ISSUE 143: Special Section

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A Revolution in Brain Surgery

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LOUISVILLE We have all heard and perhaps even used the idiom, “It’s not brain surgery,” regarding an easy and uncomplicated task. But what if it is brain surgery?

Neurosurgery is a relatively small specialty, with approximately 4,300 neurosurgeons in the US as of January 2009, compared to 20,000 orthopedic surgeons and 16,000 ophthalmologic surgeons1. Of those neurosurgeons, only approximately six percent are women.

Narrower still is the number of physicians who have been trained in endoscopic endonasal skull-base procedures of the brain. Mary Koutourousiou, MD, assistant professor of neurosurgery at the University of Louisville (U of L) and director of the skull base program for U of L Hospital, part of KentuckyOne Health, belongs to this elite group.

Koutourousiou’s expertise is bolstered by her passion for her work. “I’m always excited by a challenge,” she says. “I believe women are very adept at fixing things with their hands. There is also a kind of artistic involvement in microsurgery, and I found that could be a very good option for me.”

Koutourousiou joined U of L in July 2014 to begin building their skull-base program, after spending four years at the University of Pittsburgh Medical Center (UPMC) completing a clinical fellowship in extended endoscopic skull-base surgery and open skull-base surgery. UPMC has a 25-year history of tackling skull-base tumors and pioneered the Endoscopic Endonasal Approach (EEA). Prior to her time at UPMC, Koutourousiou attended medical school and residency in Greece and completed an endoscopic surgery fellowship in the Netherlands.

Referring to the EEA as “revolutionary,” Koutourousiou believes the most important aspect is that it leads to fewer surgical and post-op complications because the brain is not retracted during the procedure. “In traditional open surgery, after we remove the bone, we have to retract the brain in order to get to these deep structures. When we go through the nose, we approach the lesion from below, and actually we don’t have to touch the brain,” she says. Beyond fewer complications, patients enjoy shorter hospital stays (two to three days as opposed to up to 30 days), quicker recovery, and no scarring.

The EEA was originally used to treat pituitary adenomas beginning 15 years ago and was adapted for neurosurgical tumors 10 years ago. It can be utilized on any lesion located deep in the skull base, according to Koutourousiou. For example, ENT tumors such as nasopharyngeal malignancies and neurosurgical tumors such as skull-based meningiomas, chordomas, chondrosarcomas, craniopharyngiomas, trigeminal schwannomas, and dermoids/epidermoids, among others. Since July, Koutourousiou has done 12 pituitary adenomas with the EEA and four extended procedures with more complex cases.

As is quickly becoming the mantra in medicine today, Koutourousiou says the Endoscopic Endonasal Approach is a team effort. She performs each operation in conjunction with ear, nose, and throat (ENT) specialist Welby Winstead, MD, whose role is to do the initial approach, open the corridor for tumor removal, and prepare the nasoseptal vascularized flap for skull base repair. The team also includes neuroradiology, neuro-oncology, neuro-anesthesia, and interventional services.

Because the procedure is still new, outcomes data is scarce. Only UPMC has published extensively on the subject and Koutourousiou is one of the main authors of the most recent outcome publications. Based on this experience, Koutourousiou believes the EEA outcomes are at least equivalent to those of open craniotomy and that outcomes will increase as more surgeons gain experience with the technique. “The learning curve is long. I think outcomes are going to be even better in the future,” says Koutourousiou.

With such a small volume of cases appropriate for the EEA, the University’s investment in the endoscope is being maximized by utilizing the equipment for endoscopic-assisted open surgeries. “It’s very important because what we do with the endoscope is to bring the light inside the surgical field and bring our own eyes inside the surgical field, so we can have a closer look at the anatomy and look under direct visualization areas that would not be accessible with the microscope alone,” says Koutourousiou.

On November 21, 2014, Koutourousiou completed another extended endoscopic procedure for the resection of a skull base epidermoid tumor that was a first in Kentucky. Certainly one cannot solely credit the technology for revolutionizing brain surgery in Kentucky without tipping a hat to the unique skills, passion, and vision of the surgeon that is making it happen. “I find all these things fascinating, and I’m really in love with what I’m doing,” Koutourousiou says.


American College of Surgeons (ACS) Health Policy Research Institute. (2010, April). The surgical Workforce in the United States: Profile and Recent Trends. Retrieved from ACSHPRI: