Neurosurgery
Physician insights on operative techniques, spinal disorders, neuro-oncology, cerebrovascular disease, and functional neurosurgery.
Recent Discussions
What is the role of kyphoplasty or vertebroplasty in patients with osteoporotic spinal fractures?
Vertebroplasty and kyphoplasty can be grouped together as vertebral augmentation. They have a single indication: To reduce pain arising from a documented vertebral fracture. Kyphoplasty has an inflatable balloon and in theory, can improve vertebral height prior to introduction of the cement. I am no...
How would you manage a recurrent anaplastic supratentorial ependymoma in an adult?
There is no well-defined standard-of-care approach for previously irradiated, now recurrent ependymoma, in any setting, whether it is adult or pediatric, cranial or spinal, and supra vs. infratentorial. Unfortunately, the natural history at this stage is characterized by multiple relapses, each with...
What would your next line treatment be for a patient previously treated with repeat resection, craniospinal irradiation, and initial cisplatin/vincristine/CCNU with medulloblastoma?
As you will agree, this is an extremely unfortunate situation. I am assuming this patient has progressed either while on therapy or soon after completion? Depending on his age, a potential option is to enroll him on any available clinical trials. PBTC58 study uses intrathecal omburtumab along with c...
How do you approach treatment of a grade 4 IDH-mutant astrocytoma, a diagnosis now distinct from glioblastoma according to the 2021 WHO Classification for CNS Tumors?
This is an excellent question. The short answer is that until we have more data on this new entity, I would treat an IDH mutant (mt) grade 4 astrocytoma as I would have prior to the 2021 WHO revision, that is to say, with concurrent chemoradiation therapy and adjuvant Temodar for 6 cycles (or a clin...
Do patients with NPH/communicating hydrocephalus always require VPS?
This is a complicated question. Evaluations for NPH include monitoring for neurological improvement following a large-volume lumbar puncture or a lumbar drain trial. At our institution, we prefer a lumbar drain trial as it allows more volume to be removed over time and mimics the placement of a shun...
How would you manage a Grade II IDH mutant astrocytoma with otherwise low risk features, but gemistocytic histology?
Not sure there is a right answer for this one - in general, for an IDH mutant grade 2 astrocytoma with low risk features, I would consider observation. If all else is low risk with the exception of gemistocytic histology, I may still consider observation and counsel the patient about an increased ri...
How would you approach management of a patient who is status post resection of a WHO grade 1 planum sphenoidale meningioma which was adherent to the optic nerve?
As suggested by the mere fact of its posting, this is a complex question. If this were a gross total resection (GTR), I would tend toward observation and would follow the patient carefully with imaging and clinical evaluations at 6-month intervals for at least 3 years, then annually. GTR for a planu...
For an atypical meningioma WHO grade 2 s/p GTR, do molecular findings that suggest an integrated diagnosis of a grade 3 tumor change adjuvant radiation treatment recommendations?
There is no definitive clarity on this question, as the data simply do not exist. Therefore, decision-making has to be individualized. For residual disease, the GTV would be easy to estimate, but it might be prudent to utilize the pre-op scans in these patients to understand the pre-op GTV, which co...
Would you manage a subtotally resected pilocytic astrocytoma with deleted CDKN2A differently than one with intact CDKN2A?
Among brain tumors, CDKN2A loss has the greatest clinical implications in histologically low and intermediate grade gliomas. In IDH-mutant astrocytomas, the presence of homozygous deletion of CDKN2A is associated with poor outcome. Usually, pilocytic astrocytomas (grade 1) have a very good prognosis...
Is there a time interval after which you would not offer adjuvant radiotherapy for a malignant, grade 3 meningioma?
Adjuvant radiation for grade 3 meningioma is based on prior observational studies that generally reflect recurrence rates approaching 90% for grade III disease, and the insufficiency of salvage treatment approaches.Given the small numbers of grade 3 tumors, and the heavy bias towards upfront postop ...