World’s #1 Brain Surgeon: The Truth About Protecting Your Brain After 40

Introduction to Neurosurgery

0:00I'm the guy who does the cases that nobody else wants to do. My sister died of a brain tumor of all things. Yeah, I must have been born for this. Here are some of the first things that Elon said when he first thought about this. He was talking about telepathy. Elon is a visionary. 50 years from now, we probably will find ways to enhance creativity or boost intelligence that make us better humans. So do you think 50 years down the track will all be going into surgery with robots? People have fears that these devices are going in and they're reading our thoughts. That's not true. I think alcohol will be viewed like cigarette smoking in the 60s.

Consciousness and Memory

0:32I don't take a single supplement. Consciousness is more ambitious than memory. I think consciousness is at the other extreme. You may never solve that. Dr. Lawton, if I knew nothing about you, what is it that you can tell me about yourself and your career? Well, I'm president and CEO of Barrow Neurological Institute, which is where we are today. I trained here as a resident, so I spent six years of my training. The core year is right here under Dr. Spetzler.

1:04I went away to San Francisco for 20 years at UCSF trying to be like my mentor, Dr. Spetzler, there. And as you can imagine, it's a long climb from finishing a residency to becoming a leader like that.

Neurosurgery Specialization

1:22But I think I succeeded there. And then when he retired, he recruited me back, and I've been back here for nine years. And I'm a vascular neurosurgeon. I take care of brain aneurysms, malformations in the brain that relate to the blood vessels, and skull-based tumors. So I like to think that I'm the guy who does the cases that nobody else wants to do. So they get sent to places like this. They get sent to surgeons like me.

1:53And, you know, I've always just enjoyed being at that far end of the range, the fall off of the bell curve.

Complex Medical Terms

2:01We're probably going to hear a lot of words today that not a lot of people have heard. So can you explain to me, like I'm a five-year-old, explain to me what your day-to-day looks like and what the most exciting thing is about your profession? Yeah, so my days begin at 5.30. I'm like you. I like to be very meticulous about sleep and exercise. So I get up. I can never count on the day, so I have to get my exercise in first thing out of the gate.

2:32So I get up, exercise for an hour, come in here. I run with my team. It's chief residents, mid-level residents, a lot of students who are learning and shadowing. I spend most of my time in the operating room. I try and do about three cases a day, and I operate three days a week. I have a day for administrative duties and then a day to see patients in the office. So I work through that. And then at the end of the day, I spend it recapping, like we call all of our residents

3:06in and kind of like a huddle at the end of the day, and we review the cases that have been mailed to us for second opinion. We review cases that we have planned for tomorrow to make sure we've thought it through properly. We review game tape, is what we call it, or the video from the cases of that day to see what went right, what went wrong. How can I take a lesson from today's experience and share that with not only the resident who is with me, but the entire 28 residents who are here to learn from us, share that so that

3:41they actually grow and get better faster. And we do that. That leads me to about five o'clock in the day.

Time Management

3:48And then I have a little window of time for all the other stuff, email, doing seven series narrations, doing writing, all the other stuff that needs to get crammed in. So that's a day in the life. There is this theory that some of the most successful people in the world treat themselves as athletes. And I've been watching right now the World Cup, right? Australia just played a couple of days ago and won. And you look at how the coach approaches the team and they go through the analysis.

4:19And what you just said kind of reminds me of that. Yeah. Well, we have this description here called the surgeon athlete or the surgical athlete. And it's very interesting because if you look at how most programs in America select residents for training, they look at GPA, grade point average. They look at board scores. They look at signs or metrics for intelligence, which is great. You know, you have to have smart people to do what we do.

4:49But what we've always believed here, and this goes back to Dr. Spetzler and Dr. Sontag, who trained me, was that you also, surgery is an athletic event. You know, you're standing on your feet, you're concentrating, you're having to train for this incredibly difficult task. And it's physical. You know, you're using your movements and your dexterity. And that's an athletic skill. So part of what we have always believed in is the surgeon athlete prototype or stereotype.

5:23And so we live our lives that way. We train that way. We kind of think that way. The game tape is just a reflection of the surgeon athlete idea.

Brain Computer Interfaces

5:32Today, we're going to be talking a lot about something called brain computer interfaces. And it gets me thinking about robotics and robotic surgery and how much the field has changed in the last 10 to 20 years. But if we kind of take a magic pill and go 50 years down the line, how do you think your profession is going to look like then? Well, we're moving so quickly into robotics. And we're taking these pieces of what we do today and we're roboticizing them.

6:07So when we look around the landscape today, we're seeing the ROSA robot, which is a robot that implants EEG electrodes in patients with epilepsy so that you can map out the seizure focus for a seizing patient. So that's a very nice example of a robot doing some very precision oriented tasks, hitting a specific target without the human dexterity element. Can you go into that?

6:37This is just for me personally, because I'm a neurophysiologist, I've done multiple EEGs in my life. So to hear that there's going to be a robot that's going to be able to do this, can you just explain what that means exactly? Well, first off, I'm not an epilepsy surgeon. So I have people down this corridor here that are the true experts. But in layperson's terms, it's that if you have a patient with epilepsy who's got a seizure focus, you want to know exactly where that focus is so that if you excise or remove that

7:09focus, the patient no longer seizes. And that's the whole mission for us as neurosurgeons is to take that out and stop the seizures. So sometimes it's hard to find the focus because the seizure focus may not look any different on an MRI than the rest of the normal brain around it. So the idea is you want to put in these, they're called stereo electroencephalographic electrodes that go into specific spots. And by kind of triangulating this area of the temporal lobe, let's say, you can map out

