Neurosurgery
Physician insights on operative techniques, spinal disorders, neuro-oncology, cerebrovascular disease, and functional neurosurgery.
Recent Discussions
What is your approach to return to play of a contact sport after mild concussion in children?
My approach to return to play (RTP) after a mild concussion in pediatric patients follows the Concussion in Sport Group (CISG) consensus guidelines (Patricios et al., PMID 37316210), adapted for the developing brain.Following a concussion, I recommend a minimum 24-48 hours of relative rest before in...
How would you manage an enlarging brain metastasis that has progressed in size three months after radiosurgery?
Before making a decision, I would want to know the tumor histology, SRS dose delivered, and whether the current site of progression is truly within the prior radiation field (using new MRI fused to the SRS plan in treatment planning software). If the lesion is within the high-dose region and the pat...
For sellar tumors with suprasellar extension, how do you decide between an endoscopic approach versus a craniotomy?
Cranial will be preferable for a very extensive suprasellar extension of the tumor. If the majority of the tumor is intrasellar and the carotid arteries are far apart enough, then a transnasal endoscopic approach is reasonable to consider, as long as the tumor in the suprasellar part is not lateral ...
How has the EMBOLISE trial changed your practice regarding concurrent subdural hematoma evacuation and MMA embolization?
We prefer concurrent with Borvo/SEPS and embo in the angio suite; however, if the patient presents after hours, we do Borvo/SEPS upon presentation and embo the next day. Basically, two procedures under local and sedation, either together or part-based on convenience.
In the case of concomitant tethered cord and Chiari malformation with syringomyelia, how do you determine priority of treatment?
I am an old-fashioned physician in addressing this interesting question. The answer depends on the clinical symptoms and the degree of disability the patient is experiencing. This means performing a careful clinical assessment of what is the major problem the patient is having and how surgery would ...
Under what circumstances do you consider duraplasty for Chiari 1 decompression?
I always place a duraplasty for Chiari 1 to increase the space around the tonsils and attempt to resume normal biphasic flow of CSF anteriorly and posteriorly.
How would you advise a younger patient with residual/recurrent optic nerve meningioma, proceeding with radiotherapy, about the risks of malignant transformation or induction of other brain malignancies because of radiation?
The risk of malignant transformation of an optic nerve sheath meningioma (ONSM) after RT appears to be remarkably low, much lower than the risk of blindness from an untreated, progressive ONSM. In a younger patient, I would lean toward RT for patients with imaging progression or early visual loss, ...
What is the best approach in a patient with a single brain metastasis in the setting of progressing systemic disease?
There is no single "best approach" for a single brain metastasis, even in the setting of progressing systemic disease. First, ask if it is obvious that a single lesion is a brain metastasis. The patient needs to be made aware that the diagnostic error rate can be as high as 15%. If unsure, then tiss...
In light of the ROADS data, how are you choosing between intraoperative tile-based radiation therapy (TBRT) and postoperative SRT for newly diagnosed resectable brain metastases?
In light of the ROADS data, I would be cautious about broadly changing practice at this point. While the local control benefit with cesium-131 GammaTile is impressive and biologically plausible, reported OS is much harder to reconcile. A 26% absolute improvement in 2-year OS from a local therapy int...
What criteria do you use to select elderly patients for focused ultrasound thalamotomy?
Elderly patients are perfectly suitable for MRgFUS treatment and are considered if their tremor is resistant to appropriate medical therapy, including propranolol and/or primidone. It should be equal to or greater than 2 on the FTM scale for tremor, and interfere substantially with daily activities ...