Neurosurgery
Physician insights on operative techniques, spinal disorders, neuro-oncology, cerebrovascular disease, and functional neurosurgery.
Recent Discussions
Do you recommend encephaloduroateriosynangiosis in pediatric patients with Moyamoya disease?
Only if it's clearly symptomatic.
For which patients is frameless gamma knife radiosurgery most appropriate?
Patients who are good candidates are those with tumors that obviously need fractionation (large size, near optic chiasm, etc.) AND are very compliant / able to participate in their care. Noncompliant patients will be impossible - there will be too much motion. It's difficult for most patients to tol...
Do you routinely recommend SRS to the surgical bed after resection of a single brain metastasis?
At our institution it is routinely done although local control reported in literature varies from 60 to 85 percent. One problem with this approach is defining the surgical cavity target accurately. To overcome this, retrospective data suggests giving 2mm margin around the cavity to improve local con...
Is it reasonable to extrapolate data from Glioblastoma and discuss Tumor Treating Fields in patients with Grade 4, IDH Mutant, astrocytomas?
While more than 90% of Grade 4 gliomas are IDH wildtype tumors (GBMs), this question does come up occasionally. Since I have no personal experience with TTF, I asked my collaborator Chirag Patel, MD, a neuro-oncologist at MDACC who regularly uses TTF in his patients, to provide his opinion. So pleas...
When do you consider genetic testing in patients with suspected hereditary brachial plexopathy?
There are two hereditary disorders associated with brachial plexopathy: 1) Hereditary neuralgic amyotrophy (HNA), which is caused by SEPT9 mutations ~70% of cases, and 2) Hereditary neuropathy with liability to pressure palsies (HNPP), which can manifest as a painless brachial plexopathy especially ...
How would you approach treatment for a glioblastoma from a radiation standpoint that was initially thought to be a metastases and therefore treated with multiple courses of SRS over the past few years?
It appears that the patient was empirically treated with multiple SRS courses; then, presumably, the patient must have undergone a biopsy/resection which disclosed the true nature of the problem (GBM). Therefore, the question is, what is the appropriate postop treatment for this patient? There are s...
Would you recommend a CT venogram or MR venogram in patients with concern for venous sinus thrombosis?
Either modality is suitable for assessing CVST. However, I typically prefer CTV. It's easier to obtain and has a quick scan time, which reduces the chances of motion artifacts. MRV provides better resolution, but it requires a screening form and has a longer scan time, which may lead to motion artif...
What is the expected timeframe one would expect to see paroxysmal sympathetic hyperactivity/sympathetic storming persist post-traumatic brain injury?
I've personally seen as long as 30+ days but usually less.
For recurrent glioblastoma treated with combined re-irradiation and bevacizumab, how long do you continue bevacizumab?
In the event of recurrent GBM, for example, if i.e. fSRT regimen like 30 Gy/5fx to be used for salvage, would not exceed more than 12 doses (6 cycles) of bevacizumab max. Even in the pseudo-response setting, the toxicity far outweighs the benefit beyond this.
Do you place asymptomatic patients being treated for brain metastasis with SRS on prophylactic steroids?
We do not use steroids routinely for asymptomatic patients being treated for brain metastases except if there is a concern based on anatomic location, volume, and/or presence of edema (e.g. adjacent to motor strip with significant edema, in or adjacent to brain stem, V12 brain receiving > or near 10...