Neurosurgery: Open the windows of the mind | Reid Thompson | TedxNashville

Dr. Reid Thompson takes us on an expedition into the layers of the brain, opening up the windows of the mind using technological advances in the tools that neurosurgeons use.

Dr. Reid Thompson is chairman of the Department of Neurological Surgery at Vanderbilt University Medical Center. He realized as a medical student that by pursuing a career in neurosurgery, he could think about the brain every day. What he didn't fully realize then was that 20 years later, he would still gaze on the brain with a sense of wonder. In this presentation, he will convey this sense of wonder by describing what it is like to operate on the human brain.

This talk was given at a TEDx event using the TED conference format but independently organized by a local community. Learn more at http://ted.com/tedx.

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)