Here is the left optic nerve. This is the chiasm, that's the right optic nerve Here's
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the left carotid artery. This is the space between the carotid and the optic nerve. And I was gonna take it out this way, but the best approach was through the laminar terminalis, and I'll show
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you that.
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So here I'm opening the laminar terminalis in front of the A1 and the optic chiasm. There's the third ventricle.
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There's the laser. Now you can't get forceps in there.
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And now I'm going around the malformation. It's very tedious. I just severed a small vessel,
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took it out through about a three-millimeter opening.
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And
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surprisingly, in a good way, I did not give her any new deficits. And
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she went home three days later. She had diplopia initially, and that resolved. She got back to work. So I think those are the ones I wanted to show you, basically Well, that's terrific. So
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that's your data, right? Yeah, did you want to see any data? No, you can talk a little bit. Just talk about some data. I think this is good. You're
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One approach to the top of the midbrain is you can put the patient in three-quarter prone and then I think you are going to come to that, Eric, as you go through the tent and you so you're right
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directly on top of the midbrain and not coming from below in. So that's another way to think about
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that. So you're above, yes, and that's fine as long as you don't have tissue in your way if it comes to the surface. When it's in the midbrain, medially, and presents to the third ventricle,
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another way of going in, I did one of these two days ago, is to go through the
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lateral ventricle through the forymen of a row, through the third ventricle, trans-corrosal, transventricular, and
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then you're in the third and you can take it out from within the third. That's another way That is terrific. Yeah. Just here of the. hang on a second, my. Colby in the OR is just texting me.
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Do you do you use a laser like that Eric? I didn't have one. No, I'd love to get one.
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I thought it was.
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My son's using it. A few other band back was interested in a few other neurosurgeons.
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Some of my colleagues say they don't like they don't want to use it, but you know, I like it. And I'll show you why For small vessels, it's fine. If it's bigger, that's it's harder. Yeah, yeah,
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but it's it's it's it's very dramatic. There's less thermal damage. We actually show that. We
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publish this. You can see the pathology. This is with using a bipolar when there's bleeding. You can see how disruptive this is look at the interior. the tissue with
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the laser. There's minimal thermal damage. You don't have to switch between a coagulation and cutting tool for the small vessels 'cause it seals them and cuts them. And one thing I really like, it
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doesn't interfere with neural monitoring of both potentials. As I pointed out, disadvantage is for larger vessels, you still have to bipolar them at low current. And it can't operate around
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quarters but neither can I bipolar. Right, right, exactly. Oh, not surprisingly, a quarter
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of the patients had new deficits, all the things you can think of. There were no deaths related to the actual brain stem manipulation, but there were some deaths associated with other medical
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morbidities. One patient of mine was an airline pilot who had had some cardiac issues,
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admitted to them because he didn't want to lose his aviation license and he had a cardiac arrest. And you can see the predictors of a good immediate outcome and this was a series of 277 and age less
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than 40 as you would expect and better pre-operative grade location in the midbrain. This is for immediate post-operative results. There was no difference in the immediate post-operative clinical
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results between using the laser and the conventional but if you look at long-term outcomes more than three months the laser resection had a highly significant correlation with better outcomes as did
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the age again and the lower pre-operative MRS 82 percent of these patients had a good what I would consider a good outcome MRF 0 to 2.
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That's a pretty good outcome, right Eric? I mean, and Jim? I think that's very good. Can I add some brain stem cowbell, yeah. Yeah, you got it, on the other side of the equation, you've got
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to put what is the natural history gonna be and what's the outcome. And we know that these brain stem cowbells have a higher bleed rate. Right, so I think that's a terrific result. Obviously it
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isn't perfect, which sets all of us, but you're trying to save somebody here from a devastating outcome. Exactly, and three months later, see immediately after surgery, we worsen the MRS, as
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you'd expect, in both groups. After a three months later, these patients have recovered, you know, back to actually a little better than their baseline. These haven't quite recovered yet, you
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can see. So big difference, and people ask me, How do you know it's not just your learning curve because your laser patients were the second half of your career? And so what we did was we looked
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at the last 75 conventional surgeries. So by that time, you would have thought my experience was pretty good on the conventional and compared it with the last 75 of the CO2 laser assisted and
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there's still a benefit to the laser
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Anyway, that's the
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story so far with these. We're trying to get better and better. I think patient selection is important. I don't like operating on older patients.
