Translator: Tanya Cushman Reviewer: Peter van de Ven
Thank you.
You know, I just love Nashville.
What a wonderful place.
(Applause)
So I think brain surgery might be easier than this,
but I'm going to give it my best.
I'm the chairman of the Department of Neurosurgery at Vanderbilt.
I wanted to give you a sense of wonder
and talk to you about something that I deeply love
and have loved a good part of my life,
and that's the brain.
I remember so vividly
the first time that I touched the human brain in a live patient.
I was an amateur.
I was a 25-year-old medical student, at the time, at Johns Hopkins,
and I found myself, that day, scrubbed, in the operating room,
standing next to one of the world's foremost surgeons, Ben Carson,
and we were operating that day on a 12-year-old boy
who had a brain tumor.
And the thing that I remember -
and it's seared into my brain -
is wheeling that little boy to the pediatric intensive care unit
after the surgery,
and within 30 minutes, he's up, playing video games.
I knew that something really amazing, really wonderful
had happened to me that day,
and I began to think about a career in neurosurgery.
As I thought more about it,
I realized that neurosurgery
has this incredible connection between science and art,
and you need to understand the anatomy of the brain, the physiology,
but you also need to master a set of technical skills and technology,
but then, there's just this incredible sense of wonder, really, about the brain.
Neurosurgeons were the first surgeons.
There's a lot of evidence, actually,
that these patients, the first patients, actually survived this operation.
But neurosurgeons have been on the planet for centuries, as it turns out.
The brain - I love thinking about the brain.
It inspires me.
The complexity and the beauty of its shape and just the mystery of it -
100 billion neurons with trillions of connections
just stretches the mind, really, to think about it.
And here I am, using my brain to try to explain to you about the brain,
and you're using your brain to try to understand it as well.
Neurosurgeons need to think in 3 dimensions.
If you flip the brain around, it's shaped like a C,
which I like to tell some of my friends that that may explain
why my three children - Connor, Claire and Cameron -
are all named with the letter C in their first name.
Take a close look at this image for a second.
Just burn it into your brain.
Look at the shape of the central section of the brain for a minute,
and then look at this next slide - a very familiar slide to you.
Five hundred years ago, Michelangelo was on a platform in the Sistine Chapel
painting God,
and it is, perhaps, maybe no mystery
that he envisioned God next to the human brain.
You see it?
You see how God is basically superimposed, really, over the human brain.
And this was a discovery that was made some time ago.
Michelangelo was a student of neuroanatomy.
He thought the brain was incredibly beautiful,
but he couldn't openly study it because he was a patron of the pope.
So he concealed his art in his frescoes.
And a very important figure in my life, a mentor of mine,
recognized that there must be other examples of the brain
concealed in the frescoes in the Sistine Chapel.
This is a very important fresco.
It hangs right over the altar in the Sistine Chapel,
and it's an image of God separating light from darkness.
And people had wondered for years what was up with God's neck.
Michelangelo knew how to draw a neck; he was a master artist.
And people said, "There's something peculiar about his neck."
Well, my friend Rafael Tamargo,
who's a neurosurgeon and he's also an artist
working with an artist who understands neuroanatomy,
500 years later figured out that actually what he had done
was drawn a beautiful, perfect rendition of the brainstem
and embedded it there and concealed it there,
and it took 500 years to discover it.
The nice thing about neurosurgery is that the brain comes color coded.
(Laughter)
So when I do an operation,
I know the frontal lobe is pink, right?
and the temporal lobe is yellow.
The thing about the brain that's cool that I want to focus on a minute
is that there's this structural symmetry to the brain,
but it's more complicated than that because there's a functional asymmetry.
Well, what do I mean by that?
It was 150 years ago that a guy, a scientist in Paris,
figured out that there was an area right here in the left frontal lobe
that was the speech center of the brain.
It was a beginning of our understanding
of where things are localized in the brain.
I want to tell you a story.
Nashville - all about songwriters, right?
Well, what do songwriters do?
They put emotion into words, and they put words into music.
I have a patient who had a tumor right near Broca's area,
and she had lost the muse;
she had lost her ability to translate emotion into words and words into song.
We took this tumor out,
and in the intensive care unit that night - very gratifying for me -
she asked for a pad of paper
and out came, flowing, this incredible series of songs
that had been sort of trapped in there -
we were able to release that, and she was able to flow again,
her artistry and putting emotion into words.
So there've been some fundamental advances in our field,
and I want to talk about them quickly.
One is this sense of this structure-function relationship.
