Neurosurgery
Physician insights on operative techniques, spinal disorders, neuro-oncology, cerebrovascular disease, and functional neurosurgery.
Recent Discussions
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 consider a post-natal myelomeningocele repair rather than a fetal myelomeningocele repair?
There are certain inclusion and exclusion criteria for fetal repair of myelomeningocele. Fetal repair of myelomeningocele is generally offered only to carefully selected singleton pregnancies that meet anatomic, gestational age, maternal, and exclusion criteria based on MOMS and subsequent instituti...
Under what circumstances would you consider completing a decompressive hemicraniectomy and a frontal sinus cranialization at the same time for penetrating cranial trauma?
If craniectomy is straightforward and the patient is stable under anesthesia for less than 2 hours, we would consider cranialization at the time. Other considerations include whether assistance by a non-neurosurgeon (ophthalmologists, plastics, ENT...) is required and/or if cranialization will requi...
How do you approach treatment of a craniopharyngioma in an older adult patient?
There is a bimodal age distribution, with one peak in children between 5 and 14 years old and the second peak in adults between 50 and 75 years of age. Adamantinomatous (frequently with calcification) craniopharyngiomas are more common in children, while papillary (frequently lack calcification) cra...
What is your approach to using intra-arterial or intrathecal vasodilators in patients with vasospasm in subarachnoid hemorrhage despite usage of oral nimodipine?
Bottom line up front: The 2023 AHA/ASA focused update on aSAH recommends IA vasodilator infusion or mechanical angioplasty in clinically significant vasospasm refractory to medical therapy (Class IIa, Level B) and states that intraventricular nicardipine “may be considered” in selected patients (Cla...
Does CEA still have a role instead of stenting for surgical management of asymptomatic carotid artery disease?
In most patients with asymptomatic high-grade stenosis, stenting is preferable to endarterectomy based on the results of CREST-2. In a small percentage of such patients, stenting may not be technically feasible. Also, some patients may not want to take the medications usually prescribed after stenti...
How do you determine the timeline for healing after craniotomy prior to starting chemotherapy and radiation?
I typically wait at least 10-14 days post-op, always after neurosurgery has re-evaluated the craniotomy site for appropriate healing and has already removed staples or sutures.
Under what circumstances do you utilize an EVD rather than a lumbar drain for management of CSF leak after a transphenoidal resection?
Rarely is there any indication for CSF diversion at all for CSF leaks after translabyrinthine craniotomy. The reason for this is that, by definition, patients have no hearing on the operated side. Blind sac closure of the external ear canal and direct packing of the Eustachian tube successfully trea...
Is it acceptable to treat newly diagnosed small cell lung cancer with limited brain metastasis with upfront SRS?
First, to be clear, there's not good evidence regarding the role of radiosurgery in small cell patients who have not had WBRT or PCI. In patients without brain metastases, there's a clearly defined and clinically significant survival benefit, which seems to result from both control of existing metas...
How do you determine which targeting modality to utilize for DBS placement?
Target selection requires multidisciplinary evaluation involving movement disorder specialists, neurosurgeons, neuropsychologists, and psychiatrists to assess motor, cognitive, and behavioral status comprehensively. The team must identify surgical goals, weigh individual patient factors, and arrive ...