50 Years in Neurosurgery

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- Colleagues and friends, thank you for joining us for another session of the virtual operating room. My name is Aaron Cohen. Our guest today is Dr. Juha Hernesniemi. He is one of the icons of neurosurgery, does not require any introduction. He has been a mentor for so many and has one of the largest experiences in neurosurgery in the world. And I'm so excited and honored today, and truly it's my pleasure to introduce him and have him talk to us about his journey and his life in neurosurgery and his nuance of technique and what he has learned along these years. Juha, many thanks for being with us and please go ahead.

- Thank you Aaron. Thank you very much. So I'm Juha Hernesniemi. I was born in a very small village, 1947 with less than 100 people and I ended up in China with 1,001,410 million. So this was my route. I have been 50 years in neurosurgery and I, with 18 years after high school, I tried to come inside medical faculty in Helsinki. I failed. So I went to study medical science in Zurich and this was the big change in my life, and it changed my life because in Zurich, Switzerland, I was the top level of neurosciences and of course there were Krayenbuehl and Yasargil. So after finishing my medical studies in Zurich, so I became, went to train in neurosurgery in Helsinki, became neurosurgeon 1979, made PhD on traumatic brain injuries the same year. And then I was looking for a place where I could operate on as much as possible like I have seen Professor Yasargil do. So I went to Eastern Finland, a small city, Kuopio. I was told there is no return, there is no return because this is a place for one of my fellow Fred , Western Siberia will never come back to Helsinki. My chairman Hendry Troupp asked me, Juha, are you coming back? I said, in 17 years I will come back. This meant that when he's retired I will come back and I was successful. I became professor and chairman in Helsinki, '97 - 2015, 18 years. And we became like a mecca of neurosurgery for 18 years, we had more than 3000 visitors around the world. We made also lot of publications in neurosurgery. Difficult to have many readers because we are 70,000 in the world, neurosurgeons. So H-Index is 76 and more than not 22,000 citations. I made in the 50 years, I made more than 16,500 surgeries, more than 6,500 of them cerebral aneurysms 600 AVMs, 3,500 brain tumors and so on. And I was traveling also a lot, giving 3000 lectures around the world and giving life courses. So this is my 50 years neurosurgery and next slide. And so how I notice a rupture, this is a Turkey singer, Ebru Gündes, more than 20 years ago she was showing her new...