7:42exactly where that seizure focus is located by the electrical, abnormal electrical activity. And so getting those electrodes in just the right spot is really what the ROSA robot does. And with that information, you put the leads in, you gather the electrical activity information over a period of days in the monitoring unit, and then that data can then localize where that spot is. And then the surgeons can go back and resect that focus, that spot that's hot, and take

8:15it out. That kind of reminds me of deep brain stimulation for Parkinson's patients, which is going to be phenomenal, I guess. So it's the same thing. So that idea of hitting a specific target, like taking the sphere of your brain and putting it into a coordinate system for DBS, or deep brain stimulation, you're trying to hit the target with the very tip of that electrode so that when you stimulate the subthalamic nucleus or if you stimulate other areas for different pathologies, that changing that electrical activity

8:48is going to get you a change in behavior and a cure for the disease. So do you think 50 years down the track, we'll all be going into surgery with robots? Well, so that's what I worry about because there are things like what I'm describing that can, they're well suited to robotics. So you can have the stereo EEG placement and that's well and good. You can do things like, let's say, mechanical thrombectomy for stroke, which is to take the blood clot out of the artery with a robot that can steer a catheter up to the blockage and pull it out.

9:23Those are simple robots that do very manageable tasks. But to do, let's say, what I do, which is to build a new arterial circulation to sew an artery together, it's much harder to do that. That's a very, today, a very manual task. And that's not close yet. So I'm safe. And I think 50 years from now, we will probably be closer to that. But it's the simpler pieces of neurosurgery that we can use the robot for and the much

9:55harder things, what we call the legacy pieces, that we'll still need a surgeon who can, you know, take out a brain AVM, like a brain arteriovenous malformation is this big tangle in the brain that sits with like maybe 50 different arterial inputs. And you have to go around that and figure it out. And it's hard to imagine a robot who would have that combination of dexterity, judgment, intuition, ability to manage a complication like a ferocious bleeding during the resection.

10:30And it's hard for me to imagine that. But, you know, my interest in robotics is to say, well, I know what I can do. And I'm kind of at the asymptote of what can be done. So I'd like to see like with robotic assistance, what more can I do? Can I push myself beyond? Yeah, I think when I think about it, I think outcome specific, like, you know, in the unlikely unlikely event that something happens during a surgery, like what are the robots going

11:02to do in, you know, to prevent an outcome from occurring. And I think as well with the brain, right, we've already seen robotic surgery taking place, right, whether it's, you know, in different organs in the body. But when it comes to the brain, which is the most vascular organ in the entire body, it's it is very scary. Yeah, well, controlling bleeding is a very, it's a very unique thing. You know, you have a problem where the bleeding takes away visualization. A robot needs perfect, perfectly controlled environments to see, to, to know its environment

11:37and to bring things together or to, to manufacture something. And a bleeding event in an operation is, is very uncontrolled and you lose those conditions that are absolutely essential for a robot to execute. It's kind of like the famous Waymo event where there was so much rain in Phoenix during one event where the, the cars didn't know how to drive the streets because they, they lost their frames of reference. And it's the same like in a surgery during the bleeding event, it would be the analogous thing

12:08where that could destroy a robotic execution. So, um, I feel like, you know, we're, we're inching our way, um, towards a robotic future, but there's this protected, uh, set of cases that are just going to be, um, kind of beyond the pale. Guys, I think we've misunderstood what healthy aging actually is. Most people think it's about living longer. I don't really think that is what it's about. I think it's about protecting the things that give you independence, like your strength, your energy, and your resilience. And those all depend on your mitochondria.

12:39In fact, I think when you look at all the data across all the chronic diseases, the number one thing that they all have in common is mitochondrial dysfunction. And that's why I take Timelines MitoPure. It contains urolithin A, which supports mitochondrial health by helping your body renew and recycle older mitochondria through a process called mitophagy. So for me, I take four of them a day and I usually take this two in the morning and then to mid-afternoon, Timeline's clinically proven formula is now available at a much lower price,

13:09which I'm so happy about. MitoPure now starts at $79 when you go to timeline.com slash neuro. I think this is a really good segue now to get into brain computer interfaces.

Explaining Brain Computer Interfaces

13:20So for somebody who has never heard the term, what is a brain computer interface and what is actually happening when you connect somebody's brain to a machine? So brain computer interface, as the name suggests, is a direct connection between the electrical activity in the brain and a computer that's interpreting, decoding, and then executing on that. In our experience here, and we've worked with Neuralink and other companies who have

13:52state-of-the-art devices, the idea is that you're implanting a device that's able to sense brain activity from particular regions of interest in the brain. As you harvest that electrical activity and decode it, you're able to learn what the brain or the person was intending to do. The brain computer interfaces of today are focused on motor activity, the motor system. So what we read about in the popular press is these patients who are paralyzed, usually from a

14:27cervical spinal cord injury. They can't move their arms or legs. So the purpose of the device is to go into the hand motor cortex, which is one little lobule. Yeah, I can point that out for you. From my early days in neuroscience, I know the motor cortex just sits, I always describe it, over here like a set of headphones. Yes. So, right. So this is the motor strip right here. The hand knob sits right about there. And so we put, with the Neuralink device, for example, we put

15:0064, now 108 electrodes into that one little spot. And then those electrodes are then able to read neural activity at the single neuron level. As you think about moving your hand, we usually put it on the left brain, so it's the right hand. So the thought of moving your right hand, even though you can't because you're paralyzed, that thought generates a signal. And then with the decoding algorithms, the computer then knows, well, the brain was intending to move the hand to the left

