Chairman's Corner

Stem Cells

It’s been a little over a year since our findings from the Phase 1/2a study testing the safety of transplanted modified stem cells in patients with chronic stroke, were published. Those results stunned many of us in the neuroscience community, myself included. The goal of the trial was to assess the safety and feasibility of such a procedure. We didn’t expect to see functional recovery, certainly not in patients who suffered a stroke more than 6 months prior to the trial, and whom we presumed would never regain the abilities they lost to stroke. Nevertheless, the hype around the trial and the use of stem cell therapy has not subsided. Over the past year I’ve continued to receive invitations to present the findings at scientific conferences, and am contacted regularly by national and international media outlets requesting interviews about the trial’s results.

The hype is understandable; the results completely changed our notions about what happens to the neural circuits after stroke – we now know that these circuits can be resurrected in some patients, even years after a stroke. One patient, Sonia Olea Coontz, could barely move her right arm, could walk only with great effort, and her speech was difficult to understand when I first met her. She also refused to go through with her upcoming wedding, too embarrassed about her gait to walk down the aisle. When I came by her hospital room the day after she was treated with the stem cells, she could lift her arm above her head, and her speech had vastly improved. Now, more than  4 1/2 years out, Sonia’s functional recovery is sustained. After the trial, she walked down the aisle, and in 2016 she gave birth to her first child. The trial changed Sonia’s life, and the hype that continues to surround the trial is one born out of hope that this therapy may do the same for many more stroke sufferers. But there are serious risks to overpromising the results of the trial, and it’s important to remember that Sonia is just one of over 7 million people who currently live with severe disability from stroke  in the U.S.

The trial was small, only 18 patients were treated, and so many unanswered questions remain: What types of stem cells are most effective? What is the best mode for delivery of the cells? Why did someone like Sonia experience such remarkable improvements, while others less so? Is it best to transplant the cells shortly after stroke or should we wait several years? I suspect that as we continue to test this therapy we will continue to face only more questions. And while I am pleased about the results of this early phase trial, I continue to approach each subsequent phase with appropriate caution.  

I have spent my entire career focusing on the translation of science into medicine, and I am aware the process is long and arduous, and often filled with bumps along the road. We are not pursuing a quick fix. The goal of these trials is to find a safe and effective treatment that will reverse the damage caused by stroke for the long haul. Meeting that goal will take time, and we can’t let the excitement render us careless. We have already seen too many cases where the promise of stem cell therapies sold to desperate patients ruined lives, instead of improving them. This past year alone, we witnessed numerous scientific reports about patients paying thousands of dollars to clinics touting unproven treatments; the most recent of which left three women in Florida blind, after stem cells were injected into their eyes to treat macular degeneration. These unproven therapies can be quite dangerous, and it’s our responsibility as scientists and physicians, to set realistic expectations, and to proceed with care.

We are moving forward with the second phase of the trial, which unlike the first phase, is far larger – we’ve enrolled 156 chronic stroke patients - and involves multiple centers. If the current trial confirms the safety and efficacy of the first phase, then we’ll move onto the third and final phase 3 larger randomized, blinded, controlled trial. And, if we find positive results in the final phase, then I hope to see FDA approval and commercialization of stem cell therapy for chronic stroke victims. At that point we will likely want to try to apply the success of the therapy to other patients suffering loss of neurologic function from other neurologic disorders like traumatic brain and spinal cord injuries as well as degenerative diseases such as ALS (Lou Gehrig’s Disease) and Parkinson’s Disease. It’s difficult not to get excited about the future of stem cell therapies, but for now, I remind myself to remain cautiously optimistic, and to take each step at a time.

Technology and Innovation

As neurosurgeons, our aim is to continually search for, and find, technology and tools that will make our diagnostics and operations quicker, less-invasive, safer, and more effective for our patients. We are incredibly fortunate at Stanford to be located in the heart of Silicon Valley, where technological innovation surrounds us, compels us to keep searching, and provides us with so many opportunities to try new tools that will help us achieve our goals. From rapid improvement in imaging and the integration of robotics in the operating room, to the development of implantable devices and brain-computer interface, I see indications that the future is already here.

Our diverse team of surgeons and scientists are at the forefront of developing and implementing these new technologies. Our spine surgeons, such as Dr. Atman Desai and Dr. Anand Veeravagu are now using robots in the operating room to fix spinal deformities and remove tumors. Just last month, neurosurgeon, Dr. Casey Halpern, was the first to perform robotic-assisted surgery to treat epilepsy. In many cases the robots can see what the human eye cannot, and can place surgical tools more safely and accurately. Surgery times  are now shorter, less invasive, and lead to quicker recovery and less pain. 

