Neurosurgery is a relatively young discipline in medicine, one that began with a focus on survival. Today the focus goes beyond survival to restoring personalities, memories, limb function, even the ability to walk. Dr. Ketan Bulsara, chair of our Department of Neurosurgery, joins Dr. Anthony Alessi to discuss restorative neurosurgery, as well as our elite position when it comes to identifying and treating complex brain tumors, and how we are now attracting, training, and producing the next generation of talented neurosurgeons.
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Transcript
Dr. Alessi: Welcome to the Healthy Rounds Podcast, where we provide you with up-to-date and timely medical information from national and international leaders in their fields. This podcast is brought to you by UConn Health, with support from the Department of Orthopaedic Surgery and a grant from Coverys. It is not inclined to direct your personal healthcare, which should only be done by your physician.
I’m your host, Dr. Anthony Alessi, and it’s great to have as my guest today Dr. Ketan Bulsara. Dr. Bulsara is professor and chairman of the Department of Neurosurgery here at UConn Health. Ketan, welcome to the show.
Dr. Bulsara: Tony, thank you for having me on the show.
Dr. Alessi: You know, it’s always a pleasure to chat with you because it always opens new horizons for me, and one of the things I said in the teaser for this program is that people often describe the brain as the new frontier, and I’ve always felt that it’s neurosurgeons who are the new explorers, or even the old explorers, when it comes to the brain. But I really would like to ask you a little bit about your background. You know, we became familiar with each other back when you were at Yale, but if you could, talk a little bit about your training and what it took to get where you are today.
Dr. Bulsara: Well, Tony, thanks a lot. I love the concept of being an explorer, and there’s nothing more exciting than being, on sort of the final frontier in terms of trying to understand the essence of what makes us who we are. And certainly, the brain and spinal cord certainly are integral to that. You know, in terms of my training, I went to medical school at Duke and then stayed there for residency. And when I was at Duke, there was this very pioneering Japanese neurosurgeon who really got me very interested in brain and spine surgery and all the technical nuances.
Interestingly, the man that was named the neurosurgeon of the century had moved from Zurich to Little Rock, Arkansas, and I got to go work with him and some of the other pioneers there. When I finished there and I initially started my practice, I realized that the world was changing very rapidly, and I was at this point where I felt very, very skilled at performing micro-neurosurgery, but the world was changing, and endovascular neurosurgery was really kicking in. So after about a year in practice, a year and a half in practice, I decided to go back and do a fellowship and learn how to do endovascular neurosurgery.
And the plan was always to stay, stay down South, but then, you know, I was attracted to Connecticut because I was given in New Haven the opportunity to build something that would be a legacy, and that sort of has continued in Connecticut with my move to the University of Connecticut about eight years ago.
Dr. Alessi: Now, you’ve talked about interesting how in a field such as neurosurgery and even neurology, things change a great deal. I was with a cardiothoracic surgeon earlier this week chatting, and we talked about how his field has changed dramatically. What are some of the changes we’re starting to see in neurosurgery now? I know you have so much experience with skull base surgery, which is a big part of neurosurgery. What are the hot topics? We just had Chris Connor on the show talking a little bit about stereotactic and functional neurosurgery. Where do you think things are going now?
Dr. Bulsara: Yeah, I think the beauty of neurosurgery in terms of brain and spine is that it’s a profession, that is, an organized profession that is only about 100 years old. And where initially we were focused on survival, we’ve really moved into an age where we’re focused on restorative neurosurgery, restorative for the brain, restorative for the spine. And what that entails is that, whereas before we were measuring our outcomes in terms of survival, we’re now measuring outcomes and our ability to make the person whole again like they were prior to the pathology that afflicted them.
And again, as this has happened, it’s really, really exciting because you have functional neurosurgery like you mentioned, you have vascular neurosurgery, you have endovascular neurosurgery, you have complex spine surgery. You have all these different arenas that are harnessing the advantages of AI, of robotics, and just sort of continuing to push the frontier forward. So I think it’s very exciting. I think for me, what’s most exciting is, is as we’re expanding our department and as we’re recruiting to bring in folks that focus on sort of integrating all of this together, such as in brain-computer interfaces, and that’s an area that’s very, very exciting for me and an area that I think the department is going to start venturing into.
