Neurosurgery
Physician insights on operative techniques, spinal disorders, neuro-oncology, cerebrovascular disease, and functional neurosurgery.
Recent Discussions
When do you prefer pre-operative SRS over post-operative SRS for brain metastases?
For patients with brain metastases that benefit from resection, our approach is to always treat pre-operatively unless the patient requires immediate surgical intervention. Pre-operative SRS has several advantages including clear target delineation. Post-op SRS has best results with expanded volumes...
For a patient with large volume glioblastoma, what do you do if they are found to have a subdural infection in the middle of chemoRT requiring repeat surgery?
In this scenario, the patient will likely stop the daily treatments for a variable period of time that I would estimate to be measured in weeks while recuperating from surgery and receiving IV antibiotics. When cleared for radiation, I would start by doing a new Simulation using an updated MRI to ac...
How has the utilization of of mobile stroke units changed the landscape of in-hospital stroke management?
Mobile stroke units shift CT-based diagnosis, thrombolysis, and LVO triage into the prehospital setting, enabling earlier hospital activation and direct-to-angiography workflows. In BEST-MSU, onset-to-thrombolysis fell from 108 to 72 minutes, treatment rates rose from 79.5% to 97.1%, and 90-day mRS ...
Do you routinely obtain a biopsy of a presumed meningioma prior to SRS to confirm grade 1?
There is an emerging and growing body of data using various AI tools and radiomics analysis, as well as the incorporation of advanced imaging, that aim to improve the ability to predict the grade of meningioma. Most of this work remains "limited institution" in terms of applicability. In the current...
For large AVMs that cannot meet the V12 dose constraint, how low are you willing to go in terms of single fraction dosing?
We usually use a “volume staging” approach by treating part of the AVM to 18-20 Gy in one fraction (meeting the V12 dose constraint), and return to treat the remaining nidus about 2 years later. Generally, most or all of the treated nidus has occluded by then. There will, of course, be some dose ove...
What is your approach to counseling families who's loved one has a progressive malignant brain tumor but is not a surgical candidate?
Thank you for the question. There are two scenarios for answering this question. If I were involved in taking care of the patient during initial treatment up to this point and know the patient and family well. My approach to counseling in this scenario begins with understanding their experience and ...
How do you decide which patients would benefit from ECAP-closed loop spinal cord stimulation?
The EVOKE trial enrolled patients with chronic, intractable back and leg pain refractory to conservative therapy - including both persistent spinal pain syndrome (PSPS) type 1 and 2, with the following eligibility criteria: Overall, back, and leg pain VAS ≥60 mm Oswestry Disability Index 41–80 Stab...
What is your timeline for restarting anticoagulants for patients with a recent craniotomy for hematoma evacuation who are also on an LVAD?
As with many clinical situations, this is a clinical decision that should be made by the treating neurosurgical/cardiology team for the specific patient - not from general literature alone, as there is no dedicated randomized controlled study-based guideline for this exact combination. As a general ...
For which patients would you consider offering a spinal cord stimulator for management of autonomic dysfunction?
The use of SCS for its effects on the autonomic nervous system is one of the more interesting applications of neurostimulation. We’ve known for years that SCS has a potent sympatholytic effect, and it has been used for peripheral and cardiac ischemia extensively. This use has been more prevalent in ...
How do you approach management of a patient with a VNS device that is having impedance challenges?
We always take an X-ray to ensure that there is no obvious disconnect or breakage of the lead. If not, we prepare to replace the electrode, including consent and surgical prep. If we can resolve the impedance issue by checking or tightening the connection to the IPG, then we will do so and close. If...