15:35or to the right or up or down. And it was intending then to click or double click. And those commands have unique signatures electrically that can then be translated to the computer and drive the cursor. So the amount of cursor control that we've seen in our patients has been extraordinary. They can do word grid at world record speeds. Like I, when I try and compete with Nolan Arbaugh, who is our patient

16:05one. And he was the first patient of Neuralink. Yes. So like he'll do, he'll move the cursor and I'll try and follow him. And it's hard to keep up with him because his, his brain and the synergy with that device is so tight that he's, he equals what, what a normal, fully functioning human, what a surgeon can do. So just so I'm clear as the, does the, does the implant occur on the cortex or are you going deep? These are penetrating electrodes. So we do a burr hole. We excise the dura, which is the covering

16:37that's between the skull and the brain. And then these electrodes are inserted robotically. Again, another application of the robot, because the, the threads are so fine. They're about a 10th of the thickness of a hair. So, um, you, um, have a robot that can load these and implant those in a prescribed area that avoids the arteries, the arterioles. So it's atraumatic and it implants it. So it's a penetrating electrode. It goes three to four millimeters deep. And then, um, in that position, it's right in that,

17:08those layers of the neocortex that are, uh, housing the neurons that are producing these, uh, these signals. Yeah. These algorithms, I think, are getting miscommunicated when it comes to social media. When it comes to Neuralink, um, or these BCI interfaces, what is it something, what is something that you want to clear the air about? Because a lot of people are scared that this is going to be a machine that is going to take over our brain for, for, for, for bad. Yeah. So people have fears that,

17:38um, these devices are going in and they're reading our thoughts. That's not true. Um, they have ideas that these devices can, um, take, uh, physiologic data and it can be used in ways that's manipulative or, uh, violates privacy. And, and that's also really not true. The data that comes from these devices are really, it's a train of spikes. You know, the, the, the mysterious language of the brain is basically just a train of spikes. Every neuron, um, has, uh, an action potential. That's really a, a spike. And

18:13what, um, what makes, um, us able to do all that we do to think, to feel, to create, um, it's how all of these spikes come together in this mysterious language of intelligence or, or, uh, humanity. And, um, these algorithms aren't able to do that. You know, they're, they're able to do very simple tasks of, um, deciding whether, you know, that intended movement was to move a cursor right or left. We're, we're good at those kinds of things that relate to movement, but to get to the point of,

18:46um, understanding, like, what does this person think of me or what emotion did that just, just cross that person's mind? We're not anywhere close to that. Well, you mentioned that this is purely for motor so far. So ALS patients, spinal cord injuries. Do you think there'll be a time where we move into sensory? Yeah. So, um, the, um, the motor ones you mentioned, um, paralysis and ALS, um, uh, and stroke, um, those are the big ones. And then the sensory, uh, prosthetic devices are, are beginning to come

19:20online. They're, they're a lot more challenging. The, um, somatosensory system is, is easier. So, um, giving, um, or gathering data about where you're feeling pressure on a, on a body part, for example, is something that I think, um, we can get to. We, we, there are labs that are getting to that. Um, and, um, that provides some feedback for the, the robotics that are being created, uh, uh, kind of a, a closed loop system. Uh, but things like vision, for example, um, are very

19:50challenging. That, that, um, is a, uh, that, that's a keen interest of Neuralink. It's a keen interest of some other companies. And, um, uh, the idea there is the same device that is sensing these signals for movement can also be implanted in a part of the brain that, um, senses vision. And that's, uh, visual cortex in the back here. And the idea would be when, you know, you, um, captured a light, uh, through a camera, you can then decode the image and, uh, and put it into

20:22the visual cortex in a way that allows a blind person to see. The problem is that, um, the brain is tricky. You know, we think, we think of the brain as a computer and we think that if we can just take a digital image of the world and pixelate it and then, um, stimulate the visual cortex in the same, same way that we should be able to create the image. And we, we found that that's not the case. Yeah. It's, uh, Max Hodak, which I think was the former, uh, one of the founders of Neuralink is actually building that out where he is. I think he's looking at, um, solving for glaucoma and,

20:56and blindness. Uh, but everything you're saying right now, it's exciting. It's actually reminding me of a 1943 paper, um, by Warren McCulloch, the neurophysiologist who really coded what you said, like, um, the algorithm and the mathematical equation to a neuron firing and the first ever, uh, equations to artificial intelligence. That's what got me very excited. And I read that paper back in like probably 2012, really. Uh, it's just so nice to see this all coming into fruition.

21:27Well, the, the, the brain, um, it, um, it, um, it's hierarchical in how it builds information. Like, um, the sensory system, the, the, the Hubble and Weasel experience from, um, I'm sure you've, you've read those classic papers as well. You know, you don't just see things as they are, you know, you, you're, your first order of interpretation are the edges and the, um, angles of an image. And so that's first hierarchy of, of data processing. But then, you know, you start to

21:58put those together with shapes. And by the time you work up these cortical columns of hierarchy is when you finally get to an image that's interpretable. And so, um, this idea of just being able to stimulate a zone and get an image is, is, um, um, I think, um, our overly simplistic way. So I think, um, what we're headed to is that future where we will have visual prosthetics. We, we do have cochlear implants and we do have brainstem auditory evoke implants that, um, reproduce, uh, hearing for the deaf. And, and those things are either here or coming soon,

22:31but it is really much, um, it's challenging our understanding to actually, uh, build that out. So I want to keep talking a bit more about this because, um, I want to know, you mentioned that we probably won't be able to, uh, read your thoughts and communicate telepathically, but when you hear some of the first things that Elon said, um, when he first thought about this, he was talking about telepathy and being able to communicate with just our thoughts alone. So do you think that that's maybe not in the future? Well, I think, um, Elon is, um, a visionary and, um, I think, um, uh, all of us are trying to