It's really been important for us.
The second is that we've developed new technologies
like an operating microscope that lets us look deep inside the brain.
This is a view deep inside, under the frontal lobe of the brain,
and it's about a 3 or 4 mm artery on the base of the brain
with an aneurysm - that little bulge you can see there,
and the operating microscope lets us look inside and see that.
Here, we've put a small clip across the neck of the aneurysm,
and if you look at the top,
you can maybe make out the optic nerves and the optic chiasm,
and it's just incredibly beautiful structures,
but the operating microscope allowed us to see those things.
Brain imaging has transformed what we do, particularly MRI.
I love this image.
It looks like that sagittal image of the brain I showed you, right?
I mean, the anatomy is incredible.
I particularly love this brain because this is actually my wife's brain.
This is her MRI scan.
She let me share this with you.
But I love it - it's gorgeous, really, I think.
(Laughter)
The imaging has allowed us to find things in the brain.
This was a patient that was dragging her arm and leg,
and until we actually did an image of the brain
and we saw this large tumor pushing against her motor pathways,
we didn't know what was happening.
But we were able to take it out,
and as you can see here, the final result, she did well.
How do you find something in the brain, something really small?
Well, we've evolved a series of technologies
that bring together these concepts of anatomy and imaging and microsurgery,
and now we can use what's called "neuronavigation."
And really what I'm talking about is image-guided surgery.
So we can focus that microscope that you see.
Wherever it's focused,
we can see exactly where we are in that patient's MRI scan,
and that lets us map her and move her around
and navigate around when we do surgery.
There's another level of complexity here:
it's not just finding where something is; it's finding what that something does.
Here's a tumor that's very close to the language area.
I actually am very proud to tell you
that there's a patient of mine in the audience
who had a brain tumor in his language area,
and he is absolutely perfect after we took it out.
But if you can see this -
what our new technology imaging has let us do
is to do functional imaging.
So this is a patient who was in the MRI scanner.
We asked him to do some speech and language tasks,
and then areas of blood go flowing, preferentially, to that part of the brain,
and you can overlay that.
And so that red dot, that's the speech area.
Parenthetically, I notice that when I operate,
I'm so focused it's kind of like being in this moment -
I mean, athletes talk about being in sort of a zen state -
that I actually lose my ability to talk,
I can't ask for instruments that are very familiar to me,
and I'm sure it's because different parts of my brain
are preferentially getting blood flow.
So I say tumors in the brain or things in the brain
are a lot like real estate.
And what's important in real estate?
Location, location, location.
So that's a lot like brain surgery.
We can put these concepts together;
we can do things like awake surgery
and map out functional areas of the brain
and remove tumors that are close to speech areas.
Sometimes when I'm operating on the brain,
I just stop.
I just pause for a minute,
and I'm just stunned by the beauty and elegance and complexity of the brain,
and I say, "How do you operate on the brain?"
And the answer is "very carefully."
(Laughter)
This is a patient who had a brain tumor resected.
I think of neurosurgery as going on an archaeologic expedition:
you've got the hard skull, and you've got to peel that layer back,
and then finding the dura,
which is this leathery substance over the brain.
You open it with scissors.
And then when that's opened and revealed, you see below it the arachnoid glistening
with blood vessels and spinal fluid below it,
and then below that, the brain itself.
So there's this sense of an archaeologic expedition.
I really think of it as like opening the windows of the mind.
I'm going to play this video here.
In putting it all together, how do we find something in the brain?
This is peeling back the layers -
this is a five-year-old patient
who had a seizure and had a hemorrhage deep inside the brain.
We've used all of our tricks to localize this.
The brain surface looks normal.
Where's the problem here?
Well, you're looking through the microscope,
and periodically you can see a little crosshair - right there -
and you can see X marks the spot.
In a second, you're going to see the hemorrhage.
The brain is really soft, you know.
Just watch this for a second.
In a second, what we're going to do is we're going to reach in here
and pluck out this small, benign vascular malformation
that had caused the problem in the first place,
had caused this bleeding.
Once that's done, then this patient will never have another problem again,
and actually, here it comes.
This is kind of the showstopper.
(Laughter)
Showstopper if you are a brain surgeon, that is.
There it is.
(Audience) Ohh.
I just love that.
(Laughter)
(Applause)
So this patient went home in two days, perfect.
And what I like to think of as like, you know,
maybe it's drive-thru brain surgery.
(Laughter)
So I want to spend just the last couple of minutes of my talk
looking into the future, okay? and what comes next.
