Challenging Cases in Neurosurgical Oncology

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- Good evening friends and colleagues. Thank you for joining us for another session of the virtual OR from the Neurosurgical Atlas. Tonight, it's my absolute honor to introduce Dr. Jim Rutka from University of Toronto. Jim is truly a special guest because he's been my mentor for many years, and mentor for so many young neurosurgeons. It goes without saying that he's a true definition of neurosurgical gravitas. Somebody who has that special authority that is extremely unique on parallel a serious presence who truly affects many of our decisions. And we accept his authority because we have so much trust in his opinion. As a Editor-in-Chief of the "Journal of Neurosurgery", he has entered the Journal a truly a new level and a new authority in publishing. Jim has been the giant that many of us as young neurosurgeons stand on to see more and we truly appreciate for his huge legacy. Jim, it's truly an honor to have you with us tonight.

- Yeah thank you Aaron, it's great to see you and thanks for inviting me to take part in this special virtual OR, and congratulations to you for putting this series together.

- Thank you Jim. Jim you have been an incredible academician, superior technical gifted surgeon, an amazing friend, an incredible father and family man, you have the whole package together, something that is extremely rare in neurosurgery. But what is more important is that unique gravitas sense of presence, executive power that is extremely difficult to define, but you know it when you see it. I wanted to ask you before we discuss your phenomenal cases and technical pearls and nuances behind each, I wanted to see if you can define what it means and how can one to achieve neurosurgical gravitas, that sense of leadership of presence that so many of us try to claim?

- Yeah well thanks Aaron, and I appreciate your saying that about me in particular. And I would say that gravitas is embedded in pretty much all of us as neurosurgeons. It's hard not to be a neurosurgeon and not have gravitas. Just think about the work that we do each day and how difficult and challenging it is, how hard it is at times to speak to families about the work that we do. So all of us have gravitas to a certain degree. You've outlined in me and maybe some of the reasons why I might have had gravitas myself, and what is gravitas? Well, it's actually professionalism at its ultimate I think that's one definition you could use for that. And I've been very lucky over the years to have served in a number of leadership positions. I was Chair of Neurosurgery for example, at the University of Toronto for 11 years, then became Chair of Surgery at the University, I'm still Chair at the University in the Department of Surgery. Along the way I've had a number of leadership positions in organized neurosurgery; so the American Association of Neurological Surgeons, The American Academy, The World Academy. I've been very fortunate to have played out in these leadership roles. And it takes professionalism to do that, you have to be on your game, and you have to be balanced and fair, you have to have the skills of a leader that are demonstrated time and again. I think some of those skills if I had to outline them would include things like communication skills. So a leader must have strong communication skills. A leader must be able to show the commitment for the job at hand and take that commitment extremely seriously. A leader must be open-minded, so that's quite clear no leader has all the answers. And in fact, the good people around you can make suggestions that will float the organization higher, and I've certainly tried to remain open-minded in all the things that I do. Leaders must be adaptable and be able to change because not everything goes smoothly all the time. And you have to know when you have to deflect off your course and go somewhere new, so you have to be adaptable. And finally, it's all about building a team and having teamwork. So all those things have helped me over the years. So features about leadership in particular, to assume a certain level of gravitas. There are some parallels for example, in things like team sports. And I was very fortunate to play a lot of team sports when I was growing up as a child. And I think there are in those types of things at that stage for me to be able to assume other types of leadership positions as I grew older and became specialized as a neurosurgeon.

- Thank you so much. I'm excited, all of us are excited to hear your fascinating lecture, so let's go ahead and jump in.

- Great, so Aaron you had asked me initially whether I would talk about leadership or maybe about burnout or stress or something, but we decided to land on this topic. You also mentioned the time when I was President of the WANS and that was in 2011, and I spoke about this slide, this is the actual backdrop to my presidential address for the WANS. The theme of the meeting was Discovering Neurosurgery New Frontiers, and that was 2011 that's nine years ago in Denver, Colorado. But I enjoyed your presence at the meeting Aaron, and you gave a great lecture too, and thank you for your participation. So I've embedded slides from this particular topic onto the presidential address from 2011. But I wanna start first with an acknowledgement of one of my mentors. And you had mentioned the role and the importance of mentorship over time. And one of my main mentors as a surgeon was Dr. Kenichiro Sugita. I had the great privilege of working with Dr. Sugita when I was a research and clinical fellow in 1990s for some 30 years ago. And here's a photograph of Dr. Sugita underneath the cherry blossoms in Japan in April and I am standing in his shadow is appropriate because he was a beacon of light for me. He was a master surgeon, innovator, athlete, musician, inventor, artist, he did so many things at the highest level. You can see him here playing the cello as mentioned, a musician extraordinaire. But he was an innovator too, and this is his head holder and retraction system that I use to this day. I learned to use this system when I was in Nagoya, Japan and I brought it back to Toronto and we still use this system among some of the other head holder systems. But this one is one of my favorites I used it for a number of cases. Of course, Sugita was a phenomenal microvascular surgeon and he invented his own set of clips which he's written, someone wrote a book about that you can see here. But his clips are as you know, used worldwide and he managed to develop a lot of them as he was going through some of his very tough technical cases throughout his lifetime. He also was an artist, and Aaron I think you and I both agree, we both very much learned on the importance of neurosurgery as art and on this book is an illustration of one of Sugita's hand drawings that you can see, and I was very fortunate to watch his drawings come to life when I was a clinical fellow in his department as he sketched every case afterwards. And it was fantastic to see the case as mentioned, come to life. So I'll return to that theme in a moment about artistry and neurosurgery, and how important that actually is. But many thanks to you Aaron, because we've enjoyed a great relationship over many years now and here is when we started talking about bringing the Neurosurgery Atlas together with the "Journal of Neurosurgery", and one feeding off and enhancing the other. So I've really enjoyed my work with you on the Neurosurgical Atlas that you've put together. Your Atlas is extraordinary now, you've gone from strength to strength Aaron I would say, to have the cases, the anatomy, the 3D modeling that you've shown us, which I've used recently and have really enjoyed doing the grand rounds and these virtual wires and surgical approaches and so on. So many things to teach the nuances, the techniques, the tips of neurosurgery for generations of neurosurgeons present and future. So thank you for that Aaron.

- Thank you.

- All right, so I landed on a few cases and we'll talk about these challenging cases I think you would all agree. We'll go through them case by case and along the way Aaron maybe you and I could have a dialogue about some of these and how you would approach them yourself. And we could talk a little bit about some of the subtleties and as I mentioned, tips of the trade. You'll see here a Thalamic Tumor, Parasagittal DNET, Tuberous Sclerosis, bottom left is Rolandic AVM, and Paraclinoid Meningioma, and a Transvenous Meningioma. So as I'm speaking here, I don't think people can see my pointer, can they?

- They will not be able to unless you mark.