23:08see the future and predict it and go to that. It's the Wayne Gretzky escape to where the puck is going. And, um, we all want to get there. There's no question. Um, and, and, uh, um, you know, here we, we've got an effort, which we call my ingenuity, where we're putting together these labs where we focus on exactly this. Um, but, um, it's going to take incremental steps. And I think that the way to get there isn't to think like we go from, um, BCI for the paralyzed ALS patient to reading thoughts. It's, you know, how do we methodically go

23:41down this pathway of getting from one complicated problem to the next, to the next. And eventually, you know, um, 50 years from now, we probably will find ways to, um, enhance creativity or boost intelligence or do things with technology that are going to make us, um, uh, able to interface with our technology, with our devices that make us better humans. But we're a long way from that. I, I, I think most of us struggle to actually see that, um, uh, with any, um, clarity or reality.

24:12Yeah. You're pretty much talking about just a healthy average person going into elective brain surgery just to increase their IQ or intelligence. However, looking into things, you know, from, um, Google deep mind, um, and Dennis, Dennis, Dennis Asabas, who is really trying to look at, you know, proteins and, and misfolding of these proteins to eventually cure diseases. I think that artificial intelligence and artificial general intelligence and BCIs can, uh, can produce a

24:46better world and eradicate many diseases. Absolutely. When I look at neurosurgery today, um, and as chairman of this department, um, you know, I, I have people that do brain tumor work. I have people who do what I do, um, which is aneurysms and other blood vessel malformations. We, we treat spinal disease. We treat, um, epilepsy. Um, those are a very, um, important set of diseases. But, um, when I, when I retire, I think we're going to be treating depression. We're going to be

25:18treating drug addiction. We're going to be treating, um, these psychiatric disorders that are, are, are not even a part of how we do neurosurgery today. And that to me is sort of that next step, um, where we, we can, we can influence these major health problems that affect people. I mean, depression is a great example. You know, as we better understand the circuitry, the neural circuitry of depression, uh, or post-traumatic stress disorder, uh, and we find ways where our technology can impact a person's quality of life and how, uh, they manage their disease,

25:52then that, that, that opens up the floodgates as, as a, as a neurosurgeon. You know, we can, we can now treat patients that we formerly relegated to psychiatry. There's, um, there's a wonderful neurosurgeon who is looking at this, uh, for Alzheimer's disease patients. And, um, he's using, he's using light therapy to go in and eradicate the plaques, uh, you know, the, uh, amyloid beta and tau tangles through light therapy and lasers. And I think that that's a new frontier of Alzheimer's disease. Yeah. Well, I know you're interested in Alzheimer's.

26:26The other thing that really excites me is, um, this low frequency ultrasound and opening up the blood brain barriers. So drugs that we currently have that patients are taking can get in and, um, we can clean up the brain, uh, uh, with this technology as well. So, um, you know, these, these are things again, that like for Alzheimer's, we didn't treat and neurosurgeons don't treat. Um, and now not only are we treating, but neurosurgeons are going to be treating this because, um, they require the kinds of things that we do, which is to, you know, um, target

27:00the brain with low frequency ultrasound or high frequency ultrasound for boolean disorder. Yeah. My only problem with that, and this is, uh, just, you know, coming from, uh, a lifetime of work in this field is we're treating the, not the root cause of the problem, right? So how do we, you know, figure out how to not get the, the amyloid beta buildup in the first place? And that's where we're still, I don't think BCIs or, you know, artificial intelligence yet has figured out. True. I mean, a pound of prevention is an ounce of prevention is worth a pound of cure. And I

27:32think, um, the better we are at prevention, um, um, you're right. We're getting to the root causes. We'll be better off. One thing I've become much more selective about over the years is what I put on my skin, not because I wear a lot of makeup, but because I don't, I want products that make my skin look better, not products that hide it. That's why I've been using OG. Their crystal contour collection is almost 90% skincare ingredients. So instead of feeling like heavy makeup, it feels like skincare that happens to give you beautiful coverage. I especially love that it takes less

28:07than five minutes to get ready. Another crazy thing is that it's 100% organic and certified. I really think you'll appreciate that OG has built a company around this. So if you're ready to raise your beauty standards, OG's got you covered. Go to og.com slash neuro and use code neuro for 20% off. That's O-G-E-E.com slash neuro and enter code neuro to get 20% off. So every one of those threads that you mentioned is thinner than a hair and no human hand puts them in, you've done over 10,000 surgeries in your

28:39career. How do you feel about the robots that are actually putting these in rather than a human putting the BCIs in? I'm fine with it. You know, there are things, there's no question that robots can do better than I can do. And I'm perfectly happy with that reality. You know, for me to pick up 64 of those hairs and put it in just the right spot, I probably couldn't do it as fast or as well as a robot. So,

29:12you know, that's fine. I don't need to compete for everything in neurosurgery. What I like, what I love to do and what I think my gifts are and what I bring to the profession is things like creating a bypass, you know, a patient who has a arterial blockage and I can sew some arteries together in ways that will prevent them from having a stroke. Or if they have a very complicated brain AVM that I can remove and protect them from bleeding events in the future. That's what

29:43the robot is doing for me. I can focus on those things that I do well that the robot can't do at all. And, you know, we're working in partnership that way. One of the most beautiful things to me in neuroscience is neuroplasticity. And I think it's wonderful. I think it can do incredible things in the world. Over 28 months, Nolan's brain learned the device and the device learned his brain. So can you explain clinically what neuroplasticity

