Neurosurgery
Physician insights on operative techniques, spinal disorders, neuro-oncology, cerebrovascular disease, and functional neurosurgery.
Recent Discussions
In patients with vertebral bone metastases, what criteria do you use to select patients for kyphoplasty referral prior to palliative radiotherapy?
In patients with painful malignant verterbral fracture without overt instability or neurogenic compression that would warrant surgical consultation, kyphoplasty can be considered either before or after palliative radiotherapy. Vertebral augmentation to achieve immediate pain relief prior to radiothe...
When do you consider using stimulants in patients with cognitive impairments secondary to traumatic brain injury?
Perhaps most importantly, prescribing medication to address cognitive difficulties conveys hope to TBI patients that even if they have suffered structural brain damage, they can improve. Though the improvement may be fairly small, it can have important implications for better general functioning. We...
Do you routinely administer desmopressin to patients with intracerebral hemorrhage who are also on anti-platelet therapy?
I routinely administer desmopressin in patients presenting with ICH if they are on dual antiplatelets but not single antiplatelets. The evidence for this is limited, but it has not revealed any harm.
Do you have a size limitation (e.g. >3cm) for offering SRS for pituitary adenomas if OAR tolerances can otherwise be respected?
While pituitary adenoma size plays a role in my decision making for SRS, I would also take into account dose constraints to the optic apparatus. For single fraction, I like to keep my optic nerve and chiasm max dose under 8 Gy. If I am unable to achieve that, I would consider hypofractionation in 3 ...
Should pituitary suppressive medications be stopped prior to radiosurgery for patients with a functioning pituitary adenoma?
The first reported significantly lower hormone normalization rate was in acromegaly patients who were receiving antisecretory medications at the time of radiosurgery. Subsequently, similar finding was reported in prolactinoma patients. The suggested rationale is antisecretory medications alter cell ...
How do you approach the adjuvant treatment of glioblastoma following up-front laser interstitial thermal therapy (LITT)?
This is an emerging area with very limited information; there are no large prospective trials to adequately answer the question. The issues faced by a Radiation Oncologist include: 1. Interpretation of the post-op scan: what is the true GTV? This remains unclear; we include all enhancing abnormality...
What is your strategy for treating persistent headaches in the aftermath of subarachnoid hemorrhage?
In the immediate aftermath of a subarachnoid hemorrhage, regardless of whether the aneurysm has been secured or not, the following strategies can be employed to manage headaches: Headache Cocktail: This may consist of magnesium infusions, Benadryl, and an antiemetic like Compazine. Magnesium infusi...
How often do you monitor pituitary adenomas once established as non-functioning?
That depends on the size and location (close to the chiasma?). Without pathology, which may help determine aggressiveness (mitotic rate, Ki67), it is impossible to predict the growth rate. For macros, I repeat an MRI in 6 months, and, if no change, I double the interval. For micros, there is recent ...
Do you recommend adjuvant radiotherapy for an adult patient with localized myxopapillary ependymoma, WHO Grade 2, status-post gross total resection?
I assumed that this is a case of spinal ependymoma. Myxopapillary ependymomas are rare tumors and optimal therapeutic strategy involves a Gross Total Resection (GTR). The more complete the surgery the better the outcome. The role of postoperative radiation after a GTR is somewhat controversial but I...
Do you utilize tumor treating fields in patients with anaplastic pleomorphic xanthoastrocytoma (PXA) III?
I would, but I haven't actually had the opportunity. With more information appearing that TTF is effective in brain metastases, mesothelioma, and pancreatic cancer, why wouldn't you use it if you didn't have a better option? The only real risk is financial.