Neurosurgery
Physician insights on operative techniques, spinal disorders, neuro-oncology, cerebrovascular disease, and functional neurosurgery.
Recent Discussions
How do you manage a recurrent craniopharyngioma?
Complex answer—my personal view based on my Neurosurgery and SRS/RO experience:1. If the recurrence is a single large cyst—surgery (stereotactic aspiration combined with SRS to collapsed cyst immediately, have done the same day) or Intra-cavitary P32.2. If it's a small solid/micro-cystic recurrence—...
How would you manage an enlarging brain metastasis that has progressed in size three months after radiosurgery?
Before making a decision, I would want to know the tumor histology, SRS dose delivered, and whether the current site of progression is truly within the prior radiation field (using new MRI fused to the SRS plan in treatment planning software). If the lesion is within the high-dose region and the pat...
For which patients do you consider stereotactic radiosurgery rather than focused ultrasound for treatment of essential tremor?
Stereotactic radiosurgery (SRS) thalamotomy has a very limited role in my practice. Although SRS can provide meaningful tremor reduction and is an option for patients who are not candidates for DBS or MR-guided focused ultrasound (MRgFUS), I only consider it in highly selected circumstances, primari...
How do you counsel patients who do you not experience early relief of hemifacial spasm after microvascular decompression surgery?
HFS is unique in that neurovascular compression is always the cause, and the location of NVC is almost always at the initial segment of the emerging facial nerve at the pontomedullary junction. High-resolution imaging pre-op using sub-millimeter voxel T2 MRI (BFFE) and MRA (source images) is recomme...
What factors would influence your decision to use or avoid heparin bridging in patients with mechanical heart valves resuming anticoagulation after intracerebral hemorrhage?
The main conclusion from the publication by Sakusic et al., PMID 39102615 was that withholding anticoagulation for the first seven days after ICH is safe in patients with mechanical heart valves and bridging with intravenous heparin to coumadin upon resumption of anticoagulation should be avoided. T...
How do you approach treatment of a glioblastoma in pregnancy?
Glioblastoma during pregnancy could be treated safely (to mother and fetus) with certain precautions and modifications. Collaboration and consultation with the patient’s obstetrician are essential. External shielding over the patient’s abdomen during treatment will decrease the external scatter radi...
How do you manage glioblastoma presenting with leptomeningeal dissemination?
Hospice is a very legitimate option. As physicians, we recommend this far too infrequently.
What is your approach for an intact patient who is found to have new concurrent superficial cortical brain and lumbar spine masses?
In our center, a colleague of mine specializes in spine onc and I specialize in brain metastasis; therefore, we decide on the best course of action and sequencing. It hasn't arisen yet that there were two simultaneous critical cranial and spine lesions; usually, one is higher priority than the other...
How would you approach patient selection for DBS after chronic post-stroke for motor rehabilitation in light of the recent phase 1 clinical trial?
These two neurostimulation modalities occupy fundamentally different positions in the treatment landscape. VNS paired with rehabilitation (Vivistim) is the only FDA-approved neuromodulation therapy for chronic post-stroke upper-extremity motor rehabilitation, supported by a pivotal phase III RCT and...
What is your approach to treating 4th ventricular tumors in order to reduce the risk of cerebellar mutism?
I tried to use the telovelar approach to fourth ventricular tumors when at all possible, avoiding having to split the vermis whenever possible. I also find that this gives a great view of the fourth ventricle by simply lifting up the cerebellum.