30:13is and what physically changed in layman's terms? Yeah, it's interesting. Nolan and I talk about this and also with some of the other patients that we've done. The way we conceive of it is that, you know, they have to think about how they would move their hand to move that cursor on the screen. But after weeks of training, like they go beyond that. They just have this, what you call plasticity or this sort of melding with the technology so that

30:49they're not actually thinking about, oh, I've got to imagine my hand holding that mouse and moving it to the left. It becomes more instinctual. And I think there's, you know, this ability of the technology to sort of differentiate the signal and to be able to know the intent without having the person actually go through that process of thinking about that image. So that's, I think, a version of plasticity that is happening with these devices where, you know, you kind of,

31:20you settle in with it. And you kind of learn what it takes to drive the device or the algorithm. And it becomes more seamless and more intuitive. And I think that's happening. At a neuron level, you know, plasticity is a lot of different things. It's, you know, the frequently firing neurons, they learn to, they develop the additional synaptic connections. They prune their synapses. They have different electrical activities within the dendrites on the neurons. And so there's all that stuff

31:54happening that, again, is below the resolution that we have the ability to know, but is likely happening when they go from like thinking about cursor movements to just like knowing how to get that cursor to move. And what's also particularly fun is to see Alex Conley, our patient number two, who has been a real pioneer with the robotic arm. So the chip, not just driving the cursor, but being attached to a robotic arm. So he, he, he's getting the same kind of vibe with the robotic arm where he

32:28thinks, you know, um, about, uh, grabbing the donut off the table and bringing it to his mouth. He can kind of, um, um, get better with that, with more practice and more familiarity with the, with the algorithm. Speaking of that, I want to, uh, turn the focus now onto you and aneurysms. Um, so you've clipped around five and a half thousand aneurysms. When you look back in your time, do you think that there is one patient story that stands out to you? There isn't one. Um, I mean, there are some very

33:03special ones, but when you've done that many there, um, it's more of a collage. Um, I, uh, I trained here in an era when, um, some of the biggest and hardest aneurysms were treated with a technique called hypothermic circulatory arrest or cardiac standstill. And that's borrowing from the cardiac surgeons where, uh, when you would do open heart surgery and, um, you would do bypass surgery, you would go on a heart, uh, pump. Uh, so you could stop the heart. You could sew on the,

33:34on the heart, um, comfortably in the chest. And then, um, patients would then go off the pump and back onto their native circulation. And that same technology we used back in the early days, um, to treat brain aneurysms. We would actually put people on these heart-lung bypass machines so that we could stop all circulation to the brain. And as you know, um, that's 20 to 25% of the, uh, the blood flow, um, in the body. Um, the brain is exquisitely sensitive to, uh, cessations in blood

34:06flow. So we needed to cool the brain to, uh, 15 degrees Celsius, um, almost like this deep freeze so that their metabolic, the metabolic rate of the brain would drop so low, barely, barely alive. Um, and, and that would increase our time window for tolerance. And so I did 12 of those cases in my early years. Um, some with Dr. Spetzler, some on my own in, in San Francisco. And, and all of those are like these, um, incredibly poignant cases where, you know, you just, you switch the pump off,

34:40you drain the blood from the, from the body and you can see the aneurysm shrivel like a raisin. And all of a sudden you've got this incredibly charged window of time to do this repair. Um, and those are some of the most amazing cases to, uh, to be a part of. Um, I remember when I, when I was learning with Dr. Spetzler, I would watch him and it was one thing, it was harrowing enough. But then when, when I was doing them myself in San Francisco and you have like a room operating room packed of people, and it's not just, um, the anesthesia teams and the cardiac

35:15team and the neuro team, but you'd have, um, all the, uh, curious onlookers who wanted to see this. It was, these were intense operations and, um, um, those are some of the memorable ones, but, but, um, there's so many, I mean, the patients where, you know, you do some fancy bypass to fix a giant aneurysm and you open up the aneurysm sack and you have to take out blood clot or you have to take out coils that are no longer doing their job and all these, they're, they're just, it's just an amazing, uh, collage. When you look at, um, you know, a surgeon goes through their undergraduate

35:50degree, then four years MD, then you've got your residence or internship, residency, fellowship. You think, well, okay, great. If everyone goes through this and what distinguishes the difference between one surgeon from the next, do you think it's the, you know, you mentioned your mentor. Do you think it's, um, somebody who you trained under? Do you think it's natural abilities or do you think it's instinct? I think there's a recipe. There's like a formula that, um, nobody has cracked that. Um, it's funny. We did a, we did a base camp, um, which I know you, you discovered, we, we

36:23called it traits of greatness because we wanted to see, well, what, what is it? You know, how, how, how do you explain how some surgeons go through that extended training period and some turn out to be superstars and some turn out to be average and it's, it's hard to do it. You know, there, there's this formula that's probably a combination of, you know, grit and humility and strategic thinking and, um, on and on, but, but nobody knows what it is. I think, um, at the end of the day, um,

36:54some people want really badly to be, uh, great surgeons. Some people want to just, you know, have a livelihood. And, and, and, uh, I think, um, I would say that, uh, you need mentorship. You need really good training. You need to see these, these hard cases. Uh, you need to learn, um, an awful lot about the management of these problems. But at the end of the day, you know, some people really, um, are ambitious and they, they push themselves harder than the rest. From where I stand in the OR, I think it's also about, um, being calm under pressure,

37:28which is also an athletic ability. And it just reminded me when you were talking, I've had an instance, and this was probably about three years ago now where, uh, I was in a 16 hour surgery. And I remember the neurosurgeon, his phone kept calling. I said, listen, it's your wife. And he's like, just put her on, you know, and we usually do just put her on speaker. His hands were literally is ambidextrous is literally in there like this. And, um, I had her on speaker and she was telling him that she was having a miscarriage and his hands were just in there. And he just, I could just, I thought, oh my gosh, the whole room just went silent. It was,

