XII Cranial Nerves in 12 Months: My First Year as a Skull Base Attending

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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. Welcome to this session, an exciting one. We're gonna talk about the learning curve of a skull-based surgeon during the first year of training. We have talked much about, you know, a technical analysis of complex operations with senior surgeons, but there is fair amount of learning to happen during the first year as a faculty. And I think knowing how to navigate those challenges is critical for evolution of a master complex cranial surgeon. So this evening I'm so honored to have with me Dr. Ezequiel Goldschmidt from University of California San Francisco. It is his training at UPMC and his fellowship at UPMC as well under Paul Gardner, and Juan Carlos Fernandez-Miranda. He's going to talk to us tonight about those pearls of starting the practice as a first year faculty. There is a lot that goes into that. There's a lot of challenges as a complex skull-based surgeon because this is a critical year where people are really looking forward to see if you've got it or not. At the same time, it's the first year of your practice, and it's when you experience is the least. So it's almost you trying to make your best impression when you have least amount of experience. So navigating those turbulent waters can be quite an art. And so tonight I'm asking Ezekiel to share that with us, to share it with those younger faculty, and also also those residents who plan to take on the challenge of skull-based surgery. So, Ezequiel, it's an honor to be with you tonight, very much looking forward to learning from you. Please do let us know about not only the technical aspect of what it takes, but also what are those pearls in working with your senior faculty, working with the residents, and how to essentially be able to establish the foundation for a successful career in academia. Thank you.

- Thank you so much, Aaron, for having me. And your words resonate with me. Starting a neurosurgical practice, it's quite a challenge, and despite all the training that we do, like nothing compares the feeling of starting your career and having your own patients, and making your own decisions both before, after, and during surgery. And also being under the spotlight, being under the spotlight of the faculty and the patients and the staff and everybody around there that is asking themselves like does he or she have it? And so this is kind of a tour through some of my cases during my first year and I'll touch base on all those things hopefully, as we go by.

- Thank you.

- So you can, so this is how I decided to title the talk because I thought 12 nerves, 12 months, 12 cranial nerves was adequate. And the point of the few cases that we're gonna show, it's different from from case to case, but we'll organizing through cranial nerves, and we're gonna talk about big tumors, small tumors, open and the internasal approaches. So this is a picture of my friend Max Nunez, which is an expert anatomist. And kind of looking at this I reflected of how difficult it is to manage operations all around the skull base, and how different anatomical aspects can actually pose completely different challenges. So I thought that this way of organizing the talk was adequate and and made sense. So hopefully it's gonna make sense for you. So we're gonna start with cranial nerve one, and the first case was an unusual case. So this is a 39-year old female that presented with severe developmental delay and bad headaches, and she kept complaining of this headache for a while, and people were not paying much attention. She was verbal, but she minimally communicated with her caretaker, came from underserved family, they have no cell phone access and no phone access. So she came to the hospital with these headaches, and after she got a CT scan, at an outside hospital, she was on thyroid replacement, and we got pituitary labs that were normal. And her scan was this. So on the left is contrasted coronal T1. This is an axial contrasted T1 on the right. So she had this huge cystic mass. It had some ring enhancement, but not much, while remodeling of the skull base, of the anterior skull base. So one of the considerations here was her social background because of course, you can think of many challenges about this tumor. Number one is what is it? And number two, how much of it can I remove? And number three, how. And I don't think there's anything wrong in doing an internasal approach for this, but the main thing that deterred me from doing that is that she didn't have the support that this needs. So one has to think that after you do an EEA for a tumor like this, they need nasal rinses. They need to be on the look out for a CSF leak. They need to be very aware of the surgery that happened, and the care that needs to happen. So I thought I'm not gonna do that. I'm gonna do the least amount of surgery for the biggest take of the tumor. So I decided to do an eyebrow craniotomy, and I did the eyebrow on the right side of the patient, so I could have the longest axis available to me. And this is what this look like. So I used facial nerve stimulation to know how lateral I can go. A normal eyebrow craniotomy, there's nothing particular about the case itself, drill in the anterior skull base. This is a very short video because there's only one thing I like to show. I accessed the cyst, dissected the cyst wall into a guide, into the posterior circulation. I left it alone. And then after I removed the cyst contents, I use the endoscope and I looked at both optic nerve and carotid arteries that were very displaced. And this is a very unusual look of the olfactory nerve. So you can see the olfactory tract, let me signal, which is this part here, the bulb. And you can see the actual nerve going through the cribriform plate there. And the reason we're seeing this is 'cause we're having an endoscopic view, and because the frontal lobe was so moved behind, that the olfactory nerve was basically very evident, which is unusual. Next one. So I got a very decent removal, I knew I was gonna leave some tumor especially, because it was widely attached to anterior communicating artery complex. But the patient's headache resolved. She did get postsurgical radiation. And this was my third case, out of UCSF. And I thought