Neurosurgery
Physician insights on operative techniques, spinal disorders, neuro-oncology, cerebrovascular disease, and functional neurosurgery.
Recent Discussions
How do you manage the timing of adjuvant therapy in a patient with a glioblastoma and a post-operative surgical site infection?
There have been several studies on the timing of adjuvant therapy for glioblastoma including our institution https://www.ncbi.nlm.nih.gov/pubmed/26440447. In general, our practice has been to start adjuvant radiotherapy as soon as reasonably possible. If a glioblastoma patient has postoperative surg...
What is your approach to management of a myxopapillary ependymoma of the conus with drop metastases to the cauda equina?
Usually I treat with localized fields but feel there is no correct answer. I offer the patients CSI as an alternative and explain benefits and risks. These patients are expected to live very long lives and 36 Gy CSI will have tremendous adversely affect on them. I acknowledge the risk of re-irradiat...
What is your recommended follow-up schedule for a meningioma after definitive radiotherapy?
For grade 1 meningioma, I obtain annual follow up MRI for the first 5 years, and then at 18-month intervals from 5-10 years. After that I offer patients to have an MRI every other year and some of them will do it.
How do you treat a young woman of child bearing age group diagnosed with primary CNS lymphoma?
The first step is to check HIV serology to ensure that the patient is HIV negative as HIV+ve patients would need to antiretroviral therapy promptly along with chemotherapy or the prognosis is dismal. If patient is young and fit the initial approach is similar in both HIV +ve and -ve patients. Assumi...
Would you continue consolidation temozolomide for more than 1 year for a patient with grade 3 anaplastic astrocytoma, after gross total resection and daily temozolomide+EBRT?
Thank you for the question.The short answer is, "no". There is no data that adjuvant chemotherapy beyond 12 months improves outcomes. The temozolomide is usually very well tolerated, but it is associated with bone marrow injury with myelodysplasia or leukemia as risks. So, in general with no upside,...
How would you approach the treatment of resectable NSCLC with a solitary resectable brain metastasis and no other sites of metastasis?
There is a several decade history of curing NSCLC in patients presenting with a solitary CNS metastasis and with resectable lung primary. This has primarily been for patients with N0 or N1 rather than N2 disease. It is unknown whether SBRT would be equivalent to craniotomy. There is, of course, no d...
What is your preferred treatment for spinal drop metastases from a glioblastoma?
This is a relatively uncommon, but challenging clinical situation, and usually the prognosis is poor. Our approach is as follows: 1. Detailed MR imaging of the spine to ensure that the failure is truly focal, and not multifocal or leptomeningeal: 2. Thorough re-imaging of the brain to ensure that t...
What margins do you use for glioblastoma in close proximity to critical structures?
Assuming standard fractionation to 60 Gy with concurrent temozolomide, I am struggling to think of a GBM patient who has had a complication due to radiation to adjacent critical structures. Since my GBM margins are not very large (Initial: 1 cm around the T2 + cavity. Cone-down: 1 cm around the cont...
What is your approach to a patient with a glioblastoma who cannot have an MRI?
We used contrast enhanced CT. Surveillance was done with the same. We were able to provide both post operative adjuvant RT and also stereotactic radiotherapy after localized recurrence. The PTV volume was postoperative cavity and contrast enhancement with 2 cm for adjuvant (single phase) and area of...
How do you manage cavernous sinus meningiomas?
Radiotherapy or radiosurgery depending on optic nerve dose