- I'm Dr. Brian Kopell, neurosurgeon.
Today I'll be answering questions from Twitter.
This is "Brain Surgery Support."
[energetic drum music]
@ekenta_ifeanyl asks,
"What does the brain feel like to the touch?"
If tofu and jello had a baby, that's how the brain feels.
There's a give to it.
As a patient breathes or the heart pumps blood,
the brain pulsates accordingly.
@st0neyp asks,
"Did y'all know that you gotta be awake for brain surgery?"
When you're operating on areas,
especially related to language,
we literally ask them questions.
Some patients have played instruments
to demonstrate that they are doing okay.
I have had a patient play a guitar in my operating room.
We wanna see when we're trying to do a surgery for tremor,
which is a rhythmic oscillation of the hands or the feet,
the patient be able to drink from a cup
or sign their name,
which are things that they were not able to do.
And if you stimulate, and the patient's
still able to respond, they can repeat a question,
they can repeat a phrase,
that tells us that it's safe to go forward.
Aren't they screaming in pain?
The answer is no.
The brain in of itself has no pain receptors.
@BlakemBand asks,
"What is harder, rocket science or brain surgery?"
Well, that's an easy one to answer.
Brain surgery is harder.
Consider that there are a hundred billion neurons
in the brain.
The amount of connections
between those a hundred billion neurons
are greater than all of the stars estimated in the universe.
That's why it's harder.
@LightningAnthony asks,
"Do brain surgeons practice on fake rubber brains
before having a crack at the real thing?"
No, we learn on the job.
The very first time I walked into an operating room,
I was struck by the smell.
We use electrocautery, that is electricity,
in order to control bleeding in the brain.
In essence, what you're doing is cooking flesh
and well, human beings have a very particular smell
when they are being cooked.
That is a pretty eye opening or nose opening experience
the first time you go into an operating room.
It would be very hard to replicate it.
Even the best simulation technology isn't quite the same,
at least currently, than the operating room itself.
@ElikemV asks,
"Just watch the resection of a brain tumor.
Bro, how do neurosurgeons do it?
And it was done perfectly. The skill must be crazy."
Nature has inconveniently placed the brain
inside a box called your skull,
and trying to get into that skull
is like pulling off a heist.
You have to get into the brain, not cause any damage,
remove the tumor and get out,
leaving the patient no worse than you found them.
Depending on the tumor, it can look very, very similar
to normal and healthy brain
and it takes an experienced eye and some new technologies
for us to see in the operating room
where tumor ends and where normal brain begins.
Sometimes, because the tumor is particularly soft,
we would take it out piecemeal by suction.
A suction is essentially a metal instrument
that's a straw,
that also has ultrasonic energy applied to its tip
that helps the suction along.
Once all the bleeding is stopped,
we essentially then close the covering on the brain,
which is called the dura,
fix the bone flap back to the skull,
then we close the scalp, then we get lunch.
@LydiaBoheya asks,
"What happens if you need to sneeze
during awake brain surgery?
Or do they give you something so you don't sneeze?"
Sneezing is often accompanied
by something called a valsalva maneuver,
where the pressure inside the brain
temporarily spikes and then goes down again.
I do deep brain stimulation.
There's a relatively small hole that's made in the skull,
about the size of a dime.
Sometimes when a patient sneezes or coughs,
you can actually see the brain pulsate up a little bit.
That can potentially be a problem,
but it's pretty rare.
@willmiam asks,
"How do they fill the hole in your skull
after brain surgery?"
The most common way that we fill that hole
is with the patient's own skull.
We usually affix that piece of skull called a bone flap
back to the rest of the skull with titanium mini plates.
Sometimes we have to remove a piece of skull permanently.
Very often this can be in the setting of trauma.
We used to do this with titanium mesh,
so we would get a essentially like a screen door
bend it into place, and affix it
to the rest of the skull to cover the hole.
More recently, we can get a CAT scan of a patient
and computers can design a perfect plastic replacement
for what we removed that looks just about as good
as the real thing.
@darkwise asks,
"Why do most brain tumors triggers food smells?
Are brain tumors delicious?"
Sometimes tumors can create seizures in the brain,
and depending on where the seizures arise from,
can involve smell associated or olfaction associated
areas of the brain.
Very often these smells are actually bad smells,
so it is very, very unusual to elicit
a hallucination that is a good smell, but it can happen.
@Kazoodingus asks,
"If I was doing brain surgery, I would swirl my finger
through the guy's brain just to see what happens."
Dear lord, really?
Running a finger over the surface of the brain,
if you're very, very gentle, will do very little.