One of the technological advances I’m most excited about has been the integration of virtual reality in neurosurgery. We are now using patient-specific, 3-D virtual reality to train students, educate patients, prepare for operations, enhance visualization during surgery, and assess effectiveness of treatment post-surgery. The use of virtual reality allows us, for the first time, to see in 3-D, parts of the anatomy we could previously only imagine. Whether presented to the patient, the patient’s family, the surgeon, or trainees, 360VR offers a way of communicating with what seems to be a universal language - adept at quickly conveying complex, context-specific spatial information, bridging the gaps between technology, patient, and physician. Another use of VR, the EyeSync, developed by neurosurgeon, Dr. Jamshid Ghajar, is helping sports medicine professionals determine if an athlete needs to be removed from play in less than a minute. This new technology is significantly advancing diagnosis of concussion, an injury that has been plaguing the worlds of football and other contact sports.  

We are also re-thinking our approach to treating paralysis and disability, embracing the use of computers and implantable devices to help us restore abilities to those who thought they’d never be able to speak or see again. Neurosurgeon, Dr. Jaimie Henderson, is leading an effort using brain-computer interface to allow people to communicate – people can now command a computer to type for them, only using their minds. Dr. E.J. Chichilnisky, professor of neurosurgery, is also using the idea of interface between an electronic device and the brain to produce a bionic eye that will allow the blind to see again.

This is an incredibly exciting time to be in this field and to watch these technologies transform the way we do our work. From the future implementation of augmented reality in the operating room, to the possibility of performing operations remotely, I’m eager to see how these technologies will continue to transform diagnosis and treatment in neurosurgery.

Women of Stanford Neurosurgery

There was only one woman faculty neurosurgeon working in Stanford’s Neurosurgery department when I joined the department in 1987. 30 years later our department has grown to include 6 practicing female neurosurgeons and another 12 women faculty scientists. If that progression seems very slow, that’s because it is. And yet, despite the crawling pace, with nearly 25% women faculty clinicians and researchers, ours is still one of the nation’s leading departments in terms of gender diversity. While I’m very proud that our percentages are high, relatively speaking, it’s clear that we’re a long way away from parity.

Talking about gender equity can sometimes be uncomfortable – for those of us who fall into the majority and can only digest the experiences of those in the minority second-hand, and for those in the minority who may not be sure how to get their voices heard without stigma or fear of repercussion. But talking openly about these issues is critical to fixing them. As a white male, it takes conscious recognition and correction, and repeated self-reminders, that my experiences are vastly different from those of women and underrepresented minorities; and while I’m hoping that within my lifetime we can refer to all physicians, surgeons, and scientists without having to insert a qualifier, the reality is that we need to continue to talk publicly about the barriers to parity, so that we can more quickly achieve it. On that note, while it’s important that someone like me recognize the lack of gender and ethnic diversity in our field, it is equally important to give voice to the people who are at the brunt of breaking down those barriers. As part of shedding light on some of the experiences and perspectives that I cannot personally, we are launching a new series highlighting the experiences of the women of Stanford Neurosurgery. From who and what inspired them to pursue science and medicine when they were young, to the methods they each developed to persevere, despite the push-backs they received when entering the field, “Women of Stanford Neurosurgery” is just one avenue to give voice to those things that we don’t always feel comfortable talking about, but must. While the women highlighted in the series have had different life experiences and come from different backgrounds, the stories of their journey into a field so heavily dominated by males tend to be universal.

I do feel it’s incumbent upon us men, to listen to these stories, and to move forward with conscious recognition of the obstacles women face in our field. I don’t want to give the wrong impression – I have not spent my life fighting for women’s rights, and when I’ve hired women to our department or promoted them within, it was not because they were women, it was because they were the best possible candidates. However, I do believe that to affect lasting change both men and women have important roles to play – on the part of men, we must push ourselves to more consciously recognize the types of experiences our women colleagues face that are often manifested in subtle and unconscious sexism. We understand, as a matter of fact, that women are as equally capable of achieving success in science and medicine, as men are. Yet, women still make up just a tiny percentage of many programs, and even less so when thinking about women in leadership positions. There are numerous reasons for this, and we know the pipeline is no longer the main culprit we once thought it was. Things are changing, but the change is extremely slow, and in the meantime, we all lose out on the best and brightest entering and excelling in our field.

I hope this series will in the least, shed light on what it took these individuals to get to where they are today, and at most, foster the kinds of conversations that lead to actions that bring about concrete change. Expanding diversity across science and medicine will be a win for us all. 