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A lot of these patients were in poor grade preoperatively.
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And
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anyway, that's the story on that. That's a supporting cast of a million
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Yes, I.
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So, you have any thoughts about that from your perspective, Eric? Well, okay, well, first of all, it's an amazing series. It eclipses certainly what I've done in terms of brainstem calve
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valves. I mean, I've done, and I've done a good number of brainstem cavernous malformations, but nothing close to that. Let me ask you, I have done far more midbrain and pontine malformations
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than true medullary malformations. And it's been my experience from having watched some very good neurosurgeons operate on medullary, and maybe they're just less common. We don't see them
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as much, but having watched some very, very world-class neurosurgeons operate on medullary cavernous malformations and have not great results. I've always been a little bit intimidated by them
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curious um your thoughts on that um They're less common. That's why you don't seem as much the most common location is ponds, maybe because that's the largest area. No, I operate there, and
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you just have to be very careful about how you're approaching it because of the critical functions, especially
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respiratory breathing, right? And all the tracks that go through there But and I remember one patient I transferred or came out from Denver, she'd had four bleeds. She had already had a
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tracheostomy in place and was quadriperetic.
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And I took it out and
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didn't hurt her in terms of her motor sensory function, but
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when she was awake, She would breathe. But when she went to sleep, she stopped breathing. You know, you know, remember what that's called? On deans. On deans courage. Yeah. You're absolutely
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right. I've had two patients like that.
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And she, like I say, I mean, I don't do it, you know, unless they've bled usually a couple of times that have had some deficits. I wouldn't do that in someone who's neurologically intact in the
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medulla, especially if it doesn't come to the surface, but it took her - everyone was getting very depressed about her recovery. Couldn't get her off the vent for two months, but the one service
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who was optimistic was the sleep service. And somehow we got them involved, and they said she's got to recover too much, sure enough. Two months later, she started breathing on her own, took her
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off the vent, got her trach out. But
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I don't think that's a contraindication in the medulla Okay.
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you know, again, it's thinking about what are the safe zones to operate through, it doesn't come to the surface. And if it does come to the surface, what's the best angle to come to? Sure, I've
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just been, you know, and when it comes to the surface, I feel pretty comfortable unless it comes to the very most ventral surface right behind the basilar, it kind of makes me anxious, but I
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agree. I just have been less happy about violating normal, you know, and one or two millimeters doesn't bother me either, but you know, when you're going through more than that. In the medulla.
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In the medulla. But maybe that's a false, you know, maybe that's just, you know, we just haven't done it that much. Let me ask you one other thing, because I think, you know, we're all
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vascular surgeons on this call, on this talk, on this conversation. But, you know, people have started to use, and some people are big advocates of stereotactic radio surgery. You're at
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Stanford, which is one of the homes great stereotactic radio surgery. Um, we've been somewhat reluctant to use radio surgery for cavernous malformations unless we feel that they're absolutely
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inoperable, but can you comment on, do you ever go there in your practice? How do you feel about that? Yeah, I do have feelings about this because of our experience. Growing in my experience,
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we used radio surgery to treat, I think it was about a dozen of these in the brainstem or thalamus basal ganglia We were used, this was before CyberKnife, and even before GammaKnife, this is how
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old I am, we used Helium ions generated by the Berkeley cyclotron. And it does not work. And that was the same experience that Gelberg had at Harvard, and the GammaKnife had initially in
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Pittsburgh And I took out
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a number of them and none of the cab mouths were thrombosed and the incidence of radiation injury, radiation necrosis is very high
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whether it's because this is a you know an eloquent area or whether there's something different about the brainstem one. So we don't use it even for super-tentorial ones. In fact, very few places
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in the world are using radio surgery. Even Pittsburgh is very conservative. They still do some but I will almost always operate if it needs to come out
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no matter where it is including
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the spinal cord and the brainstem and the thalamus. So
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I don't like it. I don't think it works and I think there's a complication rate is high. Okay. You're going to have to go here. I guess pretty soon. So let's
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that's terrific.
