Neurosurgery
Physician insights on operative techniques, spinal disorders, neuro-oncology, cerebrovascular disease, and functional neurosurgery.
Recent Discussions
Is there a role for using an external ventricular drain (EVD) trial in the workup of normal pressure hydrocephalus?
Typically, the work-up of normal pressure hydrocephalus involves either a large volume lumbar puncture or a 48-72 hour lumbar drain trial (and sometimes both). An external ventricular drain would be too invasive.There is an excellent review article that was recently published regarding this topic:Ca...
What medications are preferred and contraindicated for insomnia in patients with a recent stroke or traumatic brain injury?
In acute brain injury (ABI), which includes stroke and traumatic brain injury the focus is often on neurorehabilitation. The presumption here is that the patient is medically and neurologically stable. For example, not having a stroke in evolution, uncontrolled gastrointestinal bleeding, or similar....
What is your timing for angiogram and treatment for patients with sentinel bleeds from recently discovered aneurysm?
My general approach is to obtain vascular imaging emergently, typically CT angiography as the first-line study at the time of presentation, given its speed and wide availability. If CTA is negative but clinical suspicion remains high, I proceed to digital subtraction angiography (DSA), which remains...
What is your approach to return to play of a contact sport after mild concussion in children?
My approach to return to play (RTP) after a mild concussion in pediatric patients follows the Concussion in Sport Group (CISG) consensus guidelines (Patricios et al., PMID 37316210), adapted for the developing brain.Following a concussion, I recommend a minimum 24-48 hours of relative rest before in...
For sellar tumors with suprasellar extension, how do you decide between an endoscopic approach versus a craniotomy?
Cranial will be preferable for a very extensive suprasellar extension of the tumor. If the majority of the tumor is intrasellar and the carotid arteries are far apart enough, then a transnasal endoscopic approach is reasonable to consider, as long as the tumor in the suprasellar part is not lateral ...
How has the EMBOLISE trial changed your practice regarding concurrent subdural hematoma evacuation and MMA embolization?
We prefer concurrent with Borvo/SEPS and embo in the angio suite; however, if the patient presents after hours, we do Borvo/SEPS upon presentation and embo the next day. Basically, two procedures under local and sedation, either together or part-based on convenience.
In the case of concomitant tethered cord and Chiari malformation with syringomyelia, how do you determine priority of treatment?
I am an old-fashioned physician in addressing this interesting question. The answer depends on the clinical symptoms and the degree of disability the patient is experiencing. This means performing a careful clinical assessment of what is the major problem the patient is having and how surgery would ...
Under what circumstances do you consider duraplasty for Chiari 1 decompression?
I always place a duraplasty for Chiari 1 to increase the space around the tonsils and attempt to resume normal biphasic flow of CSF anteriorly and posteriorly.
What is the best approach in a patient with a single brain metastasis in the setting of progressing systemic disease?
There is no single "best approach" for a single brain metastasis, even in the setting of progressing systemic disease. First, ask if it is obvious that a single lesion is a brain metastasis. The patient needs to be made aware that the diagnostic error rate can be as high as 15%. If unsure, then tiss...
What criteria do you use to select elderly patients for focused ultrasound thalamotomy?
Elderly patients are perfectly suitable for MRgFUS treatment and are considered if their tremor is resistant to appropriate medical therapy, including propranolol and/or primidone. It should be equal to or greater than 2 on the FTM scale for tremor, and interfere substantially with daily activities ...