Origins of Endovascular Neurosurgery: How I Did It. . . Why I Did It. . .

I want to sincerely thank the organizers of the 2023 Congress of Neurological Surgeons (CNS) Annual Meeting. This is the greatest honor that one could ever have, and I am so pleased to accept it on behalf of my family, friends, and associates. At the core of this CNS Annual Meeting stands a remarkable leader, Elad Levy. His exceptional drive, organizational skills, and charismatic personality have made him a great leader in the CNS, much like he has been in the Department of Neurosurgery at the University at Buffalo. He has made it one of the best departments in the country, and so I just want to say congratulations, Elad. CAREER PATH AND THE POWER OF NO The idea behind this lecture, in my view, is not to talk about neurosurgery but to talk more about what shaped my career, what made me go forward, what made me do what I did in my career—which is a little unusual—and why did I do it? Personality types are interesting. I was a fairly mild kid when I was growing up, but one thing that got me motivated was when somebody said "No" to me for no apparent good reason in my mind. That was a major stimulus throughout my career. My crazy path started with college. I was a high school hockey jock and was recruited to Dartmouth, but I got right to the doorstep and then was rejected, so I ended up going to Rutgers University. This was one of the best things that ever happened to me because it prevented me from solely fixating on hockey during college. In fact, when my dad dropped me off at college, he said "Here's my advice—don't let your studies interfere with your college education. " Well, I didn't, and, as a result, I was a terrible student in college. My medical school advisor, who I will never forget, told me repeatedly, "You will never go to medical school; you're not smart enough!" In the end, he was nearly right. I applied to 26 medical schools, and I was rejected 26 times. Even so, I knew I wanted to practice medicine, and a friend helped me get an interview at Albany Medical College. This was an incredibly strong lesson for me and, I think, for all of you: don't take "no" for an answer if you think you can do something. I was told I'd never get into medical school, but fortunately, Albany Medical College accepted me. I worked hard in medical school, graduated near the top of my class, and, just a few years ago, they made me a distinguished alumnus. That is a great example, in my mind, of why "no" is a word you should never accept. C. S. Lewis once said, "You can't go against the grain of the universe and not expect to get splinters" (https: //www. relicsworld. com/c-s-lewis/you-cant-go-against-the-grain-of-the-universe-and-not-author-c-s-lewis), and I've got a whole boatload of them from all the crazy things that have occurred in my life. I went to Case Western Reserve for my General Surgery training, and I loved it, but my wife, Bonnie, and I had 3 children in 2 1/2 years, and we decided we needed babysitters back home, so we came back to train in Neurosurgery in a really small program in Buffalo that was unknown but with some really good people. I had an academic interest from the beginning, so I also published my results. When I went to CNS meetings, I didn't know anybody, but I would volunteer for everything, and eventually, someone gave me an opportunity and put me on the executive committee, fostering valuable friendships and influencing a significant aspect of my life. A memorable moment during a bike trip in New Zealand with Robert and Nancy Spetzler, captured by Bonnie (Figure 1), epitomizes my life. I looked down and said, "That is so gorgeous down there; I've got to walk back and see it. " Of course, there's the sign saying "No, you can't go this way, " and everybody's yelling at me "No, no, no! You're not supposed to do that!" but that was just me. I had to see it. The word "No" consistently acted as a stimulus throughout my crazy career path. FIGURE 1.: Typical Dr Hopkins off the beaten path (!). The identifiable individual (the author) consented to publication of his image. His spouse took the photograph and gives permission for its publication. I started out in private practice having fun and was happy as a clam, but then in 1986/1987, we had a university chair who was crazy acting and was fired after 15 months. Many people said, "You need to throw your hat in the ring. " I really had no interest, but then Robert Spetzler, who had become a great friend, took me aside and said "Look—a neurosurgery chair doesn't have to be some bean-brain academic, it could easily be you. What you don't have as an academician and a paper writer you have as clinical skills and friendships. You can find researchers. " I put my hat in the ring, and as luck would have it, the search committee had 5 candidates coming to Buffalo to interview. Three of them were in my travel club, a group we formed many years ago that were all dear friends; a fourth was another really great friend; and then there was me. After months of wasting time, the search committee was fed up with hearing about me and how I was great from all my friends, so they named me the chair. That was an interesting start; for the first 2 years, the previous chairman was certain that I was responsible for his dismissal, had close friends on the Residency Review Committee (RRC), and got our program placed on academic probation. Fortunately, we had some friends too and brought them in. One of them, Steve Mahaley, who was previously the RRC chair, came and reviewed our program and guided me as to what to do. After 2 years, we were reviewed again by the RRC, overcame probation, and received a commendation giving us a clear path forward enabling us to start recruiting. Naturally, because of my love for cerebrovascular disease, our program was really lopsided at first. THE ENDOVASCULAR JOURNEY AND START OF THE NEW ERA How did my vascular career get started? What inspired me? Although I have always loved surgery, I found that a case when I was a first-year resident really changed my life. I was assisting a very good surgeon, but this was 1969, and we didn't