Neurosurgery
Physician insights on operative techniques, spinal disorders, neuro-oncology, cerebrovascular disease, and functional neurosurgery.
Recent Discussions
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 ...
Under what circumstances would you use onyx rather than coils to treat a ruptured aneurysm?
Onyx is rarely used for the typical ruptured saccular aneurysm, given the range of excellent endovascular alternatives: coils, flow diverters, and intrasaccular flow disruptors such as the WEB device. Its current role is as a liquid embolic for vessel sacrifice in complex fusiform or dissecting aneu...
When do you consider treatment with temporal bone windows to decrease intracranial pressure for patients with Idiopathic Intracranial Hypertension?
I would consider this an outdated operation. There are several better ways of treating this.
For patients with hydrocephalus secondary to leptomeningeal disease, how do you determine what type of shunt device to place?
For my small part, please ask neuro-oncology if they plan to use intrathecal chemo (and need a hybrid with Ommaya).
When do you consider EVD in pediatric severe TBI when initial imaging is unremarkable?
The guidelines state that intracranial pressure monitoring is indicated for severe TBI when GCS is 12 or less, regardless of what the head imaging looks like. Either a bolt or an EVD can be used for measuring intracranial pressure. In cases where our index of suspicion for elevated intracranial pres...
What is your approach to the management of a patient with traumatic unilateral perched facets?
I like to have a go at awake closed reduction under fluoro, with flexion, contralateral lateral bending, and rotation toward the side of the injury. That is purely an option, however. Since this deformity is reducible from either front or back, the ORIF approach is the dealer’s choice, although the ...
How do you manage spinal cord compression in a new suspected neuroblastoma diagnosis?
While there is evidence that chemotherapy, surgery, and radiation can all be effective for some patients,1 there are no definitive studies or data that prove the best approach for all patients. A 2017 systematic review concluded that the “currently available literature remains suboptimal as a guide ...
What specific exam findings or test changes prompt escalation of care when evaluating pediatric patients with optic disc drusen for possible increased intracranial pressure?
Both pediatric and adult patients with optic disc drusen can develop increased intracranial pressure, including IIH, like normal individuals. This is important to remember, especially if the symptoms and risk factors suggest elevated intracranial hypertension. In the pediatric group, especially youn...
When do you consider using general anesthesia for endovascular thrombectomy?
I perform all of my thrombectomy cases under general anesthesia. There is better hemodynamic control, no patient movement to manage, which increases procedural efficiency as a result. In moderate sedation cases, patients can feel aspiration and stent retriever passes through the vessel, which causes...
How do you determine when to transition a patient with a shunt placed at birth to an adult provider?
Ideally, when you have a pediatric patient with a longstanding shunt, you begin discussions with the family at the initial placement, helping them understand that a shunt is usually a lifelong device that will require follow-up in some manner the rest of the child's life. When the child is entering ...