Neurosurgery
Physician insights on operative techniques, spinal disorders, neuro-oncology, cerebrovascular disease, and functional neurosurgery.
Recent Discussions
Under what circumstances would you use onyx rather than coils to treat a ruptured aneurysm?
Onyx is rarely used for the typical ruptured saccular aneurysm, given the range of excellent endovascular alternatives: coils, flow diverters, and intrasaccular flow disruptors such as the WEB device. Its current role is as a liquid embolic for vessel sacrifice in complex fusiform or dissecting aneu...
When do you consider treatment with temporal bone windows to decrease intracranial pressure for patients with Idiopathic Intracranial Hypertension?
I would consider this an outdated operation. There are several better ways of treating this.
For patients with hydrocephalus secondary to leptomeningeal disease, how do you determine what type of shunt device to place?
For my small part, please ask neuro-oncology if they plan to use intrathecal chemo (and need a hybrid with Ommaya).
When do you consider EVD in pediatric severe TBI when initial imaging is unremarkable?
The guidelines state that intracranial pressure monitoring is indicated for severe TBI when GCS is 12 or less, regardless of what the head imaging looks like. Either a bolt or an EVD can be used for measuring intracranial pressure. In cases where our index of suspicion for elevated intracranial pres...
What is your approach to the management of a patient with traumatic unilateral perched facets?
I like to have a go at awake closed reduction under fluoro, with flexion, contralateral lateral bending, and rotation toward the side of the injury. That is purely an option, however. Since this deformity is reducible from either front or back, the ORIF approach is the dealer’s choice, although the ...
How do you approach treatment of a young adult with an intracranial anaplastic ependymoma and a single intradural cervical spine metastasis?
A high-grade tumor, such as anaplastic ependymoma, carries a higher risk of CSF seeding down the neuroaxis than lower grades. Secondary spinal drop metastases are considered a serious but relatively rare complication in this disease. Assuming that the metastasis was detected at the time of diagnosi...
How do you manage spinal cord compression in a new suspected neuroblastoma diagnosis?
While there is evidence that chemotherapy, surgery, and radiation can all be effective for some patients,1 there are no definitive studies or data that prove the best approach for all patients. A 2017 systematic review concluded that the “currently available literature remains suboptimal as a guide ...
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...
What specific exam findings or test changes prompt escalation of care when evaluating pediatric patients with optic disc drusen for possible increased intracranial pressure?
Both pediatric and adult patients with optic disc drusen can develop increased intracranial pressure, including IIH, like normal individuals. This is important to remember, especially if the symptoms and risk factors suggest elevated intracranial hypertension. In the pediatric group, especially youn...
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...