Neurosurgery
Physician insights on operative techniques, spinal disorders, neuro-oncology, cerebrovascular disease, and functional neurosurgery.
Recent Discussions
Do patients with NPH/communicating hydrocephalus always require VPS?
This is a complicated question. Evaluations for NPH include monitoring for neurological improvement following a large-volume lumbar puncture or a lumbar drain trial. At our institution, we prefer a lumbar drain trial as it allows more volume to be removed over time and mimics the placement of a shun...
How would you manage a Grade II IDH mutant astrocytoma with otherwise low risk features, but gemistocytic histology?
Not sure there is a right answer for this one - in general, for an IDH mutant grade 2 astrocytoma with low risk features, I would consider observation. If all else is low risk with the exception of gemistocytic histology, I may still consider observation and counsel the patient about an increased ri...
How would you approach management of a patient who is status post resection of a WHO grade 1 planum sphenoidale meningioma which was adherent to the optic nerve?
As suggested by the mere fact of its posting, this is a complex question. If this were a gross total resection (GTR), I would tend toward observation and would follow the patient carefully with imaging and clinical evaluations at 6-month intervals for at least 3 years, then annually. GTR for a planu...
For an atypical meningioma WHO grade 2 s/p GTR, do molecular findings that suggest an integrated diagnosis of a grade 3 tumor change adjuvant radiation treatment recommendations?
There is no definitive clarity on this question, as the data simply do not exist. Therefore, decision-making has to be individualized. For residual disease, the GTV would be easy to estimate, but it might be prudent to utilize the pre-op scans in these patients to understand the pre-op GTV, which co...
Would you manage a subtotally resected pilocytic astrocytoma with deleted CDKN2A differently than one with intact CDKN2A?
Among brain tumors, CDKN2A loss has the greatest clinical implications in histologically low and intermediate grade gliomas. In IDH-mutant astrocytomas, the presence of homozygous deletion of CDKN2A is associated with poor outcome. Usually, pilocytic astrocytomas (grade 1) have a very good prognosis...
Is there a time interval after which you would not offer adjuvant radiotherapy for a malignant, grade 3 meningioma?
Adjuvant radiation for grade 3 meningioma is based on prior observational studies that generally reflect recurrence rates approaching 90% for grade III disease, and the insufficiency of salvage treatment approaches.Given the small numbers of grade 3 tumors, and the heavy bias towards upfront postop ...
How would you approach a patient with limited stage SCLC who progressed immediately after completing chemoradiation with brain metastasis?
For 1-10 brain metastases from SCLC, consider the NRG CC009 clinical trial randomizing between SRS and hippocampal-avoidance WBRT!
When do you refer patients diagnosed with Moyamoya disease to neurosurgery?
I almost always refer patients with Moyamoya to neurosurgery. The only treatment for this condition is either direct or indirect bypass surgery. If they have any active symptoms, have an old infarct, or recent stroke visible on scans, surgery is worth considering.
How would you treat grade 3 cauda equina meningioma status post biopsy only with a history of prior prostate/whole pelvis radiation?
This question is anything but routine. WHO grade 3 spinal meningiomas are exceedingly rare. I’ve been treating meningioma patients my entire career, now beyond 3 decades, and have never seen one. If this patient’s prostate cancer radiation therapy (RT) were many years ago and if his meningioma were ...