Michael T. Lawton, MD
@mtlawton
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Neurosurgeon. Innovator. Author. Teacher. President & CEO @BarrowNeuro . Spetzler Chair of Neurosurgery. Co-Founder @MissionBrainOrg .
Phoenix, AZ
Joined November 2011
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It was a pleasure to host
@ElonMusk
at
@BarrowNeuro
recently. We look forward to our continued partnership with
@Neuralink
to advance brain-computer interface technology for our patients…
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Important tip: contralateral transcallosal-contralateral transchoroidal approach is the way to medial thalamic cavernomas but travels under fornix & requires forniceal retraction; Contralateral transcallosal-ipsilateral transchoroidal travels over fornix & avoids this retraction
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In neurosurgery, there’s nothing like dissecting the Sylvian fissure – it’s outside of brain tissue, amongst a spectacular arterial landscape, clean & precise. And w/ Sylvian arteriovenous malformations, there’s the challenge of deciphering abnormal vessels & preserving normal
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Most of what we do in neurosurgery is deconstructive – taking things down and removing them. Bypass surgery is constructive – building something beneficial that did not previously exist. That’s why these moyamoya patients are among my favorite. Tips: handle intima carefully; use
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We like to be there when trouble strikes, as with this carotid injury during nasal polyp removal @ outside office. After control w/Foley balloon catheter in the nose, we performed bypass/carotid sacrifice, which treated the carotid-cavernous fistula and enabled safe removal of
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Sewing a bypass is almost a battle against one’s physiology & limitations of equipment. Even w/ microscope’s magnification & light dialed to their max, eyes strain to define transparent tissues. Muscles tighten w/the pressure of ischemia time & precision of micromovement, but
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Usually I go into interpeduncular fossa over the P1 PCA shoulder, but this time I went under P1 axilla to reach a large midbrain cavernoma. Also used contralateral transsylvian approach for cross-court reach behind right corticospinal tract. Note how this extends back to tectum…
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The quadrigeminal cistern may be the most otherworldly spot in cranium, with cerebellum falling below, the Galenic complex of veins above, the posterior cerebral arteries coursing to the sides, within white walls of tentorium. If this is our office, what a way to work…
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Happy to announce the publication of my 6th book: Surgery of the Brainstem. While it took me a decade to do my first 75 brainstem cavernous malformations, my last 75 took only 2.5 years
@BarrowNeuro
. Hope you like the anatomy, approaches, & mgmt pearls from our contributors. . .
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Some aneurysms require the “A-Game” because you need everything – meticulous exposure, anatomical knowledge, technical skill, attention to every detail, and a little courage – like with this ruptured superior hypophseal artery aneurysm clipping…
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The supratentorial-infraoccipital approach (STIO) is an alternative to the subtemporal approach to reach the medial temporal lobe, requiring less brain retraction, minimal cortical transgression, no risk to vein of Labbe. You just need to be willing to work at a longer distance…
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Basilar bifurcation aneurysms can be tough to clip, more so when positioned high in the interpeduncular fossa. Improve the upward view by sliding over pretemporal & transposing sphenoparietal sinus to get the veins at the temporal pole out of the way. Then it’s a clear shot….
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I once thought the measure of neurosurgical success was case volume + papers published, but it’s mentorship. You train residents/fellows, develop their skills, coach them, then put them in the game. When they score touchdowns, it means they will continue our legacy of excellence.
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Spinal arteriovenous malformations in conus medullaris make spectacular tangles of arteries, veins, nerve roots. Deciphering & interrupting several key arterial inputs brings the AVM to stasis. Wait for final videoangiogram AVM to see how AVM disassembly shuts the pathology
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I learn a lot operating on brainstem cavernomas that recur after other surgeon’s resections. This case demonstrated how the cerebellopontine cistern can be seductive, but the trajectory of the trans-middle cerebellar peduncle approach is needed to expose the posterior pathology…
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Aneurysm rupture & subarachnoid hemorrhage can turn the brain angry & swollen. Usually I curate the good-looking videos, but this one is plain ugly to show what operating ruptured aneurysms is really like: hostile brain, tight spaces, arteries buried in clot, even intraop rupture
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I have always loved the technical aspects of neurosurgery. You can always get better, challenge yourself more, tackle ever harder cases. Technical excellence must remain relevant in our craft. Thank you AANS for a proud moment for me today….
This year’s AANS Cushing Award for Technical Excellence and Innovation in
#Neurosurgery
is presented to
@mtlawton
Dr. Lawton has experience in surgically treating more than 5,000 brain aneurysms. Thank you for all your contributions to
#neurosurgery
!
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Congrats longtime friend/recent celebrity
@drdavidlanger
. LenoxHill is dramatic, raw, authentic – you show the world what it’s like being brainsurgeon. We compete at most things: bypasses, skiing, etc. No way COVIDeos-19 can compete w this Netflix success!