- Fighting now, she's fighting heavily but then she's going down and everybody's... The people don't know what to do. Open the windows, put her high. This is CT, you see subarachnoid hemorrhage. And then you see has become aneurysm. They operated first become, but it was not ruptured. And then this ICA aneurysm Here she is three months after... Subarachnoid hemorrhage and the two operations coming back to the root again. And she made splendid recovery, married three times and continued to smoke. She was extremely popular, famous in Turkey, Istanbul. Everyone knew and everyone came to take pictures or ask for her autograph. So this is how it happened. We seldom see it in nature, how the aneurysm rupture is. Okay, so this is 1923. This is my father. And look at my grandma, grandfather. They are 30 years old. It's the times of depression all around the world. And it's just my oldest uncle. He immigrated to Australia like it was usual, European immigrated to Canada, USA, Australia. This was very common and this was poor family, as you can see. They had nothing, nearly nothing to eat, nearly nothing to have on, prices were lacking. And this is the small, but it's born 1947 after the second World War. There was baby boom. And I was born 1947. So this is the high, biggest, biggest number of children born after second World War. I was born in this old, old cottage, very cold. And I was sleeping about the oven so that the rats couldn't catch me and I could be warm there. This is my family, this is my father. He was five years in war, my mother, me and my brother. 1950, 1950 after the lost war. So Finland has to pay lots of money to write Soviet Union who won the war. And with that, the industry was growing up and Finland became one of the most modern countries. This is 1952. Me, my brother, my father was school teacher. This is on the pattern of the school. And here I go to school. This is here, it's seven years you went to school. This is my teacher, very reliable old teacher, Ida Ekholm. And this is the link why I became medical doctor in, Ruovesi, in the countryside. I went to high school and I was collecting coins, butterflies and this retired GP, Dr. Einar F. Palmén. He had taken care of the whole area with 10,000 people alone and retired. He had a private practice after that. And I went very afraid, knocked his door and I said, I'm also collecting butterflies and coins. Can we compare our collections? And he was very kind. And then when I grew up, he began to tell stories about his medical life and that's why became interested in medical studies. So at 18, I finished my high school and I tried to come inside Helsinki faculty, medical faculty, but I failed and it was the most important thing in my life. This is my friend Remi. And this is me 18 years. And take a look how trustful we look in the future. No worries, no worries. We didn't know what will happen. Zurich we are coming, summer 1966. And it was this way. Many people in USA don't know where is Finland. Here's Finland, Zurich very small country but famous as a center of the money, Jewish, Switzerland. I went there to study and our is Russia and now we have been hundreds of year in war with Russia. We have been also part of Russia and part of Sweden. And Finland became independent 1917. And you look on the map there. So this is our neighbor Russia, 1,300 kilometers border. And these are Baltic states. They were under Soviet Union long time. They know how it is to be neighbor of Russia. This is Russia. There's only one country between China and Finland. And this is Russia. Russia is huge. It's difficult to go to Russia and Napoleon and Hitler know how it goes when you try to make the war with Russia. Russia has seven, 8,000 kilometers so you can always escape. So I speak now about neurosurgery, how to become good neurosurgeon, international neurosurgeon, famous neurosurgeon. I never met the person who wanted to be a bad neurosurgeon. So I'll give some hints with an experience of 50 years in neurosurgery. Had to find heroes. Look around who's your heroes. When you are doing boxing then Mohammed Ali might be your hero. When you're doing running, sprinter, then Usain Bolt might be your hero. Then you need mentors who support your studies and then you need some friends. No one can do neurosurgery alone. And this is very important. So you have to be social, you have to manage in a group, team with nurses and also patients. This is very important. These were my heroes. Here you see they are here together in Chicago 1988. This is Professor Yasargil, 63 years old that time. And this is Professor, great Professor Charlie Drake, 68 years, demonstrating subtemporal approach in Cadaver lab and take a look on their faces, after thousands of operations, they are still interested in learning anatomy new techniques. And I learned from both of them, work hard, learn anatomy. This was the message I learned from them. And then I had a mentor, this is late PhD, Seppo Pakarinen. He was good mentor. He was telling me after complications in your research when I was resident, "This just training your mind", this is just training your mind. And he was also helpful in the fields outside of neurosurgery. He was giving advice when we were young. We had many problems and troubles. So he was always helpful and he was a great man, one of the best human beings I can know. And this is his son, famous cardiologist nowadays in Finland and like Dr. Drake, Seppo Pakarinen was always smoking his pipe. So the message is learn anatomy. And how to learn anatomy? You have to sacrifice your life for that. You may think that you can know the human, anatomy brain, anatomy but we should live 200 years like turtles live to learn perfectly anatomy. So we are always, always have some lacks in knowing anatomy. And this is Professor Gian Tondury, my teacher in anatomy, 1969. He was shouting always when he was speaking. He told that, yes, a microphone in his throat. Medical study is a lifetime work and anatomy even more. And that is no more, not a sentence that is, can be more true. This is late Professor Gian Tondury, Zurich 1968. He was wonderful teacher and was asking much to learn anatomy. And this was the book, Topographical Anatomy by Gian Tondury. You see that I have read it many times until now during the 50 years or even more because I was 18 when I began my medical studies in Zurich. So every word has been read and undersigned. So I learned anatomy. I still have the feeling I cannot do so well in anatomy after so many operations and learning. So one day there was a extra, extra lecture, Introduction to Brain Research and this was by Professor Kondrad Akert, professor of neuroanatomy and leader, chairman of the Brain Research Institute in Zurich. He was asking us students, is someone willing to do some research in brain research? I rose my hand and I was accepted to be there. And besides my medical studies, I was three years in the brain research institute. And this is Professor Etsuro Kawana from Tokyo. He was teaching me English and this is Miss