Neurosurgery
Physician insights on operative techniques, spinal disorders, neuro-oncology, cerebrovascular disease, and functional neurosurgery.
Recent Discussions
In what circumstances would you consider use of IDH inhibitors in high-grade astrocytomas?
Please forgive me for the length and directness of my response, but I believe it is important to first go over the INDIGO trial and explain why, in my opinion, it was a highly questionable study, with multiple significant methodological flaws and dubious evidence of Vorasidenib's efficacy.INDIGO tri...
Are you offering Lutathera for multiple recurrent meningiomas?
Lutathera is currently only FDA-approved for treating somatostatin receptor-positive gastroenteropancreatic neuroendocrine tumors (GEP-NETs). However, research is ongoing to explore its potential use for meningiomas, as many meningiomas express somatostatin receptors, which could make it a promising...
How do you determine when patients can resume their previous activities after a subdural hemorrhage?
First, it depends on the status of the SDH; if surgically removed or with embolization of the middle meningeal artery, then return to activity can be fairly rapid, over 2-3 weeks if gradually increasing, but if no surgery or intravascular procedure, then I would advise more caution. This would mean ...
How do you manage a recurrent brain metastasis in a surgical cavity that contains mixed radiation necrosis and viable tumor in the setting of prior SRS?
This diagnosis is made at our center by combining MRI, MR perfusion, and PET data. Management depends on the presentation of the patient, if there is mass effect and/or neurological deficit then surgical re-resection is preferred. As a matter of interest, the pathology on the infrequent resections d...
When do you prefer pre-operative SRS over post-operative SRS for brain metastases?
For patients with brain metastases that benefit from resection, our approach is to always treat pre-operatively unless the patient requires immediate surgical intervention. Pre-operative SRS has several advantages including clear target delineation. Post-op SRS has best results with expanded volumes...
Is it ever appropriate to omit temozolomide in unmethylated glioblastoma?
Perhaps a different perspective on this question would be which unmethylated patients would you be willing to not treat with up-front temozolomide? The genesis of the question and conundrum comes from the modest benefit described in the above-mentioned trials for this subgroup. As Hegi herself descr...
For non-functional pituitary macroadenomas, how effective has cabergoline been in reducing tumor size or preventing the need for surgery?
There is some literature suggesting that a modest effect is seen in preventing tumor regrowth in previously operated NFPA (Treatment of clinically nonfunctioning pituitary adenomas with dopamine agonists). The data on primary therapy is less convincing.Topic reviewed recently in Pharmacological Trea...
Given the new 2022 WHO classification of pituitary tumors, should we be regularly counseling our patients about the risk of malignancy for what we previously referred to as pituitary adenomas but now classified as pituitary neuroendocrine tumors (PitNETs)?
Absolutely not. Metastatic pituitary adenomas are exceedingly rare. The term PitNet is unnecessarily alarming for patients with these benign disorders and also does not provide a clinically relevant outcome classification. Accordingly, The Pituitary Society has not adopted the term PitNet and prefer...
When do you obtain head and neck vascular imaging in patients with traumatic brain injury?
When there are skull base fractures that could lead to a dissection, when there is penetrating or blunt neck injury, when it is unclear if the primary event was a brain hemorrhage with secondary TBI, or in the case of imaging that suggests a concomitant ischemic stroke. This is not an exhaustive lis...
Does the presence of thrombus in the sinus affect your decision between fractionated radiation and SRS for recurrent grade 1 meningioma?
The presence of a thrombus in the venous sinuses can be a significant risk factor for post-treatment complications after SRS for meningiomas originating near or attached to the sinuses. Venous sinus thrombosis can be increased by the SRS, leading to venous infarction, which can cause a range of neur...