Congratulations to Our Residents

Becoming a neurosurgeon is a long and difficult journey. Residency, particularly at Stanford, where expectations are high, can be grueling. Our program only accepts three new residents each year. For those chosen, the 7-year process is challenging, but hopefully it’s also fulfilling, engaging, and formative.

This summer, we are proud to announce our chief residents, Henry Jung and Maziyar A. Kalani, have successfully completed our residency training program. Henry has come a long way from his upbringing in rural Indiana, where he spent his time chasing wild animals and fishing. His interests have centered on neuroengineering – using brain-machine interface and scientific computing to advance treatments for neurological disease and injury. He is starting his neurosurgical practice at Kaiser, Sunset Los Angeles.  Maziyar, who grew up in California, has an older sibling who is also a neurosurgery resident. His  interests have focused on spine surgery and opportunities to improve the value for outpatient surgical care. He will be completing a complex spine surgery fellowship at Cleveland Clinic over the next year and then pursuing an academic faculty position. I am incredibly proud of Henry and Maziyar and what they’ve accomplished over the past 7 years, and know they will represent our training program well wherever their future work leads them.

As we say goodbye to our chief residents, we are also thrilled to welcome our interns – our new first-year residents. Drs. David Dadey,  Michael Jensen, and David Purger. All three have already accomplished much in their academic careers - they all hold MDs and PhDs from reputable institutions - each with their own unique life experiences and perspectives, and a passion for medicine, patient care, and scientific research. We are certain they have a bright future at Stanford and welcome them to our program. 

Moyamoya Disease

It’s been nearly three decades since I began performing surgical revascularization to treat Moyamoya Disease. In 1991, when we first offered the surgery, we didn’t know much about the disease. We didn’t yet realize its genetic links, its connection to other rare disorders, or the psychological impact of its symptoms on patients. We did know that the TIAs, strokes, and seizures associated with Moyamoya would continue without surgery, and unfortunately, 26 years later, this is still the case – there is still no cure for the progressive and rare disease.

At first, what was particularly troubling to me was seeing young children affected by Moyamoya, the disease was impacting their cognitive abilities during a critical time of development. We needed to come up with viable surgical solutions to treat small kids, sometimes just toddlers. Over time, we managed to greatly improve treatment, reducing surgery times, refining techniques, and enhancing anesthesia administration.  But, after thousands of these surgeries and greatly improved outcomes, I still don’t have all the answers I’ve been searching for.

How can we diagnose the disease before symptoms appear? Are there other types of procedures that we haven’t tried that would be more effective or less invasive? When is the best time for surgery? Are there non-surgical solutions we can develop? What are the long-term outcomes – will patients remain symptom free for the rest of their lives? What effect does the environment have on disease development? What can our genes tell us about the disease?

As with any intellectual pursuit, the more I’ve learned about Moyamoya, the more questions I have. I’ve spent quite a bit of time both in the lab and in the clinic trying to find answers. We did recently discover that outcomes improved when we delayed surgery for a few weeks following a stroke, so we have adjusted our treatment protocols accordingly. We’ve also begun developing a new laparoscopic approach, transposing the omentum (the fatty tissue in the lower abdomen) to the brain, when prior revascularization has failed. This novel approach substantially decreases recovery time and reduces the risk of complications compared with a laparotomy. We’re also spending a significant amount of time in the lab trying to identify genetic markers for Moyamoya, in hopes that these findings could lead to genetic screening of the disease or potentially to gene-based treatments.

When I first learned about Moyamoya, my focus was on perfecting surgical revascularization, to ensure that the options we were giving patients had merit and could halt symptoms immediately. Today, my focus is on understanding causation and tackling the disease on a genetic level – I want to stop the disease before it has had a chance to develop. Experience and time do matter, all these years later, and thousands of lives saved or improved, we’ve gained an enormous amount of knowledge for better detection and treatment. Public awareness about Moyamoya has also grown tremendously, in fact, just this month, California became the 5th state to recognize an official Moyamoya Disease Awareness Day. In the decades to come, my hope is that our understanding of Moyamoya continues to expand, so that one day we may be rid of the disease, long before one must suffer its consequences.

AANS 2017 Annual Scientific Meeting

This past week I attended the 85th Annual AANS Scientific Meeting in Los Angeles. I wanted to mention this because I think it’s of great significance whenever the top minds in my field take the time out to gather and re-connect. Many of us dedicated almost an entire week to meeting, presenting, learning, and discovering. What makes this annual gathering unique, is that it focuses specifically on neurological surgery, and that the attendees range from first year residents to neurosurgery’s long-time and foremost experts.

