Neurosurgery
Physician insights on operative techniques, spinal disorders, neuro-oncology, cerebrovascular disease, and functional neurosurgery.
Recent Discussions
How do you manage glioblastoma presenting with leptomeningeal dissemination?
Hospice is a very legitimate option. As physicians, we recommend this far too infrequently.
Under what circumstances do you send next generation sequencing or tempus for patients after a brain tumor resection?
I obtain NGS for all gliomas and most brain metastases. I also obtain NGS for high-risk meningiomas (based on clinical, radiographic, or histopathological findings). The NCCN guidelines have reflected the increasing importance of NGS testing for these tumor types in order to accurately grade these p...
How would you advise a younger patient with residual/recurrent optic nerve meningioma, proceeding with radiotherapy, about the risks of malignant transformation or induction of other brain malignancies because of radiation?
The risk of malignant transformation of an optic nerve sheath meningioma (ONSM) after RT appears to be remarkably low, much lower than the risk of blindness from an untreated, progressive ONSM. In a younger patient, I would lean toward RT for patients with imaging progression or early visual loss, ...
Do you recommend a prolonged duration of antibiotics and/or suppression for patients without pre-existing hardware who have placement of new hardware after decompression/washout of a Staphylococcus aureus epidural abscess?
If the hardware is placed in the setting of active infection, then I usually chronically suppress the patient indefinitely after treating for the acute infection.
Would you consider adding gabapentin off label for use in the treatment of glioblastoma at this time?
As an author on the paper, let me emphasize the findings and speculate on the implications. Recently, a number of laboratories have unraveled stunning preclinical and mechanistic findings demonstrating the ability of a subset of malignant glioma cells to usurp neuronal circuitry to promote tumor gro...
For which patients do you consider placing a lumbar drain prior to endoscopic endonasal resection for pituitary adenoma with suprasellar extension?
The use of a lumbar drain for suprasellar pituitary tumors is the subject of much discussion, and surgeon preference plays a role in how and how frequently drains are used. I am an advocate for more routine use of lumbar drains for almost all patients that have significant suprasellar extension. The...
How has the utilization of mobile stroke units changed the landscape of in-hospital stroke management?
Mobile stroke units shift CT-based diagnosis, thrombolysis, and LVO triage into the prehospital setting, enabling earlier hospital activation and direct-to-angiography workflows. In BEST-MSU, onset-to-thrombolysis fell from 108 to 72 minutes, treatment rates rose from 79.5% to 97.1%, and 90-day mRS ...
How do you decide when to intervene directly on a feeder artery aneurysm of an AVM?
Flow-related peri-nidal aneurysms can occur in a few different scenarios, which play an outsized role in determining management. These aneurysms can be located intra-nidal, or can be remote. They can also be detected through routine imaging, but can also present as having ruptured. AVM hemorrhage is...
When treating trigeminal neuralgia with SRS, are there vascular constraints or concern for late aneurysm?
The incidence of cerebral aneurysms after stereotactic radiosurgery (SRS) for trigeminal neuralgia (TGN) is extremely rare. High-dose radiation (60 - 90 Gy) delivered to local microvasculature can theoretically cause focal vessel wall weakening, elastin degeneration, or radiation angiopathy leading ...
What is the best way to understand functional tracts to guide the surgical approach for tumor resection in patients unable to participate in functional MRI?
This is really a language question. Motor pathways can be mapped asleep regardless of cognitive status, and nothing done preoperatively replaces direct stimulation for language. The task is to build the best structural and functional model before surgery and then decide whether intraoperative langua...