to the stage. Dr. Haynes has done yeoman's work with the Van Wagenen committee, ensuring that we have the highest quality of candidates and fellows through that generous gift of many years ago, and we look forward to hearing our lecture today. Steve, thank you. Thank you. The Van Wagenen lecture has been given annually at the AANS meeting since 2003, named after the first president of this organization and funded through the generosity of Dr. and Mrs. Van Wagenen, the lecture has highlighted some of the great basic and clinical advances in neurosurgery. Seven of the lectures have been given by mentors chosen by former Van Wagenen fellows for their fellowship training. Today will be the third lecture given by a former Van Wagenen fellow. The Van Wagenen fellowship celebrated its 50th anniversary last year. It provides a unique opportunity for graduating neurosurgeons intent on an academic career to realize the dream of learning at the side of an otherwise inaccessible mentor outside of the United States, and bring a combination of new knowledge and skills back to American neurosurgery. It can open the doors to innovation. It helps keep neurosurgery vibrant. In the 50 years since its inception, 44 of the 45 former Van Wagenen fellows for whom we have the information started their careers in academic neurosurgery. 43 of 50 are still in or completed their careers in academic neurosurgery. At least 14 have become department chairs in 16 different medical schools. Five have been president of the Congress of Neurological Surgeons, three honored guests of the Congress, and one president of this association. They've received tens of millions of dollars in federal research funding and many patents. No one better exemplifies the value of the Van Wagenen fellowship than today's observer. Dr. Lunsford took advantage of the fellowship to go to the Karolinska, work with Lars Luxell, and learn what Dade likes to call civilized brain surgery. He brought the gamma knife to America and popularized it, profoundly changing the practice of neurosurgery. Everyone who has used or been treated by the gamma knife has benefited from the Van Wagenen fellowship. The highlights of Dr. Lunsford's remarkable career are in your program. He's a graduate of the University of Virginia and Columbia University College of Physicians and Surgeons. He did his residency at the University of Pittsburgh. Pittsburgh has been the residency home of five Van Wagenen fellows. Dade was the first and most influential. He brought the gamma knife to Pittsburgh, spent his entire career there, and changed the practice of neurosurgery everywhere. Dr. Lunsford. Well, thank you. I'm deeply honored to be the lecturer here today. It's a pleasure to be here. Especially after the 50th anniversary of the creation of the Van Wagenen Award. I think that sort of the goal that I thought I was given was to do two things. One, in the hopes that there are some remaining younger people in the audience that could be recruited to consider the Van Wagenen fellowship. And secondly, to emphasize to us older members that contributions to sustain this fellowship would be welcome. So, Steve has given you a little bit of information about this. I'm going to expand that just a little bit. These are my conflicts. Either I'm not working or it's not working. I'm not working. I'm not working. So, just to reemphasize what this is, it's a 12-month fully funded experience every other year at the present time. And I congratulate the winner for this year from Stanford, Kai Miller. The goal is to do this within two years of completion of your training, post-residency training. He was first awarded in 1968 to Richard Berglund who went to Oxford. He, as some of you in the audience may remember, wrote an article somewhat after that saying that neurosurgery may die, which we're glad to see was not prognostically correct. That we're all still functioning well. There have been 53 fellows. The application is open to senior neurosurgery residents and supports a one-year outside of North America selected by a committee of the ANS. And the current award, and I'm going to show you the past in a minute, is $120,000 plus additional expenses to cover you so that, in fact, you can live quite okay for that year. Criteria for the award are originality, quality of the proposal, rigor of the design, personal attributes of the applicant, quality of the research environment, and the next award will be in 2020 to 2021 with applications due this fall. So Steve indicated what was the origins of this goal of William P. Van Wagenen. He was born in 1897 in upstate New York, went to Cornell and Harvard, trained at the Brigham with Harvey Cushing and did fellowship training in Germany with financial support directly from Cushing himself. He studied in Munich and Brasov. He had a special interest in epilepsy and, in fact, had a subsequent collaborative effort with Wilder Penfield in Montreal, and he became the chief of neurosurgery at Rochester. He had a neuroscience interest, and this fellowship