Expanding the Horizons of Neurological Surgery Outside the United States

Abstract

In February of 2020, I traveled to my country of origin,
Pakistan, and worked with the neurosurgeons at a promi‐
nent medical school with an advanced training program.

I was exposed to challenges of neurosurgery in a third-
world community and learned how those challenges are

met by the local physicians. This article summarizes
these challenges and is a tribute to the local physicians
and new collaborations. The program at the University
of Missouri continues to support educational activity
and extends support to educate and train physicians
globally in the advanced practices of neurosurgery, par‐
ticularly vascular, skull base, and endovascular neuro‐
surgery.
I have often heard the phrase, “it’s not brain surgery!”,
meaning whatever “it” is should not be difficult. As
someone who performs brain surgery, I can attest that it
is a difficult and complex task without a question. The
prolonged time and extensive training required to
become a neurosurgeon in the United States are very
challenging, particularly for a foreign medical graduate.
I have been fortunate enough to break through the barri‐
ers of hegemony to become a successful neurosurgeon at
a prominent university in the Midwest. Over the years, I
have had many important mentors and influences who
believed in me and helped me to get to where I am
today. Many of those mentors and influences, including
my family, are back in Pakistan where I grew up and
attended medical school.
Having left Pakistan after medical school and complet‐
ing residencies and fellowship in the United States, I had
lost touch with the medical community back home and
was at a loss for many years how to reconnect. I always
had a strong sense of duty and responsibility to my
native community because that community was one of
the cornerstones of my success. After trying unsuccess‐
fully for many years to reconnect with the neurosurgical
community in Pakistan, I was introduced to the visiting
observership program for young physicians from Pakis‐
tan’s military at the University of Missouri, spearheaded
by Dr. Qureshi.

In Pakistan, military healthcare institutions are consid‐
ered the most organized, respected, and resourceful
among all establishments. While in the United States,

these visiting physicians could not participate in hands-
on training, but their commitment and desire to learn,

nonetheless, was commendable on both individual and
institutional levels. Through this program I was able to
get involved with the neurosurgical programs in Paki‐
stan in a meaningful way when I visited in February this
year.
After exchanging a few online pleasantries over the pre‐
ceding months, I was invited to a multidisciplinary con‐
ference, two days after I landed in Islamabad, on a
bright Wednesday morning. I was strangely apprehen‐
sive at our first meeting. For one, I had been out of the
medical community in Pakistan for a long period of
time. Another aspect was memories of very rudimentary
exposure to neurosurgery in medical school and family’s
story about a young patient not waking up from neuro‐
surgical operations. Suffice to say, I had a very negative
opinion about neurosurgical practice in Pakistan, but
that was precisely the reason I felt driven to return and
contribute. Adding to my apprehension was the transat‐
lantic flight with approximately 24 hours of travel time.
I arrived at my destination few minutes late, with a
hangover from the jet lag and a headache after a
strangely familiar 45-minute drive. The conference
involved oncology, radiation oncology, radiology, and
neurosurgery faculty members and residents. I was gree‐
ted very warmly as we discussed treatment options for
some patients with complex neurosurgical diseases.
Later, we walked through the neurosurgical intensive
care unit and floors, exchanging views on several disea‐
ses such as brain tumors, aneurysms, and their surgical
approaches.
There is always a certain awkwardness when two neuro‐
surgeons talk about diseases, pathology, surgical techni‐
que and outcomes. By default, we are aggressive, pre‐
sumptuous, judgmental, and somewhat narcissistic per‐
sonalities, having to make life and death decisions every

Vol. 11, No. 2, pp. 60–62 Published Jul, 2020.
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Journal of Vascular and Interventional Neurology, Vol. 11

day. This constant barrage of abysmal stress inevitably
takes a toll on our lives and defines our social behaviors.
Naturally, criticism is not easily digested. One remarka‐
ble thing I have learned from the American practice of
medicine is a conscious attempt to view clinical situa‐
tions in the context of data-driven knowledge and mini‐
mize, but not marginalize, the surgeon’s own reflection
of individual experiences. Keeping all of that in mind, I
think Brigadiers Juniad, Tashfeen and myself managed
the first day quite well.
The next day was frustrating as I arrived late due to a
traffic jam and lack of personal transportation. I walked
into the operation theater with the patient in position and
a team of surgeons exhibiting varying levels of experi‐
ence. To my surprise, they were waiting for me to start
the case. I was ill-prepared, which is not typical of me,
when it comes to operating. I had not studied the images
in detail, and I had not examined or talked to the patient
and family about the risks of surgery. The images were
not in the format I am accustomed to; instead, I had to
see them on the side wall with a radiographic illumina‐
tor. To my surprise, once again, the quality of their 3D
computed tomographic angiogram was better than what
I have seen at many places in the United States. The
patient in question had suffered a subarachnoid hemor‐
rhage seven days earlier, caused by a shallow, wide neck
right middle cerebral artery aneurysm.
Fixing a car in another mechanics shop, with a new
assistant who speaks a language you have not spoken
freely in technical terms over the past 20 years, with
new set of equipment, is a daunting task. Now imagine
replacing the car with a living human’s brain, an opera‐
tion that some would regard as one of the most difficult
operations, with a low but real risk of a major stroke or
death, and the patient is on the table. It was a feeling
which is very hard to describe. The microscope illumi‐
nation and picture quality were excellent once I got used
to navigating it. After initial struggle, we got through the
sylvian fissure and exposed the aneurysm. I examined
the array of aneurysm clips on the back table. Most com‐
mon-sized and shapes were present but the clip applica‐
tors were very different from my aneurysm set at the
University of Missouri. Clip application is the holy grail
of vascular neurosurgery and any little slip short of per‐
fection can turn the surgical field into a lost battle
ground very quickly.
After some deliberation, I was able to apply the clip.
The temporal M2 appeared to have been caught in the
clip. I adjusted the clip a bit and reexamined. Next, I
asked for micro–Doppler, but there was none available. I
asked for indocyanine green videoangiography and that