this will not ever get her in trouble, will resolve the headaches. I got a pretty decent resection, and the patient has no headaches and no recurrence thus far. Obviously it's been only one year but wanna have to know that most craniopharyngioma recurrences happen during the first year. So we're following up closely. We have a neighbor that takes care of her, but I guess this is an example of the best way to do this is to do it very, very safely, and being as minimal as possible. So the patient did very well after surgery. Her poor eye remained poor, and her controller eye actually improved, and we got a pretty decent resection. So for cranial nerve two, I chose a classic operation, which is for a 56-year old woman that presented with progressive visual loss. The vision was intermittently blurry, otherwise neurologically intact. And she had this visual fields that were evident for you know, right side temporal loss, not severe but is there. And this was her scan. So in my mind this is a great to reconcile, to do endoscopically. It is medial to both optic nerves. It's obviously medial to both carotid arteries. It's displacing the optic chiasm up and posteriorly. So an endoscopic view will be advantageous to remove this tumor. So this is the operation, we'll start with a nasal septal flap and then the drilling here is tuberculum. This drill, you can see hypervascular dura that we're drilling down. We expose both cavernous sinuses, and drill plenum and tuberculum enough to get an anterior view of this arachnoid space on the tumor. After the tumor is exposed, we'll coil into superior intercavernous sinus right there. The Kerrison is actually very useful to removing the anterior dura. And then the surgery is just meningeal surgery, is continuously debulking, subarachnoid dissection, and placing cauterize bodies in between the brain and the tumor. More debulking. That's the left A1 coming into view that we're dissecting from the tumor. We're cutting the arachnoid additions, and after exposing more tumor and dissecting it, we can see a little bit of the left of the nerve there. We continue debulking it with scissors, and the electronic aspirator. The anterior communicating artery is dissected, and we continue with the debulking. Here you can see a little bit more of the nerve and the chiasm, the inferior part of the lesion is dissecting from the stalk, and the gland and the tumor is now completely free, or almost completely free of our arachnoid additions. It's important not to take the tumor out completely like that, but to visualize the additions and apply counter traction, in order to prevent pulling from any important structure, which are many here. And the A1s, the ACOM, BA2, and the chiasm need to be protected. Finally, the remainder of the tumor comes out and you can see the chiasm, the pituitary stalk, the superior hypophyseal contra. And this is an ICG injection. You're gonna see recurrent R2, subpubner, A1s, ACOMs, A2s, and a completely decompressed optic apparatus. We closed with fasculata fat, and the nasoseptal flap. We can go to the next, Luke. And these are her visual fields after surgery. And this is post-surgical MR showing a complete removal of the meningeoma, and repositioning of the the pituitary gland with a nicely enhancing plug. In these cases I, I don't think that I would have offered an open operation for this. This tumor was perfect for an endonasal approach. For cranial nerve three, I thought we could discuss a craniopharyngioma. So craniopharyngiomas really are usually in a perfect location for endonasal approaches. Although I did show one that I decided to do via an eyebrow, but craniopharyngioma sits in between the optic nerves, cranial nerve three, and the posterior arteries, and they're very much in the midline. They come from stalk remnants. So craniopharyngioma are usually better approached via an endonasal approach. This patient was having headaches for the past month, increased appetite, and personality changes. Her urinary output was normal, and she had no visual complaints. And this is actually not unusual because of the retrochiasmatic location of these tumors. And her neurological exam was completely normal, no visually deficits, and no papilledema. And this is the MRI. So she had a large third ventricular craniopharyngioma. For these kind of tumors, one of the complicated things is what kind of discussion do we have with the patient? So one of the things that I discussed is that I didn't think that I was gonna be able to dissect the stalk from the tumor. The tumor comes directly from the stalk, and the tumor is huge. So the connection between the stalk and the hypothalamus was very hard to preserve. So I told the patient that I was gonna cut the stalk, and she was gonna be panhypopituitary after the operation, and she was okay with that, and I think that was the right thing to do. It helped a lot with management. But this is one of the things that one has to discuss. And the other thing which is hard to talk about is that this is a big tumor. And vascular injury during craniopharyngioma surgery is usually related to injury to the posterior communicating arteries, and the posterior cerebral arteries, and they can be hard to fix. So a stroke is one of the very possible risks after this surgery. And you can see the location of the mass is solid. It's solid and cystic at the same time, and it's not involving the carotid bifurcation, but the carotid bifurcation is definitely being pushed by the tumor. So this is the video of what we did. The patient is supine in pins. The leg and the belly are both prepped, and this is, we're in the sella already. We're dissecting cavernous sinus to cavernous sinus. For this case, it's very important to remove the middle clindum on both sides. I'm opening the superior intercavernous sinus because I'll use this window to embolize both right and left cavernous sinus, and the intercavernous sinus. You can see this is embolizing the surgical, which is gonna help me a lot with the rear opening. And for craniopharyngiomas, all we need is access to a supersellar system. So taking the previous medic sulcals, some of the plane is more than enough. Being more anterior doesn't help, that's the left middle clina coming out. That's the drill opening above and below the superior intercavernous sinus that is correlated and cut. And finally we access this