Neurosurgery
Physician insights on operative techniques, spinal disorders, neuro-oncology, cerebrovascular disease, and functional neurosurgery.
Recent Discussions
How do you approach treatment of a spinal meningioma?
Surgery is usually the first option. If there is a good resection, the histology is WHO grade 1 (usually) and any residual tumor, if present, does not threaten the spinal cord, one could observe and decide on further action later when the tumor shows signs of growth. If the surgery is only a biopsy ...
What are the recommendations for considering deep brain stimulation in a patient with tremors and dementia or mild cognitive impairment?
In PD, studies with the strongest quality of evidence show a slight decline in global cognition in patients undergoing STN-DBS compared to GPi-DBS or medical therapy. However, the majority of controlled clinical trials and observational studies do not find changes in global cognition among these gro...
For a glioblastoma patient who had an MRI immediately postoperatively and you are able to repeat one closer to the time of CT simulation, do you use the more recent scan or the immediate postoperative scan for contouring (T2/FLAIR and T1 post)?
We usually obtain a repeat MRI closer to the time of CT sim, ideally on the day of sim, for several reasons. First, surgical cavities have a tendency to collapse which may impact target volume delineation. Secondly, peritumoral edema T2FLAIR signal infrequently subsides, which may also affect target...
Would you attempt a brain MRI in patients who present to the ER with subacute presentation of obstructive hydrocephalus?
I think an MRI is warranted to characterize the cause of the hydrocephalus in almost all cases, especially in the setting of a mass. The MRI can help identify the nature of the mass and the absolute size, and help with the differential diagnosis. It will also help you identify the mass as a solitary...
When can you utilize external ventricular drains (EVDs) in the management of posterior fossa strokes?
I would use an EVD only in combination with posterior fossa craniectomy in patients with large cerebellar infarctions. An EVD alone could result in upward herniation.
How do you manage acute exacerbations of trigeminal neuralgia?
I do not have personal experience treating TN exacerbations in the ED. What is generally recommended under those circumstances is intravenous phenytoin. Schnell et al. recently published it in The Journal of Headache and Face Pain (Schnell et al., PMID 32981076). They published the results of a retr...
Would you favor restarting anticoagulation or pursuing left atrial appendage closure in a patient with hemorrhagic stroke on anticoagulation for non-valvular atrial fibrillation?
That is a great question, thank you for bringing it up. The answer really depends on the likely etiology of the intracerebral hemorrhage. For example, if the hemorrhage is subcortical and the etiology is thought to be likely related to hypertension, it is reasonable to resume anticoagulation when sa...
In what subset of traumatic brain injury/concussion patients would you consider use of N-Acetyl Cysteine?
There are some reports that N-Acetyl Cysteine (NAC) may help the patient with TBI for behavioral recovery and it has neuroprotective effects. I also used NAC and Alpha lipoic acid in patients with post-chemotherapy neuropathy as antioxidants. There are limited studies on how effective they are but t...
How do you manage autonomic storming in patients with increased intracranial pressure?
In many respects, the treatment of paroxysmal sympathetic hyperactivity (PSH), or storming, is similar whether or not there is elevated ICP. The goal is to limit stimuli that provoke the episodes of storming and reduce sympathetic outflow or block its downstream effects. The difference is in those p...
Is there an age cutoff at which you would recommend against radiosurgery for a schwannoma or trigeminal neuralgia in someone who is a good surgical candidate with no comorbidities?
Personally, I do not have a specific age cutoff, but do have a careful discussion about secondary malignancy risks in a younger patient. With younger patients with schwannomas, one has to be careful about neurofibromatosis as there may be a higher risk of secondary malignancies from radiation. With ...