has had both clinical focus as well as research focus in its many people who have gotten the award. He emphasized that there was importance of travel, as Cushing himself told him, looking for new advances, new techniques, ways to improve neurosurgical care and advance scientific knowledge. He, as you know, was the first president of the Harvey Cushing Society, now the AANS, and served as the first president of this organization in 1932. His goal in the creation of this was to support trainees to travel and observe before they're beginning their academic career, to help jumpstart it. He wanted to eliminate some of the restrictions that were necessary in other types of grant applications to make the travel associated with it to be valuable. He wanted to specialize both clinical as well as research skill acquisition. So the award winners of this have been spread through many U.S. academic medical centers, more than 4,500 academic publications with 18 chairs that I counted to date, and has an impact factor of those who have written and published after they're ranging from 22 to 104. There have been milestone publications in stereotactic surgery, pediatrics, radiosurgery, epilepsy, trauma, and oncology. As I look at where people have gone over these years, the United Kingdom is number one, but we see several other countries represented in this, and seven who went to Sweden over the years, which is where I spent my time. Academically, I think it clearly jumpstarted a number of practices. At least 11 chairs in this first 30 years of this. It takes time, obviously, to work your way up the academic ladder. In the first 30 years, 13 became full professors, and only six in practice alone. So I'm going to take a few minutes to go back historically as to when I started on this particular process. We were, as you might have understood, after the closing of the Vietnam War, we were sort of a motley crew, and I share only one thing with Dan Wagonen, and I think that was the fact that I also had a mustache at that time. So in 1978, I had been working on a research project to try to combine image guidance with technologies. Remember at this particular time, the field of stereotactic surgery had suffered significantly because of the development of agents for Parkinson's disease, and so nobody actually knew how to do much stereotactic work at that particular time. And I had this concept that we could build a guiding device with the first CT scanner that was in the system at that time and actually do surgery in the CT scanner. So I did something which I don't advise anybody to do anymore, since nobody knew how to do stereotactic surgery at the time in this particular place in Pittsburgh. I did it on my own on some 13 patients by building a device with the only technology assistant sort of third world, I guess you would have to say, was the CT scanner tech herself. The next step was, as I envisioned perhaps spending some additional time where stereotactic surgery was being done in Europe, I needed to find a mentor. And so it's ironic in a way that some 50 years ago at this meeting, I ran into Eric Olof Backlund, this individual here, an outstanding guy who was working on the marriage of imaging and surgery, as Lex Hell had been his major mentor himself. And he said, why don't you come visit Stockholm? So I persuaded Peter Jededa, my chairman at the time, to take three months and go to Stockholm and Zurich to look at opportunities there, focusing on less invasive types of surgery, functional neurosurgery. In the fall of 1979, I applied for the bandwagon and award, and I was awarded this in March of that year. Now that was coming a little bit close to the end of when you should have a real job. Because I was graduating in June of that year. So I came home to two people. First to my wife, and I said, I have great news. I just received this award. We're going to go spend a year in Stockholm. And basically we left Pittsburgh kicking and screaming, this is the worst idea I've ever heard. We had a two-year-old daughter at our time. I can tell you a year later when we returned, I came back with my wife kicking and screaming, why don't we just stay here? This is so much better. So I went to Peter Jededa, who had been negotiating with my chairman at that time, well, don't you think you ought to build a stereotactic program here again? And he had been relatively noncommittal until I came to him at this point with this award. And I said to him, I have great news. And finally at that moment, he finally said, okay, I guess I'll have to give you a job. And that was actually good, because it was more than that. He agreed to help underwrite that time in Sweden. The actual award was given at the business meeting of the AANS. I didn't actually realize at that time that this is why it's so much better now. Dr. Jededa and Eugene Stern, who recently passed away, were not good friends. So the award was given at the business meeting. There were five people in the audience at that time. So I had the opportunity to go spend