space between the gland and the chiasm that can be seen superiorly. And the surgery persists similarly that any open operation we try to gain visibility, try to understand the anatomy, where the segment tumor from the carotid artery there. And then we need to be very careful, and identify the arteries are going to the craniopharyngioma, which are different than the arteries that are going to the chiasm, that obviously can cause a visual deficit after surgery. So this is a delicate procedure. Then we can go in, perforators, coming from the PCA to the interpeduncular cistern, the vascular artery. And we're gonna expose the vascular bifurcation shortly. And after I have all the subarachnoid space dissected, I decided to collate and cut this top, as I had discussed before with the patient, and we can push a tumor up. This feeder comes from the PCA, that's why it's not hard to injure the artery because if you pull from the tumor, you're gonna have all those arteries. Then we dissect the tumor from the right, round R3, and posterior communicating arteries. Dystrophic calcifications attached to the hypothalamus are not important to take. So then at this point I just cut a big piece that was completely dissected, and removed it. And it's very important to use sharp instruments close to the hypothalamus because we don't wanna pull from it, and give a hypothalamic injury. And this is us removing those additions sharply. And that's gonna, chiasm, that you can see right there. It's nicely irrigated. And we close the flash and the flap, and we also can use ICG to integrate the vascularization of the flap. We can go to the next one. So the patient did very well, was intact after surgery, and she was, she was completely panhypopit, and she was on DDAVP. She was discharged four days after surgery, and her MRI was gross total resection of this large third ventricular craniopharyngioma. It is important to say that not all of these can be removed, and done easily, and one has to pay close attention to a relationship with tumor two, the floor of the third ventricle. And if they are truly intraventricular craniopharyngioma, which are are not many, but if they are, this is not the right approach. And both Dr. Garner and Fernandez Miranda have written extensively about this. And this is one of the important things that I've learned with them. The other feature that was important to me was understanding where our team was ready to tackle these cases, and having no CSF leaks. And in that regard, it is important. These are not the first cases that one does, but sometimes you have no choice, not on this one, but sometimes you have a craniopharyngioma, that comes with blurry vision and severe visual loss, or even otitic hydrocephalus. And at that point, if I had one of these cases as my first case, maybe even though I would've done an endoscopic approach for a more advance in my career, I would've chosen an open approach to be safe, and not having a leak. But fortunately we have a great ENT team here at UCSF, so we're able to tackle these cases from primarily on. This is the MRI scan. Okay, so this is for cranial nerve four. And this is, this was a challenging patient, and this is one of the ones that I asked for help. Same 69-year old gentleman with progressive gait imbalance, and left hemiparesis. The guy was using a cane, and he couldn't walk with a cane anymore, and he had left hemibody hemiparesis, hyperreflexia, and Babinski. And this is his scan. So obviously very large petroclival meningioma involving the cavernous sinus and Meckel's cave with brainstem compression. So they're not many ways in which one can remove these waste, but they're definitely more than once. So one can think to do a retro sigmoid approach, or a petrosectomy. So I went running to Dr. Theodosopoulos' office, and I said, what would you do? We decided to do a combined petrosectomy for this tumor. You can see that there's a T2 signal change at the brainstem and this other enhancing mass is occupying a number of spaces. And what concerned me the most is the carotid bifurcation because it's not the hardest thing to do, to dissect this tumor from the carotid, the A1 or the MCA, but it's very hard to dissect it from the perforator, as I go to the anterior perforated substance there. So I decided anticipation for surgery that I was not gonna remove the tumor that was posterior to this carotid bifurcation. And I also decided that I was not gonna remove any tumor invaded , which that was a very easy decision. And I also decided to stage this case, and Dr. Garner's teaching very much came to mind, and it's like if you think about staging a case, just stage it. And I don't think I can do this case in one day and I didn't. I did it in two consecutive days, in this case. I'll show you one later in which I did in the two non-consecutive days, and I kind of explain why. But we did the extradural part of the surgery one day, and then we switched and removed the tumor on the day after. And we can show the video look. So classic incision for a combined petrosectomy, scalp dissection. We save the pericranal for dural closure. My colleague, Dr. Shirana, did a translabyrinthine mastoidectomy and posterior petrosectomy. The patient had no hearing on this side, and you can see the labyrinth there. And after that, we peel the middle fossa out, dura. We identify the middle meningeal artery, and cut it. We identify GSPN. It's very hard to understand which one is GSPN, until we the stimulate, and then it's very, simulation is very useful. And then we expose the rest of the petris region, and finish our petrosectomy, through the middle fault. We opened the dura, as it's classically described. I found that wet clips are very useful for this, but there are many, many ways of doing this. So I cut the tentorium here, and then I did an anterior cut to remove an big part of it because it was very useful in order to expose the tumor, in order to the devascularize the lesion. And that's a PCA that you can see there, which I know it's a PCA because, and that's disconnecting the tumor from the supratentorial compartment, from the infratentorial compartment. The tumor is now fairly devascularized, that's under seven and five. And this is us gaining access to the anterior part of the lesion. And after we do that, then we always need to be careful with cranial six, which you can see there