Joey Wahler (Host): It can be lifesaving. So, we're discussing brain surgery. Our guest is Dr. Jeffrey Beecher. He's a neurosurgeon. This is Meaningful Medicine, a Novant Health podcast, bringing you access to leading doctors who answer questions they wish you would ask. From routine care to rare conditions, our physicians offer tips to navigate medical decisions and build a healthier future. Thanks so much for joining us. I'm Joey Wahler. Hi there, Dr. Beecher. Welcome.

Dr. Jeff Beecher: Hi, Joey. Thanks for having me.

Host: Great to have you aboard. We appreciate the time. So first, in a nutshell, what would you say drew you to healthcare initially and specifically neurosurgery?

Dr. Jeff Beecher: Well, interestingly, I really originally wanted to be a psychiatrist. I had a great interest in the brain growing up. I thought I just wanted to kind of help people with their problems. And then, in undergrad, I found out that I was really fascinated with the anatomy of the brain. And my whole mindset shifted towards surgery.

And I just made a decision in college I was going to be a neurosurgeon. So, I went to med school at that point, just planning on it. And my best friend out of med school—actually, I apologized when we graduated and I got my residency saying, "I'm really sorry. I didn't believe you. I just didn't think that could happen." And the rest is history.

Host: And the brain even today—am I right, Doc?—remains something of a mystery to a certain degree, even to experts like yourself, right? So, I guess that makes it fascinating in a way, right?

Dr. Jeff Beecher: Sure. And not everybody's brain's the same. There are some areas of the brain that are very well-mapped, so we do know exactly what their function's going to be pretty much in everybody to some degree. But there's lot of areas that are not well-understood in terms of their function. And so when somebody has a traumatic brain injury or a brain tumor or a stroke, we do get different neurologic findings from time to time that are puzzling, unusual, or circumstantial. And it is a very exciting field for sure.

Host: Even as a lay person myself, you know, I'll have those moments where, on the one hand I can't remember what I had for dinner last night. But then all of a sudden, decades after something happened in my life that may have been relatively insignificant, something triggers that thought to come from wherever the heck it is, that it's buried in that brain, right? It's incredible.

Dr. Jeff Beecher: Our memory circuits are very interesting and very complex. One of the most associated things, this might make sense when you hear it even as a lay person, is the sense of smell with memory. They're very closely connected structurally in the brain and the amygdala, and in the temporal lobes. And so, there's a strong association there, which is pretty interesting.

Host: Sure. So, what are some of the signs of a brain emergency as we switch gears here, like stroke or an aneurysm? Because these are things that naturally can be life-threatening and that people need to seek immediate care for.

Dr. Jeff Beecher: Yeah, absolutely. That's very true. So, a stroke when we're talking about a blockage of a blood vessel that's going to the brain, depriving the brain from the blood-rich oxygen that supplies it and lets it function, that kind of stroke typically presents with whether it's facial droop. So, one side of the face will start drooping. They'll have arm weakness or it'll be dropping or they can't control their arm. Their speech will change, whether it's a garbled speech or words just don't even make sense completely. That's called an aphasia. So, speech is part of it.

And then, time, to your point, time becomes very, very critical for these patients because time is brain. And so, that becomes our mnemonic for identifying a stroke called FAST or nowadays, BE FAST, because balance and eyes also come into play into some stroke findings in a different circulation of the brain that can have more control over those functions.

And so, we certainly stress the BE FAST mnemonic. We want people to understand that these are all stroke-like findings. And this can lead to a patient being diagnosed with a brain tumor as well, because sometimes the pressure on the brain from the tumor being there can cause stroke-like symptoms. So, we'll find different things like that from time to time. But none of those things should ever be downplayed. One of our biggest concerns as healthcare providers in the neuroscience field is, when patients say, "Oh, I got some tingling in my arm. It'll go away," or "My arm feels a little weak. It'll be fine. It'll get better." And they go to sleep, and then they wake up, and now they're having a full blown stroke. And now, they've lost a lot of time. And sometimes that's minutes, sometimes it's hours. And that's a big difference in their outcome.

On the flip side, a brain aneurysm, well, they only present really one of two ways, most commonly. One is if it ruptures. And that is absolutely a medical emergency. And that's usually when we see a patient with a brain aneurysm is because it's bled. And that causes a sudden severe headache, the worst headache of a patient's life. That is almost always how it's described. So when a patient has the worst headache of their life, maybe they're confused or stumbling around or often they'll get nauseous and maybe have some vomiting, and sometimes the patients will pass out. And so, these are all medical emergencies that we need to get them to us as fast as possible.

Host: And just to pick up on that, the importance of speed here, if you will. You're trying to preserve healthy brain tissue. And so, explain to the lay person, please, why is getting that attention and care as soon as possible of the utmost importance here?

Dr. Jeff Beecher: Yeah. So especially with stroke, there's a part of the brain that often is still functioning. It's still getting blood from other networks, but maybe just barely. Or the cells are able to kind of hang on long enough, and they're not actually dead cells yet where a stroke has occurred and it's permanent at that point.

