Neurosurgery
Physician insights on operative techniques, spinal disorders, neuro-oncology, cerebrovascular disease, and functional neurosurgery.
Recent Discussions
Under what circumstances would you perform selective stereotactic radiosurgery to patients with multiple sub-centimeter brain metastases and 1-2 slightly larger brain metastases?
In our practice, select lesion radiosurgery is used in 3 scenarios: Patient has good CNS-penetrating systemic therapy options for treatment of brain metastases that will be starting soon. Lesions chosen then would be larger lesions and lesions in critically located regions of the brain (e.g., brain...
What first-line therapeutic regimen do you consider most appropriate for metastatic clear cell renal carcinoma presenting with brain metastasis and vasogenic edema?
For patients presenting with brain metastases, I always do local therapy, usually SBRT, before systemic therapy. I am nervous about starting immune-based therapy or a TKI in patients with uncontrolled CNS metastases. There are small series using TKIs such as cabozantinib in this setting, but since S...
Does CEA still have a role instead of stenting for surgical management of asymptomatic carotid artery disease?
In most patients with asymptomatic high-grade stenosis, stenting is preferable to endarterectomy based on the results of CREST-2. In a small percentage of such patients, stenting may not be technically feasible. Also, some patients may not want to take the medications usually prescribed after stenti...
In light of the ROADS data, how are you choosing between intraoperative tile-based radiation therapy (TBRT) and postoperative SRT for newly diagnosed resectable brain metastases?
In light of the ROADS data, I would be cautious about broadly changing practice at this point. While the local control benefit with cesium-131 GammaTile is impressive and biologically plausible, reported OS is much harder to reconcile. A 26% absolute improvement in 2-year OS from a local therapy int...
How has the ELVIS trial changed your approach for management of post hemorrhagic IVH?
Our institution is a strong supporter of this protocol and follows it closely. It is consistent with our prior management, but more closely defines intervention points.
How do you chose which patients are eligible for a percutaneous spinal cord stimulator trial?
Candidate selection for a percutaneous SCS trial involves evaluating appropriate pain indication, patient-specific determinants (psychological, behavioral, medical), and absence of absolute contraindications. The strongest evidence supports SCS for: persistent spinal pain syndrome type 2 (PSPS/faile...
How do you approach the decision to proceed with staged second-side MRgFUS thalamotomy in a patient with a good unilateral response who later develops disabling contralateral tremor?
Patients with ET who have had successful long-term tremor control on the first treated side can be considered for a second-side treatment after 9-12 months, provided they still meet criteria for the untreated side and do not have any persistent side effects. A second-side treatment can be equally ef...
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...
How do you approach anti-seizure medication management when it was started by another team for a seizure-naive patient before/after craniotomy for a tumor?
I would refer you to Dr. @Dr. First Last's answer to a similar question (https://www.themednet.org/question/15031) which beautifully summarizes data and guidelines. I usually counsel patients that everyone regardless of their medical history has a certain risk of seizure under physical stressors, th...
How do you distinguish between episodes of vascular steal and seizures in patients with an AVM?
Distinguishing between vascular steal and seizures in patients with AVMs can be challenging, but certain patterns may help. Vascular steal occurs when blood is shunted through the AVM nidus, bypassing the surrounding tissue and causing regional or global oligemia. The shunting can result in transien...