38:01it was devastating, but he was just the way that he approached that situation with patient first, obviously patient centric first and how he guided the rest of the OR and, you know, how he's going to manage this and his own emotions at the time. I just thought it's just, there's so much more to this game than just the mechanics. It's so true. Being in that hot seat is, um, extraordinarily difficult and you get these curve balls. It could be the wife who's miscarrying like in real time. It could be the AVM that all

38:33of a sudden explodes and there's torrential bleeding with a patient whose pressure is dropping. It could be, um, there's the famous story of, um, a surgeon in San Francisco who, whose son committed suicide and he got the same call right in the middle of a case and the surgeon kept operating. And, um, you know, I mean, there's these incredible stories. And I think that, um, if you were chosen to be an astronaut and you were on your way to the moon on Artemis, whatever, um, yeah, it's, it's how we're,

39:04how we're bred and trained. And, um, we're, we're kind of wired so that we can, um, manage that situation and you don't want, um, your neurosurgeon not to be that way. It's, it's a little bit weird because, um, you know, you, you could say, well, how in, how cold in a human are these people? But, um, at the same time, you know, um, this is, this is what we have to do. This is the task that we've been charged with. And, you know, we, we found ways to, to compartmentalize these things.

39:35Do you think you were born for this? I do. Um, but I didn't know it until really late in college. I was an engineer. I almost went off to a program at one of these, um, investment training programs in New York because they were recruiting engineers. And it was a lot of my friends were doing that and it sounded fun. Um, I wanted to be a heart surgeon when I was in medical school and I got some bad luck, uh, and turned away from a research opportunity. So I, um, my, my story to this has been a series of, um, random events and

40:09I view it as serendipity that led me to what ultimately was perfect for me. You know, I'm, I've been in this career now for 29 years. I love it. I'm not bored. I'm not disinterested. I'm fully engaged. And I don't know of many people who find something in life that they can say has been so consuming and so long lasting, um, that's kept them going. And I, and I have that. So I do feel like, and to answer your question, yeah, I must've been born for this, but, um,

40:40I didn't know it. I didn't know it out of the gate.

Personal Journey to Neurosurgery

40:43Came as a surprise. Yeah. So if you are not having aminos in your life, I don't know what you're doing to protect your muscles because one of the biggest myths in nutrition is that more protein automatically means better results, but it doesn't. What actually matters are the essential amino acids inside that protein. That's why I use Keon aminos. The watermelon is by far my favorite. They've also got a great flavor. I have this during my workout and I also have a scoop during the day because I don't want my muscles to waste away. I use it after training and I use

41:14it honestly on days when I don't eat enough protein or when I'm traveling. So if you want to get your hands on this, go to getkeon.com slashing euro for 20% off. We speak about, um, brain aging on the podcast a lot. You know, a lot of people I would hope, um, are listening to this podcast all because they want to prevent neurodegenerative diseases or slow the aging process of the brain. But what I'm always fascinated by is can you see the difference between an aged brain? I know that we're getting, we can get, um, atrophy of the

41:49gray matter where the brain literally shrinks and we can see white matter hyperintensities on neuroimaging. But can you look at a brain in surgery and say, okay, this brain is 80 years old without knowing the patient's age. And this brain is 25 years old just by looking at the structure of it. You can because, um, brain atrophy is age dependent. And so, um, there is definitely more atrophy, more atrophy in the aging brain. Uh, so we see that and it's actually a real gift

42:20for the neurosurgeon because, um, we work in these little nooks and crannies outside the brain. And so when there's atrophy and, um, the brain shrinks, those spaces get bigger. So we, we always love, um, a little, a slightly atrophic brain, uh, because like, for example, the sylvian fissure, which is that space between the frontal lobe and the temporal lobe where the middle cerebral arteries run, that's our main highway in. And in the, um, atrophic patient, uh, uh, that's, that's a much easier route in. In a 20-year-old, um, when the brain is full and, um, those, those

42:56surfaces are right on top of each other and they're very connected to one another. So getting into that, that, uh, corridor is much more challenging. And, um, so you, you can see that, but, um, you know, if you, if you had two 70-year-old brains that were on the, on my operating room table and one had Alzheimer's and one didn't, you, you can't, there's nothing that you can see that tells you which is which. Like there's not, you don't see amyloid plaques. You don't see tau protein. There's not like a, a color differential or something

43:30that's visible. It's, um, it's just, um, it's at the cellular level with no visual difference. You can't see the amyloid plaque buildup. That would make sense because you can really only see it, you know. Yes. You have to bring it out with a stain, uh, under a microscope in cross-section. You know, it's, it's not something that you can, um, that I as a neurosurgeon can appreciate with the, uh, with a magnified view. So then in your perspective, uh, just

44:01for every, you know, everyday people who are trying to slow the brain aging process, what is it that a neurosurgeon would, would give in terms of advice? Well, I think it boils down to the basics that you know and preach in your, in your work. And it's, um, sleep, exercise, diet, social interaction. Um, I think these are the key things. It's, um, the things that, um, healthy living is really all about. Um, and I also think that there are probably

44:34things that we're doing, um, to ourselves that are, are not helping. Um, like, you know, um, I think alcohol will be viewed, um, in 20 years like we view, um, cigarette smoking in the sixties. You know, we were just really starting to, we're just starting to understand the harmful effects of cigarettes and tobacco in, in the sixties. And, um, and now it's well understood that that's dangerous for your lung health. I think probably the same is coming for alcohol and brain health. I'm going to ask you an off the beaten path question. Um,