on our side. But of course the contralateral cranial nerve six will be also a risk. That's the dural tail of the tumor, which comes from the midline at the clivus. So this is an arachnoid end of the lesion, more debulking. And after with a fair amount of subarachnoid dissection, and the tumor has been debulked, we can follow the tumor into the tumor cavity, and quickly resect it. Quickly so to speak because these took a good two-10 hour sessions to remove. As I was taking the tumor from the contralateral cranial nerve six. And then the tumor is debulked. We turn our attention to that cranial nerve six on the other side, and we are, remove the tumor from it. And then, so this part of the tumor was too adhering to be removed, and we decided to leave it in place. And this is one of the last part of the posterior fossa component of the tumors that was removed, and at that point, the posterior fossa was decompressed, and the decision making process, this is ICG run, you can see the posterior, the contralateral PCA, SCA, and cranial nerve three, and patent vascular to both ipsi and contralateral. And this is the hard part because we had to decide how, when do we stop, and if we continue going, we are going to get to the carotid bifurcation. So we use image guidance, and I was very attentive of not debulking anything that wasn't dissected already, to prevent a bad vascular injury at the end of surgery. And that's the view of the posterior fossa has been decompressed. And then we close as classically been described with fat, fascia reconstructed skull. This is the CT scan after surgery showing a very broad petrosectomy. And this is the MRI that shows residual here, at the carotid bifurcation, and against the brainstem. But you can see that posterior fossa has been very well decompressed. This is expansion of the brainstem. The patient did very well. He did have a cranial nerve six that was partial on the other side and the brains stem decompression did cause some progressive imbalance, but he recovered from that very well. So that was chronic. I guess cranial nerve four was an excuse, but of course every time he cut the tent, he have to be aware of it also cutting cranial nerve four in tumors that are risking patient's life. It's not the end of the world, but if you can avoid it, you should avoid it. But this was interesting because my former mentor, and my current mentors came to mind, and it was like you have to stage this case, a hundred percent and you have to do the biggest approach possible to be comfortable when the time to remove the tumor comes. So we've done the first four, this is for cranial nerve five. And this was an interesting case, and a little bit of a sad case in terms of her presentation. She was 25 and she had excruciating pain on the left side of her face, and she had lost her vision during an entire year because she didn't have access to to the healthcare system. So she knew that something was off, she wasn't quite sure why or what was it. And when we met, she had a very big tumor, and she was also pregnant, so she was pregnant in third trimester. So we look at this scan, and we had a lot of decision making to do, so we involved OBGYN, and fetal medicine and social services to try to understand what was the best thing to do. And although the patient was in pain, we decided to wait until the end of pregnancy. Now she has a beautiful boy and six months after she gave birth, we did an operation. And this is her tumor and her tumor, it's cavernous sinus meningioma. One can say that it's a cavernous sinus meningioma, but it really goes over the anterior skull base, from anterior to posterior, involved the superior orbital fissure, the sphenoid sinus, and maxillary sinus, the nasal cavity, Meckel's cave, and the pontine cistern. And this tumor was causing severe proptosis. Her eye was frozen at that point. And after seeing these tumors, I also reached out to people. But in this time I reached out to people outside the neurosurgery wall and inside the neurosurgery wall as well because number one, I didn't think I was gonna be able to do this case in one day and I didn't. I staged this case, too. And I didn't think I was gonna be able to close because after removing all this tumor component here, then we have a V-communication between the sinuses and the skull base. And if you pay close attention, this tumor is basically falling. This is foramen ovale, and it's going through foramen ovale, and it was going through the superior orbital fissure, and it was going through foramen rotundum, and it was using the entire trajectory of cranial nerve five to grow, and it was also very hyperostotic. So you can start, you look, so I did a stage OZ approach, but dissected the SDA for a free flap during stage one. It's very important to keep the artery pattern because if you clip the artery during this stage, there's gonna be thrombosed for stage two. And then I just did the first operation. I removed the intracranial component of the tumor. That's the interfascial dissection. It's been described by many. I do a two piece orbito-zygomatic approach. I think it's very safe and in cases for hyperostosis, I think it's actually much, much easier to do than than one piece, because the one-piece with all the hyperostosis have been very challenging. I do a retrograde dissection of a deep temporalis fascia. I don't leave a temporalis cuff, but I attach the temporalis to the hardware, three bur holes, and then a classic two-piece OZ. There's nothing fancy about this. And in this case the main question for the operation was how much I'm gonna be able to dissect cranial nerve five. Should I need to, do I need to medical scape though? One might be able to dissect the actual nerve. This is the MMA, that's not the best way to reattach the MMA, as you can all see. There's a little bit of cavernous sinus dissection. The tumor was so big that I just dissected to peel until I saw the entrance of B2, and that was enough. And for most of the surgery I didn't see CSF. So the surgery was very boring. You can see the tentorium is on the left part of the tumor resection, the cavernous sinuses at the depth. And I'm debulking the tumor, and I'm trying to find the tentorial incisura, in the tentorial edge. The reason I'm trying to do that is because I wanna see the pons. I wanna see what cranial nerve five comes from the pons. I'm not