Neurosurgery
Physician insights on operative techniques, spinal disorders, neuro-oncology, cerebrovascular disease, and functional neurosurgery.
Recent Discussions
Would you consider adding gabapentin off label for use in the treatment of glioblastoma at this time?
As an author on the paper, let me emphasize the findings and speculate on the implications. Recently, a number of laboratories have unraveled stunning preclinical and mechanistic findings demonstrating the ability of a subset of malignant glioma cells to usurp neuronal circuitry to promote tumor gro...
When do you consider using general anesthesia for endovascular thrombectomy?
I perform all of my thrombectomy cases under general anesthesia. There is better hemodynamic control, no patient movement to manage, which increases procedural efficiency as a result. In moderate sedation cases, patients can feel aspiration and stent retriever passes through the vessel, which causes...
How do you determine when to transition a patient with a shunt placed at birth to an adult provider?
Ideally, when you have a pediatric patient with a longstanding shunt, you begin discussions with the family at the initial placement, helping them understand that a shunt is usually a lifelong device that will require follow-up in some manner the rest of the child's life. When the child is entering ...
What is your approach to treating a child with a new brain tumor who is unable tolerate an MRI?
Barring an anesthetic or ferrous implant contraindication, any child should be able to have an MRI, if necessary, with general anesthesia/CO2 control and monitor, particularly when ICP/hydrocephalus is a concern.
Do you wait to treat small asymptomatic brain metastases until they reach a certain size?
I typically treat all lesions on MRI that are found to be concerning for brain metastases. This is after a discussion with our neuroradiologist colleagues. If there is uncertainty that a small lesion may not be a brain metastasis, then I will elect to follow with a surveillance MRI and treat in the ...
How frequently do you observe transient enlargement of a vestibular schwannoma after SRS?
Transient enlargement of a vestibular schwannoma is not uncommon, and it's appropriate to reassure patients. I image these patients once every 6 months until radiographic stability, and then once yearly.
What is your approach for testing speech in bilingual patients undergoing an awake craniotomy for glioma resection?
In a bilingual patient, it is important to assess the patient's language function in both languages. This would include pre-operative non-invasive functional mapping as well as intra-operative awake mapping. Areas of language function and connectivity are less discrete than sensory and motor functio...
What is your approach for surveillance of coiled unruptured aneurysm?
DSA 6 months after initial coiling MRA TOFTR (time-of-flight time-resolved) thereafter
Should ultra-short course RT be standard for elderly or poor performance status patients with glioblastoma?
The recent phase III randomized trial published by Roa et al. examining the efficacy of short course radiotherapy in elderly and/or frail patients with newly diagnosed GBM builds upon his previous work finding equivalent outcomes in elderly patients (age > 60 years) receiving 60 Gy in 30 fractions ...
How do you counsel patients who do you not experience early relief of hemifacial spasm after microvascular decompression surgery?
HFS is unique in that neurovascular compression is always the cause, and the location of NVC is almost always at the initial segment of the emerging facial nerve at the pontomedullary junction. High-resolution imaging pre-op using sub-millimeter voxel T2 MRI (BFFE) and MRA (source images) is recomme...