Neurosurgery
Physician insights on operative techniques, spinal disorders, neuro-oncology, cerebrovascular disease, and functional neurosurgery.
Recent Discussions
What is your treatment approach for re-irradiation of a pituitary adenoma?
Re-irradiation for a pituitary adenoma is very challenging situation, since almost certainly would exceed normal tissue tolerance of optic apparatus. If re-irradiation is deemed necessary, stereotactic radiation either SRS or SRT should be used. Stereotactic RT only need minimum margin, usually 0-2...
How do you approach SRS for a brain metastasis in an eloquent area of the brain?
Short of metastases in the brainstem or next to the optic nerve/chiasm, we do not routinely decrease the dose or hypofractionate SRS in other eloquent areas such as the motor strip. While radiation necrosis is the main concern, the risk of recurrence which is shown to be higher with diminished doses...
How do you manage recurrent CNS ependymoma?
Data for treating recurrent ependymoma comes mostly from single institutions retrospective series. Patients with recurrent ependymoma should be restaged with spine MRI and LP cytology, evaluated for maximal safe resection, re-irradiation, and clinical trials. If the disease is localized, many radiat...
Would you do SRS for a patient who cannot receive gadolinium contrast and has a single brain metastasis on non-contrast MRI?
There is a reasonable concern that other small brain metastasis could be present without obtaining fine cut T1 imaging with gadolinium contrast. As long as the patient is otherwise a reasonable candidate for radiosurgery, and can return for follow up, I would feel comfortable going ahead with SRS ba...
How do you manage multifocal glioblastoma or high-grade gliomas?
In multifocal glioblastoma or high-grade gliomas, I would consider surgical resection if there was a dominant lesion or lesions causing symptoms. In cases where debulking is unlikely to provide symptomatic relief or aggressive surgery is most likely to remove a portion of disease burden, I would ten...
How do you manage the timing of adjuvant therapy in a patient with a glioblastoma and a post-operative surgical site infection?
There have been several studies on the timing of adjuvant therapy for glioblastoma including our institution https://www.ncbi.nlm.nih.gov/pubmed/26440447. In general, our practice has been to start adjuvant radiotherapy as soon as reasonably possible. If a glioblastoma patient has postoperative surg...
What is your approach to management of a myxopapillary ependymoma of the conus with drop metastases to the cauda equina?
Usually I treat with localized fields but feel there is no correct answer. I offer the patients CSI as an alternative and explain benefits and risks. These patients are expected to live very long lives and 36 Gy CSI will have tremendous adversely affect on them. I acknowledge the risk of re-irradiat...
What is your recommended follow-up schedule for a meningioma after definitive radiotherapy?
For grade 1 meningioma, I obtain annual follow up MRI for the first 5 years, and then at 18-month intervals from 5-10 years. After that I offer patients to have an MRI every other year and some of them will do it.
How do you treat a young woman of child bearing age group diagnosed with primary CNS lymphoma?
The first step is to check HIV serology to ensure that the patient is HIV negative as HIV+ve patients would need to antiretroviral therapy promptly along with chemotherapy or the prognosis is dismal. If patient is young and fit the initial approach is similar in both HIV +ve and -ve patients. Assumi...
Would you continue consolidation temozolomide for more than 1 year for a patient with grade 3 anaplastic astrocytoma, after gross total resection and daily temozolomide+EBRT?
Thank you for the question.The short answer is, "no". There is no data that adjuvant chemotherapy beyond 12 months improves outcomes. The temozolomide is usually very well tolerated, but it is associated with bone marrow injury with myelodysplasia or leukemia as risks. So, in general with no upside,...