Neurosurgery
Physician insights on operative techniques, spinal disorders, neuro-oncology, cerebrovascular disease, and functional neurosurgery.
Recent Discussions
How do you manage glioblastoma presenting with leptomeningeal dissemination?
Hospice is a very legitimate option. As physicians, we recommend this far too infrequently.
What is your recommended long term management of extensive dural venous sinus thrombosis in an otherwise healthy young patient?
From a Vascular Neurology perspective, there are two considerations when faced with patients with venous sinus thrombosis. First is the status of the intracranial venous circulation and whether or not there has been adequate reconstitution of venous outflow, either through recanalization or collater...
How do you manage disease progression during adjuvant chemoradiotherapy for glioblastoma?
Hospice.
How do you select patients with spontaneous intracerebral hemorrhage for minimally invasive surgical hematoma evacuation, if offered at your institution?
Disclosure - our institution is conservative in its approach to surgical management of ICH, as we don't seem to have the supportive evidence to warrant large-scale application. With that, we take all cerebellar ICH with depressed level of consciousness or NIHSS >4. We consider cortical hemorrhages o...
What factors would influence your decision to use or avoid heparin bridging in patients with mechanical heart valves resuming anticoagulation after intracerebral hemorrhage?
The main conclusion from the publication by Sakusic et al., PMID 39102615 was that withholding anticoagulation for the first seven days after ICH is safe in patients with mechanical heart valves and bridging with intravenous heparin to coumadin upon resumption of anticoagulation should be avoided. T...
Would you consider adjuvant radiation therapy for a grade 1 meningioma with an elevated Ki67?
An answer to this important question requires conjecture as well as additional details. Ki-67 has indeed in some studies been identified as a promising biomarker [Liu et al., PMID 32118704, Tjuatja et al., PMID 36448071, Chen et al., PMID 29624151], however not uniformly so [Jensen et al., PMID 2929...
What workup do you consider for a developmentally typical child with multiple large café au lait macules but no other signs of neurofibromatosis?
The likelihood that this is NF1 depends somewhat in part on the age of the child in question. In infants and toddlers, cafe-au-lait macules are usually the first and only clinical sign of NF1. Most children with NF1 will develop skin fold freckling in early childhood, and the majority (probably 60-7...
What is appropriate followup duration after treatment for an acoustic neuroma?
Annual follow up is appropriate for most patients, and q6m MRI may not be necessary. If possible, long term follow up of 10 year or longer is prefered. The local control of acoustic neuroma with radiation treatment (SRS or FSRT) is excellent. Most series reported long term control of 95% or higher....
How do you manage a glioblastoma of the brainstem/upper cervical spinal cord?
It used to be that we didn’t get biopsies in this location, and we treated suspected astrocytic tumors in the brainstem/upper spinal cord to 54 Gy in 30 fractions without tissue. The outcome was never good. But now we generally have at least a stereotactic biopsy. The outcome is still not good of co...
How would you approach treatment of an optic nerve sheath meningioma presenting with complete ipsilateral visual loss?
Radiosurgery to prevent further tumor growth of an optic nerve sheath meningioma in a patient with complete ipsilateral visual loss can technically be accomplished. It is prudent to not include the chiasm nor the very proximal optic nerve due to Wilbrand's knee of the optic chiasm (where crossing fi...