Neurosurgery
Physician insights on operative techniques, spinal disorders, neuro-oncology, cerebrovascular disease, and functional neurosurgery.
Recent Discussions
For patients that fail initial SRS for trigeminal neuralgia, what factors do you consider when considering re-irradiation?
Failure within 6 months/No response: Is vascular compression present? Yes = Consider Microvascular decompression. If contraindicated repeat SRS to 50 Gy. No + then was the nerve clearly visualized on MRI? Yes = Possible repeat SRS to 50 Gy. No = then that could be a cause for failure, consider ret...
Do you treat bilateral trigeminal neuralgia with SRS?
Yes, but I treat the side with more severe symptoms first and treat the other side 6 months later. I do not make dose modifications. I have treated some patients with bilateral trigeminal neuralgia in this fashion with no issues.
How would you manage a new suspected brain metastasis in a patient with a distant cancer history?
So I think there are some details missing but generally, if there is a suspected brain metastases in a patient with distance cancer history and that biopsy/resection is not feasible, I would consider additional workup including extracranial imaging. If the suspected brain metastases is asymptomatic ...
Would you offer adjuvant radiation therapy in a young adult with NF1 who has a craniopharyngioma s/p STR?
In NF1 patients, radiation therapy for craniopharyngioma has been associated with vascular damage and Moya Moya syndrome. On the other hand, subtotally resected craniopharyngiomas have a high chance of recurrence. It has been shown that, dosimetrically, intensity-modulated proton therapy (IMPT) coul...
What is your approach to monitoring the neurologic status of a patient with a traumatic brain injury requiring burst suppression for status epilepticus?
As with any other patient in status epilepticus requiring burst suppression, the neurological exam becomes limited to pupillary light reactivity. Pharmacotherapy used in the management of status epilepticus does not negate pupillary response. Not being able to obtain frequent neurological exams on a...
How do you approach a recurrence of grade 3 anaplastic astrocytoma after initial treatment with gross total resection followed by RT/adjuvant temozolomide?
As the questioner notes, this is an area where guidelines and published evidence are not as satisfying as we would like, so treatment has to be individualized. In addition, most trials until very recently did not test IDH status or 1p/19q status so the diagnoses may not be the same as people diagnos...
What is the preferred approach to managing non-occlusive or partially occlusive venous sinus thrombosis?
I would recommend a DOAC, particularly apixaban, with follow-up imaging in 3 months.
For meningiomas causing symptoms such as headaches, what percentage of patients experience improvement of symptoms after radiation alone?
Without question, patients are often found to have meningioma after presenting with headache. At times the headache may have been due to meningioma, particularly if the meningioma is large meningioma, has broad-based dural involvement, and/or is accompanied by edema, which they often are, especially...
How would you approach a patient over the age of 40 with a sub-totally resected frontal oligodendroglioma, WHO Grade II, 1p/19q co-deleted, IDH mutant, with imaging concerning for second site in the pontomedullary junction?
The pontomedullary junction is not usually amenable to a biopsy (unless the lesion is exophytic); as such, there are 2 possibilities: a) the second lesion is related to the one that has undergone subtotal resection, or b) the lesion is of a different nature. Statistically, it is more likely to be a ...
How would you manage a very large diffuse skull base meningioma involving the olfactory groove, bilateral cavernous sinuses, and abutting optic chiasm that is not amenable to surgical resection?
Skull base meningiomas are the ones that are commonly referred to Radiation Oncology departments as they are difficult to treat surgically, especially when they involve cranial nerves compartments as is the case in this patient. Given the number of OARs at risk for this patient, if the meningioma wa...