concerned about cranial nerve four, which we are seeing because she didn't have any discernible extraocular movements. So it is very adherent to cranial nerve four, first. And you're gonna see a glimpse of four in a little bit, right there. Mm, yeah, right there. And then I dissected this, and took it out. And interestingly enough, not surprisingly, the tumor was completely adherent to cranial nerve five. And what I don't wanna do with this patient is I don't wanna give her a permanent trigeminal neuralgia, I don't wanna give her anesthesia, I don't wanna make her worse. And the tumor was extraordinary adherent. So I decided to leave a little bit of meningioma attached to the nerve, decompress everything else. And that was day one. And on day two, we came back, we prepped the leg, we prepped the arm. And table. That's a flap with the skin, obviously we take the skin out, and that's our reconstruction. You can go to look. So this is the post-op scan, that's the boney removal. This is her post-up MRI. There is a clear cavernous sinus remnant here. This might have been lack of experience, but I'm still happy with the decision of not going completely into the cavernous sinus. It was gonna be very, very hard to, and obviously if the patient had any intact extraocular movement, I don't think a lot of people have gone after cavernous sinus component, but he can argue, hey, her eye is frozen, why should just not take this out? And the reason is a potential carotid injury. It's very hard or I think very, very hard in my hands at least to be able to safely remove the tumor, and safely in a significant way and not hurt the artery So I decided to stop there and I, because she's very young, I radiated this tumor and her pain is gone. She has no pain, she still had no vision on that eye, but her main main reason of concern is gone. And I think we reduced significantly this tumor, she doesn't have a complete resection, but considering the initial size and the end size of the tumor, I'm very happy with how she's doing, and she did great after surgery, And she had a TRAF-7 mutation, which is something that we are studying in the context of hyperostotic meningiomas. So, cranial nerve six. So I'll show you a lesion to the compressed cranial nerve six, but we're not gonna see cranial nerve six here. And in this case, one of my ENT colleagues approached, and said the otology department wants to do this case. But I told him we can do it in a more minimal invasive fashion. I was like, okay. So 39-year old high executive at a tech firm that had diplopia for a week and cranial nerve six palsy. And this is her scan. So she has a right side petrous osteolytic lesion, it looks extradural, and it's DWI positive. So I thought, okay, it's a cholesterol granuloma, and they were very concerned about an infection, but you know, the DWI signal might be a cause of concern, but I thought it was just a cholesterol granuloma. So I said okay, we're gonna do a contralateral trans maxillary approach to stay parallel to this carotid there, so I can have a better window because this is my window of opportunity here. And then my ENT colleague said, no, no, no, no, no, you don't understand. There needs to be super minimal invasive. We can't do that. So we can just do endonasal, and that is fine. But then that limits our approach to that. So this is not a technically complicated operation, but it's, we can play the video, look. It is an operation in which like always we need to pay very close attention that we're gonna be millimeters away from that carotid and we wanna do things safely and effectively. And I learned something here that we use for petrous apex lesions in Pittsburgh, and also for ritus clexus which is how one can use nasal mucosa to bridge, assist, and marsupialize assist into the nasal cavity, allowing for mucosal to growing. And you'll see that at the end. That's a horizontal cut and that's what we call a rescue flap because it's not a full nasal septal flap, but it allows you to do that. And here navigation and ICG angiography is key, and you'll see in a little bit that you can use ICG even through bone, and you'll see where it is. That's a Doppler. So doing all the drilling that I can to visualize adequately my surgical target constantly, which is use everything that you have in hand to orient yourself all the time. Image guidance, doppler, ICG, every piece of information. And the other thing that he also did very well on one two is communicate with your partner. If there's another surgeon there doing the operation with you, you can talk about the operation with your partner, and actually make better decisions during surgery, and keep patients safer. So I'm trying to access the lesion, and I can see a little bit of cystic content coming out there, and we'll see more in a little bit. You can see dura and cyst. The exposure here is not close to enough to marsupialize the cyst, but that's another important lesson. If there's any fluid in the field, don't aspirate it. It might be the last fluid you see. So obviously saving that for pathology and cultures in this case was very important. And then I'm starting moving laterally, and after I found the cyst, I know that I'm safe, so I can expand my bony opening. Obviously getting a CSF leak here will be a tragedy for many reasons. Number one, we'll need a flap. Number two, that content is very irritating for the brain. And number three, it will prevent me from marsupializing the lesion. So I sensed to me that those were the cystic content, and that's just a narrow hook inspecting the cyst on the inside. There's no leak. And then copious irrigation. You can see an opening. It's not huge, but considering our exposure, it is very, very good opening, and that's what we thought at the moment. And then we put a piece of mucosal that spans the nasal cavity, and the tumor. And you can go to the next one. Look. And her cranial nerve six fully resolved. But only four weeks after surgery, not immediately after, the cranial nerve six also resolved. And this is the scan, and this is exactly what we wanted to see, right? You can see how there is an opening here, and the nasal cavity is now communicating with what it was, the cystic cavity. And we think that's a very effective way in preventing recurrence. And you can see how close we were to this carotid, but this window was enough drilling, and they were