Neurosurgery
Physician insights on operative techniques, spinal disorders, neuro-oncology, cerebrovascular disease, and functional neurosurgery.
Recent Discussions
For trigeminal neuralgia in patients with multiple sclerosis, do you consider microvascular decompression or stereotactic radiosurgery as treatment options?
Secondary trigeminal neuralgia attributed to multiple sclerosis occurs when there is an "MS plaque at the trigeminal root entry zone or in the pons affecting the intrapontine primary afferents" according to ICHD-3. Note that according to ICHD-3 "Pontine lesions affecting the second order neurones of...
Do you routinely check CSF cell counts and cultures on patients with external ventricular drains to monitor for infection?
I think protocols still vary widely by institution, but we only check CSF cell counts and cultures from an EVD if there is a clinical concern for hospital-acquired meningitis/ventriculitis. It is clear that the more times you access the EVD setup for CSF collection, you are increasing the risk for i...
How do you utilize Diamox in patients with cerebral venous sinus thrombosis and vision symptoms who do not undergo thrombectomy/recanalization?
Diamox (acetazolamide) is often used to treat papilledema with associated visual loss in cases of CVST. While there is a theoretical risk of dehydration from acetazolamide with potential worsening of the thrombosis, 1) acetazolamide is a weak diuretic and 2) the risk of blinding visual loss usually ...
How do you manage incidentally found venous sinus thrombosis?
I would make sure first that it is not simply a congenitally small sinus. If there is truly a CVST, I would probably treat with a DOAC for 3 months and reassess with CTV.
Under what circumstances do you consider Mayfield pinning for fixation during a translabyrinthine approach for vestibular schwannoma resection?
I cannot think of any case in which using a Mayfield for translabyrinthine craniotomy for vestibular schwannoma resection is beneficial. Stretching to think of some reason, perhaps use in a patient with a high BMI, large shoulders, and a short neck could be helpful to achieve adequate head rotation,...
How do you manage radiotherapy for a glioblastoma when there is a delay in starting systemic therapy?
It depends on whether we are discussing a post op vs unresectable patient.It is okay to delay in post op imo up to 4-6 weeks out after a GTR. I would not start within 2 weeks after biopsy, regardless of temodar authorization in an unresectable patient.Blumenthal et al., PMID 19114694
How do you approach treatment of an optic nerve sheath meningioma?
I typically do 50.4 in 28 fractions with a stereotactic technique. We use both co-planar and non-coplanar arcs. I keep the optics point max to 54 Gy. Several single institution series including: MacLean et al. IJROBP 2013, Bloch et al. (UCSF) JCNeuroSci 2012, Ratnayake et al. (Australia) JCNeuroSci ...
Under what circumstances would you consider offering a re-do microvascular decompression?
Performing a redo MVD is usually not a high-yield intervention. Teflon pledgets tend to stay in place, and it is highly unlikely that they would move once healing has taken place. So if the goal of surgery is to see if the Teflon has moved out of position, that’s usually a disappointing exercise. If...
What is your approach for tapering steroids after craniotomy for tumor resection?
Benign disease (i.e., meningioma) without significant edema - taper dexamethasone off over 5 days. Benign disease (i.e., meningioma) with edema - taper dexamethasone off 7-10 days. Malignant low-grade glioma - taper dexamethasone off over 7-10 days. Malignant high-grade glioma - taper dexamethasone...
Which imaging features do you use when considering Normal Pressure Hydrocephalus to decide whether to proceed with large-volume LP or lumbar drain trial?
At our center, we follow the approach of the NPH clinic at the Imperial College Hospital in London.See this excellent review article for further details: Carswell, PMID 36162853.