- So I'll use the marking thing so you can see, but essentially let me just grab a red marker here so here Thalamic Tumor and so on. So I'll mark as I go along Aaron so we can talk about things, but the first case we're gonna be talking about is the Thalamic Tumor. So this is a 14 year old male, a brief history of headaches over three months, vomiting relatively recently on exam had Papilledema and a left sided hemiparesis. And what you're seeing from this CT, that was the first study that was done is of course, the obstructive hydrocephalus from occlusion of the CSF pathways. You can see the lesion that's shown here and it's got a mixture of densities here, more like brain density here, more like a cystic density. Basically obstructing the CSF pathways that you can see here. So, I think we would all agree that a lesion of this magnitude of this size is a challenging case. So here's the MRI imaging of it, you can see how deeply embedded this is. What's interesting is its proximity to the corticospinal tract, that's gonna be here. And you can see the cystic and solid nature of the tumor that lies in front of it. And now you can see in coronal projection what this looks like, and I know you're thinking right now as you're seeing these two images, what type of approach will you take for a tumor like this that's deep seated, that's embedded? You've got some options, you've got CSF pathways that are opened, you have other avenues in which you can approach this particular lesion. Here's the sagittal MRI scan. And what you can see here is, please take note of its proximity to the midbrain here that you can see. Of course, above it is the lateral ventricle. You've got the super seller region here and a massive tumor that's sitting in between all of those structures.

- While you have this OP Jim, I wanna just mention something. And I assume most people, and I suspect you had approached this interhemispherically coming down here which makes more sense, sometime coming from this direction, coming contralateral, it may give you more sort of flexible working angles at the more lateral edge. If you come if ipsilaterally, sometimes you have to do some amount of retraction, although I'm not sure it will be in this case a significant one. So I think that's one idea that I would entertain here. The other one is that it appears that maybe this area very thinned down and it provides a nice working angle to the entire sort of the surface of the tumor. So this contralateral approach is really a nice one. And may I please ask, did you guys consider doing EVD before you opened the dura, or did you just go ahead and start the interhemispheric dissection without it?

- In this case, we just went in hemispheric Aaron, as you had mentioned. I mean, I really like your contralateral approach I think that's a very good idea. I just want to point out however that what's in play is this here, right? That's the fornix and you've gotta be really careful that you don't ding the fornix on a contralateral approach. And if you're going contralateral as you say, you could go through the septum pellucidum to get there but that's a little bit hard. But essentially what you need is a widen expanded interventricular foramen Monro. That's kind of the approach I think that you're talking about, but you really need... And that has to be expanded in order for you to do that contralateral approach.

- I agree, but...

- Another case I'll show you it's all about where the fornix is situated.

- Right, and I would leave this dominant fornix alone so I wouldn't come through here, I would enter it exactly where you would enter it in an ipsilateral approach through here, but it would just maybe the working angle would be different. Again I think that's very subtle, I'm not sure if it means much, but let's go ahead and see the next steps.

- Yeah, I just wanted for the residents and fellows who might be online, of course you have many choices for types of scalp incisions to employ. In the past I've done any one of a number of different approaches like this, but I don't mind this one, which is the bicoronal it gives you a nice exposure of these and you have your choices, I'd probably use this one next the most. But I take it a little bit further across the midline if I'm coming like this, just so I have an option. If you get scuppered with one interhemispheric approach because of a large draining vein it's always good to have the contralateral side. But, if you have good navigation now and good imaging you can actually predict where all the veins are in advance and you can plan your bone flap accordingly. But it wasn't always like that, and I practice in a day long before we had this approach, and we were one of the first to popularize how to draw out the veins using neural navigation. Here's the craniotomy, so as mentioned you can do a small craniotomy. And the book say Aaron to go two thirds in front, one third behind. I'm not shy of going half and half, that's fine for me if it looks like that's best for the veins. That doesn't take you too far posteriorly to have concerns about the motor cortex for example, I think you're still gonna be slightly in front of it. But, and especially for a callosotomy that I'll show you later, I definitely go half in front and half behind. So, but I do as I mentioned previously, I do at times take the bone flap chest a little bit across the midline, just so you have that added opportunity to use the other side if you have to, for whatever reason. And then the whole trick about drilling holes do you drill them on the midline, or do you go on both sides and underneath the bone, just clear the dura away so you're not at any risk of harming the superior sagittal sinus? And this is a very important craniotomy for residents and fellows to know how to do well. Midline craniotomy, and do it well so that you don't get yourself in trouble with the superior sagittal sinus, really one of the most important. And when you're doing this in a redo case, you've got to be exceptionally careful. So just tricks of the trade for the approach. And then as you're going, and I'll show a video to some extent later about this obviously. Interhemispheric approach, do you do it in the supine position straight up and down? Or as I know that you like to do it Aaron, you like the head tilted about 30 degrees and coming in letting gravity do the work to have the hemisphere fall away from the fornix. And that's a very popular way as well, and I think that's also a very good approach. Of course, finding the pericallosal vessels is critical and staying in between them. Sometimes there are some connections between the two pericals very interesting. But not that often, and generally speaking you can separate the pericallosal vessels quite nicely going front to back, but you need, especially for a callosotomy you need to go very far forward and very far posteriorly along the corpus callosum in order to do the job appropriately. And every resident who is on the line today, needs to know this anatomy. You need to know without looking in a book or looking on your iPhone what ventricle you're in here, are you in the right side or the left side? And the reason I'm saying that is because your clues are the fornix, and I already mentioned the fornix tonight. The septal, I'll draw this. So fornix as you got here, septal vein is critical here. You've got the thalamostriate vein coming this way. And the interventricular foramen Monro here, and the choroid plexus coming this way. You should be able to draw this with your eyes closed. And it's critically important that you know this anatomy all the time. And sometimes at first when you get into a ventricle with small ventricles, you can't tell if you're on the left side of the right side. So always look for the choroid plexus, it'll lead you there, look for the fornix, know where that is you don't want to disturb it. And this anatomy will hold you in good stead over a number of cases you do in the ventricular system. And as always respect the veins. In the past I have taken a thalamostriate vein Aaron, I haven't done that recently because I learned from Roatan that is not necessary to take the thalamostriate vein you can actually work here at the taenia choroidea and avoid getting into the thalamostriate vein and preserving it as it joins the internal cerebral vein.

- I wanna mention one thing, I agree completely with every statement you made was beautiful. One thing for third ventricular tumors which we're not talking about right now, is that instead of doing the transcranial approach like Roatan described, God bless his soul. I transect the septal vein, this way I release the thalamostriate vein medially, I coagulate a little bit over the choroid plexus. And then I open the foramen and I can see the entire third ventricle all the way posteriorly to the aqueduct without touching the fornix or the thalamostriate vein of thalamus. We call that the transforaminal transvenous route to the third ventricle, and it's really very, very effective. I feel that if you leave the septal vein alone and just come here and try to dissect you're really gonna injure the thalamostriate vein thalamus or definitely the fornix. So get rid of this vein untether the thalamostriate vein, expand the foramen, and you will have a huge space to work with minimum mobility.