Bruppacher. She was teaching me how to make slides of the cat and rat prey. Prof. Etsuro Kawana didn't speak so much English, maybe 50 words and spelling was very bad but I, this was the beginning of my English and of course it was Brain Research Institute was very international. They had 20 researchers around the world. So there were also better English speakers. And the most important thing, what I learned was to use the microscope since 1969. This open a one, this was the first microscope introduced to neurosurgery. I'm operating here on cat or rat brain to find the afferent and efferent organs, subfornical organ. By Professor Etsuro Kawana. And based on these studies then I was giving in Leningrad that time the name of the city was Leningrad. During the Soviet Union time, this is the famous Pavlov Institute, statue of Pavlov is here. This is me, my girlfriend, chairman of the Pavlov Institute, Professor Akert, Professor Etsuro Kawana. I was giving my first lecture there, eight minutes, there were maybe 10 people listening to me on my lecture on Neuroanatomy. I had eight slides and I was giving this lecture and I was very happy when two girls came to me and asked my autograph after the lecture. So I felt that I'm a real big scientist. And this is Professor Krayenbuehl giving a lecture. Hugo Krayenbuehl, he was one of the leaders of the neurosurgery in the world. He was very good lecturer, he was present in patients and in very interesting way. And after finishing my medical studies, I would ask Yasargil to come, to be trained by him. He said, yes please come. But then I hear it's very difficult under him. So two of my colleagues, they began, one Swedish and one Finnish began their neurosurgical training under Yasargil. But they both finished. So the other one became ENT and the other one became GP because it was so strong and hard to work there. So I went to Helsinki to become neurosurgeon and this is my first day in neurosurgery. So dictating different hairstyle that time, 1973. And you see I'm smoking here. Nowadays even if you are chairman in Europe Helsinki, Finland, wherever you cannot smoke. But it was that time you could smoke inside the hospital. My mentor said, "To smoke is less dangerous than gossiping". And one, the first thing I was told when I became resident in neurosurgery in Helsinki was that you'll never be rich. I didn't care, I didn't care. And I think this is very important message to become a great neurosurgeon. Don't get seduced by the money. The other thing was that, you'll never get a place to work in Finland because there was only one institute in Helsinki. I didn't care because I had been just studying abroad. I was thinking I can make my neurosurgical training in Finland and then go elsewhere around the world, somewhere. I didn't care. And the third thing was, I was told, will not never become famous. So only the first thing, you'll never get rich. This was true. But I got the working place in Finland and I became rather famous around the world in 50 years. This is Helsinki before this is an operation in 1960s, chairman trained by Oliver Kronner, Gunnar Björkesten, he was six years in Stockholm. He's operating on brain tumor. And the first professor of neurosurgery Arne Snellman, he was also trained in Sweden. And this is by Chairman, Professor Henry Troupp as resident assisting here. So all three became professors. This is the history of the neurosurgery. So it began in 1930s. This 1932 was the neurosurgical clinics built up and it's from '60s. So Professor af Björkesten , he and I became resident in Helsinki and this is when I was resident in Helsinki. I used to work hard like I learned to do in Switzerland. And like you are doing USA, elsewhere, Turkey, you come early to work as a resident and to compensate that you leave late. So I was doing that late. So this is why tricky, I was '73, I become my residency and I became neurosurgeon. 1979 made my PhD on Severe Head Injuries, the same year. And then I was searching a place to operate on a lot of cases. I was in Sweden, Sala. I was in Helsinki, I was in Kuopio. Finally I selected Kuopio because it was a new department, there were only two neurosurgeons, two neurosurgeons and a professor, Dr. Professor and me. So it meant that I was allowed to operate as much as I wanted and could because in Helsinki, it was a big department I was the youngest one. So in two months I was operating four patients. So I was counting that with this frequency I'll never become a professor who can operate many cases like Yasargil. So I went to Kuopio. I was 17 years in Kuopio and I made from Kuopio, I made many visits to Zurich to see Professor Yasargil. Then I made a fellowship in London Ontario, Canada and Miami USA by Dr. Drake and Peerless. And this was my training now early beginning. And this is how Helsinki was, you see this is not the hospital, this is the old part, built 1932. And this part, 1958. So it was actually what I have seen around the world. Wonderful big hospitals. It was very lousy hospital but we could make it worth famous. More than 3000 people came to see us. Why? Because we had the team. We had a wonderful team, good effective teamwork. And the people came to see how we could operate many cases a day. And this is one of the best scrub nurses in the world, at least in my understanding. We didn't speak anything. She had two instruments in her hand. And so we could do extremely fast surgery. Record was MCA M1 aneurysm from skin to skin in 25 minutes. We don't believe that it is true. So people came to Helsinki to see our team around the world. We had this world map in the operation room and everyone was allowed to put the pin in the roadmap. So there is no continent and the people were not coming of course most from USA, the last ones were from Great Britain because Great British are very conservative. They didn't believe what we're doing. But we were doing well. So we had more 3000 visitors in Helsinki in 18 years. And I made also travelings for lectures and live surgeries in most of these countries. So this old myth that neurosurgeons should be endless and tiresome, this one will change, this one will change. This is the record I operated in one room, six aneurysm patients in one day with my wonderful team, two of them basilar bifurcation aneurysms and this can be hardly beaten. So my principles were simple, fast, clean. Clean surgery means fast because you don't make any errors, you are not disturbed by bleedings and preserved normal ana. And this was the principle we were following. And this is from Kuopio, you see this is January 27, 1982. I still remember the day, it was extremely cold, minus 40 that day. And I operated on this giant AVM on a 40 years old patient, took maybe hours because I was not so well used to that, but I did well and the patient made extreme good recovery of course that kind of big AVM without embolization, it's very difficult to do even nowadays. But I was, I trusted myself. I had the scissor, this is cuts you'll never give up. You are like a cat thrown on the