Neurosurgery
Physician insights on operative techniques, spinal disorders, neuro-oncology, cerebrovascular disease, and functional neurosurgery.
Recent Discussions
When do you re-image patients with a diagnosis of venous sinus thrombosis?
My practice is to perform early reimaging, typically at around 2 weeks, before transitioning from parenteral anticoagulation to oral anticoagulation. This early reassessment is important as recanalization processes begin early and are linked to clinical outcomes. Subsequent imaging at 6 months is al...
What is the best management of an unruptured Spetzler Martin grade 3 arteriovenous malformation in a young patient?
This is a complex question and first and foremost requires and understanding of the natural history of an AVM.Natural history of cerebral arteriovenous malformations: a meta-analysis Nine natural history studies with 3923 patients and 18,423 patient-years of follow-up were identified for analysis. T...
What specific clinical factors would drive you to recommend surgical intervention for patients with small, nonfunctional pituitary adenomas who exhibit no neurological symptoms?
I don't think there is any indication for surgery in such a case.
Should patients with non-functional pituitary macroadenomas with persistent, but tolerable, headaches be recommended for surgery?
It depends on the size of the adenoma and stability of the imaging. It is sometimes difficult to know if the headaches are related. In a younger patient, I would consider surgery.
How do you manage patients with a prior intracerebral hemorrhage from probable cerebral amyloid angiopathy who develop new small vessel ischemic infarcts?
In this situation, I would consider using cilostazol since it has both antihypertensive and antiplatelet properties. However, the safety profile is unclear in patients with amyloid angiopathy.
How do you approach treatment of a spinal meningioma?
Surgery is usually the first option. If there is a good resection, the histology is WHO grade 1 (usually) and any residual tumor, if present, does not threaten the spinal cord, one could observe and decide on further action later when the tumor shows signs of growth. If the surgery is only a biopsy ...
What are the recommendations for considering deep brain stimulation in a patient with tremors and dementia or mild cognitive impairment?
In PD, studies with the strongest quality of evidence show a slight decline in global cognition in patients undergoing STN-DBS compared to GPi-DBS or medical therapy. However, the majority of controlled clinical trials and observational studies do not find changes in global cognition among these gro...
For a glioblastoma patient who had an MRI immediately postoperatively and you are able to repeat one closer to the time of CT simulation, do you use the more recent scan or the immediate postoperative scan for contouring (T2/FLAIR and T1 post)?
We usually obtain a repeat MRI closer to the time of CT sim, ideally on the day of sim, for several reasons. First, surgical cavities have a tendency to collapse which may impact target volume delineation. Secondly, peritumoral edema T2FLAIR signal infrequently subsides, which may also affect target...
Would you attempt a brain MRI in patients who present to the ER with subacute presentation of obstructive hydrocephalus?
I think an MRI is warranted to characterize the cause of the hydrocephalus in almost all cases, especially in the setting of a mass. The MRI can help identify the nature of the mass and the absolute size, and help with the differential diagnosis. It will also help you identify the mass as a solitary...
When can you utilize external ventricular drains (EVDs) in the management of posterior fossa strokes?
I would use an EVD only in combination with posterior fossa craniectomy in patients with large cerebellar infarctions. An EVD alone could result in upward herniation.