45:09I don't know if you've looked into this, but there is a growing, uh, acceptance now of peptides and injections of peptides, you know, to slow the aging process down of the skin. And people aren't really taking these for the brain, but have you heard about these? Yeah. Um, but I, I will say this, um, I, I'm, um, more a believer of, um, uh, of the good living, the clean living and doing the things that, um, enhance your body's natural, um, uh, resources

45:42than I am about supplements or peptides or, uh, injection injectables or those sorts of things. Um, I, I don't take a single supplement. I don't do any of that. Um, but I'm an avid exerciser. Um, I mountain bike, I ski, I run, I do all that stuff. I'm very, um, aware of what I put into my body with my nutrition. I'm religious about getting seven hours of sleep every night. Um, and, and to me, um, those are just like tapping into the body's natural mechanisms,

46:15like, um, the glyphatic system, giving it a chance to do its thing to, you know, make sure you're not ingesting sugary soft drinks or, um, processed meats or all that stuff that's harmful. Um, that, that's been my approach. Yeah. I, I can't tell you the countless questions I get around what are the new, uh, therapeutic devices that we can use or what are the, you know, what are the best supplements or like, what are your opinions on peptides? And I still get questions from people who aren't exercising every single day and who aren't managing all of these lifestyle

46:48factors that have the biggest play for your brain and how you age. So I love that you said that you may be the last generation that operates with open hands. It makes me really sad, um, cause I've spent my entire career honing the craft and pushing it to the absolute highest level. And, um, what I try and do with my, uh, trainees is to see that they need to keep doing that even though they can get discouraged and that, um, they may think that, um, the days are numbered. Um, they still, um, uh, need to learn this micro neurosurgical craft

47:25because, um, when you're operating with a robot and the robot nicks an artery and doesn't know how to deal with that, that, that comes down to us. You know, that means that that particular human surgeon needs to be able to sew an artery together and to repair a problem. And, um, those skills I think are, are timeless and, um, yes, they're, they're vanishing and they're, uh, fewer neurosurgeons who can do what I do. Um, but, um, again, it's goes back to the legacy craft. You know, there's

47:56going to need to be that collection of elites who still know how to do this, who still believe in it, who still write the textbooks, who still teach it, um, who still push their trainees to learn it. Um, that needs to continue to happen. In 2021, when I was, you know, I was obviously, I was living in America. I'd come from Australia and my dream was to work with the greatest neurosurgeons in the world. I came in 2016, but in 2021, I started, uh, going deep on different neurosurgeons on Twitter and I found you. And I thought this is so incredible that this neurosurgeon

48:32is sharing his gift. You were actually like doing live surgeries and recording, which I still don't know how you were doing, by the way, if you're wearing, um, a camera on you, but I thought that this was amazing. I learned so much from you and that's what has inspired me to be here today. Barrows Mind Genuity Labs, which is your own initiative, correct? Um, is built around six mysteries of the mind, movement, emotion, plasticity, intelligence, memory, and consciousness. Which one do you think gets solved first and which one may never be solved?

49:05Uh, they're rank ordered. So I think movement gets solved first and we're solving that with, um, uh, the brain computer interface work. I think consciousness is at the other extreme where, um, we may never solve that. Um, but, um, people probably didn't think that we would, uh, that man would travel to the moon or would travel to Mars. And I think those are going to happen. Uh, they've happened for the moon. They'll probably happen for Mars. And, um, uh, same as, is maybe true for things like, um, like consciousness. We have to shoot for it. And if we,

49:40in the process of getting closer to the goal, we'll learn so much about, uh, how the brain is, is working. Consciousness is becoming a very big topic. I've actually seen, uh, um, another neurosurgeon speaking about this profoundly. He's written a book on consciousness, but for somebody who's actually had live brain tissue in their hands, is this something that lives in the tissue? Yes, it's, well, the tissue, um, is, um, what it is. It's a collection of 86 billion neurons and all these different synapses. And I think consciousness is actually the electrical activity

50:13within that infrastructure. So, um, this organ is an electrical organ. And, um, you know, I think the consciousness, as it turns out, is, is more the electrical activity than it is the neuroanatomy. We, we know the neuroanatomy. People have been looking for this center of consciousness forever. Um, some people think it's in the upper midbrain. Christophe Koch thinks it's in the claustrum, you know, and, and everybody, uh, has failed to really definitively say this is, this is the spot.

50:45They used to think it was in the pineal gland. Um, and, and clearly those things haven't panned out. So my view is that, um, you know, consciousness is sort of the, um, the metaphysical where, you know, this electrical activity that brings all the different neurons in synchrony, uh, through their, um, connectomic firings, through the oscillations that happen through the integration of all of that information, uh, from multiple different systems. That is what is consciousness. And, you know, from where we sit now, just taking one of those networks at a time and trying to

51:18understand them individually to get to that incredible symphony that we're talking about with the electrochemical activity. And that's the journey of mind genuity. Like we have to start at the, um, first few steps and just march our way along. And someday we're going to get there. Is that why you included it? Yeah. As the sixth pillar? It's the aspirational piece. When you think about memory in mind genuity labs, what are we thinking about exactly? We're thinking about structurally like the hippocampus, or are we thinking about how do we not lose our memory as

51:51we get older? All of it. Um, you know, the, um, memory is who we are and it's, it's, um, it's so mysterious how we can remember so vividly these, um, experiences, these events, these, uh, people, uh, songs, um, all of that. And, um, I think memory science, when you really dive in is so crude and, uh, we know the circuitry, we know papes circuit, we know the hippocampus, the fornix, the mammillary, but we, we know all that

