Neurosurgery
Physician insights on operative techniques, spinal disorders, neuro-oncology, cerebrovascular disease, and functional neurosurgery.
Recent Discussions
How do you approach treatment of a craniopharyngioma in an older adult patient?
There is a bimodal age distribution, with one peak in children between 5 and 14 years old and the second peak in adults between 50 and 75 years of age. Adamantinomatous (frequently with calcification) craniopharyngiomas are more common in children, while papillary (frequently lack calcification) cra...
What is your approach to using intra-arterial or intrathecal vasodilators in patients with vasospasm in subarachnoid hemorrhage despite usage of oral nimodipine?
Bottom line up front: The 2023 AHA/ASA focused update on aSAH recommends IA vasodilator infusion or mechanical angioplasty in clinically significant vasospasm refractory to medical therapy (Class IIa, Level B) and states that intraventricular nicardipine “may be considered” in selected patients (Cla...
Under what circumstances do you utilize an EVD rather than a lumbar drain for management of CSF leak after a transphenoidal resection?
Rarely is there any indication for CSF diversion at all for CSF leaks after translabyrinthine craniotomy. The reason for this is that, by definition, patients have no hearing on the operated side. Blind sac closure of the external ear canal and direct packing of the Eustachian tube successfully trea...
Is it acceptable to treat newly diagnosed small cell lung cancer with limited brain metastasis with upfront SRS?
First, to be clear, there's not good evidence regarding the role of radiosurgery in small cell patients who have not had WBRT or PCI. In patients without brain metastases, there's a clearly defined and clinically significant survival benefit, which seems to result from both control of existing metas...
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