- That's a very good point. I've not heard of any complications directly related to the septal vein being taken as you have described. There are some mentioned however, the thalamostriate vein. But there are also lots of reports that say you can take a thalamostriate with impunity. Okay so setting up here Dr. Sugita I mentioned his name again, as you can see from the writing here, always gonna be going back to my mentor Dr. Sugita, but this is about you know, 30 degree elevation of the head supine position, I did not use the lateral position that Aaron we talked about, minimal head shave that you can see here. But the Sugita retractor is quite nice because it allows you to keep things in this kind of orientation, but because it also has a screw on it that can allow for rotation, if you ever needed to rotate the head one side or the other, you can actually do that with the Sugita head rest, which is really nice. And I find that a nice advantage if you ever needed to rotate the head. This is a system brought back when I came to Toronto after my fellowship in Nagoya. And this is the retractor system when it's set up in the different component parts, it was a very ingenious system. And here's, in this particular case straddling, here's the midline I'll just draw it for you so you can see, midline is something like this. And in this particular case the reds kind of showing up with the blood, but in this particular case you've got Bernholtz straddling. But I've also many, many times often just do right on the sagittal sinus with the drill or the matchstick drill bits or whatever it's okay. You should be very comfortable operating in around the superior sagittal sinus. Okay here's the video, Luke so maybe we can just show this. Interhemispheric, but I've already shown the transcallosal approach, and what we're doing here is we just opened on top, now I'm developing the plane over top of the tumor that you can see. And one of the key moves here will be to develop that anterior border. So it's ipsilateral, it's on the right side using the Cavitron. Cavitron is a very good tool... This turned out to be a low-grade astrocytoma. And you can see the ability to develop this plane right here with the normal brain that allows us to keep the tumor behind over here, and then using the Cavitron to continue to shave and debulk as we go and clear this tumor from its attachments. And the nice thing about these pilocytics Aaron is that they generally come away very well from the surrounding structures. And they're not infiltrated, they're not invasive. You have all the nice anatomy of the ventricular system kind of keeping you safe and having an opportunity to remove these. So, here's the post-op showing nice resection of the tumor that you can see here. And this child was followed for many, many years, has gone off now to university has done really well, has not required anything else it's pilocytic astrocytoma what this child needs is a surgery like this to take the tumor away, and has done fabulously well. So I mean great case to see.

- May I ask you Jim, when you do a subtotal resection of pilocytics appear that the residual tumor remain stable for many, many years. That's unlike of any other glioma. Do you have any explanation why that is that the residual pilocytics are so stable?

- Yeah thanks Aaron. So my mentor, Harold Hoffman had sick kids. He used to speak quite often about the spontaneous Involution of low-grade gliomas after a major debulking, and he would say that it's because of the inherent change in the vascularity that you've invoked by massively debulking these tumors. Maybe it's true, maybe that's the case, but I've seen many of these low-grade glioma residuals involute over time. You can't always count on it, and certain you get progression and you need to continue with serial monitoring to follow these cases along. But on the whole, you should watch wait and see because the actual serial imaging may show you something that was surprising. That is as you said, in evolution of these tumors. Luke can you clear, or Aaron can you clear? I can't get the clear button, I can't see it maybe. There we go, nice. Okay next Aaron is a Parasagittal DNET. So this one's interesting for the position, I'll be very interested to see your thoughts on this one. But seven-year-old, seizures, of recent onset starting in the legs, so probably close to the rolandic cortex, and mild headache, but neurologically intact. Here's the lesion, and I think you can all see it here. It's situated budding against the corpus callosum like this it's mesial and it's sort of low signal intensity. And here it is on the coronal, so you can see it on the coronal right here, and right on the corpus callosum which is situated just below that. I know you're all thinking, "How am I gonna get at this lesion? What's the approach going to be to get at this?" And think about position because are you going to be supine? If you're supine, it's kind of tricky, like flat supine it's really hard to come in this way. You can't nudge you don't have this opportunity. And if you come in this way, you're going kind of, sorry. If you come in this way it's gonna be hard on the supine position. But if you come in here on a supine, you're gonna come right across the corticospinal tract. So you know, what is the best position for the head in a case like this? And I ended up choosing a 30% or 30 degree angled up and coming in from behind. So imagine the head up 30 degrees or so, and then coming in this way, and this is the approach that I chose to use. But there are many different strategies that you could use to get at this. But those that are a little bit posterior on the corpus callosum, raise questions on how are you going to get there? So what else do you wanna know about this case? Well, I want to know where the corticospinal tract was, and here you can see on the DTI imaging the nice orientation. Here's the corticospinal tract coming down here and here the tumor situated here. So they're right next to the other, so I decided to come in as you can imagine, interhemispheric this way, just gently moving the hemisphere aside and then coming in. But I also wanted to know what the venous anatomy was 'cause you want the plan, as I was mentioning earlier where are the veins? What's your interhemispheric corridor gonna look like? Where are you gonna have the best approach? Left side or right side? And I know Aaron you, you'd like to come this way you cross cord, and this way on the fault right? That's maybe a way that you might've thought about coming what do you think?

- You know, I'm gonna go back for one slide if that's okay with you? And I don't wanna sound like obsessed with a contralateral approach at least tonight. But I have done one of the, actually a few of these cases awake contralateral approach. And I come from this direction, I use a lumbar drain and then I let this fall away supine, 30 degrees just like you described. The reason I like that is that I cut the fornix and then I get a very nice view laterally. The reason I would have done this awake is because this is motor cortex right here. And I like to be very aggressive along the posterior aspects, especially the leg. And we actually wrote up one of these cases that we can very clearly stimulate ipsilaterally which is a normal hemisphere, ipsilateral leg function here I find through direct cortical stimulation. Then I use the same parameter to find a leg function here, I map it. And then I'm very aggressive and under sort of direct sural neurologic exam and white matter stimulation. I'm very aggressive to remove the tumor all the way clean. I think that, and then because of my angle it allows me to go really far and do a white matter mapping to be able to remove this tumor aggressively. So that's sort of my thought here doesn't mean I approach every tumor contralaterally just tend to be these two...