have the technology, the skill set, or the understanding of cerebral anatomy that we do now. He was treating a ruptured aneurysm using the crude, old instruments we had at the time. During the dissection, the aneurysm ruptured, and the patient died on the table. That was a profound influence on me, and I went back and started monkeying around with catheters right then and there. I learned how to use catheters and would use them whenever I had the opportunity. Back then, there weren't any rules and regulations about who could do what, but that's how it all started. There were 2 people who really preceded me in the field—the true fathers of endovascular: Dr Grant Hieshima, a very special person whom we lost in 2019, and Dr Chuck Kerber, whose story is almost unbelievable. Kerber was a naval aviator, and his student crashed their plane, leading to him being burned almost beyond recognition. He spent 2 years at Bethesda Naval Hospital but later turned out to be one of the best technicians and most innovative people in the world. So what was my path in endovascular? I started as a weirdo or a curiosity. In the early days, I was doing endovascular before the radiologists were doing it. In the very early days, nobody really knew or cared what I was doing, but neurosurgeons spun off neuroradiology early on because we got too busy to do angiography, and so the radiologists learned to do it. Once they did all the angiography, they quickly became involved in intervention when that specialty was born. Of course, they didn't like the fact that there was some renegade neurosurgeon in Buffalo who was using catheters and putting them in people's heads and writing about it. I became a pariah in the new world of neurointervention, but as with everything else in my life, I thought "Oh, what the hell. I like doing it, and I think it's really the future, " so I just went ahead and did it. Eventually, radiologists stopped attacking me and, in fact, came to me for advice on this new specialty. Two of the greatest things, in my mind, that have happened are all the fellows that we have trained and the fact that neurosurgery now leads the field. That is pretty damn exciting. What were my motivators? In 1969, I was told that I couldn't use catheters to do brain surgery. I said, "Well, I don't know why not because if you can kill somebody with surgery you can kill them with a catheter too. " Next, in 1975, I was told by radiologists "You can't use our operating room angiography equipment, " ignoring the fact that it was the hospital's equipment. I taught myself catheter technology and learned how to do my own thing with endovascular. Then, in 1980, radiologists told me that I couldn't teach neurosurgeons catheter skills. Well, I'm proud to say I've trained many fellows who are doing amazing things using these skills and now are leading the field. My first really big case was a complex direct carotid-cavernous fistula in 1975. Back in those days, we had to cut down on the leg, harvest a bunch of muscle, shoot it up the carotid artery, and say a prayer. But I was damned if I was going to do that. I heard about a triple lumen catheter that was invented by a urologist in Boston, MA, and I got a couple of his catheters. Using that catheter design, I was able to easily fix the fistula by shutting down the carotid artery and curing the patient of his fistula. THE GATES VASCULAR INSTITUTE A game changer in my opinion was Larry Jacobs. Beta-interferon was his invention and claim to fame, which made him world famous, and he unfortunately got cancer and died in 2001. Jeremy Jacobs wanted to memorialize his brother, and the whole family initially wanted to do a neuroscience institute. I told Jeremy that I loved Larry and that he was a great friend, but since he was a vascular neurologist by training, I thought that building a vascular center would honor his memory more completely. After some thought and with consultant support, the Jacobs family agreed; and with input from endovascular specialists from around the world, we ended up designing and building the 300 million Gates Vascular Institute (GVI), including the Jacobs Institute (JI) (Figure 2), designed by a world famous architect along with a multidisciplinary group of physicians. The whole concept here was to bring physicians together. We saw the incredible synergies that can occur when you bring people of different disciplines together and decided to just let them interact. The 4th floor of this building contains 15 cath laboratories for all disciplines. Everybody works together, including nurses and technicians who are cross-trained. It's a place where when you go out for a cup of coffee between cases, but you won't be sitting with a neurosurgeon. You'll be sitting with a vascular surgeon, a cardiologist, or an interventional radiologist. That really has led to incredible synergies. Five years after we got the JI and the GVI up and functioning, I decided to transition out of the leadership role and give it to some young person who could take it over. That person is Adnan Siddiqui, and he's done an incredible job of turning the JI into one of the most important innovation centers in the world with 25 full-time engineers. We have people coming from all over the world all the time to interact with and learn from our engineering and clinical specialists. FIGURE 2.: Dr Hopkins envisioned and directed the construction of the multidisciplinary Gates Vascular Institute and the Jacobs Institute vascular innovation center in Buffalo, NY, shown here. Author's photograph and he gives permission for its publication. IMPORTANT PEOPLE IN MY LIFE The people around me shaped me into who I am. Who's the most important person in anyone's life? In my case, it's so obvious. Everybody would tell you that the single most important person in my life is my wife, Bonnie. She's the most incredible colleague, friend, wife, and advisor for 58 years (Figure 3). Next most important to me is family, and that is what has made my life so rich and fulfilled, all the kids and grandkids (Figure 4) and my mom and dad. Those are the people that really led me to where I am today. FIGURE 3.: Bonnie