was not available either. It turned out indocyanine green
videoangiography was not yet approved in Pakistan for
use. There was fluorescein dye somewhere in the hospi‐
tal but no one had used it before for this purpose. I felt
helpless. With a heavy heart, I got up and we finished
the surgery. I knew the clip was fine but over the years I
have been taught by many experts that visual judgement
of a surgeon will betray you one day or another. Had I
known this before, I would have prepared for intraopera‐
tive angiogram. Nonetheless, the patient woke up fine
without any neurological deficits. Computed tomo‐
graphic angiogram obtained later demonstrated the ideal
clip position with no residual aneurysm. We got away.
The next operation was on a young man with a prior
brain hemorrhage from an arteriovenous malformation
(AVM). The military hospital is one of the only two hos‐
pitals in Pakistan with neuronavigation (standard of care
in the United States), but it was not functional that day.
Another way of localizing a brain abnormality or hemor‐
rhage would be using ultrasound; however, that was
unavailable as well. Thus, Brigadier Tashfeen and I
resorted to finding the AVM the old-fashioned way by
using surface landmarks. Having not used that method‐
ology in a long time, I was very apprehensive, but to my
surprise we were smack on target. Just to make things
more complicated, the AVM had no cortical representa‐
tion. After some exploration, we finally found the large
vein leading into the AVM and were able to resect it
safely. The patient did well postoperatively and his pre‐
existing left-sided weakness actually improved. I was
moved when the patient’s 90-year grandfather came
from home to meet me, barely staggering off his wheel‐
chair with shaking legs and kissed my hands. I helped
him back to his chair, holding back my own tears and
said “God saves lives, we just try to do our best.” The
family was overjoyed and I felt like the past 44 years of
my struggle had a purpose. I felt living my purpose at
home.
That sense slowly faded over the next few days as we
approached the harsh realities of daily neurosurgical
challenges in a Pakistani hospital. We did several cases
during my 6 days at the Combined Military Hospital
(CMH). We resected a tennis ball size olfactory groove
meningioma on a young woman with great results. The
ultrasonic aspirator worked very well; however, we deci‐
ded not to obtain postoperative imaging due to cost
issues. I typically obtain post-operative imaging not only
as a new baseline study for any residual tumor but also
to secretly pat myself on the back. Not only did it
deprive me of my opportunity to shine, it also made me
think how many, lets say, “less productive” studies I
have done over my career.

61

Journal of Vascular and Interventional Neurology, Vol. 11

We performed several AVM embolizations on the mono‐
plane Toshiba angiography machine. It felt like operat‐
ing with one eye closed, but once again to my amaze‐
ment, the picture quality was excellent, however at the
same time one could perceive the local team’s lack of
experience. The absence of my usual tools and equip‐
ment challenges made us improvise at every step. For
one of the cases, as we reached the critical part of embo‐
lization, we realized that we had only one vile of Onyx
available. Such things are very unusual in the United
States, but it is an everyday reality in Pakistan. Over
80% of the population cannot afford the expensive treat‐
ments and institutions like the CMH are forced to absorb
the cost with very limited government funding. All of
our cases went well even with limited resources. I was
particularly encouraged with Drs. Khursheed, Raza, and
Farzana’s positive attitude.
We navigated through many daunting situations, by
improvising. In one particular case of a ruptured large
anterior communicating artery aneurysm, once we pre‐
pared the aneurysm for clip placement, we realized that
the longer clips were outdated and I had a hard time
using the applicator. We then learnt that there were a few
newer Asculap® clips available, but that had to be
requested in advance. Keeping the complexity of the
aneurysm and my reluctance to use the older clips in
mind, I decided that it was worth waiting for the newer
clips. Once they arrived, I found myself in my comfort
zone again. For large aneurysms, I usually stack a bunch
of clips to reconstruct normal anatomy. While struggling
to remove the older clip, the aneurysm did what it does
best, none other than intraoperative rupture. Since we
were in a good position, I was able to secure the clip
across the aneurysm very quickly; however, as a new
experience in my neurosurgical career, I had to count the
number of clips and estimate the out-of-pocket cost to
the patient’s and families. These are things we take for

granted in the United States and still find reasons to
complain.
Overall, this was what I hoped for, an amazing begin‐
ning. All the short falls of equipment and technology
were overshadowed by the staff, residents, and attending
physicians’ hopes and enthusiasm for improving the care
of their patients. The leadership’s commitment and reso‐
lution in the face of seemingly unsurmountable hurdles
was also commendable. The faculty of the University of
Missouri and I are committed to help overcome these
challenges, to improve neurosurgical care for patients in
Pakistan. This experience has confirmed for me that I
have found my purpose of learning this difficult art in
the United States. This has been, and will be, an all-con‐
suming and fulfilling part of my life for many years to
come. Now coming back to my adopted home, I feel
contentment not only professionally but personally also
at being able to give something back to my native com‐
munity that gave me so much. I also feel it is safe to say,
the future of neurosurgery in Pakistan is in good hands.