wall. You will not fall down and you will never give up. This is how the, how it must be in AVM surgery. So in Kuopio I had no assistant. I was doing more than three 6,000 operations from skin to skin alone. Bringing the patient also in the intensive care and following their recovery. So I was nearly always in hospital early morning, late evening, my children were thinking I'm never sleeping. But it was not true. So in 1980s I noted that I have to go somewhere because I just operate, operate, I have to see some other ones to see do surgery. I knew Professor Yasargil in Zurich, I knew his presence since 1966 and this is just Helsinki later. And then I know also that Professor Drake is doing posterior circulation aneurysm. And the saying is from , "When the student is ready, he will go and find a teacher." And I found a teacher. I went 1982, being a young neurosurgeon, I had operated already two or 300 aneurysms at time. I went to Zurich and this changed my life, this changed my life. I saw Professor Yasargil do operation with this microscope-like miracle balanced microscope in Auschwitz. And I saw how to do, how to do, he was like Usain Bolt. Number one and nothing. And all other neurosurgeons in the world were number threes. So I saw him and this was the mouth switch, mouth piece. I don't know why most of the people, neurosurgeons in the world are not using it because it makes 40% quicker, faster surgeries because you can change the angle without moving yourself. I would have been operating always standing to be fast, fast and change the angle. And I have always used since 1982. This mouth piece, this is wonderful thing. Nowadays I know, there's now exoscope, it's changing their life. I had never difficulties with my pain in my back or cervical pain because I was a gymnast and I was doing gymnastics every morning. So I was strong during surgery. And because it was not allowed to say any word in the operation room of Professor Yasargil, he was thinking that this operation room is like a church. You may not say anything, you have to be quiet if we're coughing in the audience then he said, "You're sick go out," and so on. So we were silent but after surgery we went to a restaurant. Here is Weisser Wind, White Wind, the middle of is February 1982. International students of Yasargil, who came to see him. One evening, this young Mexican neurosurgeon, Jesus Martinez said "One day we will be better." We didn't believe that this is how it is always the younger generations are getting better. And this is great Professor Drake and this is Professor Peerless. I went to make my fellowship in London, Ontario, Canada and Miami because Peerless was passionate. Marcelo, he wanted to go to Seaside. London, Ontario was that time very small city, 8,000 people. So it's a big, big thing for me to move to Miami. Dangerous city at that time, murders, kidnapping and I went with my family. So it was very long and hard year but I could manage, I was working a lot. My children were saying that father is inside the computer because I was working 16, 18 hours a day on the material. London, Ontario. Basilar aneurysm. So it was very good saying because I was not on the computer, at the computer, I was inside the computer. And this also Peerless family and part of them Dr. Peerless and Anne Peerless and son, Drew in Miami. Son Drew, he was sailing around the world along soon after this picture. And this was the book we made. I was very happy to have my name in the book, Drake, Peerless, Hernesneimi. Surgery of Vertebrobasilar Aneurysms: London, Ontario Experience on 1767 Patients and forward was done by Professor Yasargil. I was very happy about this fellowship. Even I was old to do it but they helped. Drake, Peerless helped me very much to become Professor and Chairman in Helsinki. And I learned microsurgery from Yasargil but how to be a chairman I learned from Dr. Drake because he was very honest, wonderful person. He was a very good medical doctor, excellent neurosurgeon, but also a good human being. And this is maybe the most difficult thing to do in the neurosurgery. There is nice drawing of Dr. Drake. And I tried to become professor in the most northern university in Finland, Helsinki at the time. This is what Professor Pickard wrote about me, only this sentence. "At the age of 45 this man seems to be happy to analyze surgeries of others." But it was very helpful because I learned I was operating every case of Dr. Drake and Peerless in my mind. And I was not hesitant. 2002 to go scrub nurse to Padova to operate on a young Croatian girl, student who didn't have any money. This is Professor Perra from Palermo and from Padova it's good to have a friend from Padova, always. So this is Padova, Italy 2002 and this young student without money, she had 4.5cm vertebrobasilar junction aneurysm in her first two bone operations MCA aneurysm, Acom aneurysm . And then we took this patient inside the operation room the same day and operated on her giant vertebrobasilar aneurysm and it went well. And she's doing very well, married this year at her age for years he didn't wanna have any children but married a USA professor this year and has been in contact with me all the times. So I became chairman in Helsinki and first year when I was there I got the letter from China and this guy, Hu Shen was sending the letter, with very broken English. He told, "I will come to Helsinki next year." And there was a picture, he was standing in front of his car because cars were very seldom 1997, that time if you owned a car in China you were something very special. He came to Helsinki, he sent before coming, he sent me a letter. I will come that day to Helsinki, pick me up from Helsinki airport and that it that. Then Keisuke from Kyushu island, most southern island from Japan. And this was the Ayse Karatas from Turkey, the youngest neurosurgeon of the world that time, 28 years. And this is Emel Avci, she's now president of the neurosurgeons in Turkey. And these were my first fellows, this is in the live course 2003. And this was the beginning to fly high. Professor Yasargil came 2003 to Helsinki. Here he's speaking with my chairman Markku Kaste, his assistant Sucru Caclar. And this is me, 2001. And after that Professor Yasargil operated two weeks with us and then we make live courses every year. This is 2003, this is the last year Professor Yasargil with us. And you see Professor Yasargil teaching, everybody was silent and listening to him. You didn't speak about Professor Yasargil when we saying professor, it meant Professor Yasargil because there were no other professors in the . This is Professor Yasargil fighting with a difficult meningioma with at the age of 75, 78 years, 2003. This is Mrs Leena Kivipelto. First female neurosurgeon in Finland. And after that came so many. Professor Drake was saying girls are not good for neurosurgery. I didn't believe it. So nowadays, nearly 50% of the neurosurgeons are females. And in my operation room there were always many visitors, usually 10, 20 even more. And we had to put