So in that timeframe, when that's occurring, we call that actually a penumbra, the area of brain that's salvageable. And we can identify that with some pretty sophisticated imaging and CAT scans. And when we find patients that are having a stroke and they have a penumbra, all of that tissue often can be saved by a medical intervention, whether it's a clot-busting medication that we give intravenously or through the veins, or if my services are needed, where I have to go through the artery and up into the brain and pull the clot out, whether it's with suction or a device that pulls the clot out. And we often do this through the wrist and we can do it in like under 10 minutes commonly. And we are very efficient at this. So, the biggest delay is often the patient getting to us. Once they're to us, we take over and the stroke protocols here are phenomenal. So, we have great outcomes. We just got to get the patients to us. So, time is absolutely brain.

Host: And so once that happens, once the patient is in your hands and you get to work, be it for a stroke or for an aneurysm, how about being able to use a minimally invasive approach versus when you may need to do open brain surgery? In a nutshell, is there a line that determines whether you go one way or the other?

Dr. Jeff Beecher: So for stroke, it's always minimally invasive. The way we are dealing with a clot going to the brain is always through an artery, through a small puncture, whether it's through the wrist or through the leg when we have to. And we go up to the brain and we fix what we got to fix through the blood vessels in a minimally invasive fashion.

I mean, these patients, when they do like really, really well, they can go from not being able to speak on the table to speaking, because we do this with conscious sedation so the patient's not put to sleep. There's no breathing tube commonly. And so, we can see really dramatic improvement, like instantaneously. And those are just the most fulfilling situations that we have.

When it comes to brain aneurysms, there are minimally invasive ways to treat brain aneurysms, and there are more traditional or standard ways of treating a brain aneurysm. And that's with open microsurgical, open cranial clipping of the aneurysm where we do have to put the patient to sleep with a breathing tube and position them in the OR and make an incision and do what's called a craniotomy to open up the skull to then go underneath the brain to get where aneurysms are. And that's one thing that patients often do not know, is that our blood vessels are actually underneath our brain. They kind of go through it, but in normal planes. We don't have to go through the patients brain to get to an aneurysm. Almost always we can go underneath and that's where the aneurysms are going to be, and that's where we can then put a clip on them to make it so they don't rupture again.

And the line, as you described, really is the safety profile of treating the aneurysm in that minimally invasive fashion. Some aneurysms are a perfect balloon-shaped sac, where if you go up through the artery and you can fill it with coils and not worry about those coils falling out into the normal blood vessel, which would then inevitably cause a stroke. When that happens, we always will go towards the minimally invasive fashion because it's just faster, great outcomes still and less for the patient to go through. That's not always less risky. Some people think minimally invasive means less risk. That's not always the case. If you have an aneurysm that's not shaped appropriately or it's too small and you put a wire or a catheter in it, you could rupture that aneurysm. And that risk of that happening actually goes up with the different smaller, less favorably shaped aneurysms. So, the risk is actually higher to do that rather than the open traditional surgery where we can go down, find the aneurysm and put a clip on the outside to seal it off so blood no longer can get in there. Because the biggest risk with a brain aneurysm is if it rebleeds. And that is when a patient can really have a worse outcome.

Host: How would you, in a nutshell, illustrate just how successful treatment of these conditions is if caught earlier?

Dr. Jeff Beecher: Yeah. Well, with brain aneurysms, I mean, it's like night and day, we do find a brain aneurysm incidentally. So if somebody has headaches, that are more mild, not the worst headache of life, like I described. But if they have an unruptured brain aneurysm, we have a whole armamentarium of endovascular, minimally invasive techniques that can almost treat any brain aneurysm. And now, you don't have to go through a craniotomy and that recovery and just that whole experience and you can have a brain aneurysm treated and go home the next day, often through your wrist. So, it's pretty remarkable if we do find that aneurysm on the early side. With strokes, it's just, again, time is brain. The faster a family member or a patient's able to identify somebody who can call 911, I mean, it's a big difference in that patient's outcome.

Host: Switching gears again here and talking brain tumors. Give us an idea please, Doc, of the latest advanced surgical approaches to treating them.

Dr. Jeff Beecher: There's been a lot of changes in the way we manage a brain tumor, especially the aggressive malignant brain tumors that most people fear, which is called GBM or glioblastoma multiforme, or sometimes people would just say a glioma. And some of the best things that we've had recently come out, this drug that a patient actually can drink before surgery. It's called Gleolan. And when you drink this drug before surgery, it makes it so that your tumor, that tumor will then light up under our microscope under a special blue filter so that we can actually see tumor and brain.

And so, what this has translated to for patients and outcomes and greater success is we're able to perform a more thorough operation. Before this existed, you had to go by what's called navigation. So, everybody has a brain MRI, and we find the tumor. We use that MRI to use basically like GPS of the brain. I could put a little pointer that's sterile on the field on the patients head or inside the cavity of the tumor while I'm operating. And it'll tell me where I am in space relative to the patient's brain. And I can point to this part of the tumor and that part of the tumor, and I can know where I'm at. But as you're operating, things change. The tumor's less there, the brain can become relaxed more. And so, there can be millimeters of shift. And when that happens, you can feel less reliable with that navigation.