- Yeah I know you have a pension for that so I just thought I would mention. But we did monitoring on the corticospinal tract, so we're sort of measuring the trains of five corticospinal tract. We're essentially being able to stimulate as we resect to make sure that everything... We've done lots of publications over the years related to neuromonitoring and the like. Yeah, so this was a pre-op and this is a quotation from Sugita. He says when using retractors if you're gonna use them, move them not infrequently so that you're not having constant traction effects on the brain or pressure on critical elements of the brain, like the motor cortex that we spoke about. And here's the post-op showing the complete resection that you can see, and this was a DNET favorable outcome. Was a nice approach is almost like we weren't there, right? You can see the track that we took it was a really elegant approach. But positioning was key, I actually had to have the head up a little bit more than you would think in order to access that tumor from behind, which is what I chose to do. Okay, so the next case is a very interesting case, and it's not often you get a chance to do both a complete callosotomy Aaron and removal of a subependymal giant cell astrocytoma in a 12 year old, who has a Tuberous Sclerosis, epilepsy, failed medications, had previously had a vagal nerve stimulator which failed was having atonic seizures, that's the rationale for doing a callosotomy. So sudden drop attacks or complete atonic seizures that lead to head injuries and lots of other downstream effects to the patient. So that's what we decided to do, this is what it looked like in 2006, you can see very small SEGA that's situated here at the caudate nucleus, and then in about four years later. And then it just kept getting bigger and bigger. This was growing so we needed to think of a strategy, you could see the ventricle just slightly going up in size too, so we wanted to make sure that we took care of this, and we also wanted the option to treat the seizures, so we did a two for one the family was totally on side with this approach. So this is a video. Luke we can show this video and this is the video it's a little bit long Aaron, so I apologize so we'll just go through it and hopefully have a chance to discuss you and I as we go. But essentially finding the interhemispheric cleft here as you can see, and making our way down between the pericallosal until we land on the corpus callosum. The corpus callosum is very easy to identify and you don't mistake the corpus callosum because it is bright white when compared to the cingulate gyrus, the gyrus rectus, you will not make an error if you find a bright white color that's here. And so using the interhemispheric, using the bipolars, spreading the interhemispheric plane open, doing coagulation as we're going. And now sometimes Aaron, I don't know if you have tried this but sometimes I'll leave the ependyma intact. In this particular case I did not, the ependyma is taken here. But in my, some of my recent cases I've left the ependyma intact the whole way from front to back from the genu all the way back to the splenium and here we're working away on the genu going to the rostrum of the corpus callosum. Very easy for us to see where the anatomy is, where the corpus callosum is, you got the ventricle back here. You wanna know where the foremen Monro is which is kind of here, because you're gonna follow this rostrum all the way around and come back towards the foremen Monro so that you know that you've got a complete form of the corpus callosum that's been sectioned across. And you'll be following the pericallosal vessels as you're going posteriorly along this cleft here, like they're gonna be found here as you're coming back towards the interventricular foremen Monro. And essentially you're gonna be able to complete the callosotomy in that format. And then what we do typically is we'll work our way back and essentially work towards the splenium of the corpus callosum, but I think this is a very important part because you're just starting to see the vein of Galen here. So the internal cerebral vein's coming together to form the vein of Galen which is right here. And you're sectioning across the corpus callosum it's posterior extend through the splenium. Staying in the midline is a critical and very important element as well to do. And also at the same time, making sure that you do the complete callosotomy by going all the way across the corpus callosum, as it's hooked around forming the splenium and is most inferior portion. And it used to be sad that you had to do a complete callosotomy with two separate approaches but no, you can certainly with the half in front and half behind, you can do the coronal suture you can do a complete callosotomy. Okay so now Aaron what we're looking at is the SEGA, right? So this is the SEGA that's here, and we'll be dissecting out the SEGA. And we already talked about this anatomy, here's the choroid plexus coming towards the foremen Monro, which is buried behind the SEGA. You can see the SEGA was already occluding it which was there. And we're also very mindful of the fornix which is coming this way. And there we're just working, now doing combination of bipolar cautery suction. Some of these SEGAs are calcified and they're very firm and hard. I've operated on some that are very vascular and soft. So it kind of depends one to another. You know nowadays, there's a drug available to treat subependymal giant cell astrocytoma so we're probably operating on fewer of these, but we still have, there is still a role. I just recently did one this last month for a good reason, the family did not wanna go on the medication lifelong. So they decided for us to go ahead and remove the SEGA. Now here's the key part here is the fornix coming around like this. And you have to be very careful in here that you don't disturb the fornix. And here's you got the tumor, you've got the choroid plexus coming this way. And essentially what you want to do is make sure that you don't disturb that fornix that we're talking about because the fornix will be unforgiving, and you wanna make sure you see every move that you're making in this area. Spreading the bipolar is a nice way to get access here and you'll see us ultimately lift up this particular tumor and take it away. And then the last thing we decided to do in this case was after we found the margin here and we took the tumor out was a septostomy because we didn't want one to be occluded in the event that the foremen Monro on this side got occluded here, we'd have the septostomy to rely on and be able to. So there's the tumor coming out, foremen Monro's right here. And now here's the septostomy coming into play. And just you'll see us opening up in this area to connect the two ventricles so that even if there's a SEGA on the other side, it won't occlude. You've always got drainage to the other side. Now these are multiple steps involved in a two step operation. One, the callosotomy for the atonic seizures and also for the SEGA that was growing and which we managed to clear. Okay, so I think Luke that might be good. Must be close to the end of this, there's the final view. You just wanna, these are somewhat attached to the caudate nucleus, so you can never get them off completely. So I think Luke we can probably go to the next slide. So about Corpus callosotomy; patient positioning, craniotomy cross, and I've already talked about all these things pretty much, but what I wanted to make sure you saw tonight was the splenium. I think you could all see how, when you cut across the splenium the last thing you land on is the vein of Galen, and so you need to keep that arachnoid intact, because you certainly don't wanna get the vein of Galen going in your dissection.

- Jim may asked you a question, when you do the genial callosotomy and you continue your callosal transection anteriorly, how far do you go? Do you go a few millimeters short of the foremen Monro to prevent any injury to the septal region? How far do you go?

- I go as close as I can. It really thins out towards the end as you've come around the corpus callosum, and you can see the white matter fibers become almost paper thin at that juncture. But you're right, you don't wanna get an injury to the septal area, you don't wanna hit the fornix and you wanna respect where the interventricular foremen Monro is. And you follow pericallosal vessels that's your guide initially. And then you make a judgment call towards the end as to where to end up. Some authors have described doing at the same time cutting the anterior commissure, but you need a foremen that's open wide enough in order to see the anterior commissure. Just a note here about the image guided use in sectioning of the corpus callosum that we were one of the first to publish on many years ago. And I wanted to show this Aaron, because this is an illustration of the corpus callosum and how it's segmented. So you can see that the frontal lobe comes through this portion of the corpus callosum, sort of the posterior frontal, and part of the parietal region is coming back here. And then of course, a parietal occipital coming back here. So it's segmented, I'm not sure all the residents would have appreciated that. But this illustration Aaron was drawn by an amazing artist, Dr. Ian Sok who's a artist from initially from the MD Anderson Program with a Raceway, but he's gone to Hopkins following Yazogil Caslin now he's with Henry Brandman at Hopkins. But he's one of my favorite artists, and I think he rivals the artists that you have for the Neurosurgical Atlas I must say, but the importance then of artistry in the work that we do in neurosurgery.

- You know Jim, if I may interject even as from the time of Cushing and Dandy, illustration was an extremely important part of enjoying the craft finesse and art of neurosurgery. So it's interesting that all of us are very much fascinated by the illustration and art of micro neurosurgery.

- Yeah, and it comes as no surprise. If you look at the covers of the "Journal of Neurosurgery", typically over the course of any month of the year, they usually have an artist's illustration on it. Not always, but if you wanna get published in the "Journal of Neurosurgery" on the cover, think about that.

- Sure.

