Neurosurgery
Physician insights on operative techniques, spinal disorders, neuro-oncology, cerebrovascular disease, and functional neurosurgery.
Recent Discussions
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...
How do you distinguish between episodes of vascular steal and seizures in patients with an AVM?
Distinguishing between vascular steal and seizures in patients with AVMs can be challenging, but certain patterns may help. Vascular steal occurs when blood is shunted through the AVM nidus, bypassing the surrounding tissue and causing regional or global oligemia. The shunting can result in transien...
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...
How do you decide when to intervene directly on a feeder artery aneurysm of an AVM?
Flow-related peri-nidal aneurysms can occur in a few different scenarios, which play an outsized role in determining management. These aneurysms can be located intra-nidal, or can be remote. They can also be detected through routine imaging, but can also present as having ruptured. AVM hemorrhage is...
Which imaging features do you use when considering Normal Pressure Hydrocephalus to decide whether to proceed with large-volume LP or lumbar drain trial?
At our center, we follow the approach of the NPH clinic at the Imperial College Hospital in London.See this excellent review article for further details: Carswell, PMID 36162853.
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...
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 ...
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.