Neurosurgery
Physician insights on operative techniques, spinal disorders, neuro-oncology, cerebrovascular disease, and functional neurosurgery.
Recent Discussions
How would you manage an unresectable central meningioma in a young patient with evidence of mild compression on the optic nerve and 4th ventricle involvement?
Sometimes, unresectability is in the eye of the beholder. In a young patient, with a decent size meningioma compressing the chasm and the 4th ventricle, there are several significant risks from not pursuing a surgical approach. Our first approach would be to get an expert opinion from a renowned men...
How do you manage a large surgical cavity following resection of a melanoma brain metastasis?
I've used 30 Gy in 5 fx before for a cerebellar melanoma cavity about 4.5x3 cm. It's much less likely to cause necrosis and edema than single fx. There may be some local enhancement of IO response. Regarding immunotherapy, I don't give steroids unless symptoms occur, and try to keep it to no more th...
In a healthy patient >65 years of age with glioblastoma multiforme, what is the recommendation for temozolomide when given concurrently with adjuvant radiation therapy?
Glioblastoma (GBM) is primarily a disease of older adults. The median age of diagnosis is around 60. Many of these patients present with a host of co-morbidities that impact their performance status (PS), overlapping with GBM-related complications. There are multiple scenarios to consider when evalu...
How do you approach imaging in the treatment planning of resected high grade gliomas/glioblastoma?
We typically obtain an MRI on the same day as the planning CT (whether or not the patient had a post-operative MRI). We are biased as we operate a dedicated MRI. If this were not the case, we would probably assess on a case-by-case basis (how long has it been since the last MRI, how visible is tumor...
What risk, if any, do you quote for erectile dysfunction in a young male being treated for a lumbosacral ependymoma?
I have not been quoting a specific risk of ED in spinal ependymoma patients. ED is common with advancing age and is often multifactorial. In ependymoma, prior spine surgery, the disease itself, concurrent medication, concurrent health issues, and the psychological impact of a cancer diagnosis are, f...
How you approach treatment of a glioblastoma in the setting of prior WBRT for a metastatic non-CNS malignancy?
I think treatment to 25 Gy in 5 fractions or 40 Gy in 15 fractions to areas of enhancement and/or post-op bed can be safely delivered after whole brain (assuming the patient was treated to 30 Gy in 10 fractions). We commonly treat with SRS after whole brain RT. Just be cognizant of cumulative dose t...
How do you manage a symptomatic meningioma and associated vasogenic edema in a poor performance status patient?
Superficially, this resembles a straightforward question, but in reality, it is very nuanced, with numerous variables driving decision-making. My sequential "thought-experiment" in a situation like this would proceed as follows:1. Why does the patient have poor KPS? Are there underlying comorbiditie...
When do you consider deep brain stimulation in patients with Huntington's disease?
DBS targeted at either the globus pallidus interna or subthalamic nucleus has been used to treat many forms of dystonia. Occasionally, dystonia can predominate in Huntington's disease, rising to the level to consider DBS. However, the response is generally fairly limited, and side effects can be sub...
How do you approach decision making in terms to adjuvant chemotherapy after CSI in adult medulloblastoma?
Medulloblastoma is a chemotherapy sensitive disease. The NCCN guidelines have options for CSI alone or followed by chemotherapy for standard risk disease (M0, residual disease <1.5cm2, classic or desmoplastic histology) and recommend post-CSI chemotherapy for high risk disease. Unfortunately, 25% of...
How do you manage asymptomatic radiation necrosis in a glioblastoma?
If a patient is not symptomatic from radiation necrosis, the only thing that would make me consider initiation of dexamethasone (Consideration of Avastin reserved for symptoms refractory to steroids) would be significant midline shift that is progressing, but this is usually going to lead to symptom...