Neurosurgery
Physician insights on operative techniques, spinal disorders, neuro-oncology, cerebrovascular disease, and functional neurosurgery.
Recent Discussions
How do you approach a recurrence of grade 3 anaplastic astrocytoma after initial treatment with gross total resection followed by RT/adjuvant temozolomide?
As the questioner notes, this is an area where guidelines and published evidence are not as satisfying as we would like, so treatment has to be individualized. In addition, most trials until very recently did not test IDH status or 1p/19q status so the diagnoses may not be the same as people diagnos...
What is the preferred approach to managing non-occlusive or partially occlusive venous sinus thrombosis?
I would recommend a DOAC, particularly apixaban, with follow-up imaging in 3 months.
For meningiomas causing symptoms such as headaches, what percentage of patients experience improvement of symptoms after radiation alone?
Without question, patients are often found to have meningioma after presenting with headache. At times the headache may have been due to meningioma, particularly if the meningioma is large meningioma, has broad-based dural involvement, and/or is accompanied by edema, which they often are, especially...
How would you approach a patient over the age of 40 with a sub-totally resected frontal oligodendroglioma, WHO Grade II, 1p/19q co-deleted, IDH mutant, with imaging concerning for second site in the pontomedullary junction?
The pontomedullary junction is not usually amenable to a biopsy (unless the lesion is exophytic); as such, there are 2 possibilities: a) the second lesion is related to the one that has undergone subtotal resection, or b) the lesion is of a different nature. Statistically, it is more likely to be a ...
How would you manage a very large diffuse skull base meningioma involving the olfactory groove, bilateral cavernous sinuses, and abutting optic chiasm that is not amenable to surgical resection?
Skull base meningiomas are the ones that are commonly referred to Radiation Oncology departments as they are difficult to treat surgically, especially when they involve cranial nerves compartments as is the case in this patient. Given the number of OARs at risk for this patient, if the meningioma wa...
Do you recommend encephaloduroateriosynangiosis in pediatric patients with Moyamoya disease?
Only if it's clearly symptomatic.
For which patients is frameless gamma knife radiosurgery most appropriate?
Patients who are good candidates are those with tumors that obviously need fractionation (large size, near optic chiasm, etc.) AND are very compliant / able to participate in their care. Noncompliant patients will be impossible - there will be too much motion. It's difficult for most patients to tol...
Do you routinely recommend SRS to the surgical bed after resection of a single brain metastasis?
At our institution it is routinely done although local control reported in literature varies from 60 to 85 percent. One problem with this approach is defining the surgical cavity target accurately. To overcome this, retrospective data suggests giving 2mm margin around the cavity to improve local con...
Is it reasonable to extrapolate data from Glioblastoma and discuss Tumor Treating Fields in patients with Grade 4, IDH Mutant, astrocytomas?
While more than 90% of Grade 4 gliomas are IDH wildtype tumors (GBMs), this question does come up occasionally. Since I have no personal experience with TTF, I asked my collaborator Chirag Patel, MD, a neuro-oncologist at MDACC who regularly uses TTF in his patients, to provide his opinion. So pleas...
When do you consider genetic testing in patients with suspected hereditary brachial plexopathy?
There are two hereditary disorders associated with brachial plexopathy: 1) Hereditary neuralgic amyotrophy (HNA), which is caused by SEPT9 mutations ~70% of cases, and 2) Hereditary neuropathy with liability to pressure palsies (HNPP), which can manifest as a painless brachial plexopathy especially ...