0:01
Hello, I'm Jim Ausman, and I want to thank you for inviting me to speak to you at the
0:12
5th Shalom, Congress sponsored by Hina and Provencio, People's Hospital, and for giving me a lifetime service award to neurosurgery
0:25
If you know something about me, or nothing about me, the reason I went into neurosurgery is it was a field that was very challenging with many complex problems. And I love to solve complex problems,
0:42
and I've studied many years about being a futurist, which is thinking and knowing about what the future will be
0:55
There's one of the challenges that we solved and that was people didn't know much about China
1:02
and as chairman of the World Federation of Neurosurgery Education Committee, we brought the first international meeting in neurosurgery
1:13
to Beijing, China And from that time on,
1:19
the Chinese neurosurgeons have developed many international neurosurgical meetings and have become widely known and that workers have become widely known around the world.
1:33
60 years ago, I had another challenge.
1:36
People who were dying of glioblastoma, the only treatments available were surgery and radiation and at that time, people thought chemotherapy might be helpful and they were giving intercorrodded
1:52
methotrexate. which was very toxic,
1:57
but it didn't work.
1:60
And people blamed the fact that it didn't work on the fact that there was a blood-brain barrier.
2:08
So I went to the NIH and did research for several years studying the blood-brain
2:13
barrier in animals. And we found there was no blood-brain barrier in metastatic tumors that we induced into monkeys.
2:25
But it was President Gliomas in models we had of SV40 virus-induced malignant appendamomas in mice.
2:40
So what it said is that if you were trying to give a drug to treat a brain tumor,
2:46
the drug would have to diffuse in a glioma from the center of the tumor. the necrotic portion where the blood brain barrier was broken to get to the distant parts of the tumor.
2:60
And you can see how chemotherapy might fail because it wouldn't get into the all the different parts of the diffuse infiltrating glioma.
3:11
We also developed a mouse brain tumor model for testing anti-tumor drugs.
3:18
And it was to be used to select drugs that might be beneficial in brain tumors was used for many years.
3:25
One of the drugs selected was BCNU.
3:29
The reason BCNU worked, it was a lipid-soluble molecule, which means it was able to cross all the cell membranes and the blood-brain barrier could not prohibit it from getting into the brain because
3:44
the blood-brain barrier was a lipid barrier, a membrane barrier
3:49
So we're left with a problem of. Now we can get the drug into the brain. There was some increase in lifespan and animal, semi-animals were cured with BCNU. But why didn't it work completely? And
4:04
those answers are becoming apparent today. You have to have enough, the drug has to get into the brain, has to get into the extracellular space. It has to be able to get into the tumor cell and
4:19
then have the right chemical composition to interrupt the metabolic machinery of the tumor cell. It has to overcome the drug resistance the cell can mount and also including the extracellular space
4:33
and environment, the immunologic resistance. And those are many of the problems that are being discovered today on why chemotherapy or any therapy involving molecular drugs getting into tumors is
4:49
not effective. It also tells you that if you give a imaging agent,
4:57
the imaging agent will only show a certain definitive amount of the tumor, usually the leading edge which is vascularized, in which the blood brain barrier is beginning to break down, but not the
5:09
diffused parts of the tumor. It also tells you why using intraoperative agents, fluorescent agents to demonstrate the tumor won't tell you where all the tumor is, because in order for it to reach
5:25
the tumor, it has to diffuse all the way through the tumor, and there are studies that show that about 30 of
5:34
glioblastomas are solitary or localized, but 70 are diffuse, and so you can't get the agent all the way in multiple gyri and through the hemispheres. So those are some of the reasons,
5:49
My drug failure has failed. Immunotherapy is coming up as a means to overcome that, but yet it still has a long way to go.
6:00
Another challenge after this was I became interested in stroke. At that time it was a disease treated mainly by neurologists. They didn't like to do angiograms because they said they were too risky.
6:17
And even if they found something they couldn't do anything about it, so why even do an angiogram? So they never made the diagnosis. And the treatment was aspirin, and then I played with agents.
6:30
And I looked at that and said, there's got to be a better way. There were other people who were thinking along the same line. They were thinking that there was, after doing angiograms, you would
6:40
find multiple vessels compromised or occluded, and that there was a perfusion loss And that began. that you're a bypass surgery to the brain.
6:54
And so in the 1980s, 40 years ago, I began working on bypass surgery. We developed different methods of trying to find the best way to do an SDAMCA bypass. We found that a nasty, most seen the
7:09
superficial temporal artery to the larger portion of the mental cell artery in the fissure was the best way to go. So
7:20
we used different varieties of SDAMCA surgery. We developed the first SDA to superior cerebellar artery and astomosis from posterior circulation disease and also to the posterior cerebral artery or
7:36
using the occipital artery, we connected it to the posterior inferior cerebellar artery or in tandem, the occipital artery and pica.