- Okay, so I tossed in this one, I know it's not a tumor but I just thought it was interesting, it's a Rolandic AVM. 11 year old, sudden onset of headache, a weakness in the right leg, which makes sense given where there's this bleed, this hemorrhage is located that you can see here in the rolandic cortex. And totally wide awake and intact, here's the CT angiogram showing the lesion right in the rolandic cortex. Here it is on the coronal, you can see that. So this is all about real estate Aaron, as you know, it's location is not the fact that it's a big hemorrhage or anything like that. It's just, what are you gonna do about this? So angiogram shows essentially feeders that are coming off of the middle cerebral artery that you can see here also possibly a one or two elements coming from the anterior cerebral branches. So these are important that you know about here's the lateral injection view, you can see its location. And so what I thought I'd show you is the DTI which we got with this. And you can see its relationship is just behind the DTI that's showing where the motor cortex is situated. So yeah, it's in a prize real estate territory. So we decided to approach this, as you can imagine through the hematoma cavity. So Luke we can play this video, that would be great. So choosing the corridor, we had a big rolandic vein here, like the vein of trolard was right here Aaron. And this is where the hemorrhage was right in front of this vein, so we decided to cut pretty close to the vein, dissect here, stay in front of the vein and then come upon the nidus, and then separate the feeding vessels and to coagulate them as we go preserving the draining vein, you could see there right until the very end. And this came out beautifully, we we're able to get this out without any trouble whatsoever. So slide, Luke we can go to the next slide. And this is the post-op, the lesion as you can see here has been removed nicely in the angio's clear. And I have this video Luke can show this just, I wanted to show some function, you can watch his right foot, it's not perfect. He's got a bit of a foot drop, he got a little bit better, but he's definitely kind of got a tiny foot drop there. And that was the I guess, the price to pay for resecting this. Our angiographers were not interested at all in trying to embolize this. We thought this was a perfect surgical case, even though it had a location like that. So we, I actually just made a series of these to the "Journal of Neurosurgery" and it was accepted for publication it'll come out in the next couple of months, these rolandic AVMs. Most of them had had a bit of a hemorrhage beforehand, but not all of them Aaron, just so you know.

- Yeah you know Jim, may I ask you this question? I have come to the conclusion that hemorrhagic AVMs, if the brain is not swollen and the patient in relatively good condition. Removing them relatively quickly, it facilitates the recovery and actually allows the patient to recover faster because rather than waiting for the AVM and the clot to become loose and then having them recover from the hemorrhage and bringing them back again three months later and giving them another hit and letting them recover again, is actually much more involved than removing hematoma very early, within 24 hours to 48 hours of this hemorrhage and then removing the hemorrhage into AVM. The hemorrhage is very gelatinous, comes out easy, you remove the mass effect. The AVM is actually very easy to remove, and this is really contradictory to what a lot of dogma is in AVM surgery. And you know, I've done already about 400 AVMs it's one of my most favorite operations. And every time I have been convinced very early evacuation of hematoma resection of the AVM, provides incredibly better results than a delayed fashion and bring the patient back.

- Yeah, I don't disagree. I think it's a great suggestion you're making Aaron, I guess also one has to factor in size of the hematoma perhaps. And also, what does surrounding brain looks like? As you said, if you've got an angry brain that's adenitis and it's gonna fight against lesion going after the AVM that may not be the best solution. But I agree with you, if it's a small hemorrhage like this yeah, you could have fired ahead and you get into that hematoma cavity and it would be pretty straightforward to remove this one that I mentioned to you. Okay, next one is a 14 year old female, previous I had operated on her for an anaplastic ependymoma which is an unusual tumor to have in the left frontal lobe, but she required radiation therapy after that. But seven years later, you just kind of set your clock and she developed this other lesion, which turned out to be the following. Which was a small lesion here, but in an interesting location. And here's the coronal, you can see the radiation helped right? In the basal ganglia, that's interesting from the anaplastic ependymoma. But here's a lesion in the field of the radiation on top of the carotid artery, but also a budding the optic apparatus you know, the chiasm. So I'll just show you how we took care of this one. There's the lesion there you can see small but it's in a fairly delicate location and you can see the chiasm right here. So it's right next to the chiasm. Okay so we did the wide Sylvian Fissure split, and we can show this video Luke that's great. Paraclinoid Meningioma, it's a very rare tumor in a child to have this. And so what you're seeing is the optic chiasm, the lateral margin of it before it becomes the optic tract right here, this is the optic apparatus here. The sphenoid wing is a planum sphenoidale is up here and here's the tumor coming out with the Cavitron as you can see in the carotid artery is gonna be sitting underneath the tumor that's there. So very nice approach by splitting the Sylvian Fissure widely, almost no retraction was needed. We could take out that Paraclinoid Meningioma, no problem. So that was a very interesting case and she did really well and hasn't had another recurrence of Meningioma since.

- Were you able to inspect the space, the potential space in the optic foramen to make sure there is no tumor infiltrating the foramen Jim?

- Yeah, we basically cut the dural sleeve on top of the clinoid processes and we drilled it up and took a good look to make sure there was nothing underneath there. And that's a very key point that I didn't show in this video was making sure that you have it all because that's a site of recurrence, unless you recognize it and visualize that space as well. Okay Luke, next. Okay this is interesting, Dominant hemisphere Sylvian Epidermoid in a 17 year old, who's completely intact neurologically. She's the valedictorian in her class, she played the violin. And like, what do you do here? Here it is, here's the lesion. These rectangles represent the MEG showing where some spiking activity was coming from. Just showing you in advance, what the epidermoid looks like after you're splitting the Sylvian Fissure. And I just showed some video, Luke, we can show this one, just you know, this was attached to all of the middle cerebral candelabra Aaron. So this was tricky and we had to, I basically had to painfully dissect this off every branch of... Next video Luke, and using sharp dissection combination of dissectors, and then sharp resection cutting right on the middle cerebral artery until we got the plane that was coming off. So this is where you have to be right on the game with your technique and make sure that don't have any issues with either spasm or obviously getting side branches of the middle cerebral. So we ended up doing that painstakingly. We made the cover of the "Journal of Neurosurgery" with this case when John Jane was editor. And here's the post-op showing a nice resection. I think she had many, many years later she had a recurrence, as you can imagine. I don't know about you Aaron, appreciate your comments, but it's hard sometimes to completely get the epidermoids out to the point that they'll never come back again, although Yazogil did describe that.

- Yeah absolutely, you're very right Jim. Two points that you really mentioned that are critical. Number one, is adherence to the vascular chair. You just can't be too aggressive because the capsule's right here. I'm convinced the capsule itself, if it's purely capsule probably there's no tumor there. But it's so difficult just to leave the capsule and don't leave some cells that are trapped there. This spasm is a critical problem that has to be addressed. And what I usually do, I irrigate intermittently with Papaverine. In other words, I do some resection then I have them irrigate with Papaverine, give it a few minutes, do more resection, irrigate, and then at the end of the case, when we were close dural I just relieve a lot of Papaverine into subdural space. And it's really worked beautifully, we've never had any chance of spasm post-op, which is very common with epidermoid tumors. And so I highly recommend using that technique of just irrigating and leaving a lot of Papaverine intradurally, and even in intraoperatively, when you dissect you'll see the vessels have these beaded appearance of vasospasm, and when I irrigate within 10 seconds it is impressive under high magnification how these vessels just balloon up and the spasm goes away.