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Anything else we can ask them about, Cam? I can tell you a couple things that I used to do that was that I always used to use the irrigating, Len Malice's irrigating bipolar. You know that. I
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don't know if you use it, but most people don't use it. And to me it was an incredibly good tool because what you
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did is you were able to, and I used one millimeter or a half millimeter forceps. And you really get that pinpoint coagulation that was excellent to use. But most people didn't use it, didn't know
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how to use it, never used. You have to develop a rhythm and know how to use that kind of thing. And then when Manuel Dohov knew it was with us, and you remember Manuel, we didn't use the
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conventional suckers. What we did is they make a, Escalop makes a little angle connector, and we put a spinal needle on it. and you take various final needles, you cut them off flat. So
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obviously you don't have the spear at the end of it. And what it means is you don't suck on the tissue so you don't create damage that way. Now with your laser, it's terrific because you can go
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around it and
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it's dissecting it and coagulating it at the same time, which is terrific So I
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think that you've evolved a combination of techniques that are very, very good. So
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that would be my comment there. I made a comment. I use almost always the malice irrigating bipolar. Great. One is a 05 millimeter tip. Yeah.
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And different lengths depending on what I'm doing. I don't use the neurosurgical suctions. I use the brachman suctions, which are ENT, because they're so small and they're rounded at the tip and
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they don't damage the tissue. Good for you. That's true. Same feeling as you do. The other bipolar I like is the Sutter because it has a lower profile than any other bipolar. It's not irrigating
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And it doesn't have a conduit for the irrigating porter, but that means it can be the two blamions of the force. That's gonna be much closer together so it has a much lower profile to get it into
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deep spaces. That's the only one I sometimes use for deep, deep cases. And
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that's good. So
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the other thing that you were doing, we were gonna talk about it, if we're running out of time, we don't have to, but we can come back another time. But in doing lesions that were in eloquent
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areas, you had some papers out there where you, they took out the AVM, it recurred, they had some radiation and so forth. What you're thinking about, you wrote a bunch of papers on that. Yeah,
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and in fact, we have run, we just, we submitted a minor revision to neurosurgery on my 25 year experience with AVMs in eloquent areas. Now, the word eloquent is still a little controversial
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because Spencer Martin developed it to refer to not only language areas, which is the formal definition, but motor sensor, we visual.
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And in fact, the only comment we had on our paper was that use a different word than eloquent. because I won't tell you who it was, what reviewers said that. So, let's call them critical brain
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areas.
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And
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yes, I tell you what I think are the keys to these, 'cause some of the ones that we see are very large, they're grade three, four, and fives, and they're in eloquent areas. Sometimes, well, I
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should say we often use
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multimodality therapy. I think we were one of the pioneers in that 30 years ago. I like to use embolization to cut down the vascularity, cut down the volume of the AVM, and obliterate any
31:09
high-risk bleed features like intranidal aneurysms or feeding vessel aneurysms. And we do that in several sessions staged a week apart We don't like to obliterate more than about 20 of the AVM any
31:24
one time, let the brain adjust hemodynamically.