If there is pathology near the surface,
the brain's surface can be fryable,
where just the nearest touch can cause bleeding.
But a healthy brain can be touched
with very little recourse.
@zeldafitzlauryn asks,
"Why were lobotomies ever a thing?"
Lobotomies were not only a thing,
they are the only instance where neurosurgery
ever won the Nobel Prize.
In the early days of the 20th century,
psychiatric care was extremely rudimentary.
There were many, many, many patients institutionalized.
It was a huge burden for families.
John Fulton, a physiologist at Yale, discovered
that the frontal lobe was really important
in creating the manifestations that we associate
with psychiatric disease.
Igatz Monet speculated that,
if we were to interrupt certain fibers
inside that frontal lobe,
that we could in fact help patients.
An instrument called a leucotome
was inserted into the brain and then a hole was made
inside the deep portions of the frontal lobe.
Once Thorazine was invented, the use of lobotomy
as a treatment for psychiatric disease fell out of favor.
But the whole process actually helped mankind
really truly understand the physiology
of psychiatric disease for the very first time,
that psychiatric disease was not a weakness
in a patient's soul, but a real disease,
like diabetes, and actually led to a lot of
understanding and treatment that we are using today.
@dibsondebs asks,
"Hearing the term neurosurgery seems to have
such a different connotation than brain surgery.
Do they have the same meaning
or are they entirely different entities?"
The term neurosurgery encompasses brain surgery.
So when we all become neurosurgeons,
we actually learn the entire surgical technique
of treating surgical conditions of the brain,
the spine, and the peripheral nerve,
which is the entire nervous system.
Brain surgery is just a segment of neurosurgery itself.
@GoBlueTsunami asks, "What is a craniotomy?"
A craniotomy is a temporary window
that we make in the skull in order to allow us
to access the inner contents of the brain.
To remove a brain tumor, or to clip an aneurysm,
we start off by placing bur holes or small holes
around the periphery of the window that we intend to make.
We then take a type of saw called a craniotome,
and we essentially connect the dots or the holes
and we create a window called the craniotomy itself.
Do not try this at home.
@GLADSTONEWRITER asks,
"More brain surgery on the way for me.
This time my neurosurgeon is going
to go through my nostrils.
It's a procedure known as endoscopic endonasal surgery."
So one of the areas that we encounter
tumors and other types of pathologies
is in the pituitary gland,
at the very, very bottom of the brain.
And it sits inside this little bony pocket
called the pituitary fossa.
At the very back of the nose
sits these pockets called air cells inside the skull itself.
And so, by inserting a tube and a camera through the tube,
we can unroof this air cell and we are right
at the pituitary base, and we can take out a tumor
without having to disrupt normal anatomy of the skull.
One of the more common restrictions is
limiting the use of things like straws
that can develop a lot of suction inside the air cells
while the healing process is occurring.
And yes, also don't blow your nose.
@chrisconwayy asks, "What clothes do brain surgeons wear?
Cerebral gore-tex ha ha ha."
I start off by wearing my surgical scrub hat.
I also wear my scrubs.
Over the scrubs are the sterile layer of our garb,
which involves an operative gown
and a pair of surgical gloves.
And this whole process of gowning us up
in a sterile fashion is assisted
by either a scrub nurse or an OR tech.
Once we are garbed completely,
we can begin the operation.
@peggytrill asks,
"Did you know when they do brain surgery
and need to remove part of your skull
for an extended period of time,
they just cut an incision in your abdomen
and put it in there?"
Sometimes there is so much swelling in the brain,
we have to give it room
so that patients can survive the injury.
We have to remove the entire side
of a patient's skull for a long period of time.
Ultimately, if you wanna be able to put that skull back,
it's gotta remain sterile.
And what's the most sterile place for a patient's body part?
Their own body.
What you're referencing is something that is
falling out of favor but is still done.
Neurosurgeons would make an incision in the abdomen
and place the bone flap inside this temporary pocket
and close it up.
And as long as there was no infection of the wound,
that bone flap remained absolutely sterile.
@DatRickyDude asks,
"So I heard somewhere in random conversation
and I'm not sure if it's true.
He was having brain surgery and the doctor
poked something and he remembered being at a party
many years before in vivid detail."
Well, in fact, this did happen,
during an operation called deep brain stimulation.
The electrode was going to be placed
in a part of the brain called the hypothalamus.
The trajectory went through a structure connecting
areas of the brain involving memory, called the fornix.
A patient, being awake on the table,
recalled a series of events from their childhood.
And the amount of detail was so striking
to both the patient and the investigators and the surgeons,
they developed a technique to stimulate this particular area
of the brain and have created trials looking to
help patients with Alzheimer's disease.