very happy. But it's a challenge when somebody ask you to do an okay, can you this operation? Of course. But we're gonna do this operation even in a more minimalistic way than we're planning on, and safety needs to be number one. So if I didn't think this was safe, I wouldn't have done it. But I thought it was very reasonable, and it worked out very well. So obviously the canal is right at the back end, and it was decompressed and that's how her diplopia got better and she got better. And this was done maybe nine months ago, and she's still doing very well. And this is a follow up endoscopy, and you can see how the mucosa continues inside that surgical cavity. And I'm not saying there's no way this cyst can recur, but we can agree that this might be, doesn't mean a foramen that it's gonna be hard to close because there's mucosa on either side. Okay, so this one was my first vestibular Schwannoma, and it was something that I hadn't seen before. It's another case in which I asked Dr. Theodosopoulos for help during the surgery. And the reason is I think making decisions during schwannoma surgeries, it's probably one of the hardest things one can do because there's so many aspects that I have to account. One is surgical pride, but we always think about what's good for the patient. So I was very clear in this case. So this gentleman was 76 year old, and he didn't present to clinic. He didn't present because he had progressive hearing loss or tinnitus or facial pain. He presented because acute nausea and vomiting, and he could not take a step without falling. Severely disabled, to the emergency department. All hyperacute. The guy goes to the gym every day, and now he cannot stand up and he can't stop vomiting. So on exam, he had complete hearing loss and facial numbness and this is the scan. And the scan obviously doesn't look like a classic vestibular schwannoma but it does look like a vestibular schwannoma. It goes into the IAC, but you can see it's definitely cystic. The T2 is not hyperintense on T2, it conversely hypointense on T2. It's spontaneously hyperintense on T1, and attrition is on T1, and most of the tumor is not enhancing but the IAC is. So what is this? And what this is is a hemorrhagic vestibular schwannoma. So it was an unusual case because number one, I decided to do the operation as an inpatient. And number two I had to make hard decisions affecting other colleagues in this case. And the decision was I'm not gonna drill the IAC. So when you first start and you call your orthology colleague to an operation and then the operation happens, and you're like, I think we're good here, then that's not easy to navigate. Fortunately, they're very nice about it. So you can see that's, you know, our classic RMC approach, and you can see the cerebellar surface here. And the excuse for this tumor was the crown nerves. You can see 11, 12 and the 10 and 9, and you can see that it's a very unusual looking tumor, and you can see actually it's arachnoid hemorrhage. I swear I did not cause this hemorrhage. We were stimulating the tumor, entered the hematoma cavity, and then I just removed the hematoma with a two suction technique, similar to the same way I use a pituitary adenoma, and cleared the hematoma from inside the tumor. And very quickly, this tumor became very soft. So I dissected the tumor from the brainstem. I went around the lesion until I identified cranial nerve seven simulation, at around 0.5, right there. And then I was happy about that. So I went on the other side superiorly, I decompressed six, and I also said, I'm not gonna drill the ISC because I don't think the risk is worth it. So you can go to the next one. Look. So I decided to stop there, and the patient did excellent. The patient is 76, I did gamma knife the remnant and I know that I think you probably wouldn't have, but I decided to go ahead and gamma knife, the remnant of the tumor. But the patient symptoms went away immediately. He was able to walk, and he was able to eat again after we were done. You can see, not surprisingly, that all the IAC component is there, but again, this guy is 76, and this is not going to be his problem. So as Dr. Theodosopoulos said a bunch of times, the hardest thing for surgeon to do is to leave the tumor there. The easiest thing is just to take the entire thing out, but you have to hold yourself on this case. He helped me do exactly that. So that was that story. And this is the the last case that I would like to show. And an important thing about this one is the patient was a nurse known by everyone. Everybody knew who she was, and a lot of people had worked with her, and she knew a lot of people in the hospital. So when that's the case, I do think it's very important to at least consult with other people. So I think the wisest thing here to do if you're starting out like I am, is to call a friend and say, how do you think? What would you do? What would you approach? Would you operate? Would you not operate? And it went very well. But that end up being very helpful in this case as well. Don't be afraid to ask for help. There's no way to avoid complications. The only way to avoid complications is to not do a surgery. But when you have a complication, it's important to know that you've done everything in your power to prevent it. And that very often it's eating your pride. Pride can play no role in skull-based surgery. So, oh, I forgot the the age, but she's 59, and she has shooting paresthesias when extending her head. Otherwise her exam was normal, and this is her scan. So classic looking foramen magnum meningeoma pushing the corpus * signal cord change symptomatic but not very symptomatic. She didn't have weakness, and she had a little bit of imbalance, but with the shooting paraesthesias, they were getting worse. She had some neck pain. We decided to proceed, and we were further enough that the tumor was controlled, but expressing itself to the left. And one of the things that I do to prepare for surgery is actually watch your operations are here in the atlas because it's the best way, short of like doing the operations over and over, and going to the lab. Watching surgery, it's very, very important, especially, you know, on the eve before doing a big operation. It helps so much, especially with making decisions. For instance, one of the things that you repeat over and over is that the approach