Patrick Brouwer speaks to NeuroNews about what he considers to be the most important developments in the neurointerventional field to date. As president of the European Society for Minimally Invasive Neurological Therapy (ESMINT), Brouwer touches on the society’s long-term goals within the context of global expansion, and tells us about his most memorable case, what motivates him, and offers some honest advice to those beginning their neuro-career.
What initially drew you to medicine, and later, to neurointerventional radiology?
When I was around nine years old I heard some stories about lobotomies and psychosurgery which I thought it was interesting, and I was intrigued. I had two teddy bears that I was poking with needles all the time and I told my grandma that I wanted to do that as a doctor when I grew up.
I only started medicine at the age of 22 after a very poor school career with only music and jobs on the side. After my graduation from medical school, I worked as an emergency physician for almost 1.5 years in Amsterdam. If there would have been a formal training for this specialty, I would have taken it. Since my neurosurgical colleagues operated only one day a week, I chose the field that would give me as much hands-on time possible: interventional radiology. During my radiology training I met Rene van den Berg at Leiden University Medical Center and because of his enthusiasm, and the fact that it came full circle to poking the brain, I elected to work in neurointervention.
Have you had any important mentors throughout your career? What have they taught you?
The person that made me change my perspective on “being a physician” was an ENT surgeon in Amsterdam—Freerk van der Meulen. He was my supervisor during extracurricular research work at the Laser Center at the Academic Medical Center in Amsterdam where we worked on photodynamic therapy in oncology and AIDS related diseases.
The countless examples of the compassionate way he treated patients is something I will never forget, always being respectful and seeing things through their eyes. I spent a number of summer holidays house-sitting for him when he went away with his family, so I got to know him as the family man he was, exactly the same. This man never put up an act and always listened to the input and opinions of others but defended what he thought was right. He is my hero and great example both in and outside of medicine.
What has been the most important development in the neurointerventional field during your career?
It is very easy to say that stroke treatment is the most important one, as simply, it has the biggest impact on patient wellbeing and makes up the majority of procedures we perform. However, from both a technical and personal perspective, I would say that the introduction of the flow diverter made a real difference. The reasons behind this are not totally altruistic. Being the worlds first SILK (Balt) user created an opportunity to present and proctor around the world, which in turn allowed me to meet some of the key opinion leaders in the field.
On the contrary, what has been the biggest disappointment?
Personally I found it very disappointing that some niche products were taken off of the market and were not developed into the useful products that they could currently be. Examples are the trispan, symbiot stent, ascent balloon and the enzo microcatheter. Furthermore, most of the larger companies are focusing too much on “me too products”, which arrive on the market too late, and not on new technology which may put them in the lead again. Start-up companies are obviously the future since the large companies cannot take the financial risk. This, unfortunately, shows the differences in motivation and incentive between industry and physicians in our field.
What are your current research interests?
I am currently involved in the TENSION study, which is a European Union Horizon 2020 sponsored initiative which looks into the thrombectomy effect in patients with extended lesions and extended time windows. This study will give us information on the patients that were not included in the original thrombectomy trials. Besides that, there are a number of projects I am working on such as the SURMOUNT Registry, BRAVO early evaluator study and so on.
As president of ESMINT, what are your goals for the society?
I personally feel that the course of the society should not be too dependent on the president. The definition of a society should imply that it is a concerted action for the benefit of the members and without egos deciding.
Some of the goals I set myself for this term is to structure the society in a way that it will continue to function no matter who will take the lead. This means that the goals for the next five years are set, in collaboration with our 20 executive committee chairs. Obviously, in this day and age, our society also needs to focus on the organisation of care in Europe and define who should and, more importantly, who should not do neurointerventional treatments. We have a responsibility locally and therefore we established theoretical courses, the ECMINT and the EXMINT, and facilitate practical fellowships for young colleagues to build their portfolio.
Furthermore, the certification, accreditation and credentialing needs to be done in a way that will help local governments, hospitals, health inspectorates and insurance companies to determine which physicians are up to par.
We started a pilot project to see how we can help local governmental bodies implement our standards and guidelines. Due to the differences in the local organisation, language and culture, it is important to see what works best for that country. Personally, I really want the society to be professionalised and run by a fulltime dedicated office, which will enable us to account to our industrial sponsors for what we do and how we do it.
Finally, ESMINT receives a lot of requests from areas that are not covered by a society, such as the Middle- East and Northern Africa, to help with training and guidance. With industry having EMEA as a region, it would make sense to make ESMINT supportive of those regions too.
What are the themes and highlights of this year’s meeting?