31:29
And that's a presurgical adjunct, but we published about a hundred of these cases where we use stereotactic radio surgery as a presurgical adjunct. So it turns out that
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the radio surgery for AVM, which you think are still too formidable to operate on, even after embolization and when they're in critical areas,
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it will take at least three years to obliterate and it doesn't always obliterate. But I've operated on about 150 after radio surgery. And what I found is that after radio surgery, even if the AVM
32:14
does not look any different on the angiogram, It turns a. unreceptible AVM or very difficult one into an easy one. So it thickens the vessels. There's very little bleeding. They take the bipolar
32:29
well. You know how AVMs are difficult often to coagulate because the vessels are so thin, they lack the structural elements, smooth muscle and elastic tissue. And you have to actually use little
32:42
clips instead of coagulating. After rodeo surgery, it's easy What I think it does is turn the ABM more into a fistula and the small vessel component seems to be obliterated. So that is a very
32:57
useful presurgical adjunct if it doesn't obliterate by itself. And then of course for the eloquent ones or the ones in critical areas,
33:08
presurgical
33:10
mapping with both DTI tractography to look for critical pathways and also functional MR. is very, very important, I think. Even more important is mapping its surgery 'cause the preoperative
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functional MR and even the tractography is not as sensitive as stimulating at surgery. Motor sensory, you can stimulate or look at phase reversal with the patients asleep. In language areas, I do
33:42
these. Even the high flow AVMs, as long as they're not giant ones or very large, I even do those now with the patients awake. I didn't use to awake mapping. I think that's very useful. And again,
33:59
you want to have bipolars. I like the malice irrigating. I've used the spacer malice. Also, they were developed. You remember not to need irrigation, and there were still three really great -
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now, they're actually marketed with irrigation, which
34:20
When I used
34:22
to, they still caked. I like the malice, I'm, you know. Yeah, I know where to, I know where to make some now. It was, I think actually,
34:33
I think Zeiss marks it some now. It was cognitive for a while, I think it's Zeiss now. Oh, okay. Well, actually there's different bipolars you can use with the malice irrigator. So,
34:45
you know, you choose whatever you like, but I like the malice irrigating I think that's the way to go. I think that was a great, great invention. Yeah, that's true. We, along to what you're
34:55
doing, we interviewed Hughes DeFolk, you know, he is the Blyoma surgeon from Montpier, France. Yes. And he is very, he's just a terrific job. And he's very high. He did all this, he's done
35:12
all the things that you did. He was up training with, with George Ojeman and Mitch Burger was up there, but he came away with a different message. And his message is that we shouldn't, we need to
35:24
do more than the motor sensory mapping. We have to know where the white matter tracks are going. And where they're transferring information from one part of the hemisphere to the other. And the
35:36
tractography is exactly what he said. He said, it's a static measurement. And by the time you get there in surgery, it may be different And so he does a testing at surgery. And he's got a whole
35:49
set of neuropsychologists. He does them all awake. And they're testing various functions all the way through. They do it post-operatively. He does an elegant, elegant way to do this. And he
35:58
takes these lesions out. And he spares the white man attraction. His goal is quality of life. He says, because the problem is most people just map motor and sensory. And you go and you get into
36:11
these other traction. People wind up. and neurosurgeons say how you're doing, you're doing fine, you're doing an examination, which tells you nothing, and their life is not very good. I think
36:23
it's gonna be the way of the future, but
36:26
it was interesting to hear as you evolved it, you basically were doing what he was doing, and that is you found that you gotta have a wake, real time mapping to know exactly where you are. I agree,
36:40
I've heard this talk, and he's done some really impressive work, and I agree with him. So we're getting better, I mean, you remember, you know, when you trained, Jim, what the status of the
36:55
field, when I trained, which is, you're a little older than me, you look good, are you 80, are you 80 yet, you're 70? I'm 88. Yeah, when you look like you're about late 60s, I'm old, I'm
37:07
gonna be 74, Eric's the young man here.
37:13
Yeah, I'm gonna, so I'm gonna have to drop off in a minute. You should watch along. Yeah, but I want you to thank you, you too. Both of you, but I wanna just say a couple of things. First of
37:24
all, and ask another question.
37:28
Again, the work that you've done, Gary, with the multimodality management of the large AVMs is great. We've used it, you know, we've learned from you.
37:38
I like the awake AVM surgery I did not train doing that here at Minnesota, but up in London, Ontario, did you know John Gervin? Sure. Yeah. I did a few epilepsy cases with him, yes, great guy.
37:51
So we did, so I did some awake AVM surgery with him, and it opened my eyes, and so we've done it since then, and I think that that's very important for some of
38:02
these cases, so I appreciate that. Just jump back for one sec, Jim, you'll have to edit this properly, to the calf mouse in the brainstem. One thing I noticed on your videos is you're typically
38:13
delivering the malformation. Are you delivering it as a single specimen always? Yes, that's a good point. Sometimes if they're very large, you have to take them out piecemeal, but the best way
38:26
in my view to take them out is in one piece because I think you have less chance of leaving some residual because they're irregular. So do you do that? Well, I mean, it depends because it's that
38:42
play between trying to make a small and a cortical incision and opening as possible. And I'd love to take them out in one piece, but when they're larger, and so that was gonna be my next question.