And so, with this new medication that we can have the patient drink before, You don't have to rely on that as much. You still absolutely use it every single time. It's great for planning and customizing our approaches. But for the actual resection to say, when we feel like we're done, we can now say, "Hey, look, there's no more fluorescein lighting up." And it's a bright pink, so there's no mistaking it. So, it's really helped our ability to maximally resect the tumor to give the patient the opportunity for the best outcome and recovery. And also, keeping it away as possible. And also, we have what's called brachytherapy. It's a radiation seed that we can implant for specific cases, glioblastoma being one of them. Sometimes on the front end, sometimes if there's a recurrence, that actually gives immediate radiation to the tumor one centimeter deep into the brain beyond what we can see that lights up with the drug that I was referring to or the navigation, because these tumor cells are so infiltrative, they go beyond where the contrast shows it on the MRI. And so, by giving immediate radiation, it gets that patient immediately to the radiation step of their care, instead of having to wait two or three weeks to get radiation after you've had fresh brain surgery, because you don't want to radiate externally a fresh incision and fresh surgery. We got to make sure that wound heals and all those things. So, this is that bridge to get that radiation process already going. So, that's another novel thing that we have here at Novant.

Host: Couple more questions for you. While naturally, Doc, brain surgery cases vary greatly, I'm sure, generally speaking, what does a typical recovery involve? Is there physical rehabilitation included in that?

Dr. Jeff Beecher: Yeah, very much so. Obviously, we hope that our patients, have their surgery recover from their surgery and get some physical therapy while in the hospital, and then get cleared to go home, which is commonly the case. But unfortunately, in our line of work, patients often come to us with neurologic deficits, of course. That's why we're neurosurgeons. And when they have a neurologic deficit, sometimes with surgery, it can get a little worse before it gets better as things start to kind of calm down after a tumor's been removed or the patients recovering from aneurysm surgery, and spine surgery as well.

And it is certainly not uncommon that a patient will require, physical rehabilitation, and rehab stay. And I think our rehab does an excellent job of taking care of these neuro-specific patients, especially stroke patients. I think they really feel a special bond to our stroke population, partially because we just have so many stroke patients. They've almost become like an expert in rehab for stroke. I think it's like 60% of the rehab is stroke patients, because we just are that busy unfortunately with stroke. And so, they have just all the different techniques, modalities, and all the different necessary equipment to help these patients maximize their recovery.

But yeah, after brain surgery, once in a while, patients will need that as well. I would tell you, and what I tell most patients, I have some patients that I call rock stars. And they go home in two to three days after brain surgery. And then, there's the patients that are probably more kind of standard recovery, which is where I think I would probably fall in the five to six days after a pretty complex brain surgery. And then, sometimes we have patients who just need a little bit more time. Sometimes it's pain, sometimes it is a physical limitation, and they need some rehab. But we're fortunate here at New Hanover Regional Medical Center that we have a rehab center on campus, and we maximize our utilization of that when necessary.

Host: In summary here, Doctor, this is what's most fascinating to me about what you do. You often literally have someone's life in your hands. I wonder what that's like? Not just the difference between life and death perhaps, but even if they live, it could be a difference in what kind of quality of life they have to have that kind of responsibility. Can you tell us what that's like?

Dr. Jeff Beecher: It is immense. I have a great deal of respect for that. I think about it all the time. I think about how amazing it is that we are able to help so many people, and that we're given the privilege, and that patients trust us to do what it is that we do. I mean, you know, specifically, there are a few instances where I have performed a few surgeries that just haven't been done anywhere else the way we did it, and with the technology that we use.

Commonly when we are doing our aneurysm surgery, it's the next time in the world it's been performed with that technology all used on an individual at one time. It's pretty remarkable what we're capable of doing and how much we can affect a patient's life. And, it's never lost on me and all my mentors and my partners as well. We always say it's almost a joke in neurosurgery when you lose that. If you lose that, you're done. You should retire. because it's really what draws you to neurosurgery, is the ability to have that much effect on the patient's life quality and just to change the trajectory of how their life's going. Even in spine surgery, when maybe it's not so life and death, it's more quality of life, like you said. I mean, it's still super satisfying to have a patient come in with severe leg pain, to a point where, I mean, they're like, "Cut my leg off." There's nothing that's made it better. And, you know, of course, they're kidding. And you go and you do a pretty small surgery to remove a disc herniation, and they go home the same day with no pain. It is very satisfying. I mean, I really think there's nothing like it.

Host: Yeah. The passion you have for it certainly comes through, and we're certainly all very fortunate that there are people like you that have made this their life's work. Well, folks, we trust you are now more familiar with brain surgery. Such a fascinating topic. We could talk about it forever. Dr. Beecher, keep up all your great work. I hope we can do it again and thanks so much again.

Dr. Jeff Beecher: Thank you.

Host: Absolutely. And to find a physician, please do visit novanthealth.org. For more health and wellness information from our experts, please visit healthyheadlines.org. If you found this podcast helpful, please do share it on your social media. I'm Joey Wahler. And thanks so much again for being part of Meaningful Medicine, a Novant Health Podcast.