Neurosurgery
Physician insights on operative techniques, spinal disorders, neuro-oncology, cerebrovascular disease, and functional neurosurgery.
Recent Discussions
Would you offer post-operative SRS/SBRT in the case of a resected brain metastasis from metastatic NSCLC with an EGFR mutation?
Absolutely. For symptomatic brain metastases, I would not rely on the efficacy of systemic therapy alone either in the intact or post-operative setting. CNS objective response rates are around 60% for osimertinib with DCR around 90% which is quite good. However, intracranial complete response rates ...
How are you incorporating 68-Ga Dotatate PET scans in the management of grade I/II meningiomas?
Thank you for posing such a leading-edge question. I surmise its answer may have a rather different din a few years from now. However, to date, I am not using DOTATATE PET for meningioma. This is due partly to habit, availability, insurance constraints, and the specific clinical circumstances of the...
How often do you screen for cerebral aneurysms in patients with autosomal dominant polycystic kidney disease who do not have a family history of intracranial aneurysms or for whom the family history is unknown?
We recently wrote an editorial about this topic. Our conclusion was as follows: "considering the potential for morbidity and mortality in this unique population at risk for ICAs with possibly higher-than-average risk of rupture, we believe that presymptomatic screening for ICA in all individuals wit...
How do you determine timing and frequency of stability scans for a patient with spontaneous, non-aneurysmal intracerebral hemorrhage?
We typically obtain a follow-up “stability scan” about 6 hours from the index scan. The AHA guidelines do not mention a specific timeframe. Situations, where we would consider sooner repeat imaging, would be clinical deterioration (increase in NIHSS by 4 or more points or decline in GCS by 2 or more...
What antibiotics would you use for empiric treatment of a brain abscess in patients allergic to penicillin, metronidazole, and vancomycin?
Linezolid/Bactrim/Ceftaroline?
Should follow-up imaging for unruptured intracranial aneurysms include MRA head and MRI brain to evaluate for arterial wall enhancement?
I prefer CTA to assess asymptomatic intracranial aneurysms if there are no concerning morphological features (e.g., daughter-sac, bi-lobed, or dysplastic/irregular shape) and if the size is less than 5 mm (although size/rupture risk can vary depending on the location of the aneurysm). CTA is easier ...
How would you manage a local recurrence of a spinal hemangioblastoma following prior surgical resection alone?
Hemangioblastomas are benign rare tumors that arise from the linings of blood vessels (embryonically arrested hemangioblasts) and can form in the brain, spinal cord, and retina. When they occur in the spine, they have a tendency to recur ~25% of the time. The primary treatment for a recurrent spinal...
Do you routinely recommend suppressive antibiotic therapy for patients with spinal hardware infections who have undergone surgical debridement with retention of hardware?
Executive Summary: "State-of-the-Art Review: Diagnosis and Management of Spinal Implant Infections" was published in Clinical Infectious Diseases, December 15, 2024 issue, by Tai and colleagues from the University of Minnesota, Mayo Clinic, Hospital for Special Surgery (New York) and the University ...
Under what conditions would you offer observation for asymptomatic low volume brain metastases?
This is becoming an increasingly more common scenario with patients undergoing routine brain MR for staging, even in the absence of symptoms, and also, with a very modestly small number of settings demonstrating excellent radiographic responses to targeted agent or immune checkpoint inhibitors (ICI)...
When do you consider treating intracerebral hemorrhage associated with cerebral amyloid angiopathy as an inflammatory CAA?
Inflammatory CAA should have areas of edema, often with microhemorrhages within.