- Okay thanks Aaron, next Luke. Okay this one Aaron I'm not sure you've seen a case like this. A 14 year old, six month history of dizziness, headache, and neck pain, previously well and here's what you get. All right, so you've got a sort of tentorial kind of, and I'm gonna clear this so I can drop better. Tentorial based lesion here, you can see it, this will be no problem right? You can take this one away, no problem. But look at this Aaron, so it comes down into through the sigmoid sinus and also is going out the jugular bulb into the jugular vein. So this was quite an impressive Meningioma. And we did an angiogram before and you can see that the transverse sinus on the side is basically occluded by the tumor 'cause it's filling the entire transvenous system which was quite unusual. And here's the video, Luke we can show this one. So this is removing the tumor and we've already taken out the tentorial based occipital based lesion. And now this is going down the jugular bulb. And I don't know if you've operated a lot in the original jugular bulb, but it's tricky 'cause on the other side of what you're seeing here at the base are all the lower cranial nerves, right? They're all on the other side of the venous walls so it's sitting on the other side back. And here's the next step video. And this is now having taken out that tumor from within the jugular bulb, we're going into the jugular vein. And now just to using the Penfield Dissector to lift it off the vein, it's inside the jugular vein. And this Meningioma was transvenous and taking this away and just showing how complex, multi compartment this particular Meningioma was. And until we finally got this out completely. But it came away nicely and we were able to preserve the back wall of the vein, which was quite nice to do that. But very, very unusual Meningioma. And I think we can probably, Luke let's see if it'll... Yeah that's probably it, then we can move to the next slide. Here's the resection, so we did more of a cranioplasty or sort of craniectomy here to take out the occipital bone just to have access here. But you can see on this contrast scan the complete tumor has been removed, like all the way down here Aaron, it was extraordinary and a fascinating case. These have been reported before but rarely, and I don't think there have been many in the past reported in children, but this was a case that we reported in 2000. And I actually showed this first to Samuel Mufti and he talked about he had seen a few, not many of these before, but he said they usually respect the venous lining, which is very interesting. And you can take these out almost like a sausage root in its casing, which is the terminology that he used. Okay, now we're gonna go to the Pineal Region Tumor Aaron. I was just looking at the time, so we don't have so much time left, but here's a Pineal Region Tumor, 10 year-old, headache, double-vision, limited upward gaze. And here's the lesion that you can see on the coronal scan. It looks a little bit irregular that you can see here. So what kind of a tumor is this? It's not a totally solid tumor. We did an endoscopic third ventriculostomy and a tumor biopsy, watch your management just to save some time here. So you can do that all from one approach as you know, you can use your endoscope to come in here, do the third ventriculostomy. And you can either use the flexible endoscope or the solid one if the foramen is big enough, and you can take a biopsy of this lesion, which is kind of what we did. And then we did CSF Markers biopsy et cetera, markers were negative, and it turned out to be a papillary tumor of the pineal region. They're quite rare. I'm not sure if you've seen those before but what do you do? So it's a benign tumor typically requires... So here's the video let's see if we can play this video Luke. Many different ways to get here Aaron we could have talked about that in advance, so you can either do occipital transtentorial super cerebellar which is what we're just showing you here. You could do a interhemispheric maybe retrosplenial. You can do the, I think he would like a precuneus approach sometimes to get to these lesions. But here we are super cerebellar, so just to orient you the tentorium is here, the midline is here. And here we are just dissecting all of this arachnoid that's quite commonly thickened in this region. In this particular case, the precentral cerebellar vein we took, you'll see as we now I'm kind of dissecting out a little bit more here cutting the precentral vein. You don't have to I know, I'm bringing back again the cross cord approach 'cause I know Aaron you love that and you do that very well in this location using a sort of off lateral approach to the pineal region, which is a very good approach. And then here we are dissecting and taking, peeling the tumor off of its attachments here to the tectal area. You can see the approach, the normal brainstem is found here, here's the tumor being lifted off here. And so this was an excellent approach, it worked out really well. I did not use a sitting position, this was in Concord position Sugita taught me the Concord position, so that's the position that we approach here. And then this is the superior vascular pedicle here that we're cutting across at the very end to release the tumor completely, and then try to get the complete resection, then final debulking and you'll see the end result, and the fact that we felt that we got all of this papillary tumor out of there completely. There's the final view with normal sidewalls here, that you can see entrance to the fourth ventricle here. And here's the post-op showing a complete resection in here. So these tumors, you need to watch. Some of them will recur these papillary tumors, but many times they don't. And so some will require radiation if they recur as opposed to re-operation, but they're fairly rare tumors in this region, but they tend to act more benign than on the malignant side. Okay, and how are we doing for time?

- We're doing great Jim. We're all excited, everybody's hanging in. We've got a peak at 180 people, they're not going anywhere. So you got all the time you want.

- Okay, so we're working our way through. Here's another case, Pineal Region as you can see. This is more shaped like an egg right in the pineal that solid tumor in this region. A younger population, so three-year-old with a brief history of a headache and so on. So what kind of approach here? Aaron, we talked about that right? So this is kind of more like a precuneul interhemispheric approach. His occipital transtentorial, this is supracerebellar infratentorial. This is midline, but you come off midline right? I think you'd like coming this way. One of your favorite approaches.

- I do come because the wing of the cerebellum steeps inferiorly, so you actually, you have to minimize their retraction of the cerebellum you don't have to fight the Coleman. And also the bridging veins are much less frequent laterally, so you don't take them. And after all their craniotomy is much smaller you don't have to expose the contralateral transverse sinus torrential is intact and the exposure really takes almost 15 minutes. So the whole case is much faster. But again that's just, but it's definitely technically more challenging, go ahead please.

- Yeah, so I did endoscopic third ventriculostomy. We did a posterior transcallosal, interhemispheric, interforniceal, internal cerebral vein. So we came right down like this Aaron I'm not sure you tried that approach, but to me I wanted to get on top of the tumor and have the ability to come front and back. You have to remember when you're doing this approach that the two internal cerebral veins are separated more as you go anteriorly, now as you come posteriorly towards the vein of Galen, they merge together. So your best window to come is right about here to get in between the two internal cerebral veins. I thought this was a great approach and it worked out really well for us. Have you used that approach before in your experience?

- Very infrequently Jim. We've wrote a series of cases with Rick Woop, who is truly a master surgeon when it comes to regionally as you are. And their outcome was superb than the ones who I did and we published together, all the outcomes are fabulous. It's a very technically challenging operation, but it's a beautiful operation and works very well.