This year’s congress is organised by Anne-Christine Januel from Toulouse, France. Her motto, a quote by Mark Twain, is very interesting: “They didn’t know that it was impossible, so they did it.” She has, in collaboration with the European Stroke Organisation (ESO), the European Association of Neurosurgical Societies (EANS) and the Society of NeuroInterventional Surgery (SNIS) built a programme that is enticing and I look forward to seeing it. This year we will honour another honourary member, James Byrne, who was one of the founders of the society. A new addition in this edition is the “Amy Walters Foundation lecture”. Amy Walters worked in industry for a long time, and even sang with the ESMINT band on the beach in Nice (France) a couple of years ago, but sadly she suffered a major stroke during a congress two years ago. SNIS and ESMINT have started a foundation to be able to host a patient to our congress in order for them to have a presentation in which they let us see their experience through their own eyes. I recommend that all colleagues listen to Amy’s story, it is very impactful.
What technological advances do you see shaping stroke treatment over the next 10 years, or beyond?
We focus a lot on the thrombectomy treatment as being the mainstay, but I think that we will gradually move to other focuses. The neuroprotective agents are moving in and I very much look forward to the results of the NA-1 study that will be analysed in December and presented afterwards. Drugs of this type may protect the brain in the early stage and thus have an even larger impact for the stroke patient. A second focus will be on the clot properties. Once we know what type of clot it is, we can tailor the treatment with drugs that either address fibrin, von Willebrand factor or neutrophil extracellular traps. That is where I think the real progress can be found.
What recent publications have caught your eye?
At the risk of getting blamed for quoting my own paper, I do think that we collaboratively should work to standardisation of measurements in our field. We published a paper in the Journal of NeuroInterventional Surgery this year called “Size matters… but how do I know what size it is?”. Our field, as well as cardiology and peripheral intervention, is currently using all kinds of units of measurement to describe our materials (eg. inches, French, 18-system, centimetres). Mistakes are made and it is unclear what device fits in what other device with the current naming. To start a potential revolution we wrote a paper on how this should be changed, and based on an collaborative initiative of SNIS and ESMINT we created a taskforce, with our industrial partners, that will look into creating a comprehensive metrical system for all companies and all products. Obviously there are legal and regulatory implications and the process will take time, but this initiative is something I consider very important.
Could you tell us about a particularly memorable case you have had, and what you learned from it?
The worst case in my life is that of a teenage patient that suffered a hemorrhage from an arteriovenous malformation. Initial targeted embolisation went well, but the follow up surgery was pushed forward because of family pressure. The mother was in the endstage of an oncological disease and she wanted to know that her child would be “cured” before she died. Although the surgery seemed to have gone technically well and the patient woke up the day after, the child died of a re-hemorrhage on day two and the mother the day thereafter.
They were buried together. It showed me that no matter how much you try to help the patient and his family with their valid treatment related requests, it may still be wrong and we should stick with our proven regimen, irrespective if it would have changed the outcome in this case.
From your research and experience, what motivates you?
My main motivation lies in getting answers. I am a person that questions everything, even my own thoughts and opinions, and want to get to the underlying answers and motivations. With research it is the same; why do people claim that one treatment is better than the other, even if there is no clear evidence. I have detected similar biases in my own thinking and I love it when people confront me, even though it may take a while to admit it. It shows me that I am not yet where I want to be.
What advice would you give to physicians at the beginning of their neuro-career?
Do not look up to key opinion leaders and do not believe everything you hear without checking the validity. Try to stay away from people badmouthing other colleagues and putting their egos first, and try to surround yourself with people that bring out the best in you and be that person for your colleagues. Most of all, be honest to your family regarding the time that is involved with this specialty and do not think that it will get better.
Outside of medicine, what are your hobbies and interests?
I have too many and actually need to stop working to maintain them. I love running, cycling, and sailing, but my main hobby is playing and writing music, which actually became a job too. I started a music production company, together with my son, writing film music and songs for artists, as well as producing and mixing. Both my daughter, who studies singing at the conservatory, and my son are gifted musicians and I am very happy that they found a life in the performing arts, rather than medicine. If I only could do it all over again…
Clinical and scientific appointments:
2019–Present: Leiden University Medical Center, the Netherlands – Neurointerventionalist
2014–2019: Karolinska University Hospital, Stockholm, Sweden – Neurointerventionalist
2010–2014: Neurovascular Network NorthSea – Neurointerventionalist
2001–2010: Leiden University Medical Center – Neurointerventionalist
2018–Present: President of ESMINT
2017–Present: Member at large for the World Federation of Interventional and Therapeutic Neuroradiology (WFITN) board
2016–Present: National representative for Sweden in the UEMS section of Neuroradiology
2016: ESMINT annual congress president
- EXMINT stroke course
- ECMINT course
- Examiner for annual ECMINT and EXMINT diploma
- Proctor for SILK and Surpass flow diverters in more than 100 cases
Current research (selected):
SURMOUNT – Principal investigator
SPERO trial – Principal investigator
TENSION – Swedish project coordinator and coordinator for Work Package on training and guidelines
BRAVO – Steering committee member
Emboline study – Clinical events committee member and DSMB
Percutaneous Laser Disc Decompression for Sciatica – Principal investigator, PhD-thesis