Neurosurgery
Physician insights on operative techniques, spinal disorders, neuro-oncology, cerebrovascular disease, and functional neurosurgery.
Recent Discussions
Under what circumstances do you consider placement of a reservoir for infants with congenital hydrocephalus?
Only if the baby is premature or there is a contraindication to permanent diversion (hostile abdomen, systemic disease, infection of unknown etiology, etc.)
In light of the ROADS data, how are you choosing between intraoperative tile-based radiation therapy (TBRT) and postoperative SRT for newly diagnosed resectable brain metastases?
In light of the ROADS data, I would be cautious about broadly changing practice at this point. While the local control benefit with cesium-131 GammaTile is impressive and biologically plausible, reported OS is much harder to reconcile. A 26% absolute improvement in 2-year OS from a local therapy int...
What is your timeline for restarting anticoagulants for patients with a recent craniotomy for hematoma evacuation who are also on an LVAD?
As with many clinical situations, this is a clinical decision that should be made by the treating neurosurgical/cardiology team for the specific patient - not from general literature alone, as there is no dedicated randomized controlled study-based guideline for this exact combination. As a general ...
Under what circumstances do you decide to place an EVD for patients with cerbellar ischemic stroke?
Although placement of an EVD in a patient with cerebellar infarction can be lifesaving, I rarely use it as a sole treatment for that condition due to the risk of upward herniation. Typically, when the cerebellar infarction has created enough mass effect to cause hydrocephalus, the patient also requi...
What is the best time frame to utilize intra arterial verapamil for vasospasm after subarachnoid hemorrhage?
We do not use AA verapamil prophylactically. We follow our patients in the Neuro ICU with daily transcranial Doppler. If they have clinical signs or symptoms of vasospasm and TCD and CTA evidence of spasm, we take them immediately and usually perform IA injections daily until radiographically and cl...
Which patients do you give LITT (laser interstitial thermal therapy) for intracranial radiation necrosis?
So we don’t believe that one single option is ever the answer for any condition. Avastin works quickly but has both neurological and systemic complications, and there are medical conditions that preclude use of this drug. In addition, there is early evidence to suggest that lesional response duratio...
For which patients would you consider using stealth for placing hardware for cervical fixation?
Usually for complex revision cases with loss of normal anatomical landmarks.
How do you counsel patients who do you not experience early relief of hemifacial spasm after microvascular decompression surgery?
From a neurology standpoint, I counsel patients (preferably ahead of time) that surgery has a reasonable chance of improving hemifacial spasm but is not always effective. There can also be both early and late (reemergent) persisting spasm. I have treated some patients after MVD with botulinum toxin,...
Should ultra-short course RT be standard for elderly or poor performance status patients with glioblastoma?
The recent phase III randomized trial published by Roa et al. examining the efficacy of short course radiotherapy in elderly and/or frail patients with newly diagnosed GBM builds upon his previous work finding equivalent outcomes in elderly patients (age > 60 years) receiving 60 Gy in 30 fractions ...
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...