here goes as far as the virtual artery enters the dura. If you're gonna go further than that, then you need to transport the vertebral artery, which I didn't think I needed to. So I knew exactly how far lateral I had to go. And the other thing which was very important in this case and that was tattooed on my brain was Gardner's words like for far laterals, you mark the incision in PACU because after the head is rotated, you have no idea the skin that corresponds to midline, and which your next one we can start. And I decided there are many, many ways of doing this incision. This in my mind is the most familiar way because you find midline and median, it's very familiar, dissect everything back to the condyle, the joint with C1, do a C1 laminectomy. The craniectomy can be very small, and that's the entrance of the vertebral artery into the dura. And that's all you need. So after the dura is open, you can see that this approach, short of being ventral, lateral, sorry to the vertebral artery, gives us great exposure. I use wet clips to approach the arachnoid to the dura there. That's the vertebral artery, and cranial nerve 11. And here the key step is to get ventral to that vertebral artery entrance in the dura. After we do that, and you can see that the tumor basically occupies that foramen, and I'm not aiming to remove the tumor there because I wanna preserve that artery pattern. So as long as we stay here in the dural insertion of the dissected from the brainstem, bringing it into view on the bulkhead, and I see how many others have taught us, you can actually get a rotum dissector, get the tumor in to view, and debulk it while the dissector's in the tumor, and use that as an anchor. This is most superior aspect of the tumor. And we're seeing on the other side here. Here we're looking at the subarachnoid space on the other side. Cranial nerve 11 can make the patient jump on. Dr. McDermott have described using lidocaine to numb the nerve for a little bit to facilitate dissection. I didn't have to do this in this case. And then here also, when to stop. It's not clear when enough is enough. And neurophysiology monitoring is so important in my mind because at some point the compliance of the brainstem, it says enough at that point I think, I think we have to, again, privilege patient safety and neurological outcomes versus here where you're doing what it says, sorry, it's a little bit out of focus, but basically the rotum six is getting the tumor in to view and then using the Sonopet to dissect it out. There's a little bit of calcification that we're taking at the end, more tumor coming out. This is always true. There's always a lot more than we think it is. But after the vertebral artery has been dissected, the surgery is a lot of repetition. This is a superior part. But on the contralateral side, and then I'm here just taking care of the last part of surgery. We'll move to the next one. The patient was very well, she was discharged on post-op day three, and this is her scan, and there is some meningioma surrounding the entrance of the vertebral artery, but I'm very happy with this resection. The brainstem had been decompressed, and almost the entire tumor had been removed. So I just wanted to, those are all the cases that I wanted to show. But eh, one of the things, the first thing that I learned is that the, when you are a resident and you look at a case, and you say, yes, this is a great case. When you're attending and you look at the similar case, you say, oh no, and it's a completely different feeling because the cool case, the hard case, it's still a cool case or still a hard case, but your concerns are completely different. And all you can think is, how can I do this operation safely? And sub question of that is, can I do this operation safely? And if the answer is no, then it's okay. It's always better to pass that along than to go after that you don't think you can do. And it might not take years and years, but it might take a couple of months before you are comfortable at a new institution with a new team. Because skull-based surgery is not individual surgery anymore. Skull-based surgery, it's team surgery. I'm very fortunate having very experienced mentors here too. Well I guess everybody knows who these people are, but Paul Gardner during one and Carl Snyderman, Juan Fernandez-Miranda had left for Stanford at this point. But he was also key in my education. And these two people, they're not only amazing surgeons, but they are extraordinarily safe, and all they think about is patient safety. How can we have a good outcome for this patient? And there's nothing more important than that because if that's not the case, then there's no way your career is gonna move anywhere because everybody's looking at you. You don't always get to choose what cases you're going to do, but as long as you do them safely and that you show the residents, the staff, and your senior partners that you are a safe and effective surgeon, then there's no move to make in your career because everything comes in a second plane. All the research projects, all the academia, that's all super important. But there's nothing more important doing safe and effective operations, nothing, especially during your first year because there's no room for mistakes, and it's a lot of pressure. After all this time, the question's still can this guy, can this girl, can this newly graduate do this? And it takes a while to get them to answer the question, and they have to answer it for you. So I'm enormously thankful for both Dr. Berger and Dr. Theodosopoulos. And this is the other key, right? Like for endonasal surgery, your ENT partners are absolutely everything. They're gonna give you a lot of cases, there's gonna be an incredible mentorship that's gonna happen. Dr. El Sayed and Dr. Gola, and the mentorship that you get from them, is very different than a mentorship that you get from your senior neurosurgeons? They're not neurosurgeons. They come from a different background, and they're super excited about working with you because they know that it's about building a team together. And that goes the same with the residents, and it goes the same with the staff, the instruments, and all those things. So in my mind, very, very, very, very, very important to have great ENT partners, and I'm very, very lucky that I am, I do. So that's my presentation.