Dr. Alessi: Let’s talk a little bit about being a department chairman. Actually, I didn’t know you weren’t a department when, when I came here, so I’m finding out that it, it recently became a department, but let’s talk a little bit about it. What’s the biggest challenge right now in chairing a department such as neurosurgery here at UConn Health?
Dr. Bulsara: Well, Tony, I was really fortunate that when I started here, Dr. McFadden, my chair of surgery, had always helped me chart out this plan where we would become an independent department, and he gave me the liberty, in many ways, to function as a department, so I’m always grateful to him.
In terms of the challenges, my challenges as a department chair are probably no different than any of the other department chairs. We’re in an era now where our resources across the board, across the country, are limited, and yet we have all these technological advances. And so you’re faced with the situation where you have these limited resources, all these technological advances. You want to have the technological advances ’cause you want to make sure that you provide care to your patients that’s second to none, and you’re shaping the future of care, but it becomes a struggle sometimes in terms of navigating that.
I think the other thing as a department chair is it’s very, very exciting to grow a program, to grow a department, and I think what’s really, really important, especially for neurosurgery as we’re continuing to grow, is that, sort of the, the main ingredient of our success has been the culture that we’ve cultivated within the department, within the context of the institution. And I think maintaining that as we continue to grow is something that I’m, I’m really, really focused on.
Dr. Alessi: What’s recruitment like? I mean, obviously you’re competing for a very limited pool of gifted neurosurgeons. I mean, for example, we have a residency here now in neurosurgery. How many residents do you train in neurosurgery?
Dr. Bulsara: We accept one resident a year. The number of graduates is, as you point out, is very, very small. I think it’s probably about 220 or 230 a year, if I recall correctly.
Dr. Alessi: Nationally?
Dr. Bulsara: Nationally. So the number of graduates, it’s a small number of graduates, but you know, something absolutely amazing has happened at our institution. I remember when I first came here and I was recruiting, we were getting people that were applying for jobs and things to that extent, but now during our recruitment process, maybe it’s because, I know for a fact it’s because of, sort of the reputation that all of us have contributed to for UConn Health and the University of Connecticut, we have had a tremendous number of applications for our open positions.
And so now the onus is to try to screen through those and, try to make sure that the individuals that we bring in will fit into the culture, not only of the department, but also the culture of our university.
Dr. Alessi: One of our challenges in medicine here in the state of Connecticut has been retaining our trainees, right, to go into practice and either stay at our institution or, or another institution in Connecticut rather than go south or go west. Are you seeing a change in that from the neurosurgical standpoint?
Dr. Bulsara: You know, we haven’t had a, neurosurgery, since it’s a seven-year training program, a new residency program, we haven’t seen a graduate yet. However, my general sense is UConn Health and University of Connecticut has become a very desirable place to work, at least that’s the sense that I’m getting. And, and what sort of reinforces that for me is the vast number of applications we’re getting for neurosurgery positions. And I have tremendous trainees right now, and would be happy if all of them or any of them decided to stay with us.
Dr. Alessi: Oh, that would be great.
Dr. Bulsara: So I think it would be tremendous.
Dr. Alessi: Let’s move on. We chatted a little bit about middle meningeal artery occlusions, correct, for chronic subdural hematoma. And it took me a little bit by surprise, ’cause whenever I think of the middle meningeal artery, I think of an epidural hemorrhage and someone dying pretty quickly. So can you talk a little bit about what a chronic subdural hematoma is, and how occluding the middle meningeal artery can help that?
Dr. Bulsara:This is an area of considerable controversy. At least it started off as an area of considerable controversy.
Dr. Alessi: All these things start as controversy, believe me, and that’s why we’re on this podcast, because that’s what we like here. So let’s go with it.
Dr. Bulsara: There you go. So what is a chronic subdural? Well, usually when patients, suffer some form of trauma, they may have an accumulation of blood along the brain, inside the membrane of the brain, and usually it’s not initially causing any significant pressure or anything of significance. Now, there are some subdurals that require emergent evacuation, like the acute subdurals, but what we’re talking about is a chronic subdural.
