Neurosurgery
Physician insights on operative techniques, spinal disorders, neuro-oncology, cerebrovascular disease, and functional neurosurgery.
Recent Discussions
When do you order an MRA to better evaluate results from a CTA?
MRA is better for aneurysms that have been coiled (too much artifact on CTA). CTA is better for aneurysms that have been clipped (too much artifact on MRA). MRA usually focuses on the Circle of Willis. The rare distal MCA/ACA/PCA aneurysms may be missed. In contrast to CTA, MRA does not require cont...
How do you choose between titanium and cobalt-chromium rods in a patient undergoing multilevel posterior spinal fusion?
I very much favor titanium due to its increased ductility (with improved MRI compatibility as an extra). It is critical to remember that the instrumentation is there solely to stabilize until fusion occurs, NOT to substitute for fusion-related stability. If you are a strong advocate of anterior colu...
After lumbar laminectomy and fusion, how long do you keep a subfascial drain in place?
I try to remove my subfascial drain when the drainage is less than 50 cc in an 8-hour shift. Typically, this will be about 48 hours at the maximum time. This will also be influenced by the number of levels involved in the fusion and possible other comorbidities.
Under what circumstances would you give nimodipine to patients with non-traumatic, non-anuerysmal subarchnoid hemorrhage?
In my practice, the decision to use nimodipine in non-traumatic, non-aneurysmal subarachnoid hemorrhage is largely guided by the hemorrhage pattern and perceived vasospasm risk. For classic perimesencephalic SAH with low blood burden and reassuring vascular imaging, I do not routinely continue nimod...
What is your antiplatelet strategy after aneurysm coiling?
In general, I don’t use antiplatelets for JUST coil embolization. A different scenario if we are planning or inadvertently need a stent.
Under what circumstances do you perform an MMA embolization prior to chronic subdural hematoma evacuation?
Current evidence from randomized trials such as EMBOLISE and EMMA demonstrates that MMA embolization reduces the risk of recurrent CSDH. However, the purpose of MMA embolization is to reduce recurrence, not to provide immediate decompression.Therefore, for patients with symptomatic CSDH requiring su...
Would you use a lumbar drain in a patient with spinal stroke from fibrocartilagenous embolism?
There are no clinical trials to suggest any benefit. Smaller studies - particularly case series have shown some benefit with the use of lumbar drain in the first 48 hours and keeping the pressure around 10 mmHg. These include mostly patients post a cardiovascular surgical procedure as a cause in the...
Is there a role for using an external ventricular drain (EVD) trial in the workup of normal pressure hydrocephalus?
Typically, the work-up of normal pressure hydrocephalus involves either a large volume lumbar puncture or a 48-72 hour lumbar drain trial (and sometimes both). An external ventricular drain would be too invasive.There is an excellent review article that was recently published regarding this topic:Ca...
What medications are preferred and contraindicated for insomnia in patients with a recent stroke or traumatic brain injury?
In acute brain injury (ABI), which includes stroke and traumatic brain injury the focus is often on neurorehabilitation. The presumption here is that the patient is medically and neurologically stable. For example, not having a stroke in evolution, uncontrolled gastrointestinal bleeding, or similar....
What is your timing for angiogram and treatment for patients with sentinel bleeds from recently discovered aneurysm?
My general approach is to obtain vascular imaging emergently, typically CT angiography as the first-line study at the time of presentation, given its speed and wide availability. If CTA is negative but clinical suspicion remains high, I proceed to digital subtraction angiography (DSA), which remains...