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12 spinal AVMs operated this year - how is it that something so rare keeps coming around so frequently? Unlike most intramedullary spinal AVMs that are mostly intramedullary, this one was mostly extramedullary with a small intramedullary part, supplied by anterior spinal artery…
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Look what came in the mail…Harvey Cushing’s right hand! Happy to receive my trophy for the AANS Cushing Award for Technical Excellence and Innovation in Neurosurgery, 2023.
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Conus arteriovenous malformations are one of the 7 types of spinal cord AVMs, located at the end of the spinal cord in the arterial basket formed by anterior & posterior spinal arteries. These malformations have a nidus but in this case, were small, tight, almost like a
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If you’ve ever doubted the power of love or the wisdom of the universe to pair 2 people so perfectly, then look at these pictures. It felt heavy being the father of the bride giving away my firstborn, but what more can a father want for a child than to feel this magic. Congrats
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I say about our patient, "One small step for a man, one giant leap for the mind of mankind." We're pleased to be partnering here
@BarrowNeuro
w/
@Neuralink
on this groundbreaking work on brain-computer interface to help pts w/spinal cord injury return to autonomous lives.
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Successful surgery for acoustic neuroma resection depends on facial nerve preservation. This video shows the technique of preserving the cochlear nerve and dissecting along it sharply from medial-to-lateral to preserve it as a protective layer for the underlying facial nerve….
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How do you breed technical excellence in neurosurgery, and get residents to want to be their best? One way is to give them cadaver heads, get them Kinevo microscopes, challenge them with complex dissections, and watch them discover the fun. Saturday classroom
@BarrowNeuro
…
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Perimedullary spinal arteriovenous malformations are classically on ventral cord, fistulous, fed by anterior spinal artery. But this one was dorsal, fed by 2 posterior spinal a. feeders. So how do we classify this? Do our current classification systems adequately describe what we
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Today marks Seven Series’ 4th Anniversary. This video series is intended to help neurosurgeons keep their technical edge. "Excellence in Mind" speaks to the fact that our work demands technical excellence; that we must strive to better ourselves; that we work in the most sacred
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Aneurysm Clipping 101: ruptured fetal posterior cerebral aneurysm. Key steps: establishing proximal control to gain confidence; liberating the often adherent, always crucial anterior choroidal artery (supplies internal capsule & optic tract); preserving fPCA flow to visual
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Next masterpiece!
Work in progress on a figure for
@mtlawton
‘s 7 Cavernomas. This illustration will depict cerebellar cav mal approaches
#neuroscience
#brain
#MedTwitter
@OGdukeneurosurg
🧠✍🏻
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Giving the Yasargil Lecture today at AANS2024 was a special honor. This father of modern neurosurgery, inventor of the STA-MCA bypass, master of subarachnoid dissection, and author of Microneurosurgery textbooks continues to inspire all who knew him.
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Clipping an incompletely coiled aneurysm after the brain gets less “angry” from subarachnoid hemorrhage and vasospasm is usually straightforward and smooth. The risk of intraop rupture is reduced and the remnants and extra lobes can be cleaned up with clips below the coil mass…
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An supracerebellar-infratentorial approach for thalamic cavernous malformations may not be your first thought, but gravity retraction of cerebellum lets you climb thru the posterior incisural space and reach this pulvinar lesion, plus the generous surrounding cyst helps too…
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More triangles…we’re going invisible now
New publication in
@TheJNS
by
@graffeo
@visishs
@mtlawton
et al
@BarrowNeuro
on expanding the reach of the trans-middle cerebellar peduncle approach. Full article available here:
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The “down and out” pupil is an eye that deviates downward and laterally with pupillary dilation, caused by posterior communicating artery aneurysms projecting postero-inferiorly and impacting the oculomotor nerve. Decompression of the nerve after clipping increases the chances of
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Preservation of capsule with epidermoid tumors protects brainstem perforators and cranial nerves but may result in recurrent tumor years or decades later. Here’s one such recurrence. The “liquid pearl” is a little firmer but still pure white, shimmering, and suckable…
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Happy Valentine's Day🩷
Here’s another example of cavernomas in cranial nerves, this time in the trigeminal nerve. Pathology extended from the intrapontine to cisternal portions of CN5, out to Meckel's cave, making it different from a purely peritrigeminal pontine cavernoma….
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When an ophthalmic aneurysm is intimately related to anterior clinoid process, I like an intradural clinoidectomy to see all anatomy and pathology in front of me, just in case. Also, dissection mobilizes aneurysm downward off optic nerve, rather than manipulating optic nerve
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Recurrent brainstem cavernomas are tough: the patient must deal w/ new symptoms & another surgery, and the neurosurgeon must confront the fact that resection was incomplete. Usually, the previous approach works best for the recurrence, but occasionally a new approach is better…
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My office is like most neurosurgeon offices, with some nod to Harvey Cushing somewhere. I have his Meningioma book, 2 copies of “Tumors Arising from the Blood-vessels of the Brain,” & best of all, a bronze trophy of his right hand – an award from the AANS in 2023. His legacy of
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Some say open vascular neurosurgery is fully matured, stagnant. Middle communicating artery exemplifies why that’s not true. It demonstrates 4th generation bypass concept, novel end-to-end reimplantation of M2 trunks, innovation. We are the authors of our future - keep evolving!
