German neurosurgeon Dr. Florian Roser is chair of Cleveland Clinic Abu Dhabi’s Neurological Institute, and a professor at Eberhard-Karl’s University of Tübingen, Germany, the Cleveland Clinic Lerner College of Medicine at the Case Western Reserve University in Ohio, USA, and at the Biomedical Engineering Faculty at Khalifa University, Abu Dhabi.
A passionate writer and researcher, he holds the position of Editor-in-Chief at Clinical Neurology and Neurosurgery, and he has written over 100 articles on neurosurgery. He has performed more than 2,500 intracranial surgeries in the UAE, UK, Germany and the US, with his live surgeries regularly broadcast across the world.
He speaks joined the Livehealthy podcast to talk about the benefits of doing brain surgery while the patient is awake, the latest research in dementia prevention, and why robots are helping to make brain surgery more accurate.
What was your first brain surgery like?
Getting to the stage of doing your own surgery is a gradual process. For the first few years you have a mentor to guide you and show you everything that’s involved. After that, taking the responsibility and doing it on your own feels like the natural next step. It doesn’t feel like the first time because you’ve been doing it for years already.
There’s so many steps involved in brain surgery. You need to work out why the patient needs surgery, what type of surgery to do and what position they should be in to allow you to have the best access to the brain. If you don’t follow these steps before picking up the knife, then you’re going to be a bad brain surgeon.
It is an honor to be able to touch, see and work on the brain. It’s amazing that I am allowed to do this.
Are brain conditions hard to diagnose?
If you have a condition in the brain, it’s very hard for you to visualize it because you can’t see it. It’s not like how you immediately know you have a broken bone, or a heart condition. In these cases, even people with no medical knowledge can understand that there’s something wrong.
Brain conditions are very different because often patients have hardly any symptoms. People have benign conditions that just sit there for many, many years, and these can cause problems if you don’t treat them. In these cases we do proactive treatment to avoid something worsening in the future. Our recommendations can sometimes be very difficult for people to accept if they feel totally healthy, their memory is okay, they’re feeling good emotionally and they are competent at decision making.
So, we need to have a very strong relationship with our patients and a lot of trust. They need to know that we don’t have any financial incentives and that we are suggesting what is best for them.
What’s the most interesting brain surgery you’ve done?
It’s not easy to say because every surgery is really beautiful and different. Whether that’s because of the patients age, the texture of the brain or the specific challenges, they’re all unique. The first awake brain surgery we did was very special. When the patient is communicating with you and talking to you while you do surgery on their brain, it’s a very rewarding process.
Some of my patients have kept in touch with me for almost 25 years. Even though I’m working in the UAE, my patients from Germany and the UK still send me follow-up images of their brain because they don’t trust anyone else. We have a very strong bond.
In what instances do you need to be awake for surgery?
We have full control of our functions but language, emotions and memory are things that we cannot control. When we have to work in close proximity to the language area, we offer the patient the chance to be awake because it’s so helpful to be able to talk to a patient and give them tasks. It lets us exactly workout the limits of our working space and it is actually much safer.
The brain looks beautiful, it has different gyri and surfaces, but it doesn’t show us exactly where the functions are. They can move around and some patients have a larger language area. Or, if they speak two or three languages, it can be represented bilaterally in both sides of the brain. We do a test before we begin to help us identify this area.
Unfortunately, the Arabic language is underrepresented in neuroscience. Even though it’s spoken by 700 million people. All the tests are based on English, German or French. But by working with NYU Abu Dhabi, we have established a language test in Arabic. It’s the first one in the world that really gives us an accurate idea about the Arabic language. Because if you just test somebody in English whose mother tongue is Arabic, it doesn’t give you the true picture or the small details we need to know.
Visual recognition tests should also be adjusted to the cultural environment. For instance, if someone comes from a rural mountain area in the UAE, they might not know some of the signs or symbols that are used across the world because they’ve never been exposed to them. For instance a culturally appropriate test might show a picture of a camel instead of a lion.
Is standardized medicine unsuitable for the Middle East?
I think so. That’s why Cleveland Clinic has a unique chance to really ramp up the medicine offered in the Middle East. We have great universities all around us, including NYUAD and Khalifa University, and they are very interested in identifying the gaps that exist in neuroscience. We have the clinical expertise and over the next years we will take our studies up to an international level.
Can you see things like maths or science in the brain?
Yes. We did surgery on a young professor at NYU. She started having headaches and it turned out she had a benign brain tumor. She needed a resection and she volunteered to do it awake because the tumor was in her language, calculation and spatial orientation areas. For somebody who’s a researcher, obviously these areas are very important.
As she had an IQ of more than 130, counting down from 100 was not enough to stimulate her brain. So we had a very in depth discussion in the operating room about her research projects. That was very important to help us really identify the area.
Why are cases of dementia and Alzheimer’s on the rise?