38:53
So it's better for you. And I wonder if your laser shrinks them a little bit. I don't know if it does, but when you take them out piecemeal, which I do do sometimes, one of the hardest things is
39:06
inspecting that cavity looking around a corner and hoping that you don't leave any. So I thought, I was wondering if you had any
39:13
thoughts. I, you know, I feel the same way with large ones. I have not, I think I tried using an endoscope,
39:22
but the endoscopes are too big to get it right. So that, that didn't work.
39:30
As I say, I think sometimes you're forced to take it or it just, you can't get it all out in one piece And you need more room to actually see around it, so you have to take it out peacefully. I
39:44
think that's okay, but the recurrence rate in my series, when I think I've gotten it completely out visually under the microscope and when the post-op MR scan says it looks clean, there's no T1
40:01
hyper intensity, there's
40:04
still a recurrence rate of 2.
40:08
And do you think that's because you left something behind? Or do you think there's something about the Venus anatomy that's encouraging and new? I think sometimes I've left some behind that we can't
40:18
see and we can't see on MR other times because it's sometimes not quite in the same area. I think it's a de novo one. Yeah, we reported that quite a few years ago, de novo development of, you
40:30
know, whatever. So, well, anyway, it's been a pleasure on my end. If you guys continue, I'm jealous that I won't be part of it, but thank you so much and, you know, for the work that you
40:40
continue to do. Thank you, and thanks for participating in this, Eric. I'm a big fan of yours. You're one of the most thoughtful neurosurgeons that I have encountered, and you too, Jim, which
40:56
is
40:59
an important statement. 'Cause sometimes, and you'll see this at the meetings, we can, as neurosurgeons, and you have to be confident, to be a neurosurgeon and a vascular neurosurgeon.
41:10
Sometimes I feel like we're still getting in a little bit too much of the beating our chest about look what I can do and not so thoughtful about how we get the best patient outcomes. But I think both
41:22
of you are in that rare category. Well, that's nice to say. So if you want to drop out, maybe I'll talk to them a little bit more. Thanks. And then we'll, thanks a lot And we'll talk to you
41:37
soon. Yeah, and Gary, I have this very difficult case that I was talking to Jim about before. I'd love to get your thoughts on it. Maybe I'll be in touch with you. It's a giant
41:46
vertebral basilar aneurysm. So I'll talk to you about it. Yeah, those are challenging. Yeah, email me or text
41:54
me or something and send me the image, we can talk about it. Okay. The other thing I might as well say now, but as I think about this, and Eric and I were talking about it a little bit, I don't
42:03
know what your thoughts would be, Carrie, but - One of the things that I think is missing is exactly what we were doing here. It was fun, it was challenging, it was intellectually, we're getting
42:16
to the intellectual aspect of surgery. I mean, the reason that Paul Bucey called surgical, his journal, surgical neurology. You know what the reason was? He said, you know what you are, is you
42:30
are a neurologist first, and so you're a surgical neurologist So you have to understand that. He was absolutely right on target. Don't you agree with that? Yes, I do. I also had to be
42:46
a neurologist. I was gonna go into neurology 'cause I loved the
42:52
neurologic aspects, diagnosis, and pinpointing where the lesion was. And I think what you really wanna have is a appropriately, a
43:04
team where you have a, an appropriately aggressive neurologist and an appropriately conservative neurosurgeon? Yeah, you know, what we did at that when I went to Ford, we established an apartment,
43:16
AB Baker, I don't know if you remember him, AB Baker was a head of neurology at the University of Minnesota. He was Jewish and in the 30s, when he grew up there, the city was really very
43:30
anti-Semitic. So he had a very unusual position to be head of neurology there. And this guy was really smart. He was really good, a superb teacher. And he was used to say, treat the patient,
43:46
don't treat the disease. And so it gets back to the art of neurology and I was always amazed how much neurologists, we invited a neuro, Ben Boschus. I had all neurologists come up and give us
43:60
talks. Ben Boschus came up to me and just to get to your point, At that time, we were doing bypass surgery and so forth. He said, Jim, you're not being aggressive enough. Just exactly what you
44:12
said. He said, You're not being aggressive enough. And so it was a wonderful association and those guys were just tremendous.