7:48
So we now have ways of providing additional circulation to all parts of the brain, both the cerebral hemispheres and in the posterior circulation. My experiment with vein grafts with my team,
8:02
arterial grafts, vein grafts were too large and they had too much of a flow and we had complications with hemorrhage in the brain. Arterial grafts, I didn't like so much because you had a sacrifice,
8:14
an important artery, usually the one to the wrist, the
8:20
radial artery. We also did experiments, and this is 40 years ago, on intracranial bypass grafting. And as to most different portions are jump grafting from what proximal to a distral portion of a
8:32
metal servo or anterior servo artery, or connecting the middle servo artery to the anterior servo artery through a jump graft in various formulations And now this technique is being used. commonly
8:48
in the treatment of some aneurysms.
8:52
We had a patient who came to us with basilar artery thrombosis,
8:57
progressed rapidly. We were able to, Instagram him in the hospital, found that he had a basilar occlusion, and at that time we gave him intra arterial, arterial thrombolytic agents. We were able
9:12
to dissolve the clot, see that there was an
9:16
atheroma in the proximal portion of the basilar artery,
9:20
and after the patient got over the intra arterial its infusion about
9:26
a week later we did an STA, to SCA and anastomosis, the patient did well. And we wrote many papers about all this bypass work. If you look back in our literature 40 years ago, you'll find it We
9:42
also publish papers summarizing a work on posterior circulation disease. You'll find that also written recently.
9:52
Treating pineal tumors was a challenge over many, many decades. There was a high complication rate, and it was very difficult to get the tumor out. And we developed an approach, which is a
10:07
three-quarter prone, operated side-down approach So the folks had basically held the brain up, and the gravity lowered the inferior portion of the hemisphere.
10:24
We put a catheter in the ventricles, that
10:31
brain from falling away. So we used little retraction, and we were to get a direct vision to the pineal region with two surgeons operating, and the complications really went to zero.
10:48
So it was a very successful procedure. You need to think about ways of finding solutions to new challenges.
10:59
40 years ago, in 1980 to 2010,
11:02
we also began to work on cerebral aneurysms. I visited Dr. Suzuki, who was an outstanding surgeon, neurosurgeon in Japan, who was doing early surgery on aneurysm patients
11:16
and ruptured aneurysms
11:19
The two major complications at the time were re-bleeding
11:24
and was
11:27
vasospasm. And people used to wait for the patient to get over the acute phase. And many patients would die in the interval. And the vasospasm became so severe that people didn't want to operate.
11:40
In that case, the mortality was high.
11:44
He believed in early surgery. We believed in early surgery and introduced it to the United States.
11:50
And with early surgery, you clip the aneurysm, you stop the repleting, and you allow yourselves to go ahead and treat the cerebral edema that follows, usually with hypertensive therapy, which is
12:02
what we had at the time.
12:06
With Gerard de Brunde, who is an internationally known neuro-radiologist and interventionalist, he came to our center, we worked together with other centers in the United States and began to
12:20
put coils in aneurysms.
12:24
And I found that after looking at that, this was going to be the treatment of the future would replace surgery, it went and gave talks about it, nobody liked to hear about it because people liked
12:35
to do surgery for aneurysms, I did, but there was a better and safer way. And eventually that became true also.
12:46
We looked at AVMs
12:50
and at that time they would rupture, you would also wait to do the surgery.
12:54
And then eventually go ahead and take the AVM out, there was some radiation therapy and at the time Gamma Knife was coming up and that was used to treat it.
13:06
Some people had tried early intervention but it had improved to the point where you could put either coils or liquid agents in and include many portions of the AVM, particularly the NITES.
13:22
And with Dr. DeBrun, we treated patients with very complex large AVMs with multiple analyzations and then went ahead and did resection or localized radiotherapy to the
13:37
remnant of the AVM.
13:41
And just as an aside, 60 years ago, we published work on spinal AVMs working with a vascular interventional vascular radiologist in embolized spinal AV. We reported that.
14:02
From the 19th 2070s to 2050 to 20 years ago, I was chairman of two departments of neurosurgery spanning 23 years.
14:14
And we tackled some of the problems facing organized neurosurgery. Neurosurgeons at the time would try to do every operation themselves, every different kind from pediatrics, to spine, to vascular,
14:29
to stereotaxis And I found that everybody could not be an expert in every field. So we developed along with others some specialization in neurosurgery. And that's why you spine surgeons, you have
14:42
vascular surgeons, you have interventional
14:47
neurosurgeons,
14:50
tumor surgeons that basically devoted a principal portion of their work to a particular field, gained a lot of experience, complications went down
15:01
The eye she used at that time. We're being controlled by surgeons and anesthesiologists.
15:09
So it was a great deal of political fighting, but we were able to get our ICUs with nurses who knew essentially how to treat these patients. Patient care of neurosurgical patients in the hospital
15:20
wasn't good, so we had our own nurse practitioners who basically supplemented the
15:28
care of nurses in the hospital so we could guarantee good results after surgery.
15:36
We developed the first internet, TV, internet, international consultation service by telephone. It was telephone lines being used to transmit images at that time, so we could consult with people
15:49
in different countries about complicated cases they had.
