Neurosurgery
Physician insights on operative techniques, spinal disorders, neuro-oncology, cerebrovascular disease, and functional neurosurgery.
Recent Discussions
How do you manage a recurrent craniopharyngioma?
Complex answer—my personal view based on my Neurosurgery and SRS/RO experience:1. If the recurrence is a single large cyst—surgery (stereotactic aspiration combined with SRS to collapsed cyst immediately, have done the same day) or Intra-cavitary P32.2. If it's a small solid/micro-cystic recurrence—...
For which patients do you consider stereotactic radiosurgery rather than focused ultrasound for treatment of essential tremor?
Stereotactic radiosurgery (SRS) thalamotomy has a very limited role in my practice. Although SRS can provide meaningful tremor reduction and is an option for patients who are not candidates for DBS or MR-guided focused ultrasound (MRgFUS), I only consider it in highly selected circumstances, primari...
What factors would influence your decision to use or avoid heparin bridging in patients with mechanical heart valves resuming anticoagulation after intracerebral hemorrhage?
The main conclusion from the publication by Sakusic et al., PMID 39102615 was that withholding anticoagulation for the first seven days after ICH is safe in patients with mechanical heart valves and bridging with intravenous heparin to coumadin upon resumption of anticoagulation should be avoided. T...
What is your approach for an intact patient who is found to have new concurrent superficial cortical brain and lumbar spine masses?
I assume by no deficits you mean the patient is asymptomatic. This sounds like metastatic disease. The first course of action for the asymptomatic, no-deficit patient is to do a metastatic evaluation, i.e., to search for the primary historical clues about what the primary could be; definitely a ches...
How would you approach patient selection for DBS after chronic post-stroke for motor rehabilitation in light of the recent phase 1 clinical trial?
These two neurostimulation modalities occupy fundamentally different positions in the treatment landscape. VNS paired with rehabilitation (Vivistim) is the only FDA-approved neuromodulation therapy for chronic post-stroke upper-extremity motor rehabilitation, supported by a pivotal phase III RCT and...
What is your approach to treating 4th ventricular tumors in order to reduce the risk of cerebellar mutism?
I tried to use the telovelar approach to fourth ventricular tumors when at all possible, avoiding having to split the vermis whenever possible. I also find that this gives a great view of the fourth ventricle by simply lifting up the cerebellum.
Under what circumstances would you perform selective stereotactic radiosurgery to patients with multiple sub-centimeter brain metastases and 1-2 slightly larger brain metastases?
In our practice, select lesion radiosurgery is used in 3 scenarios: Patient has good CNS-penetrating systemic therapy options for treatment of brain metastases that will be starting soon. Lesions chosen then would be larger lesions and lesions in critically located regions of the brain (e.g., brain...
How has the ELVIS trial changed your approach for management of post hemorrhagic IVH?
Our institution is a strong supporter of this protocol and follows it closely. It is consistent with our prior management, but more closely defines intervention points.
How do you chose which patients are eligible for a percutaneous spinal cord stimulator trial?
Candidate selection for a percutaneous SCS trial involves evaluating appropriate pain indication, patient-specific determinants (psychological, behavioral, medical), and absence of absolute contraindications. The strongest evidence supports SCS for: persistent spinal pain syndrome type 2 (PSPS/faile...
How do you approach the decision to proceed with staged second-side MRgFUS thalamotomy in a patient with a good unilateral response who later develops disabling contralateral tremor?
Patients with ET who have had successful long-term tremor control on the first treated side can be considered for a second-side treatment after 9-12 months, provided they still meet criteria for the untreated side and do not have any persistent side effects. A second-side treatment can be equally ef...