I've told you how neurosurgery has evolved now
using technology and imaging
and our understanding of structure, function, anatomy,
but what's next, really?
One thing that we are focusing on at Vanderbilt
is recognizing that we need to develop new surgical tools.
The tools that we've been using for 20 years,
they're not the same that we're going to be using in the future.
So we've started a collaboration.
And one of the ways that we're collaborating
is developing new ways of imaging.
So here's a patient with a tumor close to the speech area.
Here's the post-operative MRI scan on the right,
and this video shows you -
this is cool -
when you go to the grocery store and you check out your carrots and milk
and there's a little laser that runs across it,
we're using that in the operating room.
It's runs a laser across the surface of the brain,
and essentially, it's taking a picture and mapping it out.
So this is actually a superimposed image of the patient's brain
at the time of surgery,
superimposed on this three-dimensioned, reconstructed MRI of the brain.
I just love that because it's sort of new ways of imaging,
new ways of thinking about
how we see the structures of the brain while we're operating.
This is cool. This is how we make cars.
So what is going on here, this technology,
this sort of robotic technology?
I mean, this almost looks futuristic, but the reality is we use it now.
Well, we want to develop robotic instruments
that we could use for the next generation of surgeons.
This is a little, steerable needle
that my colleagues in mechanical engineering have developed at Vanderbilt.
It's a very small scale,
and it has this almost organic sort of movement to it.
You can imagine this is a new surgical instrument.
Who would have imagined that as a surgical instrument?
But that's what it'll look like.
This is cool: these are tiny little hands,
probably a couple millimeters,
that are going to tie this little knot,
and this is all being driven by a robot.
You can just imagine the implications, the opportunities and the possibilities
for using this sort of technology in brain surgery of the future.
We put stents in arteries, and the cardiologists do it,
and many of you know patients and family who've had stents.
What if we wanted to put a stent in a capillary?
I mean, a capillary is so tiny you can't even see it with your eye.
Here is a 70 micron guide wire
delivering a 200 micron stent in the back of the eye.
This is a capillary.
You can imagine the possibilities of operating almost at this scale
and particularly,
maybe how that might look in the world of neurosurgery.
What is going to be the look of a neurosurgical robot?
This is a pretty good estimation
of what it is.
This is by a guy, a brilliant, young mechanical engineer,
Bob Webster,
and this thing will latch on to the facial skeleton,
and it will allow us to have little platforms
and move around and deliver instruments,
and we might be sitting back, having a cup of coffee.
Not really, not really.
(Laughter)
I still like, you know, being right there.
So I just wanted to give you a feel for sort of a sense of what might happen.
But you know what?
In addition to all this amazing technology
and the technological developments that are happening at almost light speed
and that are influencing how we do neurosurgery,
we just heard a talk on creativity.
Where's that in the brain?
We know where things like speech are located, movement, vision -
those sort of fundamental tasks -
but where's imagination?
Where's music? Where's philosophy?
I'll end by telling you a story.
Some of the brilliant surgeons I work with at Vanderbilt
do what's called "deep brain stimulation."
You've got to be really smart to do deep brain stimulation.
I just mainly do tumor surgery.
But these guys, what they do is treat movement disorder.
They put electrodes deep into the brain.
And what they can do -
there are these little contact leads that go inside the brain -
and they can turn them on.
These are surgeries done with the patients awake
and being able to communicate with them.
There was a story just, really, only a few years ago
where they were putting in one of these leads
in a patient with Parkinson's disease, who had a movement disorder.
And they turned on the contact lead,
and all of a sudden, the patient had this incredible sense of elation,
and they were kind of like, "What?"
And she goes, "I feel great."
You know, it's not like you feel great during brain surgery and you're awake -
but they turned it off, and her mood sort of stabilized.
And they turned it back on again,
and she had this sense of incredible elation.
What they had discovered was an area in the brain, previously undiscovered,
that regulated mood.
Now, stop and think about the implications of that.
I mean, imagine patients with really refractory depression
understanding where things are located in the brain.
This structure-function relationship,
it's going to be really important.
It's been a real joy here today.
I really appreciate the opportunity to come and speak.
I mean, it's just an incredible group,
and I'm really honored to be here.
I appreciate everyone's attention.
I just want to leave you with a sense of -
neurosurgery, really, for me, on a daily basis,
is nothing but a sense of wonder.
I mean, it's an incredible opportunity and responsibility
to take care of patients with neurosurgical problems.
And, for me, it's been a lifelong pursuit of that sense of wonder.
So thank you very much.
(Applause)