@rockcock64 asks, "You know
how during brain surgery doctors will have
the patient play the violin if they're violinist
or whatever, so that they don't [beep] up their brain?
Do you think that they would have a gamer
speed run "Super Mario 64" during brain surgery?
If they're a famous video game athlete, I suppose why not?
We could do that. Sure, no problem.
@illionaire asks,
"I just seen a billboard for gamma knife brain surgery
where apparently they operate on your brain
without cutting anything open. The [beep]?"
The gamma knife is a type of
what we call stereotactic radiosurgery.
Pinpoint beams of radiation are focused
deep inside the brain,
and wherever these beams of radiation intersect,
they deposit a therapeutic dose of radiation.
It's an very important tool, especially
in the realm of certain vascular disorders,
brain tumors, and certain functional disorders.
@producerdani asks, "Hi yes,
can a brain surgeon weigh in here
and tell me which part of my brain is responsible
for getting the "Jurassic Park" theme song stuck in my head?
I'd like to remove it, please."
Well, that would be a really bad idea,
because the controller of attention is called the thalamus.
It's a deep area of gray matter inside the brain,
and it actually acts as a gate
as to what is grabbing our attention
from moment to moment to moment.
I highly recommend keeping your thalamus.
@Daniellebabe26 asks,
"Is deep brain stimulation surgery worth the risk?"
So like the heart, the brain is an electrical organ.
Everything that we do, from writing a sonata
to hitting a baseball, is the result
of an electrical pattern of activity in the brain.
Diseases such as Parkinson's disease,
or dystonia, or things even like depression
and obsessive compulsive disorder, are the result
of abnormal electrical patterns of activity in the brain.
What is deep brain stimulation?
Essentially what it is, is a pacemaker for the brain.
We can place an electrode through a very, very tiny hole
at the top of the skull into deep structures of the brain.
What we are trying to do is take a one millimeter electrode
and hit a one millimeter target inside the brain.
So it's really, really, really super precise.
By regulating that electrical activity,
we can actually make patients' symptoms much, much better.
The scariest risk is bleeding in the brain or stroke.
Generally around 1%.
@BigDaddyonair asks,
"A robot which can perform brain surgery
was showcased at the hashtag World Robot Conference.
How good are you at your job?
Robots are coming to take it away."
Well, believe it or not,
robots are already in the operating room.
There are some limitations.
One, the skull itself.
In other areas of the body where robots are used,
such as the abdomen, robots have a lot of access
because the abdomen can be temporarily inflated with air
and there's a lot of room for robots to move around.
The skull's inconvenient.
There's a skull, and then there's a brain,
and not much else.
And so, robots to really become very useful
for brain surgery, they're gonna have to be
miniaturized to a huge degree.
Furthermore, somebody's gotta tell the robots where to go
and that still will likely be a human process
for many years to come.
@fiend_mrs, "The brain does not feel pain
as it has no pain receptors.
If that is the case, why do we experience headaches?
I have severe migraines and feel like I have
an ax in my brain sometimes."
In the case of migraines, the blood cells constrict,
and then as the blood cells begin to relax,
that physical relaxation stimulates the pain receptors
and causes the pain.
@lemurgxrl asks, "Can a brain surgeon cut open my head
and take out the pieces with ADHD, please? Thanks."
There are some non-invasive brain stimulation
techniques called transcranial magnetic stimulation
that people have explored for ADHD,
but not neurosurgically as of yet.
@QwetzalCohete asks, "How do you choose the area
of the brain where the electrodes are implanted?"
We place an electrode inside the brain
to interact with networks of the brain,
and networks of the brain are distributed
pockets of neurons that are all working together
to create a behavior.
If we're talking about a network function
that's related to movement, we are interested in
placing these electrodes in movement associated areas
of the brain, deep gray structures
called the basal ganglia, which can be seen over here.
Other avenues of research are looking at
placing electrodes along the surface of the brain
to stimulate the network along the cortex,
because everything is connected.
Even though you're stimulating locally,
you're affecting things globally.
@PristineMartian asks, "How far away
is superhuman intelligence with a brain-computer interface?"
I think currently we are fairly close
to having brain-computer interfaces really help
a process called neuroplasticity in the brain,
and neuroplasticity is the brain's normal process
to learn and adapt to the outside world.
I think that's something that we're going to likely see
within the next several years.
The idea of having a Bluetooth implant in the brain
that helps you Google something on the fly,
we are talking decades upon decades
before we would see something like that occurring.
So those are all the questions we have today.
Great questions.
Thanks for watching "Brain Surgery Support."