Neurosurgery
Physician insights on operative techniques, spinal disorders, neuro-oncology, cerebrovascular disease, and functional neurosurgery.
Recent Discussions
How do you manage disease progression during adjuvant chemoradiotherapy for glioblastoma?
Hospice.
How do you select patients with spontaneous intracerebral hemorrhage for minimally invasive surgical hematoma evacuation, if offered at your institution?
Disclosure - our institution is conservative in its approach to surgical management of ICH, as we don't seem to have the supportive evidence to warrant large-scale application. With that, we take all cerebellar ICH with depressed level of consciousness or NIHSS >4. We consider cortical hemorrhages o...
Would you consider adjuvant radiation therapy for a grade 1 meningioma with an elevated Ki67?
An answer to this important question requires conjecture as well as additional details. Ki-67 has indeed in some studies been identified as a promising biomarker [Liu et al., PMID 32118704, Tjuatja et al., PMID 36448071, Chen et al., PMID 29624151], however not uniformly so [Jensen et al., PMID 2929...
What workup do you consider for a developmentally typical child with multiple large café au lait macules but no other signs of neurofibromatosis?
The likelihood that this is NF1 depends somewhat in part on the age of the child in question. In infants and toddlers, cafe-au-lait macules are usually the first and only clinical sign of NF1. Most children with NF1 will develop skin fold freckling in early childhood, and the majority (probably 60-7...
What is appropriate followup duration after treatment for an acoustic neuroma?
Annual follow up is appropriate for most patients, and q6m MRI may not be necessary. If possible, long term follow up of 10 year or longer is prefered. The local control of acoustic neuroma with radiation treatment (SRS or FSRT) is excellent. Most series reported long term control of 95% or higher....
How do you manage a glioblastoma of the brainstem/upper cervical spinal cord?
It used to be that we didn’t get biopsies in this location, and we treated suspected astrocytic tumors in the brainstem/upper spinal cord to 54 Gy in 30 fractions without tissue. The outcome was never good. But now we generally have at least a stereotactic biopsy. The outcome is still not good of co...
How would you approach treatment of an optic nerve sheath meningioma presenting with complete ipsilateral visual loss?
Radiosurgery to prevent further tumor growth of an optic nerve sheath meningioma in a patient with complete ipsilateral visual loss can technically be accomplished. It is prudent to not include the chiasm nor the very proximal optic nerve due to Wilbrand's knee of the optic chiasm (where crossing fi...
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...