Neurosurgery
Physician insights on operative techniques, spinal disorders, neuro-oncology, cerebrovascular disease, and functional neurosurgery.
Recent Discussions
How do you manage acute exacerbations of trigeminal neuralgia?
I do not have personal experience treating TN exacerbations in the ED. What is generally recommended under those circumstances is intravenous phenytoin. Schnell et al. recently published it in The Journal of Headache and Face Pain (Schnell et al., PMID 32981076). They published the results of a retr...
Would you favor restarting anticoagulation or pursuing left atrial appendage closure in a patient with hemorrhagic stroke on anticoagulation for non-valvular atrial fibrillation?
That is a great question, thank you for bringing it up. The answer really depends on the likely etiology of the intracerebral hemorrhage. For example, if the hemorrhage is subcortical and the etiology is thought to be likely related to hypertension, it is reasonable to resume anticoagulation when sa...
In what subset of traumatic brain injury/concussion patients would you consider use of N-Acetyl Cysteine?
There are some reports that N-Acetyl Cysteine (NAC) may help the patient with TBI for behavioral recovery and it has neuroprotective effects. I also used NAC and Alpha lipoic acid in patients with post-chemotherapy neuropathy as antioxidants. There are limited studies on how effective they are but t...
How do you manage autonomic storming in patients with increased intracranial pressure?
In many respects, the treatment of paroxysmal sympathetic hyperactivity (PSH), or storming, is similar whether or not there is elevated ICP. The goal is to limit stimuli that provoke the episodes of storming and reduce sympathetic outflow or block its downstream effects. The difference is in those p...
Is there an age cutoff at which you would recommend against radiosurgery for a schwannoma or trigeminal neuralgia in someone who is a good surgical candidate with no comorbidities?
Personally, I do not have a specific age cutoff, but do have a careful discussion about secondary malignancy risks in a younger patient. With younger patients with schwannomas, one has to be careful about neurofibromatosis as there may be a higher risk of secondary malignancies from radiation. With ...
What is the shortest interval you would consider to deliver re-irradiation for a recurrent glioblastoma?
Re-irradiation (assuming infield local progression) doesn't usually get discussed until more than 6 months following initial radiation therapy, likely because any increase before that is going to be possible pseudo progression. But after that point if there is increasing contrast enhancement suspici...
Would you recommend radiation therapy for a pathologic vertebral compression fracture already treated with kyphoplasty and RFA (OsteoCool)?
Assuming there is active disease in the vertebral body in question, I would recommend radiation therapy. An abstract was presented at the last ASTRO describing a retrospective small series from Roswell Park (Prezzano et al) suggesting that the combination of RFA and RT was beneficial for spine metas...
How do you manage grade III oligodendroglioma?
Given that these tumors predominantly occur in younger adults, and are often slowly progressive, there is an easy tendency to become complacent about the long-term behavior and outcomes with this disease. The bottom lines with this tumor are as follows: The diagnosis is complex, and often difficult,...
How do you manage recurrent atypical meningiomas in patients who have previously received radiotherapy?
This question, I fear, requires some underpinning. A recurrent atypical meningioma is an aggressive tumor, more so that than appears to be appreciated broadly. Even between first and second recurrence, as shown in a study by Bagshaw and colleagues at the University of Utah (Neurosurgery 126:1822–1...
For a recurrent medulloblastoma in the posterior fossa several years after initial standard risk therapy (23.4 Gy CSI), and in which the patient is still less than 18, how would you approach re-irradiation?
If the recurrences are localized to the resection bed, I would re-irradiate only the recurrences (and possibly the entire resection bed depending on number of recurrences). If there is evidence of CSF dissemination (recurrences not associated with primary--whether in posterior fossa or not) then CSI...