times there. I didn't like to speak surgeries before operation. But after operation we were discussing heavily what was going on. This unruptured cerebral artery aneurysm and the patient's name Elmy, she's the sister of famous Elmy. And this day I was lateral supraorbital approach that I was using since eighties. Only little opening of the not I used you got exactly not 40 pushing first time in and side cutting and I'm using a few instruments less than 10 in one operation because to change the instruments takes time. Hope I open always and strong wall then and then we see the rupture with the very thin wall, very thin wall. You see that? So I didn't use any string in the cutter because they would be touching somewhere inside I was not allowed to do that. I had to use string, I didn't. I was allowed and we're not counting them but we're careful. So wearing the strong of Mrs. Elmy sister. And then they went here to put clip with code and color on M1 and then so take a long curve clip base, put deeper, take the temporary clip out very carefully. It's not, the game is not over. The important track structure if you want do it as and now we see what is the situation. The base is not totally taken. I was thinking down even so some part of the aneurysm here thinking okay clip more of that, two clips more here and then perfect tools and open and the aneurysm. Then how it looks when you coil aneurysm, you get recurrences especially MCA aneurysm because they are very special, they have very special anatomy. This patient is also coming from Italy was several years ago, means that result scarring one part of the coil sliced that in two ICG before operation and then how to do, I put temporary clips on three branches in one and two and then open the aneurysm which is of course no return, opening the aneurysm and I exam part of the coils out and try to put the clip on the base of the aneurysm that the coils inside the aneurysm push the clip down and it's... I'm traveling here with the clips but the tools remain closed so I have to take more and more coils out. You see that the tools are uploaded. So I'm traveling with the clips upwards, upwards but it didn't work. I couldn't open the tools. And so now I take the what call pilot clip. Now I take the temporary clips out and then it's bleeding something bleeding and I the clips. I add clips and then I open the aneurysm take coils out is by far more easy to put coils inside the aneurysm, then we take them out after years. So we draw cord cut and then finally have the aneurysm nearly empty. I didn't want to take all of them out because there is scarring. So but now I can, as you see I can save the two because the aneurysm is empty and the coils are not that massive coils is not pushing down. So the two clips the has been taken care and those are filling and this a good result. And of course in postoperative pictures you have a lot of artifacts because of the coils and clips go. Let's take a look on the next video here. This is a acom aneurysm. This is a pediatrician coming from . The age of 58 years old, female. She was getting , we went first to , they didn't want operate on her. She came back to Helsinki, Finland and this is the operation. I go from left side and my I have to dissect to see and hyperextension step say you have more time to do your surgeries because that's feeling of the backflow through the, a tools. So you see that the aneurysm is mainly thrombost it's like the mass combusting optic nerve chiasm, I'm dissecting carefully. And then I searching for . A1, here is left A1, post lateral A1. And then I'm searching, putting the clip on the right contralateral and then I can dissect more carefully. The aneurysm, you see it looks yellow, this ruptured but there's also thrombus inside it that this thrombotic aneurysm is compressing optic system chiasma. And that's why the patient basically is getting blind. So I have one clip there, pilot clip, I take the out and then I begin to work on the aneurysm and the difficulty was that the main part of the aneurysm base, was on the right side. So I had to change many times the clips and see here is a ring clip and I had, I'm opening the aneurysm, taking coagula out. You see a CUSA next to the aneurysm is a giant one here, I just cut the thrombotic thrombosis away and then I put once more in clip there and then change the clips. They cut one part of the aneurysm out. But you should leave some part of the aneurysm that is attached to the optic nerve in the place, as if you try to take out to a this optic nerve and chiasm patient might get blind. So leave aneurysm attached to the optic system and skull fibrotic down and putting again clips only once and then change the clip, change the clip, clip taking out base. So now you see I took a curved clip and this takes perfectly on the base of the base of the aneurysm removing and then we should be now happy. Part of the aneurysm out but if the part of the aneurysm is attached to the optic system then this is . Immediately after the operation the patient was seeing better and she left on the fourth day to St. Petersburg that time because it was already . So this was a 18 years old girl, had a big AVM and huge bleeding came with bilateral fixed pupils. And I began to take the hematoma out and then I had terrible bleeding. Like all the blood from Helsinki was coming out and what we did, we gave, I did not see. I down and put several clips and then I was very happy to stop the bleeding. I was thinking the patient will die on the table but we could stop the bleeding. Next day we made the CT and the hematoma temporal, right hematoma was as big as earlier and the patient had again bilateral pupils dilated. So I went once again and in three sessions I could take the AVM out and the patient made good recovery at paralysis of the right limb that she's living in and is independent. So we can take the next slide. This is a terrible bleeding. So this is a giant macular superior aneurysm. Looked in the pictures that that's a very sharp, very thin neck, Dr. Drake was always saying we have to check, we have to explore. And here I'm exploring, I'm exploring here macular artery but especial that SCA aneurysms. So the SCA is always coming from the base of the aneurysm. This is very important for the treatment. So here I'm putting temporary clip to taking temporary clip out of the and this is good trick, to take the temporary clips out. You put the cotton there and then it protects when you take the temporary clip out. I think it's not yet ready. So I once more on this right side temporal approach and then I put also temporal clip on the vertebral-basilar artery above the clip is superior cerebellar artery. And then I push the clip deeper taking the whole base of the aneurysm. And so this was rather easy aneurysm to do because the base of the was so small. So I opened the clip and push it deeper and then I can take the temporary clip cells from PCoA and basilar artery. And here again taking temporary clip from basilar artery and very careful, very carefully