52:23anatomy, but to really understand how it is that we're able to remember these things is, is to me, super exciting. I think that's not quite as aspirational as consciousness. I think we can figure this out. Dr. Ponce here has tried, um, uh, stimulating the fornix, like with deep brain stimulator devices that we use for Parkinson's and, uh, that didn't work. Um, but you know, we're on our way to something like that, where as we understand the memory circuitry better and we can influence

52:55the way that emotion and memory and the hippocampus come together to, to supercharge our memory. There's something there that we will be able to, to tap into that will, I think, enhance our memory for some restore memory. Um, but whether it's a device, whether it's a drug, whether it's, um, some cognitive behavioral thing, uh, I think, um, that's what the science needs to focus on and take us to. Why do you think that where that consciousness is more ambitious than memory? I think it's just, um, harder to, harder to unravel. You know, it's, um, you know, there's traveling to

53:32the moon and traveling to Mars, but then there's like traveling at the speed of light. You know, I think consciousness is sort of that level of order of magnitude, more mysterious that, um, will take a lot more work to figure out. It's still so hard to define. Everybody has a different definition. I don't know if you're aware of Dr. Is it Michael Egnor? Yeah. Yes. He's, uh, he speaks a lot about consciousness. Yeah. I mean, we don't even know. I just read, uh, Michael Pollan's book on consciousness and I am obsessed with him. I mean, we don't even know if a plant is conscious.

54:04Exactly. He thinks they are. So like, um, we're, we're so, um, I think in the early stages of understanding even what it means. One of the best health decisions aren't reactive. They're proactive. And most people wait until they don't feel well before they start asking questions. I'd rather ask the questions while I still feel healthy. That's why I am so aggressive with my blood work. If you are not doing blood work, how do you know what's happening under the hood? You don't, even if you feel fine, you should be getting regular blood work. I do this twice a year

54:36and I do this with function health because they give you access to 160 different biomarkers. I think of biomarkers as an early warning system. They tell you where your body is headed before your body starts telling you through symptoms, which is incredibly valuable, right? You can know everything about your long-term health, your brain, your metabolism, because prevention always starts with information. So if you want to check your health the way that I do, you can do this actually for a dollar a day, or you can, you know, get more advanced imaging. If you want, just go to functionhealth.com slash louisernicola. Use code neuro25 as your access code to receive your credit.

55:14So you've seen up close what a failing brain looks like. Back in 2019, my father, he's got AFib and he decided for some reason not to take his medication, his blood pressure medication. He's also had high blood pressure as well. He just thought, oh, you know, why do I need meds? And he ended up having a stroke. It was a right pareto lobe infarct. And I've seen over the last six years, a decline, even in his motor abilities, he's lost function in the lower part of his limb and left arm. And it's

55:49scary as a, as a daughter as well, who's seen so many of these, but it's so different looking at my father. When you look at these people and they're looking at you for advice, what is the one piece of advice that you could give people, parents who've got aging parents and families? It's hard. I think we're all so fragile. I mean, we all have our stories of loved ones close to us who you just can't fathom why these things are happening to them. I, my sister died of a brain

56:23tumor of all things. And, um, you know, your story is, is very moving and, and these things just happen. And, um, I think, um, there are these random events. Um, you know, I think, um, actually Stephen Colbert said it really well when he talked about the death of his father and his brother in a plane crash. It's like, we're, we're here, we're given this gift of life. And when things like that happen, you just have to find a way to absorb it and not, um, let it defeat you. You know, he said

56:53he was thankful for the death of his parents because it was part of what it meant for him to be alive. And I think, um, you know, that's kind of my view. We, we see tragedy. This is a house of tragedy. People don't come to a neurological institute because they want to hang out and be happy. You know, they come here in crisis and we deal with this all the time. We put a good face on it. We give it our best shot. We bring cures to some, um, for those that we can't cure a problem, we try and make it better. And, um, my advice is just to, you know, keep your chin up and you fight as best

57:26you can. Um, you give them the love, the care, the attention, and, um, that's the way life is. I don't know if you get this often, but you are remarkable. That was a, thank you for sharing that story with me. I have one last closing question. Is there a world where a paralyzed person walks out of the hospital where Alzheimer's is a treatable disease and a stroke is an outpatient repair? Absolutely. That's what my ingenuity labs is all about. You know, we, um, we are fueled by

57:59this idea that we are on the cusp of getting to these places that you just mentioned. Like I was an engineer at Brown back in 19, I graduated in 1986. And, um, when I came out, I was thinking, oh, all this technology is going to happen. You know, we connect peripheral nerves to chips and they would control prosthetic limbs. And this was like what drove me into medicine. And it didn't happen. You know, it, it, we went decades before any of this stuff got far enough along. BrainGate

58:30came from Brown and that was in the early 2000s. That's the, one of the very first, um, brain computer interfaces with, uh, a very crude device called the Utah Ray. But here we are, you know, uh, 40 years down from my college graduation and it's finally here. And so like, I feel like we are at the dawn finally after a long waiting period where this stuff is, is starting to take shape. Um, it's being driven by amazing people like Elon and like my partners who are working on this stuff and, um,

59:01the scientists in our laboratories. And I think, um, that day will happen for sure. Um, I wish it would be faster. I'd love to see it. Um, but even if I don't, I know that it's coming. Well, I'm so excited to follow the rest of your career and my genuity labs. And, um, I'm just so thankful to, uh, you giving me this opportunity today. Thank you. Yeah, it was great to meet you. And I love your story about you, um, hunting down neurosurgeons. Yeah. Yeah. They're a good group.

59:31Yeah. Yeah. Yeah. Yeah. Yeah. Yeah. Yeah. Yeah. Yeah. Yeah. Yeah. Yeah. Yeah. Thank you.