Neurosurgery
Physician insights on operative techniques, spinal disorders, neuro-oncology, cerebrovascular disease, and functional neurosurgery.
Recent Discussions
Should adjuvant radiation be given for an atypical (WHO II) meningioma of the thoracic spine after gross total resection?
Overall data are thin in this arena, in large part due to the relative scarcity of the disease. We recently published a bi-institutional experience (Wash U/U of Utah) of the largest cases series to date of 102 patients with spinal atypical meningioma (AM) underoing resection (Simpson I-IV) (Sun et a...
How would you manage a patient with surgically resected T3N1 NSCLC who is found to have one small brain metastasis on staging MRI?
For adjuvant chemotherapy, this is a difficult question for which there is no evidence-based answer, really. The "textbook" answer is that this is metastatic disease, and adjuvant therapy has only been proven for early stage disease. However, since there is still a reasonable chance of a cure after ...
Is there ever a situation where you would recommend radiation after gross total resection of a craniopharyngioma?
I favor observation.
How to you manage radiation brachial plexopathy in head & neck patients?
I am not aware of any effective therapy for brachial plexopathy. Bevacizumab has been reported to be beneficial in radiation-induced brain and retinal injury but I am not aware of its use in neuropathy. In any case, brachial plexopathy after RT of HN cancer is quite rare. I do not recall any BP case...
How long after WBRT would you wait to give SRS to a recurrent brain metastasis?
Practically speaking, radiation necrosis from whole brain radiation is very unusual. So most progression post whole brain radiation would be considered tumor recurrence and may be best treated with SRS. With newer immunotherapeutics, however, pseudoprogresion may be seen and needs to be considered. ...
What is your treatment approach for re-irradiation of a pituitary adenoma?
Re-irradiation for a pituitary adenoma is very challenging situation, since almost certainly would exceed normal tissue tolerance of optic apparatus. If re-irradiation is deemed necessary, stereotactic radiation either SRS or SRT should be used. Stereotactic RT only need minimum margin, usually 0-2...
How do you approach SRS for a brain metastasis in an eloquent area of the brain?
Short of metastases in the brainstem or next to the optic nerve/chiasm, we do not routinely decrease the dose or hypofractionate SRS in other eloquent areas such as the motor strip. While radiation necrosis is the main concern, the risk of recurrence which is shown to be higher with diminished doses...
How do you manage recurrent CNS ependymoma?
Data for treating recurrent ependymoma comes mostly from single institutions retrospective series. Patients with recurrent ependymoma should be restaged with spine MRI and LP cytology, evaluated for maximal safe resection, re-irradiation, and clinical trials. If the disease is localized, many radiat...
Would you do SRS for a patient who cannot receive gadolinium contrast and has a single brain metastasis on non-contrast MRI?
There is a reasonable concern that other small brain metastasis could be present without obtaining fine cut T1 imaging with gadolinium contrast. As long as the patient is otherwise a reasonable candidate for radiosurgery, and can return for follow up, I would feel comfortable going ahead with SRS ba...
How do you manage multifocal glioblastoma or high-grade gliomas?
In multifocal glioblastoma or high-grade gliomas, I would consider surgical resection if there was a dominant lesion or lesions causing symptoms. In cases where debulking is unlikely to provide symptomatic relief or aggressive surgery is most likely to remove a portion of disease burden, I would ten...