- Yeah so here it is, you can see on the one hand the arrow that I'm pointing here shows the approach, the posterior interhemispheric corpus callosum. And then this is where the ETV was performed here. So you can see the two arrows. So we had two small approaches through the interhemispheric space through the corpus callosum. But a nice thing, and here's the screenshot that shows coming in between the two internal cerebral veins. There's one coming this way, one this way, the vein of Galen Galen's back here and basically clearing out the tumor, having gone with this approach. Yeah technically challenging, but if you're on target and you're in it, it just works out beautifully for you. It's a very, very nice approach as mentioned. The anatomy is key for that one.

- Yeah, that case Jim specially the part of callosum at that region was attenuated. So that was really a nice case selection of that as well.

- Exactly, okay next Aaron, another Thalamic Tumor but this one has a cap on it, you can see of CSF. So that opens the door to some other options that we'll talk about in this 12 year old with neurofibromatosis, headaches, and we got this DTI that shows here's the tumor, but look at how the corticospinal tract is jut all over this lesion. So what approach are you gonna use to get there? And we took advantage of this CSF cap as mentioned because we thought one of the sort of minimally invasive you know, trans tubular approaches might be kind of nice for a lesion like this in this location, but this is a definitely deep in the thalamus, cortical spinal tract's in playback here. It's really you know, a really important case to choose the right trajectory. So, I know we've been doing some work with some of the tubular retractors, this one is from Nico Incorporated. And certainly we've been able to use this approach using a trans-sulcal approach, and using trains of five navigation, so on the Nico Myriad as mentioned to debulk this lesion. And here's what she looks, there's a post-op showing resection of the tumor, but here's more importantly what her function is like Aaron, you can see, she was perfect. She hadn't had no weakness whatsoever afterwards. And this is I think at her one year followup. But what was on our side was the CSF cap as was mentioned, but also the fact that this didn't have a very strong attachment at all, and it was a pilocytic like one of the first cases I showed. An excellent outcome, no recurrence, pilocytic, no other treatment required. I think this was a good strategy, minimally invasive strategy using some of the newer technologies that have come forward. Okay next. Okay I wanted to show this one as, I could spend the whole hour on craniopharyngioma Aaron, but we're not going to today maybe another time, but this is a craniopharyngioma I had operated on in a nine year old who was sports affixed on playing hockey, headaches, visual failure. And we got a nice resection of this I used the sub frontal approach, which is one of my favorite approaches if I'm gonna do open interhemispheric sub-frontal a very nice approach. I used that just recently in the last couple of months on a different case. This child was doing extremely well after surgery went back to playing hockey, as lots of kids in Canada liked to do. And then unfortunately, a few years later I had this very small sub-chiasmatic recurrence that you can see right there. What do you do? Like I wasn't about to think about another interhemispheric trans that's not... I mean the best approach is right here, like coming endoscopic endonasal. So that's what we did Aaron, here's the approach you can see next is the video I think. Luke, yeah here we go. Yeah, so what you're looking at here is the chiasm which I'm gonna color for you here, going across. We have the suction tool here coming down and there were grasping the grasping force of the tumor. This is the sub-chiasmatic craniopharyngioma. It all come out in one piece, perfect approach. And before this grew and became a much bigger problem, we thought this was a very good approach. There you can see the chasm at the end there, beautiful. What becomes a problem is patching this afterwards. And this child, I must admit had a CSF leak that drove me a little insane trying to correct this problem. We had to go with the route of ventricular drain and then we had to go back in and patch this again with more packing gel foam to seal and so on. But eventually we got it solved and the child did really well. But just to mention complication of CSF leak with this approach. Okay Luke, let's go to the next. If there's still time Aaron, I could do very quickly.

- I wanna mention something about the last case. The fact that you run into CSF issues here is not unusual actually, this is not because it's endonasal. People who have a transcranial operations and score down their CSF pathways that way are more prone to have a leak after endonasal operation. So in these cases we really do extra measures you know, very, very generous inlay, an onlay flab, really a very generous nasal septal flab, fat, and even potentially a little bit of gasket seal technique. I think the gasket seal technique in combination with a nasal septal flap in this area is fabulous. So something that has really worked with us and the risk of CSF leak is almost less than two to 3%. Go ahead please.

- Yeah thanks, okay I just kind of maybe show one, I have a couple of laser cases, but just in the interest of time here I think I'll show one laser case. And then at the very end, I have some, either the second last slide or the penultimate slide, just some tips for all the residents who are on the line today so that they can learn some other teachings from Sugita. And I'll close with some teachings from Dr. Sugita. But you can see that this whole space is getting very interesting with laser guided therapy for a variety of lesions including brain tumors and in kids, hypothalamic harmatomas and so on. But what you need to get started in this realm is a dedicated MRI, you need intraoperative MRI, some kind of laser delivery system. We actually use the Monteris. Navigate your workstation, epilepsy team, which for hypothalamic harmatomas and it's costly. So I mean, you need dollars to do this. So our colleagues who may be in some of the developing countries around the world watching this, it's not the kind of technology that's gonna be readily available to you. But this case started, the first case started as an open case, seven-year-old, complex partial seizures, previously well, on anticonvulsants and had this tumor Aaron a small mesial based tumor. And you can think about strategies for resecting this lesion in this location. I chose transsylvian approach 'cause this was a very nice approach. Let's do the video on this one Luke. So just now we've split the Sylvian Fissure widely there's like almost over traction and demonstrating. This is a ganglioglioma that we resected and it just was peeling away off the mesial peel bank up against the optic tract, and so you have to be careful there. You go to superior, you'll get into the basal ganglia, but this is a very nice approach for lesions like this. And so next Luke, slide show. What I thought was a complete resection but in retrospect there might've been a tiny little bit of tumor here. But seven years was great, but then the seizures came back there was a small residual lesion. I tried talking to the family into more surgery, but they weren't interested in an open approach. And so they, but we had just managed to get lasers just a couple of years ago, and so for this small lesion here it's hard to believe, but they wanted the laser to eradicate this. We had determined from EEG that this was the one that was pretty active from an epileptiform standpoint. So here we are putting on the Monteris Headframe and here's the registering using neural navigation. There's the probe going right into the lesion ex-mesial base. And we got a nice burn about this big and the temporal lobe and getting care, taking care of the lesion as well. And so this was a very for them, for the family, since it was just a same day procedure and they left the same day was perfect, that's kind of what they wanted. So the laser probe was inserted a laser profile, and there's just a video here Luke, that just shows how the energy profile builds for these laser cases. And you follow the thermography Aaron, and it'll start to turn from like a yellow color, which indicates a certain temperature range and as it goes higher to a blue color, that means you're in a higher temperature zone that you want to be careful about. There, you can see the expanding yellow temperatures down here, and then it'll turn to blue one. And sometimes if you're around CSF spaces, there's like a thermal sink, but there's the blue color that you can see coming in there. And sometimes you have to be longer or shorter on the laser time period in order to get the full extent of the burn that you want. Okay so I think Aaron, I'm just wondering now if Luke can take us maybe to the second to last slide, is that something you can do Luke? Let's see if we can keep coming. I'll skip through this one, skip through the video. Yeah, this was the hypothalamic harmatomas, just because it's interest at time. Maybe go back one Luke and just the current neurosurgery residents and fellows you're very lucky to have all of these at your disposal. Everything here, many of these weren't an option for me when I was training as a neurosurgery resident in the 1980s. But now, and I showed examples of how virtually all of these are in use today to help us do the surgeries that I showed you time and again, through multiple cases. So very, very important that you have these in your armamentarium to make surgery as safe as possible. And then finally Aaron, just what I learned from Dr. Sugita. I want to stress neuro anatomy. There's a tendency for us to rely on our iPhones too much and look up neuroanatomy. But I can't value how important this is and to go back to the books and to know this, to learn from Dr. Roatan, to learn from the Neurosurgical Atlas. I'm just making highlights there because there's no substitute for knowing neuroanatomy. Patient positioning, brain retractors. I know there's this quiet revolution, Robert Smith there talks about retractor surgery you do that Aaron all the time. If you're using retractors, I would say it's okay but use them sparingly and move them frequently so that you're not getting constant pressure on the brain. Micro neurosurgical techniques need to be practiced all the time. Respect and protect, Dr. Sugita really paid way more attention to the draining veins than he did the arteries, why? So he was way more interested in the veins. Drawing your cases, we talked about the artistry of neurosurgery. I used to draw mine, I don't know what you Aaron but I used to draw my cases, I'm nothing like Ian Sok I'm not thinking like your artists for the Atlas, I'm nothing like Mark Schornack at the Barrow Neurological Institute. But it helps to render things in three dimensions in your mind. Make full use of your colleagues in the operating room and the nurses that are around you. And then finally just to achieve balance in your life. You know, we all work hard as surgeons Aaron, and we have to look after ourselves, enjoy our families as much as we can as best we can, but also to enjoy your hobbies and to make sure that you're a balanced individual, when you come back into the operating room with, with your undivided attention for your patients. So that's it Aaron, I thought I would just leave it there. I don't know if you have some comments, we thought we'd close with the theme of the 2011 WNS Annual Meeting, Discovering Neurosurgery New Frontiers. It was a real pleasure to do this with you as always and great to see you this evening.

