Neurosurgery
Physician insights on operative techniques, spinal disorders, neuro-oncology, cerebrovascular disease, and functional neurosurgery.
Recent Discussions
How do you evaluate for improvement in tremor from FUS in essential tremor?
The best method for the assessment of improvement in tremor after a FUS thalamotomy is by using a standardized clinical rating scale. These include the Essential Tremor Rating Scale (TETRAS) or the Clinical Rating Scale for Tremor [also known as the Fahn-Tolosa-Marin (FTM) score]. The TETRAS scale h...
What is the best way to understand functional tracts to guide the surgical approach for tumor resection in patients unable to participate in functional MRI?
This is really a language question. Motor pathways can be mapped asleep regardless of cognitive status, and nothing done preoperatively replaces direct stimulation for language. The task is to build the best structural and functional model before surgery and then decide whether intraoperative langua...
When treating trigeminal neuralgia with SRS, are there vascular constraints or concern for late aneurysm?
The incidence of cerebral aneurysms after stereotactic radiosurgery (SRS) for trigeminal neuralgia (TGN) is extremely rare. High-dose radiation (60 - 90 Gy) delivered to local microvasculature can theoretically cause focal vessel wall weakening, elastin degeneration, or radiation angiopathy leading ...
How do you approach treatment of a glioblastoma in pregnancy?
Glioblastoma during pregnancy could be treated safely (to mother and fetus) with certain precautions and modifications. Collaboration and consultation with the patient’s obstetrician are essential. External shielding over the patient’s abdomen during treatment will decrease the external scatter radi...
What first-line therapeutic regimen do you consider most appropriate for metastatic clear cell renal carcinoma presenting with brain metastasis and vasogenic edema?
For patients presenting with brain metastases, I always do local therapy, usually SBRT, before systemic therapy. I am nervous about starting immune-based therapy or a TKI in patients with uncontrolled CNS metastases. There are small series using TKIs such as cabozantinib in this setting, but since S...
What is your approach to management and surveillance in low grade traumatic blunt ICA injury?
For blunt cerebrovascular injury (BCVI), I use the Biffl scale to evaluate the extent of vessel trauma. The extracranial neck vessels, such as the cervical ICA or VA, are most commonly affected. The Biffl classification consists of five categories, with Grade 1 representing a low-grade injury. This ...
How do you manage glioblastoma presenting with leptomeningeal dissemination?
Hospice is a very legitimate option. As physicians, we recommend this far too infrequently.
What restrictions do you have patients follow after a lumbar MIS microdiscectomy?
Minimize excessive bending, lifting, or twisting for six weeks. Weight-carrying limit of approximately 10 pounds (a gallon of milk). Ambulate as much as possible. Listen to your body.
How do you decide on head-of-bed positioning after mechanical thrombectomy for acute stroke?
First, there is some evidence that HOB positioning is related to deterioration/improvement before endovascular thrombectomy (EVT) from the ZODIAC trial. Second, safety comes first. Follow your ABCs. If the airway is ok, the patient does not develop orthopnea with a supine position, and the BP is ok ...
When do you consider using stimulants in patients with cognitive impairments secondary to traumatic brain injury?
Perhaps most importantly, prescribing medication to address cognitive difficulties conveys hope to TBI patients that even if they have suffered structural brain damage, they can improve. Though the improvement may be fairly small, it can have important implications for better general functioning. We...