- Great work. Really enjoyed it. You know, I always said if you do enough surgery as a senior surgeon, it only takes you less than a few minutes to watch somebody operate under microscope to know how good they are. And I really can see that you really have tremendous respect for normal tissue, handling of the normal tissue, and really efficiently going around the tumor. It's very obvious, very proud to see it. I wanna echo some things that you said that are very important. Number one was that your colleagues are so important during the first years of your training. It's so important. I always tell fellows it's not about how much you get paid about the job, it's not about the location, it's certainly about your colleagues because you'll know that training continues. In fact, I would say there's more training happens during the first five years of your faculty or private practice than even the year of your fellowship. Because that's really the time you are stepping up the plate and people need to hold your hand. So if you really want to achieve your full potential, you gotta have people who support you get there. Otherwise, if there are people who are watching you and look for your deficiencies, you are doomed to fail. Because if you really wanna look for trouble, you're gonna find it. Neurosurgery and skull-based surgery is an extremely unforgiving specialty, probably the most unforgiving of all. The other thing that you said is that you not only had no issues reaching out when you need help, you also had people in the operating room. People sort of doing it as a team sport, which is very true. And obviously your first goal during your first few years of faculty is to stay at trouble. But you cannot be timid and you cannot try to not expand your armamentarium of surgical skills. So it's a very fine balance. You do wanna start with the most difficult cases, and try to prove yourself. That's a very much a losing strategy. You have to focus on small and medium size cases for the first six months, eight months, then get people to help you in the OR for more difficult cases, and then show your worth. I can tell you, it becomes a losing cycle that you do tough cases, you have complications, then you want show yourself you're good, you're gonna do more difficult cases, and you're gonna have more complications, and then you're gonna go at a point that, boy I really, I'm falling behind in my overall agenda. So I think being very much clear about your goals, knowing your limitations at the same time, not being too conservative and not too aggressive is very important. You said that one has to be very careful, there is no question about that. But there is three elements that define an incredibly gifted surgeon, and that has been true since 1601. That one of the barbers of the Elizabeth, King of England has mentioned that. And he, she said he did that sort of barber, which was, you know origin of surgeons, obviously at the time said there are three qualities for a surgeon that will make them a master surgeon. And that is true to this date, from the time of barbers. And that's heart of a lion, hands of a woman, an eyes of a hawk or a eagle. That is never gonna change. You gotta have this soft hand, you gotta have extremely wide vision that is not compromised by fatigue. But importantly, heart of a lion is important. You are gonna go, you're going to have complications, as you said. The only way not to have a complication is not to operate. So what really dissects you outside of the average surgeon is how to handle your operations, and your complications most importantly. So you want to be able to, how to deal with them, you want to be honest about them, you want to tell people what you learn from it, and move forward. You cannot let complications compromise your future career. And unfortunately it happens often in neurosurgery. And again, all of this, everything we talked about revolves around supportive colleagues. If they wanna hold you accountable to every complication, it is gonna compromise your full potential. Nobody can reach their full potential without having supportive environment that are forgiving for mistakes when you have given your best to avoid them. So those are components that I have come to learn across 20 years of mentoring young neurosurgeons. Is there anything I'm missing that you wanna add?

- I think you hit all of the most important points. I think maybe the other element is once you have a complication, things are rough. You are gonna, you feel terrible, you don't sleep and you are not in character for a little bit. You need to try to make that as short as possible, and just the next day there's a new operation, you go at it. But also a week after, two weeks after, after things have settled, after your, you can think about it, that's a great time to talk to a colleague again, and say, let's go back, let's look at this case, let's see what happens. And the other thing that I find immensely helpful is I edit a hundred percent of my surgeries, I edit all of my videos because that's, you can learn so much from that, but those will, what you mentioned, it's so important. It's impossible to do this job without support. It's just not possible. It's too much. And you're gonna burn during your first year. So I'm very, very happy and I'm very lucky. But I agree with what you said when you're looking for a job looking, okay, who's gonna be my immediate senior, who's gonna be the person I discuss the case with? That is the most important thing.

- Very good. Well I wanna thank you for your pearls of advice. Very well said. Very enjoyable videos to watch without a question, and I'm really looking forward to hearing more of your successes in the coming years.

- Thank you so much, Aaron, for the opportunity, and had a great time.

- Same here. Thank you.

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