this year at the Karolinska Institute. And just to put it into perspective, the stipend for the Van Wagenen was $10,000 for a year to live in Sweden. At that time the Kroner was $4 per dollar. And if you even rounded it up to today's money's worth, it would still only be $29,000 worth of income. Now it's $120,000. We were so desperately in need of a vegetable that in the holidays in 1980, we went down to the market and bought a $4 cauliflower just to be able to have a fresh vegetable. I had the opportunity to work with two outstanding pioneers, Lars Lexell and Eric Backlund. Backlund was a pioneer in the treatment of craniopharyngioma. He had taken work done in 1947 when Lars Lexell said we can stent the aqueduct of sylveus. He did it stereotactically. He was a pioneer in craniopharyngioma management with intracavitary irradiation and of course radius surgery. But the variety of techniques that I learned during that particular year, stereotactic surgery with Backlund, Lexell, functional neurosurgery with Bjorn Mayerson here, glycerol rhizotomy because believe it or not, not every patient had a perfect result with a microvascular decompression. There needed to be another minimally invasive procedure in the patients who failed that. And radius surgery obviously which became part of what I did with a number of friends and you've seen this picture of trying to create sort of a civilized form of brain surgery. So Hawkinson's technique was serendipitous. He had found that in preparation for doing gamma knife, you need to have a target. You put glycerol into the nerve with a little bit of a marker, a tantalum powder. Then while you're waiting to do the gamma knife, the pain actually went away. And so we learned this particular technique. When I came back to Pittsburgh in 1981, I had this plan to build a stereotactic and functional program. We developed a CT scanner operating suite but the first CT scanner in the operating room in 1982. At that time there were only two CT scanners in the city of Pittsburgh. And in order to justify this, we had to tell the health systems agency which monitored expensive technologies that this was not a diagnostic device. It was a therapeutic tool. And we sold it on that basis and then we created this operating room. So innovation of these techniques I learned in Sweden were important to pursue. I thought one was this concept of you could actually drain a colloid cyst stereotactically with the patient awake. And Lexell and I collaborated on a paper to allow the technology to do this and do interoperative imaging. But sometimes that's not enough. You could expand this entering into a colloid cyst using a technique that Haydon Joe taught me about putting a small tubular retractor in and moving this endoscopically. But clearly one of the things I was interested in was the evolution of radiosurgery at our center starting out with the earliest generation device and over the last two years the most recent device. And over time this led our program to be able to pursue over 15,000 patients who have had radiosurgery in our program. And what we started out was realizing that while Lexell's vision of the usage of this tool was primarily for functional indications such as pain and severe anxiety depressive disorders, the actual role of this grew as a disruptive innovation across multiple aspects of the field of neurosurgery, benign brain tumors, malignant brain tumors, vascular malformations, as well as functional disorders. Facial schwannoma, trigeminal schwannoma was certainly one of the things that we thought could benefit from this pioneering work that had been done in Sweden. My goal became more of a concept of yes, we put in this gammonite but the goal of this we had to show as we have to do with any new technology placed in, does it have value? Does it have value and is that sustaining value? So that became my goal in a variety of these different options. And interestingly, what we saw over the course of time is it changed practice of how we must teach trainees because the number of cases that are undergoing resection here has gone down as the number of radiosurgery cases. Now it's gone down a little bit because everybody has some form of radiosurgical technology. One of the applications was in arteriovenous malformations, especially for difficult AVMs that were high risk for surgical removal. This expanded the options that we could have and others developed for this. We knew again that this could be used for trigeminal neuralgia, so both glycerol, microvascular decompression, this became another part of the armamentarium of treatment of these pain problems. And then of course the largest growth of this occurred with the cautious application of this to treat metastatic disease to the brain. And this really opened the door for hundreds of thousands of cases where neurosurgeons could get involved, rather than just doing craniotomies in the management of this problem. Skull-based tumors, a very big program over the last 30 years at our center. And we wanted to look