44:24
And actually, many of the things they did predated what MR was telling us. And unfortunately, what people did is abandon neurology and they're just getting images, which is brilliant. I mean,
44:37
that's not what it's about. That's what Hughes Defoe is doing. He's saying, It's function, and it's not structure. And I asked her to go, They're a wonderful thing, but it's more than anatomy.
44:50
It's function. So, and there are not a lot of people who think about it and so
44:57
forth and so on. So anyway, one of the things I thought about, and Erica I've known for a long time. is if you were willing to do it, if you wanted to do it, something like we just did today,
45:09
we take an hour and discuss the most, the case is gonna present you, it's very complicated.
45:16
Present a very complicated case to see just how a bunch of people who think their way through this, what would you do with this? And the audience gets out of that, a lot of information, not only
45:29
did they get the technique, and I think your technique is pristine And we had a - I was at Grand Rounds in Latin America once they had a -
45:40
I'm not going to define it, because it would give too much away. A neurosurgeon from a prominent institution in the United States came down and talked about going in and taking on a pituitary or
45:52
something like that. It was the bloodiest feel. I mean, it was - I don't know how you could see anything.
45:59
No, I like a dry field.
46:02
A dry field? I mean, how can you see the anatomy in the middle of all this blood and you're sucking it out and it's bleeding and it's bleeding. But this was, and I saw a comment and I said, I
46:13
don't know how you know what you're doing. And I was the bad guy because I sort of and I made a comment, but to me, you just have to have a pristine field. And when I looked at what you did, I
46:24
knew right away. I could see the way you draped the patient. I could see the way you're opening was Every, you are just very much interested in that. The neurosurgeons, when I was at UCLA, the
46:38
residents and the residents, they don't know how to coagulate. So what do they do? They put a bag on the bed.
46:47
But if they put a bag on, I said, what are you doing there for? Oh, because we expect to lose blood. I said, no, you're not supposed to. You're not supposed to lose any blood.
46:56
So, it's a technique that people just don't think about anymore, but you have to be very careful all the way in. You just showed that, and the laser was just beautiful. Sometimes if it was too
47:09
big, I'd take the irrigating my mailers by polar and I shrink it. And I didn't want to obviously touch the wall because I'm giving them a deficit, so I shrink it away from the wall, and that was
47:23
helpful But the laser is just terrific addition, so I was really good. So anyway, the thing I'm thinking about is if you were to be willing, we could set this up, but we could be willing, we can
47:36
get ourselves, and maybe with time it goes to a few more guys. But in presenting some really complicated, challenging case, what would you do? We could do that in a basket of cases, do it once a
47:50
month or do something like that. once a quarter, we could spend two hours if it's a quarter once a month, I don't know. Everybody can decide, but it leaves a message with today's kids that's
48:03
different. Would you include, for vascular cases, an endovascular person as well? And, or is this, would you focus on surgery primarily? No, I'll tell you what, I'm willing to include all
48:18
that. Gerard de Brundon worked with us That guy was, he was a superb endovascular technician. It was one of the best parts of my professional career. And we would sit down and we'd go through all
48:28
these things together, so no, it's the same thing you do, I'm sure. Let's get the most talented people we get and think about it
48:30
and then put them together. We can have
48:43
a session on a regular basis. We can figure the time for it, but I think it would be, it would be fun for us It would be educational. Yeah. Everybody to look at it and see and understand my God,
48:56
that's what they did. And it doesn't mean that we're going backward in how you do surgery because at this time,
49:07
you know, Raphael tomorrow. Yeah. He's an Hopkins, okay. And so he presented a series recently, I've always wondered about this, Gary. A series recently, because we went through that, we
49:19
were pioneers in that too And including aneurysms, intervascularly. And I always wondered what happened long-term, and eventually all these people went to the neuroadiologists and they never came
49:30
back to the neurosurgeons. How many of these lesions were still existing? Well, he comes back and he comes out with an answer 'cause he went through the letter. She's a very careful guy, very
49:40
careful received. Raphael, yes, very smart. And he said 20 have to have be retreated. Well, now you know that's already more complicated right away, right? Yeah, the recurrence rate, there's
49:56
no doubt is higher. The endovascular folks would argue that's true, but even if you require retreatment is still less morbidity than operating, that's their argument. And the re-bleed rate is very
50:11
low for aneurysms, but I think it's controversial But if you had a basilar
50:20
under the aneurysm, how would you have it treated?
