• From Science Fiction to a Platinum Era: Vascular Neurosurgery in 2065






    Authors: Samer G. Zammar
    Kristin Swanson
    Youssef J. Hamade
    Michael B. Bendok
    Nernard R. Bendok, MD
    Rami J. Aoun

    In Harry Kleiner’s 1966 sci-fi movie Fantastic Voyage, a band of heroes attempts to save a dying patient’s life by navigating a miniaturized submarine through a patient’s bloodstream (Figure 1). The team on board saves the day by removing a clot located in the patient’s brain using an advanced laser weapon. Such a scenario, even in today’s world, seems completely implausible. But what once only existed within the realms of science fiction is fast becoming reality as advancements and innovations accelerate on an exponential scale. From artificial intelligence to tablets, laser guns, and vertical airplane takeoffs, what was envisioned in movies and media is now becoming reality per IBM’s Watson, Apple’s iPad, LaWS (the Navy’s new laser weapon system), and the Lockheed Martin Military F-35 Joint Strike Fighter (Figure 2).

    Figure 1: The Fantastic Voyage (Brit Posters Odeon, 1966)

    While challenging to envision, the state of vascular neurosurgery in the year 2065 will likely be shaped by three seemingly disparate forces that have historically fueled innovation. The first is need. Stroke remains the leading cause of disability in North America and a dominant cause of mortality. The onerous impact on society will almost certainly stimulate significant public and private research funding initiatives over the next five decades with resulting incremental enhancements in diagnosis and management. Second is the accelerating rate of innovations unfolding in various fields of health care and the biomedical sciences, including genomics, proteomics, molecular imaging, and bioengineering, to name a few. Third are the current and expected innovations in seemingly unrelated fields including the military, nanotechnology, and space exploration, with an eventual trickle-down effect into medical applications, thus illustrating the “adjacent possible,” the concept that one novelty can pave the way for new possibilities through naturally formed networks of meaningful associations that are thematically adjacent.1

    Figure 2: An aerial photograph of the F-35 in action (Lockheed Martin)

    By 2065, biomarker research from five decades interpreted through elegant mathematical modeling and supercomputing will allow for very precise early disease detection and more refined understanding of disease evolution. The “natural history” for diseases like arteriovenous malformation and aneurysms will be individualized and used to provide patients with very precise recommendations based on a true, patient-specific “crystal ball”—which is fundamentally lacking for neurovascular diseases today. These detection and predictive capabilities will enable early therapies before morbid neurovascular diseases and stroke strike.

    Figure 3: A rendering of a hospital drone delivering medical supplies (The Futures Agency, 2014)

    When these diseases do strike, however, it is likely that an individual’s own “home robot” will make the diagnosis and initiate emergency medical services. Moreover, ambulance sirens will not be heard wailing from afar. Instead, mobile diagnostic and therapeutic tools will be flown in by drones equipped with robots that are prepared to stabilize and treat the patient (Figure 3). One can envision a team of human physicians working from home or a hospital in a virtual environment in coordination with the drones to make the diagnosis and guide therapy.

    It is even plausible that nano-submarines could be injected into the femoral artery, making their way to acutely occluded vessels to deliver therapy or reestablish flow. A craniectomy and/or ventriculostomy could be performed in a mobile operating room operated by robotics to relieve pressure. A spontaneous intracerebral hematoma could be evacuated with image-guided aspiration. In five decades more complex treatments would likely remain centralized, but they will have become much more refined.

    Figure 4: A rendering of a vascular nanorobots breaking up a thrombus with lasers (Victor Habbick Visions/ Science Photo Library)

    By the year 2065, dramatic advances will have likely occurred in the microsurgical, endovascular, and radiosurgical approaches to neurovascular diseases, to a point perhaps of rendering them obsolete in their current form. On the microsurgical front, significant strides will have been made through a combination of sophisticated intraoperative navigation, making tailored cranial and micro-endoscopic approaches safer, allowing greater maneuverability and visualization through minimally invasive procedures. Furthermore, pharmacological advances in cerebral protection and more precise intraoperative monitoring will allow for safer operative processes. Robotics will undoubtedly be a big part of the neurovascular surgical environment.

    On the endovascular front, MRI-guided interventions will likely have supplanted fluoroscopic-guided procedures. Moreover, nanotechnology will allow a revolution in devices that can be navigated to the brain without the use of catheters and wires (Figure 4). It is also likely that biological therapies will be commonly delivered endovascularly. It is conceivable, for example, that embolic agents for aneurysms and AVMs will be targeted at the biology of the disease itself.

    Radiosurgery will likely continue to become more precise. This could be achieved by combining radiosurgery with biological sensitizers that are delivered endovascularly. Furthermore, parent artery reconstruction for atherosclerosis and aneurysms will have become more biologically sophisticated with less need for antiplatelets. And finally, postoperative care will be enhanced by sophisticated neuromonitoring modalities, which incorporate both robotics and advanced brain physiological monitoring. The field of rehabilitation will also be radically different, with brain computer interfaces and robotics restoring function where it has been lost.

    Over the next 50 years simulation (Figure 5) will evolve to the point of making a simulated operation indistinguishable from a real one. Such an operation would likely be holographic and enabled by computing technology that makes today’s technologies appear primitive. This will result in a dramatic enhancement of surgical skills at a younger age. Patient-specific simulation will facilitate more precise device selection, reduce infection and radiation doses, and accelerate research on best surgical and interventional approaches.

    Figure 5: Vascular bypass simulation at 2014 CNS Annual Meeting

    From science fiction to reality, human creativity and ingenuity seem to have no boundaries. The next 50 years in vascular neurosurgery will be exciting beyond imagination. Given the exponential explosion of progress in biomedical and non-biomedical sciences and the spirit of ingenuity that marks our current time in human history, it is beyond plausible that we are entering the dawn of a platinum era in vascular neurosurgery that will manifest brilliantly in 2065.


    1. Tria F, Loreto V, Servedio VDP, Strogatz SH. The
      dynamics of correlated novelties. Scientific Reports.
      2014;doi: 10.1038/srep05890.

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