at the facts of how can we improve cranial neurofunction. We've had one paper at this meeting already, and see what the long-term tumor response was in terms of regression. So one of the things I found out, as all of you do, is that when you try to change a few things, occasionally you find obstacles or people who are doubters or non-believers. Every once in a while you have to take a little bit of flack from people within the field. And when Sam came to take our course, I think the real goal of it was he was trying to see if he could do my lobotomy. We've ended up with 650 peer-reviewed articles, book chapters, and books, all of whom are written by having one of our students, one of our residents, sit down, look at our database, look at the programs, and say, okay, is what was done good? Does it have traction? And should it be pursued? There still are some issues that are present with the Van Wagenen award. As Van Wagenen said to Harvey Cushing himself, he said, look, he's at the end of his training, I've been at the bottom so long, being away a little bit longer won't hurt anything, so maybe I'll go to Europe after all. And what do current residents think? They've been through 20 years of schooling, seven years of neurosurgical training, really, can you devote one more year to additional training? Why don't you just go out and get a real job? We can't do this, which is similar to what my wife's reaction was in 1980. And finally, the funding for this award, which has in the past largely been every year given, needs to be increased enough to be able to do this. So I have to sum this up. What was the value that I found in this as part of a jumpstart of my career? First of all, it was a great time to recover from the PTSD of your chief residency year. It allowed me to focus on the part of neurosurgery that was of most interest to me. I was able to learn some innovative techniques. For others, it will be a research paradigm, technologies that might help change neurosurgery. It gave me a year to sort of have my daughter actually recognize me when I came in the door at night. I really could immerse myself in a new culture and a new language. I was able to work with several of the most creative people in the field of neurosurgery. I was able to help collaborate on technical innovations. I actually learned to write during that time academically. And I made a number of lifelong friends over that time. So in a way, and I've never had a sabbatical since that time, but it was like taking a sabbatical before you started your first job. And I had the honor last year of going back to Sweden to receive the 2017 Oliva Crona Award and visit again with both friends, Dan Lexall, my mentor, now 88 years of age, Eric Backlund, Krister Lindquist, a great friend and colleague, and Sten Hawkinson, who originated the original percutaneous lisseral rhizotomy. We know that there are a number of prestigious scholarships across the world, one of which the Rhodes Scholar, of which there are several neurosurgeons in our group who have had Rhodes Scholarships, and Fulbright Scholars, established by Senator Fulbright in 1946. So I have this sort of proposal for the NREF. Maybe the fellows now could be called the Van Wagenen Scholars. In my view, this is our organization's prestigious scholarship. It was established 50 years ago. It has produced many outstanding academic neurosurgeons. So I want to give special thanks for the offer to give this talk. It's really a great honor to Alex for doing this, Steve Haynes for making very nice comments, and of course followed me as the next Van Wagenen Award the following year. The Van Wagenen family, which began the funding of this Frank Smith, who carried it through the years, the 54 prior Van Wagenen fellows, and as many of you may have seen released online, a lot of the data related to the Van Wagenen Award, and Van Wagenen was recently published online by Tyler Schmidt and Web Pilcher. I'd also like to give my thanks to the many mentors, trainees, fellows, colleagues, and students who all have collaborated over these 38 years since I came back from Sweden for my Van Wagenen Fellowship. I'll leave you with this thought, is that when you're beginning to think of where you're going to jumpstart your career, think about what's out there in the ocean that's just beginning to rise a little bit in the ocean, to begin to sort of think maybe that's where I want to do my focus as you begin to think about building your, look for the small swell out in the ocean, and then go somewhere where you can get special training in order to be able to be an innovator in the future. So, the ANS is a way to jumpstart your career, providing new energy after you complete a busy residency, and I hope you will join me in donating to the fellowship so we can move this back to an every year gift. It is the premier fellowship in my view, and I'm somewhat biased, of our society, and I think it needs to be given every year. Thank you very much.

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