- Jim spectacular lecture, really very informative, enjoyable and challenging cases. No question, very challenging. You know, sometimes obviously people like you show these cases, their case appears very easy, it isn't. When I'm watching your movements, you can see those delicate motions, respecting the tissue. You let the tissue dictate your movement you don't dictate your agenda. That is very difficult to teach. Just that fine motion, letting the tissue respond to you and you respond back. It's a dance with a cerebral vascular structures that are normal. Unfortunately recently a lot of patients become impatient, a lot of surgeons I'm sorry, becoming patient with managing or handling tissues. And that can unfortunately lead to a tissue injury. But as I said, it may look easy when you watch somebody like you, and MRI looks great and everybody feels empowered that I'm ready to go to the OR and show the world. Unfortunately, that's not a case. It requires many years of experience, dedication, passion, and service. I think that's extremely important. Before we finish I wanna ask you a question and that's, what are the pitfalls of young neurosurgeons in their careers? In my opinion, the young neurosurgeons when they finish residency or fellowship, they feel so almost ready to conquer the world. And they start taking on very difficult cases early on. They feel like they have to prove themselves too much. They don't respect their colleagues or opinions as much. They don't feel as much dedicated to self-reflection all those issues combined can really cause major issues in the early career of these young neurosurgeons. Would you be able to tell me what you think the pitfalls are for the early career in neurosurgeons?

- Yeah thank you, and that's a really good point. I mean, after you see presentations by, I know Roberts Betzler, you see them from Bill Caldwell. I know you had a spinal surgeon on your bay the other day. They make things look easy, as you say. And so the trapping of that is that junior either faculty or perhaps even fellows or senior residents are gonna think that this is a cakewalk and it's gonna be very easy to do. I would say one of the pitfalls to try to get around that would be to identify mentors early on in your career. Individuals with whom you can have a very decent, honest discussion about a case. And when I was first starting my practice, I was very lucky. I was blessed with having the three Hs. So that was Harold Hoffman, Bruce Hendrick, and dear Robin Humphreys available during any case. So from Harold, I learned about craniopharyngioma. From Robin Humphreys, vascular malformations, from Bruce Hendrick, congenital malformations. And I would go to them with a case in hand, those days the x-rays would go up on the box, you'd look at them and talk through the nuances of a procedure. And then if I really felt the case was challenging, like my first rolandic AVM I did with Robin Humphreys and I invited him into the operating room and I asked him to show me what he would do to do this case and he scrubbed in with me. And that was worth 1000 cases I can tell you. Just watching and being with him and learning from his experience can avoid the pitfalls that you're talking about in a very major way. And these early in one's career. And then some of the other things I mentioned were on Dr. Sugita's slide like always knowing your anatomy, knowing when to be humble and to really recognize that the disease is beyond your potential to salvage a particular situation. That biology is not on your side, and very quickly do what you can what's in the patient's best interest. And according to the book by Henry Marsh, do no harm. So I mean, these are the things that need to resonate very clearly with junior faculty before they embark upon craniopharyngiomas, rolandic AVMs, other cases that I showed, hypothalamic harmatomas and other things in this lecture this evening.

- And I think that's so well said because when people ask me, what should I look for the most in my first job? And I say the first three most important thing is your colleagues, your colleagues, your colleagues. I don't think you should look for finances, I don't think you should look for location. I think what is absolutely most important to you is that really you're learning starts when you finish residency. Because that's when you're most vulnerable to errors. And many of those in the intense heat of surgery are very much over looked. As I wanted to do the surgery, especially early on in my career, and I watched a video afterwards at leisure at home, I am so humbled by very redundant movements, but at the time it sounded like a great idea. But in fact, afterwards it appeared to be very below average. It took over 15,000 hours of reviewing surgeries and more than 2,500 surgeries for me to really realize what it takes to be a good surgeon, and that's after residency. So there is a very long and steep learning curve. And unfortunately some of our senior colleagues are not collegial enough toward our junior colleagues to provide them mentorship. And that's really an important deficit that people don't address very clearly.

- Yeah no, I agree with you 100%. And so find that job where you've got good colleagues and you'll never feel like you're gonna work. It'll feel so enjoyable, each day will bring a big smile on your face, happiness, and you'll be able to help your patients to the best potential possible because they'll have the best outcomes.

- Very nice, well Jim, God bless you for how much amazing work you have done for neurosurgery and your incredible legacy, it's such a role model for all of us. I wanna congratulate you, all of us want to congratulate you for what you have done, truly dedicated yourself to the care of children, which are the most valuable assets in all our lives. You have dedicated so much of yourself to The Journal. I work with a Neurosurgery Focus, and I can tell that it is an incredible amount of work, incredible amount of dedication required that you do it just because you love neurosurgery and you love academic neurosurgery. So you're the people who really define the best of us. And we're really thankful for what you have done for neurosurgery.

- Thank you Aaron, it was great to be here this evening and to spend the hour with you.

- Thank you, have a good evening.

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