Lifestyle issues and the region’s ageing population are some of the many reasons why there’s a significant increase in dementia in the Middle East. Vascular issues, such as having not enough blood flow to the brain, can be down to genetics.
Females are at a higher risk of several types of dementia because of hormonal system changes that happen throughout their lifetime.
Dementia needs to be diagnosed with in-depth neuropsychological profiling. This allows us to figure out what areas of cognition are really impaired.
Most of the time it’s not a global impairment, just a focal impairment in some areas. Then we do some imaging to see if there’s some shrinking of the brain. We also do functional imaging to record how active certain areas of the brain are in terms of their metabolism. For example, how much glucose that part of the brain is utilizing.
This doesn’t help us with the treatment, but it does help us work out how fast it is progressing. Any treatment is just symptomatic. There’s no cure and there’s no medicine that can slow down dementia. All the medicines that have been released by the pharmacy industry in the United States failed in clinical applications.
Just recently an infusion was released for Alzheimer patients. It was even administered in the UAE. But then the FDA recalled it because it turned out there was no benefit at all. Symptomatic treatment basically means doing brain training. You need to improve your blood flow to the brain and its sensory input. This is a continuous process that the family members have to help with as well. Patients with dementia often get very lethargic. We need to push them to stay proactive.
Does good food and movement help?
There’s a lot of unknowns, but we know that with simple measures you can improve your lifestyle and prolong or slow down the progression of Alzheimers.
The Cleveland Clinic in the United States launched a huge longitudinal study involving 200,000 patients. It took between 10 and 20 years and every patient was routinely tested every six months. They were looking to see if there was any way of identifying neurodegenerative disorders with artificial intelligence software before any symptoms appeared. This is very important because the moment you have a cognitive decline, it’s already late. There’s no regeneration in the brain and the best-case scenario is stopping the progression. But if we could identify signs of dementia 10 years in advance, we could intervene with lifestyle changes and potential medications before the degenerative process happens. They’ve gathered a lot of data and it sounds very promising.
But telling a patient they may develop dementia puts a burden on them. Sometimes with neurodegenerative disorders like dementia, you don’t want to know you have it.
How common are brain tumors?
Fortunately they are rare. Between five and 10 people in 100,000 get a brain tumor. In kids they are unfortunately more frequent, and they grow faster. But everything that is aggressive and fast-growing can be treated with medicine and radiation. That’s the upside.
In children, the more malignant tumors are, the better you can treat them. With adults, we have to distinguish between two different subtypes of tumors: ones that grown within the brain tissue, and ones that grow outside the brain. In the brain there’s no sharp border, so a complete resection is difficult. We try to take out as much as possible, without impacting quality of life or the function of the brain. If somebody’s life expectancy is 10 or 15 years after surgery on a tumor, you don’t want them to be disabled for all of that.
Tumors that sit between the bone and the brain are often benign or slow growing, but they bring completely different challenges. They sit where all the vessels and the cranial nerves are, so we have to try and peel the tumour out around these, which can be even more challenging than cutting one out of the brain.
Thanks to the tools and equipment that we have today, we can really push the limits and get as much tumor out as possible without harming the brain.
The instruments are navigated with a computer. This means that we always know where we are and how deep we can go. Functional mapping lets us work out where the important fiber tracks are running.
We have a special dye that the patient drinks a couple of hours before surgery. That dye accumulates only in the tumor, not in the brain. On our microscope we have a special filter that makes this dye glow. This again helps us to identify the borders of the tumor more accurately.
With all these tools we have, we can really push the limits to do a 98 to 99 percent resection. This means that adjuvant therapies such as chemotherapy or radiation therapy have a much better chance of working too. Because treating 1 percent of cells is much easier than treating 10 percent.
Do mobile phones have any effect?
No, that’s one of those urban legends. There’s very clear data that shows there’s no relationship at all between the use of mobile phones and brain tumours. The frequency and the power of the mobile phone is so low it doesn’t increase the temperature of the brain at all. There’s no way it can affect the brain so it’s totally safe.
Are some nationalities more prone to brain issues?
Yes. The East Asian population has a higher genetic incidence of vascular malformations in the brain at a young age. Unfortunately, those don’t show up unless they have a problem such as a stroke. The local population have a lot of genetic disorders, which can create mostly benign brain tumors in different forms.
What causes damage to the brain?
Whether you are a Nobel Prize winner or you only had a brief education, your brain looks the same. It’s actually fascinating and you can’t see if somebody is intelligent. It’s such a beautiful organ and you have to take good care of it. Alcohol is very, very bad for the brain. Smoking is too because it means your brain doesn’t get enough oxygen. If you don’t take care of your vascular system, the vessels leading towards the brain will narrow. We can see this when we do surgery on unhealthy brains. With your brain you don’t even feel you have a problem until it’s too late and there’s no way of reversing it.