50:23
Well, when I'd rather go into vascular versus surgery, it depends upon the person doing it. Yes, of course, but if I got the best of everything - Even in the best of hands. And it's projecting
50:39
posteriorly.
50:42
Not anteriorly, there are no peripherators projecting posteriorly. So is this basilar tip? Yeah. Okay, so you're gonna see all the perforators and everything else? Well, it's tougher to see the
50:56
perforators. Right. That's the problem with that. That's the problem with that. You can't see the other side. For me, I would, if they could do it safely into a vast majority, that would be my
51:05
first choice. That's what I would do too. Yeah, so we have made advances into a vast majority, but I agree, I think the problem now that I see is that we are not training enough operative
51:18
microsurgeons who can treat difficult vascular lesions that can't be done endovascularly or that recuror endovascularly, right? So that's the issue is now every community hospital has an
51:33
endovascular surgeon, either a radiologist, a neurosurgeon or sometimes even a neurologist, and they
51:40
need one to treat the acute strokes to do thrombectomies, but they. And so since they have such a person, they treat every hemorrhagic vascular lesion, aneurysms, fistulas, they treat them all
51:55
endovascularly, whether they are best treated that way or not. And that I think is a problem. Fortunately, in this area, I get referrals from endovascular radiologists in the community who are
52:10
thoughtful enough to say, I can do this, but I won't get a complete occlusion, or, I think it's better treated surgically, but they don't have anything in their hospital to do it. We're in the
52:21
area and they said that here, but I'm not gonna be around forever operating. I think this is a really good point. And I remember I was in New Year's Eve and I was, we had a fellow who came in with
52:34
a giant basilar aneurysm and
52:38
he came to the operating room and I was down there and exposed it. And this was so big. I said, No matter what I do, I'm gonna give this man a deficit or kill it. My call, Gerard, on the phone.
52:52
That, this is New Year's Eve. I said, Gerard, would you come? And his wife was also helped him for his whole career. I said, Gerard, if I do anything on this man, I'm gonna have a worse
53:04
result than you are. And I wanted him to see the pathology. And then he went ahead and called it later. So it's a team. Yeah, absolutely. And, you know, we built a team I'll take a little
53:15
credit. I started the Stroke Center at Stanford in 1990. It was my idea. And you know what? I based it off. I based it off the model in London, Ontario. Interesting. Charlie Drake, Henry
53:29
Barnett, Alan Fox, Fernando Vinuela. They were all working together. And it was a clinical department of neuroscience. And we were the second Stroke Center in the United States but I put together
53:43
a team of.
53:47
And when I started, there was no endovascular and radiosurgery was just, hadn't been invented. But I recruited Michael Marks, who had just finished his endovascular fellowship, and Greg Albers,
54:01
who was a neurologist, just finished his fellowship and started on faculty. And it was just the three of us, and that was the Stanford Stroke Center in 1991, 1992, and then now there's probably
54:13
300 people involved But
54:17
Michael just retired. He still works a little, Greg is still here. So I've been working with Greg for, what, 35 years. Some of the people that I'm still working with for over 30, 35 years,
54:31
which is remarkable. But I think, I agree with you, it's a team effort. And I don't think, I don't believe that each individual should think they have to be able to treat, this vascular problem
54:43
with their technique alone. I
54:48
absolutely agree with that. You said with the high flow of AVMs, I remember in the late '80s, I started on faculty in 1987. We did not have embolization. We did not have radio surgery. And these
55:02
large complex AVMs, we would operate, when they bled, we'd have to operate. And what we would do, because they were so vascular, is we'd operate, we'd get terrible bleeding, like you were
55:14
discussing. And we would put them in bbabcoma. So we would give, we would just put them on thiopental infusions or phenobarb. And then we'd keep them on that to let their brains calm down. We'd
55:29
keep them hypothermic, sometimes for a week or two. They'd have fixed dilated pupils. They would bring Dan, essentially. And it would take another week for the barbs to clear out of the adipose
55:42
tissue. And then we'd wake them up and some of them would do well, but we had, you know, you'd get scans and there was bleeding you didn't like in the bed. And with embolization and radio surgery
55:55
as part of the multimodality treatment, it has revolutionized the treatment of AVMs. Yes, I think that's right, that's right. Well, okay, why don't we do that? I'll get back to you about
56:07
putting this thing together.