always because when you try to take them very quickly out, have to take a look that they're not bleeding. And now this is how the aneurysm is clipped totally taken and I opened the aneurysm. Then we can take the next slide, the next video. So this is giant basilar tip unrupted aneurysm. So this is 68 years old female, who had neurological deficits because of this huge aneurysm, giant basilar tip aneurysm compressing the brain stem. It's like a golf ball that's also MCA aneurysm. But we were concentrating on this giant aneurysm. I don't know how you would do nowadays. I was operating all the aneurysms by microsurgery. I never used endovascular means until 2015. This is surgery. This is going right side, subtemporal approach. Good flap. patient is in position and then cutting deep one layer flap and then one bull hole and then making a temporal flap and tracking the bone flap out after weakening and base with drill and then drilling on the middle fossa and then opening, opening the dura so that you can have stitches to prevent any bleeding. And now I go subtemporal, you cannot do subtemporal approach without spinal needle. This is, we are coming to enteral edge carefully and when you open the basal systems here, then you get good room and now we are looking for basilar artery. We cut the tentorium to come lower and now I put here is right vertebral artery maybe big . So I put temporary clips on both vertebral arteries. Left vertebral artery clip and then... Then I was cutting inside the aneurysm with a knife. I made a hole and then was pushing. Dr. Drake was teaching me the first clip must be a ring clip and I'm doing something else but this bleeding is bleeding because it is backflow to the aneurysm. I'm collecting the base of the aneurysm and then changing the position of the clips. Many times it's difficult to understand here but the first clip was ring clip and then I put long straight clips. The length of the clip must be 1.5 times the base method in the , so it covers all the base end. Now I'm taking temporary clips out and this is the ring clip. I'm traveling backwards to save the base because one of the PCAs was occluded so I have to travel with the clips and leave some base because the base is strong. So I'm traveling with the clips backwards now. And finally there's one quick ring clip and then one long straight clip to take the base of the open aneurysm. Difficult to understand the situation here at the final pictures. Look fine. Now internal was cut and make hemostasis here and this supposed to put the images, so you remember, it was big golf ball. Now it's perfectly clipped and the patient made good recovery and this is how I think it should be done. You can push clips and coils and whatever there but they are buried inside the brain stem. And the same happens like in the next video. We will see this patient came from Germany. Can we take the next video? So you see what happens even with the best endovascular means nowadays when some years go is giant basilar tip aneurysm, it was coiled and you see that the massive coils is buried inside the brainstem and we measured that there's enough base to keep this aneurysm and actually it went wonderful. The German neurosurgeon was with me in Helsinki, he made subtemporal approach. And this is the pictures, you see there is a lot of clips and coils but there is some base we were thinking we can take it out. I was doing right presigmoid approach to come down. this is trochlear nerve there and then dissecting carefully. The patient had had subarachnoid hemorrhoids and this coiling. So that was a lot of scarring but we were thinking we are doing well, dissecting the base of the aneurysm. And these are the Metzenbaum scissors is very useful because they're side cutting and I'm using very few instruments, less than 10. So I'm doing many things and here's the special dissector. It has the same thread than the clip plates. So if you can push this dissector above, around the base of the aneurysm so you can push the clip also in this hole. And this is very important. So dissecting a lot of scarring. But then finally we find the base, we don't touch the coils inside the brain stem. 'Cause if you try to take them out they are attached there, you'll kill the patient. So we were doing extremely well here, we were happy and we were certain we'll do well. The patient was tetraparetic, she could walk but couldn't take care of himself because the coils were compressing the brain stem. Now we are close to the final solution and all the time this is a broader dissector. So we're dissecting the base free and then put in first, like Dr. Drake's principle was put first always ring clip first because it doesn't slip out, here the ring clip is going out and you can leave this artery inside the fenestration. And then you should have closed the opening of ring clip with another clip. Straight clip here I put two ring clips at different levels so they help each others to upload the whole base of the aneurysm. We thought everything went well but the patient was not in good condition because somehow inside the scar one perforator was taken and the patient was inverse condition than before the operation and never recovered. So if you take one perforator in the basilar tip, so the result will be poor, the patient will not die but remains at risk. Here I'm changing still the clip positions and the ICG looked beautiful, looked beautiful, every big artery was open but I think we occluded one perforator. Of course there is so much clips and coils that we cannot see what went wrong. Everything looked beautiful and we were happy and proud but the result was sad. So the patient was living many years but always, always bed ridden and... We tried our best. So you see, you cannot see anything that is wrong. You don't see any infarction. There must be a small infarction because of the perforator occlusion. The aneurysm has been taken but with the price of losing one perforator. So this is my successor, Professor Mika Niemelä, with the smallest shortest nurse in the operation room. So 1973 when I began neurosurgery, there were 750 operations in Helsinki. Then when I came back to be chairman there were 1,700 operations and when I retired at the age of 68, like the law says, in 2015. The year 2015 we had 3,500 operations. And by this increase imaging came, CT and MRI came. So we could diagnose by far more cases, of course microsurgery was there but then also better neurological resources, treatment methods and life time was by far higher. 1973 was forbidden to operate on any case. It was older than 60 years, it was strictly for forbidden. And so strong selection of the cases and difficult cases were left outside. So during my time, 18 years, we were increasing the number of operations, doubled the number of operations. Then 2015 I went to the world searching a place in the world to continue my career. The next presentation is telling mainly about the neurosurgery in China. So we finished with that. So the next, last slide here. So this is thanks. Kiitos.