By bringing together neurosurgeons at all levels, from around the world, this annual meeting provides the perfect opportunity for us to reflect on our accomplishments in the year since we last met, share and discuss the latest research we’re excited about, and inspire the newest generation of neurosurgeons. It also provides a new and different platform for many of us to learn and teach new approaches and refined techniques.

This year’s meeting theme was “A World of Innovation,” an apt theme considering the advances rapidly being made in neurosurgery around the planet. From stem cell therapy, brain mapping, and devices, to virtual reality and robotics, these advances are quickly changing our perceptions of what is possible.

I was fortunate to have the opportunity to re-connect with old colleagues and to meet those just entering the field, and to take home new information that will help to advance research and clinical care, back here at Stanford. I look forward to seeing everyone again at next year’s AANS Annual Scientific Meeting.

Brain Injury Awareness Month

It wasn’t lost on me when I heard that Dwight Clark, the famed former 49ers’ wide receiver, announced publicly that he had ALS, that the announcement also took place during Brain Injury Awareness Month. Hearing about an ALS diagnosis is deeply saddening, it is a devastating disease, but it did not surprise me to hear that Clark himself acknowledged the development of the disease was most likely linked to his years playing Football. In 1999, after several concussions sent then 49ers star quarterback, Steve Young, to my office for a series of neurological exams, my recommendation that Young retire from football to save his brain health was considered quite controversial.

At the time, many were reluctant to acknowledge the strong connections between head trauma acquired during sport and the development of brain disease. Today, the NFL publicly recognizes that head trauma is much more serious than previously believed, and the public is far more educated about the risks associated with concussions. Despite the progress made, there is still much we need to learn about concussions and brain injury. This is an area of research not only football players should be concerned with; nearly 2 million people suffer a brain injury in the United States every year, most of which are caused by auto and motorcycle accidents, falls, and violent assaults.

The effects of brain injury can be overwhelming; disability, increased aggression, anxiety and depression, or loss of memory or functionality are all common. Many of these symptoms can linger for months, and sometimes years after injury. At Stanford, we have focused our efforts on research that will help us better understand everything from mild concussion to severe injury, to more quickly identify symptoms and improve outcomes.

At our Concussion and Brain Performance Center, our physicians and surgeons including Jam Ghajar, MD, PhD and Gerry Grant, MD are developing a much-needed new brain trauma classification system that will help standardize definitions of concussions, and aid in developing more effective diagnosis and treatment. At the VAPAHS, Stanford neurosurgeons such as Odette Harris, MD, MPH are working with veterans to advance our understanding of how neurosurgical intervention after brain injury can help repair damage and restore function. In addition, our doctors have studied how traumatic brain injury (TBI) specifically affects women. There has been a notable research gap, with much of the studies on TBI focused on men. Having already identified significant ways these types of “invisible injuries” affect men and women’s brains differently, we tailored treatment and policy recommendations specifically for women veterans.

We are currently studying the process of neurogenesis, in hopes we might one day manipulate the process, and repair damage to the brain once thought irreparable. Additionally, we are testing the safety and efficacy of stem cell therapy in increasing mobility for people rendered disabled from traumatic brain injury. Soon, we will be evaluating the use of deep brain stimulation as a potential treatment for TBI.

Those of us who have been studying the neurosciences for decades have been aware of the many connections that exist between head trauma and its long-term implications to brain health. I applaud sports organizations for publicly recognizing the seriousness of concussions, and players themselves talking about the sport and its connection to their brain health, or in some cases donating their brain to scientific investigation. I am encouraged by the military’s commitment to investment into neuroscience research and development of diagnostics and novel therapies. I am hopeful when I see public awareness growing, with the creation of Brain Injury Awareness Month or individuals raising funds for additional research. Football has positive aspects related to participation in a team sport and isn’t going away any time soon, and we certainly can’t eliminate accidents, but the efforts to focus on better understanding and treating brain injury will lead to improved therapeutic options for all of us; athletes, veterans,  you and me.  

Research Matters

Most people rarely consider the impact of disease or injury until they face the unfortunate circumstance of having to seek treatment for themselves or a loved one. By the time someone finds themselves in this predicament, they are hopeful that research and experimentation were long-ago completed, and therapies have been technically perfected and proven effective. The reality is that the journey from basic science research in the lab to its translation into clinical application, can be a long and drawn out process.

Luckily, we scientist-clinicians are aware that the long-awaited discovery we seek will take time and effort, and are motivated by the process. We’ve spent much of our life learning basic science, dedicating years to research, and testing potentially-life saving therapies in clinical trials; all so that one day, when a patient walks into our office seeking that perfected treatment, we’re able to offer it. That laboratory-clinic connection is the foundation to everything we do, and we are keenly aware of the need to focus much of our energies on that less recognized part of our field – the years in the research lab.