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Number 3: I love anatomical triangles because they guide you to safe corridors in the brain. This paper introduced two triangles for anterior communicating aneurysms: precommunicating & junctional. Opening the JX triangle makes post. and sup. projecting aneurysms much easier.
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As neurosurgeons, we work at the borderline between life and death. With patients so sick, some will be saved and others will succumb. The Marin fog in summer forms a line along the coast, which reminds me of the line we straddle between life and death, between heaven and earth.
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Neurosurgical learning must go on, which is why I launched COVIDEOS-19: Survival Kit for Neurosurgical Quarantine. These are doses of op. neurosurgery during whatever self-isolation is imposed. Why sit on your hands when videos can help you improve them?
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Spectacular, as usual! I appreciate the support for us disadvantaged lefties…
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With rare pathology like conus AVMs in the spinal cord, seeing a few simple, easy ones and a few complex, hard ones helps figure them out. The concept of disassembling the basket formed by anterior and posterior spinal arteries is the same for all. Here’s one of the hard ones…
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The current issue of Ignite Neurosurgery has a nice tribute to a true master and giant of neurosurgery, Juha Hernesniemi. Check it out....
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The greatest reward is when a patient thanks you for saving her life. When that patient is a Hollywood icon, it doesn’t get any better.
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The suboccipital craniotomy is one of the most versatile approaches to cerebellar & posterior fossa lesions. Here, this rare, low-grade glioneuronal vermian tumor had some nice margins & cystic compartments that helped get to complete resection. Wait for view into 4th ventricle
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Example of ingenious residents
@BarrowNeuro
rising to the challenge of COVID-19: With the shortage of PPE, 3D printers producing spine models in Barrow Innovation Center were repurposed to produce masks. The filter material in one N95 mask partitions to 6 printed masks!
#Update4
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This paper is the most cited paper in the history of the Journal of Neurosurgery. You cannot talk about AVMs without mentioning Spetzler & Martin and their AVM grading. Neil Martin will be the 3rd annual Alumni Lecturer at the Barrow Neurosurgery graduation in June 2020.
#TBT
: In Oct. 1986, Drs. Robert Spetzler and Neil Martin published a paper in
@TheJNS
proposing a grading system to predict the risks of surgery in individual cases of AVMs. The
#SpetzlerMartin
grading scale is still widely used today. Read the paper:
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Here is a provocative article in The NY Times on the dexterity of surgeons in training, in which both I and Dr. Spetzler are quote. Swiping screens is not the problem - it boils down to practice, touch, tissue handling, and pursuit of perfection.
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Being chosen as the 1st site in
@Neuralink
's trial to develop & test brain-computer interface
technology is a testament to our mission at
@BarrowNeuro
: accept challenges, reject norms,
& push boundaries. Check out this video & learn more about the study:
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Unconventional uses of extended retrosigmoid craniotomy, Part 2: this high-riding, ruptured PICA aneurysm was 26mm above foramen magnum on shoulder of V4 vertebral artery – perfect for xRS rather than far lateral craniotomy. Note re-rupture & overlapping fenestrated clip
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Infectious or mycotic aneurysms can be ugly, with hemorrhage, fusiform morphology, damaged arterial wall, and thrombus inside. This MCA aneurysm had all of that. Excising the aneurysm and reconnecting the parent artery with an end-to-end re-anastomosis repairs the artery…
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This podcast is about technical excellence in neurosurgery. There's more to it than just your hands - it's also the head & heart. It's hours in cadaver lab, hunger for cases, logging lessons from each case, learning from mistakes, writing, observing others, pushing boundaries...
In today’s podcast we‘re joined by
@mtlawton
, chair of
#neurosurgery
at
@BarrowNeuro
, as he shares what it takes to become a master surgeon - passion, innate skill, and work ethic - and lessons learned from watching
@RFSpetzler
during his training
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Brainstem cavernous malformations rarely get to giant size, but here’s one. I used a combined trans-middle cerebellar peduncle and supracerebellar-infratentorial approach thru one retrosigmoid craniotomy to access all the pathology thru 2 adjacent corridors. 1+1=3….
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At BAARC, we are learning about the role of mast cells in aneurysm rupture. By stabilizing these cells pharmacologically in our mouse model, we decreased their rupture rate. A new therapy may be on the horizon to prevent intracranial aneurysm rupture, and put me out of business…
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