Presidential Address to the 2023 Annual Meeting of the Congress of Neurological Surgeons

Welcome to our 73rd Annual Meeting of the Congress of Neurological Surgeons (CNS) in Washington, DC. It is truly the greatest honor of my professional career to serve you, the membership, and guests of the Congress. “Imagine, Innovate, Inspire”—this meeting theme—represents foundational tenets coloring the lenses through which I, and many of you, perceive our distinguished specialty. It is a fast-paced world now! Change is constant. And the future is uncertain. Imagination, innovation, and inspiration are more important than ever. When I queried Chat Generative Pretrained Transformer (ChatGPT) on the meeting theme, it said: “they are the key to solving complex problems, improving our lives, and creating a better world for future generations.” I then asked ChatGPT—based on science, speakers, and content—what is the “can't miss event for the neurosurgical community in 2023?” It answered, “This CNS annual meeting, of course!” I concur. Certainly, it is with earnest nostalgia to return to DC, where I attended medical school and was introduced to neurosurgery at the George Washington University School of Medicine & Health Sciences. Many of the school's faculty and students are here today. It is wonderful to see you again. I hope your time at this CNS Annual Meeting stimulates you to imagine what could be. Or perhaps you develop innovative techniques, technologies, or practice paradigms. And it is my wish that your time here in our nation's capital, surrounded by friends and colleagues, inspires your personal journey, your “next,” in this beloved specialty of ours. IMAGINE It is not who you are today, but who you are working to be. And what you are doing today to effect that transformation. Nobel Prize laureate George Bernard Shaw states “Imagination is the beginning of creation. You imagine what you desire, you will what you imagine, and at last, you create what you will” (https://www.goodreads.com/quotes/34474-imagination-is-the-beginning-of-creation-you-imagine-what-you). We are often limited by what we imagine. Eliud Kipchoge broke a world record in the 2022 Berlin Marathon. What inspires him? He runs for humanity and globalization of education. It is this shared devotion for global access to quality education, which is his second passion, that creates common ground between him and many of us here today. And you know what… he must have imagined running at a pace never known to humans. Remarkable! He is a world champion. Imagine running a marathon, and every mile of the 26.2 mile race, at 4½ minutes. (I clocked in at double that during the CNS 5K.) Kipchoge was the son of a single mother who was a Kenyan school teacher. Like his story, many of our origin stories start with humble beginnings. This was my humble beginning, a small house in the north of Israel (Figure 1). Gazing up at the night sky from this very porch as a young boy, I too imagined a better future. Maybe 1 day I could join my father, one of my many inspirations, in the selfless brotherhood and sisterhood of the medical profession.FIGURE 1.: Home in Tiberius, Israel, where my grandparents, parents, and I lived from 1972 to 1978 [Author's photograph].Two and a half decades later, a few blocks from this very convention center—what I only imagined—started to crystallize. Dr Laligam Sekhar, then chair of the neurosurgery department at George Washington University, allowed me to shadow him. I never imagined that surgery for petroclival meningiomas was the most common neurosurgical procedure, with recurrent cavernous sinus meningioma surgery a close second (that was through the lens of a clueless medical student). At least that was my experience as an eager first-year medical student—collecting tumor samples. Nonetheless, “Shake” imagined that there has to be a better way—a uniting ethos shared by luminaries in our field. He imagined a future where therapeutics involving cytokines and interleukins would obviate the need for these extensive resections or even prevent recurrence. He inspired many skull base surgeons around the globe, some of my first few articles, and my first oral presentation at a CNS meeting—just like this—25 years ago. We failed to move the needle in the care of meningiomas. But that relatively insignificant failure unlocked, ignited, and inspired an academic curiosity at a nascent point in my neurosurgical career. Imagination, creativity, and the willingness to coalesce avant-garde medical findings, epitomize our honored guest Dr Douglas Kondziolka. I credit him with teaching many of us the rigors of academic writing. He cultivates in his trainees inquisitiveness and imagination… for the benefit of our patients. Dr Dade Lunsford, Dr Kondziolka (Figure 2), and others, through perseverance and the relentless pursuit of meticulous data, sparked the paradigm shift. No longer did intercanalicular acoustics or cavernous sinus tumors require surgery, and more importantly, exceptional clinical results were heralded as superior to gross total resection.FIGURE 2.: Dr Dade Lunsford and 2023 CNS Honored Guest Dr Douglas Kondziolka. The identifiable individuals consented to publication of their image [Author's photograph; circa 2002].INNOVATE Like many innovative luminaries, Lars Leksell believed “there has to be a better way.” Drawing on his training experiences in the 1930s, he implemented his stereotactic frame in 1949. Then, in 1988, the first publication of stereotactic radiosurgery of Lunsford1 would forever change the treatment of vascular, functional, and neoplastic lesions. What Leksell imagined in the 1940s led to countless innovations in stereotactic surgical applications over three-quarters of a century and inspired generations of functional and stereotactic surgeons over the next 80 years. I witnessed the birth of a similar innovation-driven paradigm shift as a Hopkins fellow in 2001 (Figure 3). It was at a CNS meeting just like this where I heard our esteemed honored guest, Nick Hopkins, inspire our audience. He envisioned using our body's vascular highway to access pathologies of the central nervous system. I was inspired! After a failed stroke intervention, Nick said: “We need to do better. If cardiologists can stop heart attacks, we can and will do the same for stroke.” He imagined a day when stroke was no longer a disease treated by rehabilitation, but rather by a surgical intervention. With a million Americans suffering stroke or transient ischemic attack annually, ponder for a moment the potential impact.FIGURE 3.: 2023 CNS Honored Guest Dr Leo Nelson (Nick) Hopkins III and CNS President Dr Elad I. Levy during the fellowship years 2001–2003. The identifiable individuals consented to publication of their image [Author's photograph].Our special guest lecturer Safi Bahcall, in his book Loonshots: How to Nurture the Crazy Ideas That Win Wars, Cure Diseases, and Transform Industries,2 tells the story of Polaroid creator and visionary, Edwin Land. Land aptly suggests we “don't undertake a project unless it is manifestly important and nearly impossible” (https://www.brainyquote.com/quotes/edwin_land_193298). How many of us have done that? A loonshot? It would take a decade and a half for Nick and his supporters to persuade the neuroscience community through Level-1 evidence that mechanical thrombectomy is superior to intravenous tissue plasminogen activator (IV tPA), aspirin, and supportive care. The recalcitrant and deafening clamor of neurologists demanding randomized controlled trials, gripping to the hope that IV tPA was the panacea for stroke care, faded to a forgotten whisper. Case reports eventually led to trials approved by the Food and Drug Administration for stents that showed efficacy for thrombectomy. There was a massive opportunity for innovation here, limited by nuanced understanding of stents and the need for more supple technologies. Loonshots are defined as ideas initially received as having no chance of actually working. As Bahcall2 describes, both strategy-type and product-type loonshots created a frenzy of device development in a quest to create the quintessential thrombectomy system. One decade ago, a tsunami of contradictory Level-1 evidence dispersed across the stroke community. These trials showed that intervention was not superior to medical management for the treatment of acute ischemic stroke. But…there was a population of patients in desperate need of physicians willing to rise against the dogma and challenge the flurry of these negative studies published in the New England Journal of Medicine. Imagining a better world, the neurointerventional community of several specialties, joined forces, in a heroic effort to provide the reproducible, Level-1 evidence that forever changed stroke treatment after 2015. Thought leaders rejoiced! We helped usher in a paradigm shift in perpetuity. As you sit here today, you are joined by the first cohort of residents beginning training having only known a time when thrombectomy, and not hemicraniectomy, was the mainstay first-line neurosurgical treatment for acute ischemic stroke. If we want innovation to continue, celebrations of our successes should be meaningful but brief. What is our next? We knew there was more work to do. Technological progress that started less than 2 decades ago with simple clot retrievers has evolved at breakneck pace to result in modular, highly flexible, thrombectomy devices. But what about patients who could not receive care within the 6–8 hour therapeutic