Those years spent in the lab can be difficult. Aside from the fact that most research scientists don’t receive the public recognition they probably deserve, finding therapies and cures can take decades, and can sometimes remain elusive beyond a lifetime. As research scientists, we must also learn one of life’s greatest lessons early – repeated failure is necessary, it allows us to learn and grow, and improve. Toiling in the lab is not without some obvious upsides. Discoveries in the lab, when translated to clinical application, can give someone a second chance at life, or at a minimum, teach us something new about the way our body functions that we didn’t know before.

I feel quite fortunate to be in a place where so many people deeply understand the importance of research, and have been extremely proud when those efforts are rewarded with the discovery of new diagnosis and therapy options.

In a very short time, our labs at Stanford alone have made discoveries that will change the way injury and disease are treated in the future. From testing the effects of hypothermia on protecting the brain from damage caused by stroke, to inventing the CyberKnife radiosurgery system for treating brain tumors and other neurologic disorders, to using stem cell transplantation to restore function after neurologic injury, it is incredibly exciting and fulfilling to see how far we have come in just a matter of decades. We are testing the efficacy of using new brain-computer interface technology to allow paralyzed people to communicate, and have successfully shown how using awake brain mapping techniques helps to retain language skills during tumor resection. We study the impacts of genetic changes on conditions like autism so that we can one day prevent its occurrence, and have proven the efficacy of using MRI-guided ultrasound to reduce the severity of chronic tremors. We support over 30 active labs investigating everything from brain injury, degenerative spinal conditions, and deep brain stimulation, to the retina’s role in vision loss, epilepsy, brain tumors, and the effects of stress and aging on the nervous system. My own lab focuses on investigating the pathophysiology and treatment of acute stroke, as well as methods to restore function after chronic stroke. The work my colleagues  achieve in our labs fills me with hope for the future.

While most people tend to consider just the outcome, we scientists are always considering the journey – what basic science understanding are we still lacking that may help us on the road to discovery; what questions must be answered to find better, less invasive modes of diagnosis; and what steps must we still take to find new therapies and cures? The journey can be long and arduous, but in many cases, that journey is what got us hooked on science, and what ultimately allows us to find answers that heal.

Reflection And Gratitude As We Move Into The New Year

As we usher in the New Year, I have spent the last few weeks also reflecting on all of the incredible accomplishments and lessons we learned in 2016.

Our tireless commitment to improve care and outcomes for our patients continued to drive innovation in 2016. We were proud to announce the pioneering of new techniques in stem cell transplantation, innovative treatments for spinal cord injuries, the use of technology to create new means for brain-computer communication, technology that makes brain surgery more safe, and improving our understanding of causes and potential cures for Parkinson's disease.

I was also reminded of the amazing people we serve-patients who despite immense health challenges, fight not only for their own healing and regained strength, but for others like them. For example, 12-year-old Kendall Kemm, who after successful Cyberknife treatment at Stanford for a hemorrhagic stroke caused by a rare defect called AVM, decided to form Kendall's Crusade-a nonprofit aimed to provide financial assistance to families affected by AVM, raise overall awareness of the condition, and support neurosurgery research.

I am also incredibly proud of the many talented and compassionate physicians on our team, whose work continues to make us a world leader. In fact, I'd like to give a special recognition to our own Dr. Laurence Katznelson, Professor of Neurosurgery and Endocrinology. Helping us kick off the New Year right, Dr. Katznelson was selected by the Endocrine Society for their 2017 Outstanding Educator Award which recognizes exceptional achievement as an educator in the discipline of endocrinology and metabolism. Congratulations, Dr. Katznelson!

I was especially excited to share the news this past Fall, of the opening of the Stanford Neurosciences Health Center, a one-of-its-kind outpatient facility that brings together 21 neuroscience sub-specialties all under one roof. The new Center offers patients a unique experience, providing the convenience of one location for all of their diagnostic and treatment needs.

Finally, I was also humbled and thankful to be honored this past year with the prestigious J.E. Wallace Sterling Lifetime Achievement Award in Medicine from the Stanford Medicine Alumni Association. I have dedicated my life's work to advancing science and medicine in Neurosurgery, and was very touched by this recognition.

I continue to be inspired by the community of people I work with every day; our brave patients, committed and passionate surgeons, caring and experienced nurses, innovative researchers, dedicated donors, and visionary students. As we continue together to seek new ways to translate discoveries in our labs into new therapies for our patients, I’d like to wish all of you a happy and healthy New Year, filled with many new achievements in 2017.