- Juha, I wanna really thank you for the great lecture. Great pearls. I've also been always impressed. But your attention to details making surgery simple and clean and really very efficient. I think those are the three elements that you have showed us really very well in neurosurgery and you have taught us so much. Besides these three elements, obviously there's a lot of details we can talk about today. What would you say besides efficiency, simple surgery, clean surgery and really doing what you need? In other words, you don't need an orbital zygomatic for every pterional approach. You don't need to, you know, really overuse the skull base approaches and do necessarily unnecessary big procedures to get where you need to go. So what are the other elements that has been really critical in your career for?

- Extremely good neural anesthesia, best ones in the world. Best ones. The people, more than 3000 they were always wondering why the brain is so slack. Brain is so slack so you can do everything without big scalp based surgeries. So it's totally different. Like my experience in China, the brain was bursting out in three years. We could change it better but never at that level and in Helsinki. So neuro anesthesia was extremely good and then wonderful scrub nurses. Wonderful team, wonderful team. So this, without team you cannot do anything. I'm invited nowadays to go Baghdad, Iraq, wonderful hospital, but I cannot go because I don't have a team. I don't have a team who speak my language. So I cannot go alone. If I go there, operate something, I will destroy the patient because the people don't understand my language. So I went always approach. I went with my team, two wonderful scrub nurses. They change the operation room. Like home game. Home game is different than to play elsewhere. So if you think that you can go operate on difficult case somewhere, the team doesn't understand what we are doing. So you'll destroy the patient. And this is, you should understand that home game, own kitchen. Like Alex Kristi is saying, this is the best place to operate on because the people know how we are doing and they know everything automatically. I think this is extremely important. So... And one of the most important things is also that there are no easy cases. There are no easy cases. You have to take seriously every case because if it's the patient has only one life and one disease. So you have to take very seriously if you're thinking this is like a good friend. Dr was talking, saying even my mother could do it. It's not true. It's not true. Even it looks simple. So everything may happen terribly, this may happen and we'll have difficulties in there.

