Neurosurgery
Physician insights on operative techniques, spinal disorders, neuro-oncology, cerebrovascular disease, and functional neurosurgery.
Recent Discussions
How would you approach treatment for a glioblastoma from a radiation standpoint that was initially thought to be a metastases and therefore treated with multiple courses of SRS over the past few years?
It appears that the patient was empirically treated with multiple SRS courses; then, presumably, the patient must have undergone a biopsy/resection which disclosed the true nature of the problem (GBM). Therefore, the question is, what is the appropriate postop treatment for this patient? There are s...
Would you recommend a CT venogram or MR venogram in patients with concern for venous sinus thrombosis?
Either modality is suitable for assessing CVST. However, I typically prefer CTV. It's easier to obtain and has a quick scan time, which reduces the chances of motion artifacts. MRV provides better resolution, but it requires a screening form and has a longer scan time, which may lead to motion artif...
What is the expected timeframe one would expect to see paroxysmal sympathetic hyperactivity/sympathetic storming persist post-traumatic brain injury?
I've personally seen as long as 30+ days but usually less.
For recurrent glioblastoma treated with combined re-irradiation and bevacizumab, how long do you continue bevacizumab?
In the event of recurrent GBM, for example, if i.e. fSRT regimen like 30 Gy/5fx to be used for salvage, would not exceed more than 12 doses (6 cycles) of bevacizumab max. Even in the pseudo-response setting, the toxicity far outweighs the benefit beyond this.
Do you place asymptomatic patients being treated for brain metastasis with SRS on prophylactic steroids?
We do not use steroids routinely for asymptomatic patients being treated for brain metastases except if there is a concern based on anatomic location, volume, and/or presence of edema (e.g. adjacent to motor strip with significant edema, in or adjacent to brain stem, V12 brain receiving > or near 10...
When do you re-image patients with a diagnosis of venous sinus thrombosis?
My practice is to perform early reimaging, typically at around 2 weeks, before transitioning from parenteral anticoagulation to oral anticoagulation. This early reassessment is important as recanalization processes begin early and are linked to clinical outcomes. Subsequent imaging at 6 months is al...
What is the best management of an unruptured Spetzler Martin grade 3 arteriovenous malformation in a young patient?
This is a complex question and first and foremost requires and understanding of the natural history of an AVM.Natural history of cerebral arteriovenous malformations: a meta-analysis Nine natural history studies with 3923 patients and 18,423 patient-years of follow-up were identified for analysis. T...
What specific clinical factors would drive you to recommend surgical intervention for patients with small, nonfunctional pituitary adenomas who exhibit no neurological symptoms?
I don't think there is any indication for surgery in such a case.
Should patients with non-functional pituitary macroadenomas with persistent, but tolerable, headaches be recommended for surgery?
It depends on the size of the adenoma and stability of the imaging. It is sometimes difficult to know if the headaches are related. In a younger patient, I would consider surgery.
How do you manage patients with a prior intracerebral hemorrhage from probable cerebral amyloid angiopathy who develop new small vessel ischemic infarcts?
In this situation, I would consider using cilostazol since it has both antihypertensive and antiplatelet properties. However, the safety profile is unclear in patients with amyloid angiopathy.