time window? Due to the disparity of care resulting from the lack of thrombectomy centers within 1 hour of many geographical locations, especially in low-income counties, how would those stroke patients survive? I will share with you a quote from the former Prime Minister of the United Kingdom, Benjamin Disraeli, “nurture your minds with great thoughts. To believe in the heroic makes heroes” (https://www.brainyquote.com/quotes/benjamin_disraeli_121570). We believed that “time is brain.” But our patients are not Fords off the assembly line. Each deserves a unique vascular investigation. For 10 years, we imagined a day when the arbitrary time constraint for thrombectomy could be eliminated. Most importantly, by extending these therapeutic time windows, we could significantly reduce health care disparities, affecting communities remote from thrombectomy centers. A decade would pass, consisting of early reports and registries using sophisticated imaging to extend time windows for stroke therapy. Bold, pioneering investigators paved the foundation for Level-1 evidence for thrombectomy without a time constraint. A decade later… A second paradigm shift! As poet William Blake stated, “what is now proved… was only once imagined” (https://allauthor.com/quotes/153908/). There are many who look to innovate for the sake of innovating. How often do we say this is a solution looking for a problem? Innovations need to be impactful, improving on the status quo and addressing a critical need. Let me tell you a story of my firsthand experience as a college oarsman at Dartmouth. For centuries, oars used to be shaped like spoons. Our coach and former Olympian Larry Gluckman imagined and innovated a new design. The hatchet blade. He, along with the engineers from Concept2, challenged this dogma. They engineered this new blade for increased power per stroke. Like most innovations, the new design was at first rebuked by scholastic rowing. However, a paradigm shift happened instantly after a few key victories using the hatchet blade design. It takes a few bold early adopters that find success to “catalyze” innovation. Continued and reproducible success is then necessary to galvanize innovation into a state of permanency. The other lesson I learned early on: as the only non-Olympian in the boat, was the importance of surrounding yourself with exceptional teammates who are at the top of their field (Figure 4).FIGURE 4.: As the only non-Olympian, surround yourself with excellence! Canadian Henley Championships, Summer 1992. Reproduced with permission of Scott Armstrong [Author's photograph].Our honored guest Nick Hopkins epitomizes early assessment of innovation. Nick Hopkins gifted our specialty with novel approaches to complex problems. Not everyone was as eager to embrace endovascular innovations—not even his closest friends. Along with early contributions from other innovators, such as Sean Mullan, Fedor Serbinenko, Guido Guglielmi, and others, we are now able to offer tailored options to our aneurysm patients. It is not about the novelty of innovation, rather the potential to reduce the morbidity of our interventions in our quest for zero: zero complications, zero morbidity, zero iatrogenic mortality. Innovation is not about product creation, but rather, about thinking differently. As Sir William Osler said, “The tragedies of life are largely arterial.”3 A prime example: Neither arterial bypass nor endovascular stenting has proven successful for holobasilar dolichoectatic aneurysms. Innovative thinking requires S-type loonshots where augmented pharmacology may allow for perforator patency and controlled remodeling.2 Who should we observe and who should we treat? Innovative artificial intelligence (AI) algorithms composed of computational flow dynamics, aneurysm genomics and proteomics, novel imaging, and anatomic variability will provide guidance for elective aneurysm treatment. In the operating room, our ways of performing open surgery have also been drastically changing. We can now visualize patient anatomy in real-time with augmented reality, navigate hardware with higher safety, and maximize accuracy with robotics. Does the innovation of robotic and remote control promise a future eliminating health care disparities? Will we be able to remotely offer intricate and complex surgical interventions to all patients located in the farthest reaches of the globe? We must be careful to resist the replacement and outsourcing of what it means to be a clinician surgeon with automation. As described in Dr Phillipp Taussky's article, “Resistance makes us stronger,”4 we can learn much from Toni Nadal, coach and uncle of the 17-time Grand Slam tennis tournament champion Rafael Nadal. 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