- So well said.

- Serious attitude. Serious attitude because only one time. The best saying here is what Dr. Drake said that, "If we only could have a second chance in those who were badly hurt or lost with that what we have learned in operation room." And this tells about the experience, when you are experienced, you can do many things that when you think back now after 50 years I think back, so the unsuccessful cases are coming like crocodiles from the river, I remember many of them and they are hurting. And the same Professor Yasargil was saying that those he was telling 600 cases he failed. They're coming like nightmare even now at the age of 97 in his mind. This is because why? Because you don't have the flow of successful cases you are doing all the time 90% successful and they just go home and go back to work and forget you and you forget them. This is the good, good thing. And that's why you can manage followers with the difficult cases.

- I think that is so well said. You know a team, it's not all about the surgeon. You think as a surgeon we feel like we can do everything. We are so dependent on a good team. That's number one. Number two, that you very eloquently mention is that no...

- Dr. Drake.

- Yes.

- And when Dr. Drake died, 1998, so Professor Peerless was giving a speech. How to become a wonderful world famous neurosurgeon. Number one, select a good wife or nowadays the husband because many females are neurosurgeons. But this is important because this is the support from the home, this is the support. And after that, work hard, learn anatomy support is extremely important. We have to appreciate the support from those people because we come home, our mind is in the operation room, we come with worries. So if we don't have a good wife or husband, they don't understand you and they'll not do good surgery. This is extremely important for the support. I had a good luck or could select well in that way. And I had always females who were understanding these things. And this is one of the big secrets in your surgical life. Support from the family.

- I agree. Well said. And something that you really mentioned very well, is if we only could know before surgery, what cases could go more difficult than we expect. And that's the really what differentiates a master surgeon. They have a vision, they know what can go wrong and they prepare for it. You know, the more novice or more junior surgeon looks at cases and they think, oh this would be relatively straightforward. But in fact it isn't. When for a surgeon to have an ability to predict what case and at what stage, things can turn around and not be right and we've prepared and therefore provide an excellent outcome. I think in my opinion, what differentiates a master surgeon from an average surgeon and that only comes with experience. You mentioned that we have to take every case seriously, which I agree, there's no simple case, there's no standard case. Any case can become a major problem. So on top of that, having the ability to predict how a standard case could potentially have features that would make it complicated and be prepared, I think that preparation is critical. Any other closing thoughts you have, please?

- I think you said all. So we have to take every case seriously because the human, we have only one life. Cats have eight lives, but human beings have only one life. And so we have to take every case extremely seriously. If the case is not interesting for us, it's not wonderful. Aneurysm or tumor, it's not the patient's fault, we have to take it seriously. Take even the simple tumor or aneurysm or AVN out even it might feel like routine, but even in the so-called routine cases, all things may happen. And we have to see like you said beforehand, what may happen in these cases and like PICA aneurysm, where called that these are easy cases, but you can kill the patient if you don't do it well, if your mind is so that, I can do it in 25 minutes. Like I know in one case, I was visiting one departments or the chairman was, we were at the dinner, he was discussing the case. Can I clip it in 25 or 30 minutes or when I left and I had the email which told that the patient died. It was deep and he pushed the clip inside aneurysm base, so the patient died on the table. So you have to take carefully. We don't have to be fast, you have to be clean. And when you do clean surgery without making errors, then you are fast and you can do beautiful surgery. To be fast is no competition because this is human life and you should not compete with that. Of course, when you're experienced and you see all the things beforehand, then you can do good surgery and have good thankful patients. This is the best thing of course in our life.

- Well I wanna thank you for your incredible career, giant legacy and truly what you have done for neurosurgery and your passion and art of the surgical technique. Juha, we're very, very much proud of being one of your colleagues and look forward to having you with us in the future. Thank you again.

- Thank you very much. Thank you very much. Bye-bye.

- Bye.

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