Sample Prep of a Patient Prior to a Neurosurgery Consult

Here are suggested questions for your appointment with the neurosurgeon tomorrow afternoon:

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I. Patient’s symptoms and presentation

1) Have you seen many colloid cyst cases where the patient’s symptoms have involved leg numbness and not headaches or other symptoms? (Note: this sample case presented a benign colliod cyst but in some cases surgical pathology might have determined that the mass was a malignant astrocytoma.)

2) If the neurosurgeon says that he has not seen many colloid cyst cases with the patient’s presentation, then ask him what kind of brain lesions/masses does he see that are associated with leg (“extremity”) numbness, and are those masses usually benign or malignant?

3) Does the patient technically have hydrocephalus now? Is she heading toward hydrocephalus? Please explain what hydrocephalus is, and what leads to hydrocephalus. When a patient has enlarged ventricles ("ventriculomegaly" as in mega ventricles!), is that the key indicator for surgery because the patient is symptomatic?

4) How long do you think patient has had a colloid cyst? Are we talking years, or are we talking months? How quickly does the cyst grow?

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II. Patient’s MRI and Differential Diagnosis

5) Let’s discuss the cyst found on the MRI:

a) Is it unusually large in your experience--at what point is a cyst of this size operable? We have read that cysts can be excised when they are only tens of millimeters in size--and that’s much smaller than the patient's cyst.

b) Is there anything about the MRI that you think argues for ordering a second MRI so that it is reviewed by your own neuro-radiologists?

c) How typical for a colloid cyst is the presentation of being “in the midline of the foramen of Monro region?” What is the foramen of Monro, and what does it structurally do for the brain’s functionality? How does the colloid cyst affect the ventricles and the cerebrospinal fluid?

d) What is your surgical experience with respect to colloid cysts? Is it a frequent diagnosis or a relatively rare one? (The neurosurgeon may say that his team sees quite a few cases since they not only get referrals from all over the country but also since diagnostic imaging has improved so much that an increasing number of cysts are being discovered.)

6) Because of the location of the cyst, is there any possibility that it could be some other kind of specific brain mass or lesion, whether benign or malignant? The neurosurgeon will probably tell you that there is a very, very small possibility that the cyst could be something other than a colloid cyst, and he will explain the concept of differential diagnosis--i.e. all the types of brain diseases or conditions that the current problem can turn out to be, and what factors influence the finding of “a” versus “b” versus “c” versus “d.” Ask him whether he has had cases where, going into the surgery, he and his team are convinced that it is a colloid cyst only to find, once they are operating, that it is not at all cystic in nature and the surgical pathologists confirm, after the surgery, that it was not a colloid cyst but something else such as one of the lesions in the following differential diagnosis analysis for colloid cysts:

Colliod Cyst vs. Other Possible Diagnoses
Astrocytoma Meningioma
Central Neurocytoma Metastasis from another primary cancer
Choroid plexus papilloma Subependymal Giant Cell Astrocytoma
Ependymoma

7) What does dilatation of the lateral ventricles mean? What would her symptoms be if the dilatation was, instead of being mild which is what the MRI has found, more severe?

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III. Compelling Reasons for Surgery so that the Patient has a Maximum Comfort Level; Discussion of the Surgical Technique that Will be Used and How the Patient Can Best Prepare for this Procedure.

8) There seems to have been a difference of opinion among neurosurgeons in the 1990's about how to remove a colloid cyst--whether surgical excision through craniotomy (for example, the Dr. Michael Apuzzo view at USC) or stereotactically (such as the Dr. Friedrich Kreth view in Germany). How has that debate been resolved, and where does your team of neurosurgeons stand? What are the pros and cons of both methods in terms of after-effects, risk of death by virtue of the procedure itself, and risk of not being able to evacuate the entire cyst? Does a craniotomy carry with it the risk of destroying brain tissue? What parts of the brain are near the foramen of Monro that could be functionally impaired during surgery?

9) Does your neurosurgery group use the dual-port endoscopic procedure that Dr. Marvin Bergsneider has pioneered at UCLA?

Please discuss with the neurosurgeon this excerpt from the UCLA website:

At UCLA, the neurosurgeons have been developing a two port endoscopic approach to colloid cysts that maintains many of the advantages of an open craniotomy approach but in addition adds benefits not achievable with a craniotomy. The main benefit is that a “far frontal” approach can be easily used with endoscopy. The far frontal approach provides the neuroendoscopist a direct (endoscopic) view of the roof of the third ventricle – the location where the colloid cyst is attached. This view is generally not obtainable with a craniotomy without destroying possibly critical brain tissue (the fornix) necessary for memory function. Being able to visualize this part of the brain allows the best opportunity to completely and safely remove the entire colloid cyst capsule.

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IV. Complications or Side-Effects of any Surgical Removal of the Colliod Cyst

10) What happens if I say "I don’t want surgery!" What are the consequences of not removing a colloid cyst? Do you have patients who say "let’s do watchful waiting and see if this grows to a point where it could lead to a severely compromising situation?" Are there non-surgical "fixes" for a colloidal cyst?

11) What are the after-effects or complications of any surgery? The neurosurgeon may well explain "informed consent" and perhaps give an Informed Consent document to you after he answers all your questions. The Informed Consent is going to be an extremely detailed document.

12) What should the patient do to prepare for the surgery? Please have the neurosurgeon review ALL medications you are currently on, including the specific vitamins and NSAIDs you may be taking.

13) How long will either the microsurgery or the stereotactic procedure take? How much time should we plan on staying in the hospital?

V. Treatment and Follow-up after Patient’s Surgery

14) What are the post-surgical complications that we should watch out for?

15) Whom should we call if we have a problem before or after surgery? Your nurse? Does she have a direct line or cell phone/pager?

16) What is my treatment plan, if any, following the surgical procedure?

17) What are the worst complications you have ever experienced following colloid cyst surgery?

18) If the surgery does not work and the cyst somehow recurs, what do we do?

19) What are the guidelines for release as well as resuming work and normal activities? How soon do we need to return to the hospital for the post-surgery check-up?

20) After I have recovered from the surgery, what do you recommend in terms of "follow-up" time with you and your office? After I recover, will I go for follow-up MRI scans? Every six months?