56:10
I'm open, I'm sure you think the same way. I'm open to any ideas, I'm willing to listen to anything. And to
56:18
me, as I look in the future of medicine and neurosurgery, it has to be much more integrated, high and low level team approach, basic research, all the way up to different clinical people. Where
56:30
compensation's gonna be different, and people just have to be willing to admit, and you're probably gonna be doing complicated cases.
56:40
That's the future. You also have to break down the barriers, you know, between the specialties, right? That's right, silosh. Right, we're treating as neurosurgeons, patients with psychiatric
56:52
disorders. Right, absolutely. We're using stimulation, neuromodulation, and that I think is gonna be the future for neurosurgery is gonna be restoring function. When I trained, there was no
57:06
hope of restoring function patients who were devastated neurologically after an injury, a stroke, a traumatic brain injury, spinal cord injury, or had degenerative disease,
57:19
or had epilepsy. But now we're using these other techniques to modulate circuits, right? We thought those circuits were dead. Right after a stroke, you recover for six months. We know that's not
57:32
true. We're doing stem cell transplant and resurrecting circuits We thought we're not. We're completely non-functional That's terrific. We maybe we should get together and talk about that
57:46
separately But that would be a very and if you wanted a team of people with you when we did that We should do that and because what we're trying to do is put this stuff on video So people all around
57:55
the world can see it I mean I got to see Gary Steinberg and I heard him and I saw it and so far than the For people who can't afford these things. That's that's extremely important It's true and what
58:08
do you think about, you know, why not use focused ultrasound to modulate circuits not just put lesions in why not use magnetic stimulation Or electrical or even optogenetic, you know what
58:22
optogenetic is it's using. Yes With with you know with promoters so that channels open We're doing that in the lab, but I think we'll be stimulating the brain and modulating circuits with light in
58:35
the future Tony DeSallis, you know Tony, Tony, is either.
58:40
He's an advocate of that. He's in Brazil. I think we should be open-minded and maybe get really be creative. Really be creative. Get some really good minds. Okay. Sound good? All right. Thanks
58:56
a lot. Have a thank you for all the time and you appreciate your secretaries arranging it. And so
59:02
be back to you. Okay Yeah. I'm sorry I was late. I didn't expect to be there, but my, you did some advice. So good. Well, thanks for doing this. I've looked at some of the other videos that
59:16
you're posting. And I think it's a real contribution to the field, Jim. So, and I admire you at 88. It's young. I mean, you know, my father lived to 100. My mother's 90 is going to be 97.
59:27
And, you know, you should look for, you know, I'd say 100 to 110 is the, goal these days. I hope so. So, so what did you talk about retiring for?
59:39
I know you're not, but that's the whole point, right? They got things to contribute, things to do. Keep it up. I do. All right, thank you so much. Bye-bye.
59:51
These are the references for Dr. Steinberg's talk today. For your reading pleasure later and information, you take screenshots of
1:00:03
the subsequent slides for your records.
1:00:08
This is the first set of references on the topic of surgical treatment of brainstem lesions. Take a screenshot of this slide
1:00:19
On the topic of management of AVMs and eloquent brain regions, this is the first four references that he has. Take a screenshot here.
1:00:30
The next four references,
1:00:34
the final two references on eloquent-located AVMs.
1:00:43
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