Neurosurgery
Physician insights on operative techniques, spinal disorders, neuro-oncology, cerebrovascular disease, and functional neurosurgery.
Recent Discussions
How do you approach treatment of an optic nerve sheath meningioma?
I typically do 50.4 in 28 fractions with a stereotactic technique. We use both co-planar and non-coplanar arcs. I keep the optics point max to 54 Gy. Several single institution series including: MacLean et al. IJROBP 2013, Bloch et al. (UCSF) JCNeuroSci 2012, Ratnayake et al. (Australia) JCNeuroSci ...
Under what circumstances would you consider offering a re-do microvascular decompression?
Performing a redo MVD is usually not a high-yield intervention. Teflon pledgets tend to stay in place, and it is highly unlikely that they would move once healing has taken place. So if the goal of surgery is to see if the Teflon has moved out of position, that’s usually a disappointing exercise. If...
What is your approach for tapering steroids after craniotomy for tumor resection?
Benign disease (i.e., meningioma) without significant edema - taper dexamethasone off over 5 days. Benign disease (i.e., meningioma) with edema - taper dexamethasone off 7-10 days. Malignant low-grade glioma - taper dexamethasone off over 7-10 days. Malignant high-grade glioma - taper dexamethasone...
When do you consider hemispherectomy for patients with Rasmussen encephalitis with stable epilepsy and preserved function of the affected half of body?
Depends on several factors. First, how debilitating are the seizures? If the person cannot function, like going to school for children or adult activities, then surgery to stop the seizures should be considered. Also, age is a factor. Children under the age of 5 years should be considered to make us...
How would you manage a CVST secondary to a traumatic brain injury with the presence of intracranial hemorrhage?
When dealing with CVST after TBI, the mechanism of injury is not the same as a spontaneous CVST. There is often direct injury to the vein or the area overlying it. Given that these patients often have other traumatic injuries, and given the lack of clear evidence to support one therapy or another, I...
In patients with confirmed hypercortisolism with a high/normal unsuppressed ACTH who have both a pituitary adenoma and adrenal adenoma identified on imaging, can you reliably use DHEA-S to determine the source of cortisol production?
There is a difference between high-normal and unsuppressed ACTH. If ACTH is high-normal, this is ACTH-dependent Cushing. However, you can have mild adrenal Cushing without fully suppressed ACTH (e.g., ACTH in the 10-20 pg/ml range and sometimes even above 20). I don't think you can rely on DHEAS in ...
Under what circumstances would you consider transitioning back to a ventricular peritoneal shunt from a ventricular-pleural shunt?
If a VPleural shunt is working and well tolerated, there is generally no reason to move it, as for many older patients (usually beyond early childhood) these shunt are well tolerated with no long term complications. If there are recurrent issues, such as pleural effusions or a patient with poor resp...
At what point do you consider referring for neuromodulatory treatments (TMS, deep brain stimulation) for treatment refractory-OCD?
This is a fantastic question! Although I do not use a standardized "protocol" to determine when to refer for TMS or DBS, I typically think about this in terms of (a) medication trials, (b) comorbidities, and (c) OCD severity.Medication TrialsI would only consider TMS after trialing multiple serotone...
How long after resection for brain metastasis do you wait to request a radiation planning MRI?
This is a good question, and I agree with the sentiments above. I think there are two competing issues here--1) evolution of the cavity and 2) regrowth of microscopic disease.While intuitively, one might think that waiting longer might allow the brain to normalize and the cavity to shrink, our data ...
How would you approach a patient with recurrent grade 3 oligodendroglioma (MGMT-methylated, IDH mutant, 1p/19q co-deleted) 1 year after gross total resection and adjuvant chemotherapy and radiation?
There are multiple options to consider for the recurrence of grade 3 gliomas after prior chemotherapy or radiation. Regardless of whether or not the recurrence overlaps completely or partially with the prior treatment fields, options include systemic therapy (including IDH-targeted therapies for IDH...