15:54
One of the biggest problems at the time was the brain drain of surgeons or people from other countries who wanted to study in the United States,
16:04
and that depleted the quality and the talent of people available to any country to solve a problem. So we developed the largest fellowship program in the United States with my associate, Manuel de
16:18
Hovey, and we trained 400
16:21
neurosurgeons. People only could come to us after they had completed their neurosurgery training. They stayed with us from one to three to six to 12 months. Some stayed 24 months They were from 90
16:35
countries, 95 returned home, and most of them became leaders in neurosurgery or in their government and their countries.
16:44
We were honored to be lectured, invited to lecture in 70 countries around the world. So we learned a lot about people everywhere.
16:53
30 years ago today, from today, I was asked to be editor of a journal called, one of Bucey Paul by, founded neurology surgical
17:02
the pioneers of neurosurgery. became the third leading earth surgery journal in the world. It was a paper journal.
17:10
But we realized, in 2010, this technology was taking over
17:16
and that there was high communication, that that wasn't the answer. The answer was internet journals. That everybody could see instantly. And so we developed surgical neurology, international
17:31
That's called SNI, now, surgical neurology, international. It's written virtually every country and territory in the world,
17:40
239 33., 000 people a month read it. It's the third leading journal in neurosurgery. And it's free. It's free. All the contents are free. And then there, you can see SNIglobal. That's how you
17:54
get onto it SNIglobal, and
17:56
it'll take you to
18:00
the home page,
18:03
All access to all this information is for the practicing neurosurgeon. There are case reports from all over the world, original articles, review papers. We have 1200 of Dr. Ernest Nimi's videos,
18:17
outstanding videos by an outstanding neurosurgeon that you can look at and see almost every conceivable cerebral lesion. And we also have some free e-books there Many of them are from Dr. Ernest
18:34
Nimi.
18:36
SIglobov.
18:38
What we're looking at the future of medical communication, again, another challenge. And so we started a new service in 2023. And it was it because we noticed that neurosurgeons wanted to have
18:52
information discussed, not just more information. They wanted to have people talk about it. So we established a journal called SI Digital. It's peer review. There's a massive information, video
19:07
information. It's not peer review. This is peer review. It's interactive. There are discussions with the electorate.
19:16
It's a video journal and neurosurgery. And if you want to get on the website, it's called snidigitalorg.
19:23
Snidigitalorg. It's also free. It's also free. Lectures from around the world. Case discussions International people giving their opinions. For all ages of people who are interested in
19:38
neurosurgery. Young to old. Interviews. New science evaluations. News and discussion. Discussion.
19:48
This is the homepage of surgical neurology international. You see in blue the surgical neurology international in the upper left corner. And in red if you click on that, that's another way to get
20:00
to,
20:02
In the center, you put
20:05
in the blank section in the center, your search term, and out will come a list of items that will answer your search term. Our goal in surgical neurology, international, and our goal in our life
20:19
has been to help people throughout the world.
20:22
On the bottom, you see the most recent five papers that are being published, be published continuously, and within three weeks of acceptance It's all free.
20:35
What's the future gonna be like?
20:38
Seven years from now, in 2015, 2075, 2100, what's it gonna be like?
20:49
In July 11th, 2022,
20:54
a new telescope was launched by satellite. Beyond the atmosphere around the earth, infrared radiation.
21:05
And it uses infrared radiation to take a picture of the universe. And in this narrow area in which this telescope was able to view, there are thousands, if not millions, of galaxies just like ours.
21:22
Can you imagine, in a 360 degree view, millions of galaxies? What's the likelihood that there are other civilizations on the world or we're the only one?
21:36
And given the unidentified flying objects, which people now acknowledge have technology beyond what anybody in this world can achieve, there are other civilizations. They're likely to be more than
21:49
one and many. Now we're then going to be faced and you're going to be faced with how do we live with these people? Are they going to be friendly? Or are they going to be hostile? If we can't live
22:01
together in world we're living in, how are we going to live with other people?
22:06
And it also tells you, the universe is beyond man's comprehension, beyond our comprehension, beyond what we know. It also tells you that just because you don't see it,
22:20
just because you don't see anything, it doesn't mean that there is nothing there
22:28
So in 2, 175 years from today, as my feeling and my belief is neurosurgery, as you know it, will now disappear as a specialty. Medicine is changing right in front of us. If you look at the
22:46
medicine journals that are dramatically making advances in medicine, which are metamolecular and biochemical. Medicine has changed over thousands of years, it's going to change in the future.
22:54
There's no real reason that it will be the same in 75 years from now as it is today. It will change. You will have to change with it. I'm going to leave you with one last question.
23:07
We're in an age now where technology seems to be promoted as the dominant force in the world. It'll solve everything.
23:15
Is that true?
23:18
Is technology really life? Think about
23:26
it. Thank you very much for listening to me Write me at jameshousemanmagcom. I appreciate this invitation.
View Transcript
Listen to Podcast