Hopkins and Dr Hopkins—still going strong after 58 years! The identifiable individuals consented to publication of these images. These are their photographs, and they give permission for their publication. FIGURE 4.: Dr Hopkins and Bonnie with their children and grandchildren. The identifiable individuals consented to publication of this image. This is the Hopkins' photograph, and they give permission for its publication. I grew up in an area where I didn't have neurosurgery mentors at the time when I was starting practice or in residency. There was no Charlie Drake or anyone with a huge name that I could look up to every day. In that way, I was lucky enough to be surrounded by people in my career that I have been able to look up to every day; they are really my mentors as well as my great friends: Adnan Siddiqui, Elad Levy, and Kenneth Snyder. Another really important person in my life is Robert Spetzler. Robert, his wife Nancy, Bonnie, and I have been dear friends for many years; they've led us on adventures that we couldn't have even thought about without them. And I learned a great deal from Robert about building a program. The other incredibly important person in our lives—for both me and my family—is Farhad (Fred) Khosravi. He was born in the mountains of Iran as an Iranian Kurd, so his family was unfortunately the scourge of the earth in that country. His father talked him into leaving about the time of the Iranian Revolution when the tragedy that was going on in his life and his world was just immeasurable. He left and did college, engineering, and business in Tennessee and started thinking about entrepreneurship after working for medtech companies. It was when I gave a lecture in Washington, DC, back in 1997 about the need for protecting the brain during carotid stenting that he approached me and said "I have an idea that I think you might like to see. " I said "Sure, why not, " so we looked at his idea for a little filter on a wire that ended up being called the FilterWire. It was perfect for brain protection. I never could have dreamed what would happen. Neither of us had ever started a company, but we started a company together. I was just a clinical voice, but with his business acumen and personal skills, he basically turned it into a phenomenal company. There were several other companies that we've created in succession, with me always contributing the minor clinical part, but the experience that I've had with Fred learning about people and other cultures and how much love he has for this country has changed my life completely. LESSONS LEARNED AND MY ADVICE FOR YOUNGER GENERATIONS As you go through life, you get some really interesting leadership lessons. One of the most important ones I've ever heard was from Home Depot cofounder Ken Langone, who said that to motivate people, "the 3 most powerful things are a kind word, a thoughtful gesture, and a passion for what you do" (https: //www. cnbc. com/2022/07/18/billionaire-investor-ken-langone-names-3-most-powerful-things-in-business. html). In the whole world of neurosurgery, our residents and fellows have meant the most to me. We've produced somewhere near 60 endovascular neurosurgeons, and many of them are leaders in the field now. Nobody would have ever thought that would be the case 40 years ago, but we did it. There are a few leadership lessons that have been helpful to me, and hopefully, some of these will be of some benefit to you as well: (1) failure is the best teacher if you embrace and learn from it; (2) when somebody says "no, " don't think you have to listen to them; (3) have the courage to go against the grain; and (4) learn to listen. Another important lesson I have learned is that you have 2 ears and only 1 mouth, so you should use them in that proportion. I love the Dalai Lama, who said "When you talk, you're only repeating what you already know, but if you listen, you're going to learn something new" (https: //www. quotespedia. org/authors/d/dalai-lama/when-you-talk-you-are-only-repeating-what-you-already-know-but-if-you-listen-you-may-learn-something-new-dalai-lama/). I think that's a profound statement. I also love this Iranian (Kurdish) proverb: "listen 100 times, ponder 1000 times, and speak once" (https: //www. worldofproverbs. com/2012/04/listen-hundred-times-ponder-thousand. html). Music has always been very important to me, and I've always loved having music in the operating room. I know a lot of people think that's nuts, but in addition, I learned about how patients really enjoy listening to their own favorite music—especially when you're operating on an awake patient. Playing their music is like giving them an extra layer of anesthesia, and it is truly amazing. THE CIRCLE OF LIFE AND CONCLUSION Reflecting on the circle of life in my career, I encountered challenges, including in the year 2000. I got into a disagreement with the then Dean and Vice President at the University at Buffalo, and subsequently while on a trip to Patagonia—as far away as you can be from Buffalo—I got a telegram saying that I was fired and that all my full-time faculty were fired. Fortunately, all was resolved when I arrived home, but I didn't give in. The GVI and the JI were conceived in 2007 and opened in 2013. My circular journey culminated in being named a State University of New York distinguished professor in 2013 and receiving the University at Buffalo's highest award, the Chancellor Charles P. Norton Medal, in 2019 (Figure 5). This really proves to me that the world is round and everything goes full circle. I'd like to close with this: don't bet against endovascular. I don't care what the organ is because there's no organ in the body that doesn't need blood, and there is no condition in the body that doesn't somehow relate to its blood supply. So don't ever bet against it. FIGURE 5.: University at Buffalo Council Chairman Jeremy M. Jacobs (left) and University at Buffalo President Dr Satish K. Tripathi (right) honor Dr Hopkins (center) with a framed proclamation noting the awarding of the Chancellor Charles P. Norton Medal to him. The identifiable individuals consented to the publication of this image.