What happens over time is the body realizes that there’s blood there and it needs to get rid of the blood, and it starts this inflammatory-type response to try to get the blood away, break down the blood products, and things to that extent. It works, probably works more often than not, but in the situations that it doesn’t work, what ends up happening is that very small amount of fluid that you had, as it’s undergoing its changes, increases in volume, and as it increases in volume, it starts to put more pressure on the brain. And as it puts more pressure on the brain, and as the body’s still trying to sort of fight it off, it forms membranes around it. And so the current state of middle meningeal artery embolization is such that if you have a patient who has a subdural hematoma, chronic subdural hematoma, they undergo surgery for it, then if you embolize the middle meningeal artery, embolize meaning you close off the middle meningeal artery, the chance of them recurring is much, much lower.
And the, the etiology behind that is because the membrane is supplied by branches in the middle meningeal artery. So if you shut that down, then you get less of the exudate and things to that extent that contribute to the expansion of the subdural fluid.
So that’s the only sort of group that we have definitive data on. In terms of using middle meningeal artery embolization without surgery, there are ongoing randomized studies to try to determine if there’s a role for that. And I think in very, very, very select patients, you may choose to do that, patients who may have to go on anticoagulation or patients, uh, who may have other sort of issues that may preclude them from being surgical candidates.
We recently published the guidelines from the Society of Neurointerventional Surgeons, and clearly the strongest evidence right now is for patients who have a chronic subdural hematoma have surgery, and following that, they undergo middle meningeal artery embolization, the chance of recurrence of that subdural is much smaller.
Dr. Alessi: So when you mentioned doing the procedure, the embolization, in lieu of surgery, so for example, if you find a chronic subdural and the person is not a surgical candidate, you would go ahead and embolize just to avoid it from getting any larger?
Dr. Bulsara: That is certainly one of the gray areas right now. It’s a gray area because we don’t have any strong randomized evidence to suggest that it works for this patient population. We don’t know for a fact if it’s better than the natural history.
Dr. Alessi: Gotcha.
Dr. Bulsara: And, as you know, if you have a procedure that can be applied relatively easily, the chance is it may be overused if you don’t have strong sort of guidelines in terms of when it should be used. So again, a lot of these patients would benefit just from observation, most likely.
Dr. Alessi: You know, one of our past discussions has been, and it’s probably a whole show in talking about neuro-oncology and talking about brain tumors. Where are we with the status of brain tumors? Have we made progress with the treatment of glioblastoma and glioblastoma multiforme? I mean, it’s just, that’s always been a, a huge issue.
Dr. Bulsara: Glioblastoma multiforme is such a heterogeneous tumor type that we’ve really had trouble identifying specific initiators of the disease process. I’m really excited to say though that we have been on the forefront of the diagnosis and leading to subsequent treatment of glioblastomas, and also all other tumor types in the brain and spine. In collaboration with Dr. Wu from pathology, and Dr. Becker, who’s in my department, who’s a neuro-oncologist, we’ve been able to work with Jackson Labs and become one of four centers in the country that is capable of real-time clinical methylation profiling, which allows for very, very precise diagnoses.
Dr. Alessi: He and I, Dr. Becker and I, recently shared a patient, and it was an eye-opener for me as to what’s available.
In wrapping things up, what’s the next big thing we’re going to hear about in neurosurgery? What do you think?
Dr. Bulsara: Again, I think it focuses on this theme of restorative neurosurgery. It’s absolutely amazing that we’re at a stage, it’s such an exciting time to be involved in the neurosciences, that we can return people’s sort of personalities, we can return their memories, we can do all these sorts of things. We’re at a stage where we can now start thinking about realistically making people who couldn’t walk, walk again, or move their arms, move their arms again. And that’s what I think is the most exciting aspect of the neurosciences in general right now, this restorative neurosurgery.
Dr. Alessi: That’s so great to hear. Ketan, thank you. Thank you for your time today, and more importantly, thanks for everything you do for our community, and being such an essential part of UConn Health. Thank you.
Dr. Bulsara: Tony, thanks a lot. Thanks for the opportunity.
Dr. Alessi: If you have any questions or ideas for future programs, you can reach out to me at healthyrounds@uchc.edu.
Jennifer Walker is executive producer for the Healthy Rounds Podcast, and Chris DeFrancesco is our studio producer here at the podcast. Until next time, this is Dr. Anthony Alessi. Please stay healthy.
