Neurosurgery
Physician insights on operative techniques, spinal disorders, neuro-oncology, cerebrovascular disease, and functional neurosurgery.
Recent Discussions
How do cytopenias factor into your decision of whether to hold radiotherapy during treatment of a glioblastoma?
Patients will sometimes need a chemo dose reduction or hold, but we typically do not stop RT, once started. In the case of severe cytopenia, I might hold RT on a case-by-case basis (e.g., platelets <10k despite holding temozolomide) and in discussion with the neuro-oncologist.
How do you manage a supratentorial anaplastic ependymoma in an adult?
Unfortunately, given the rarity of this tumor, we'll never know for sure. However, I do treat those patients similar to high grade gliomas in adults. Having said that, in high grade gliomas, I use smaller margins 0.5-1 cm (GTV --> CTV) and I think it would be appropriate in this setting as well. A b...
How do you manage a recurrent craniopharyngioma?
Complex answer—my personal view based on my Neurosurgery and SRS/RO experience:1. If the recurrence is a single large cyst—surgery (stereotactic aspiration combined with SRS to collapsed cyst immediately, have done the same day) or Intra-cavitary P32.2. If it's a small solid/micro-cystic recurrence—...
How soon after surgery do you start chemotherapy for extensive stage SCLC following resection of a brain metastasis?
I believe chemotherapy is the backbone of therapy for small cell lung cancer. If a patient has asymptomatic brain metastases, I start with chemotherapy (or chemoimmunotherapy) alone and follow with repeat brain imaging. I will treat with RT after initial 4 cycles of chemotherapy if brain disease is ...
How do you approach treatment of an IDH wild-type low-grade astrocytoma in an elderly patient?
Inherent in this good question are really two separate issues: 1) how to approach IDH-wt LGG and 2) how to treat glioma in the elderly (and/or frail).The first issue is addressed by the recent cIMPACT-NOW update #3 which states that in the presence of an IDH-wt gr 2-3 glioma, the presence of one of ...
What is your treatment approach to radiation-induced meningiomas?
There is an unambiguous relationship between ionizing radiation and meningioma, the most commonly reported radiation-associated neoplasm [1,2]. It is thus perhaps curious that radiation therapy (RT) is 1 of the only 2 definitive management options for meningioma in the current era. Systemic therapie...
In the treatment of recurrent trigeminal neuralgia, what local therapy would you recommend after failure of medical therapy?
I will recommend surgery (microvascular decompression) only when there is a surgically fixable abnormality, such as vascular compression. In that case, microvascular decompression is more effective than SRS. Otherwise, I will offer SRS, which can be offered twice targeting a root entry zone and a mo...
How would you manage the cavity of a resected anaplastic meningioma with pulmonary metastases?
Metastatic meningioma outside the CNS is rare, and its incidence has been estimated to be 0.1% with the lung being the most common site for distant metastases (Surov et al., PMID 23404622). There is no clear standard therapy for the management of metastatic meningioma. Suppose this was an anaplastic...
Is placing a VP shunt a major risk to spread medulloblastoma or other malignant brain tumors into the gut?
While most malignant primary brain tumors will NOT spread to the gut via VPS, case reports of pediatric brain tumors dominate the literature regarding this risk. Germ cell tumors are probably most commonly reported, followed by PNETs and medulloblastomas [Piatt and Garton, PMID 18431216, Kay et al.,...
Are there any therapeutic options for cauda equina syndrome secondary to dural ectasia in end-stage ankylosing spondylitis?
The cauda equina syndrome is a rare complication in patients with ankylosing spondylitis (AS). Patients with longstanding disease leading to significant ankylosis of the spine have the highest risk of developing it. The likely underlying mechanism is arachnoiditis leading to damage of the lumbosacra...