Harvey Cushing and Oskar Hirsch: early forefathers of modern transsphenoidal surgery

2005 ◽  
Vol 103 (6) ◽  
pp. 1096-1104 ◽  
Author(s):  
James K. LIU ◽  
Aaron A. Cohen-Gadol ◽  
Edward R. Laws ◽  
Chad D. Cole ◽  
Peter Kan ◽  
...  
Keyword(s):  
Transsphenoidal Surgery ◽  
Sphenoid Sinus ◽  
Sella Turcica ◽  
Future Generations ◽  
Content Type ◽  
Harvey Cushing ◽  
Transnasal Surgery ◽  
Sublabial Approach ◽  
First Time ◽  
Fine Print

✓ The transnasal transsphenoidal approach is the preferred route for removal of most lesions of the sella turcica. The concept of transnasal surgery traversing the sphenoid sinus to reach the sella has existed for nearly a century. A comprehensive historical overview of the evolution of transsphenoidal surgery has been reported previously. In the present vignette, the authors focus on transsphenoidal surgery in the early 1900s, particularly on the methods advocated by Harvey Cushing and Oskar Hirsch, two prominent pituitary surgeons who pioneered the transsphenoidal technique. Cushing championed the sublabial approach, whereas Hirsch was the master of the endonasal route. Coincidentally, both surgeons independently performed the submucous septal resection for the first time on June 4, 1910. Although Cushing's and Hirsch's approaches were predicated on the work of their predecessors, their transsphenoidal procedures became the two most popular techniques and, for future generations of pituitary surgeons, laid the foundation for modern transsphenoidal surgery. In this comparative analysis, the authors compare the operative nuances of the approaches of Cushing and Hirsch and describe the contributions of these pioneers to modern transsphenoidal surgery.

Thickening of sphenoid sinus mucosa during the acute stage of pituitary apoplexy

2001 ◽  
Vol 95 (5) ◽  
pp. 897-901 ◽  
Author(s):  
Kazunori Arita ◽  
Kaoru Kurisu ◽  
Atushi Tominaga ◽  
Kazuhiko Sugiyama ◽  
Fusao Ikawa ◽  
...  
Keyword(s):  
Transsphenoidal Surgery ◽  
Sphenoid Sinus ◽  
Pituitary Apoplexy ◽  
Sella Turcica ◽  
Acute Stage ◽  
Mr Images ◽  
Content Type ◽  
Subepithelial Layer ◽  
Sinus Mucosa ◽  
Fine Print

✓ The authors treated two patients with pituitary apoplexy in whom magnetic resonance (MR) images were obtained before and after the episode. Two days after the apoplectic episodes, MR imaging demonstrated marked thickening of the mucosa of the sphenoid sinus that was absent in the previous studies. The relevance of this change in the sphenoid sinus was investigated. Retrospective evaluations were performed using MR images obtained in 14 consecutive patients with classic pituitary apoplexy characterized by acute onset of severe headache. The mucosa of the sphenoid sinus had thickened predominantly in the compartment just beneath the sella turcica, in nine of 11 patients, as ascertained on MR images obtained within 7 days after the onset of apoplectic symptoms. This condition improved spontaneously in all four patients who did not undergo transsphenoidal surgery. The sphenoid sinus mucosa appeared to be normal on MR images obtained from three patients at the chronic stage (> 3 months after onset). The incidence of sphenoid sinus mucosal thickening during the acute stage was significantly higher in the patients with apoplexy than that in the 100 patients without apoplexy. A histological study conducted in four patients who underwent transsphenoidal surgery during the early stage showed that the subepithelial layer of the sphenoid sinus mucous membrane was obviously swollen. The sphenoid sinus mucosa thickens during the acute stage of pituitary apoplexy. This thickening neither indicates infectious sinusitis nor rules out the choice of the transsphenoidal route for surgery.

The Mayo brothers and Harvey Cushing: a review of their 39-year friendship through their personal letters

2005 ◽  
Vol 102 (2) ◽  
pp. 391-396 ◽  
Author(s):  
Aaron A. Cohen-Gadol ◽  
J. Michael Homan ◽  
Edward R. Laws ◽  
John L. D. Atkinson ◽  
Ross H. Miller
Keyword(s):  
Mayo Clinic ◽  
Professional Association ◽  
Future Generations ◽  
Special Relationship ◽  
Content Type ◽  
Harvey Cushing ◽  
Neurological Surgery ◽  
Fine Print

✓ Mayo Clinic founders, William J. Mayo and Charles H. Mayo, and Harvey W. Cushing were among the most significant pioneers of modern American surgery. A review of their personal correspondence reveals a special relationship among these three individuals, particularly between William Mayo and Cushing. Their interactions within the Society of Clinical Surgery initiated their close personal and professional association, which would endure for 39 years. William Mayo strongly supported Cushing's efforts to develop the specialty of neurological surgery, and Cushing sought Mayo's advice in making important career-related decisions. Their supportive friendship and professional alliance remains an example for future generations of neurological surgeons.

Microsurgical anatomy of the sellar region

1975 ◽  
Vol 43 (3) ◽  
pp. 288-298 ◽  
Author(s):  
Wade H. Renn ◽  
Albert L. Rhoton
Keyword(s):  
Sphenoid Sinus ◽  
Carotid Arteries ◽  
Sella Turcica ◽  
Acute Angle ◽  
Surgical Approaches ◽  
Microsurgical Anatomy ◽  
Optic Nerves ◽  
Content Type ◽  
Sellar Floor ◽  
Fine Print

✓ Fifty adult sellae and surrounding structures were examined under magnification with special attention given to anatomical variants important to the transfrontal and transsphenoidal surgical approaches. The discovered variants considered disadvantageous to the transsphenoidal approach were as follows: 1) large anterior intercavernous sinuses extending anterior to the gland just posterior to the anterior sellar wall in 10%; 2) a thin diaphragm in 62%, or a diaphragm with a large opening in 56%; 3) carotid arteries exposed in the sphenoid sinus with no bone over them in 4%; 4) carotid arteries that approach within 4 mm of midline within the sella in 10%; 5) optic canals with bone defects exposing the optic nerves in the sphenoid sinus in 4%; 6) a thick sellar floor in 18%; 7) sphenoid sinuses with no major septum in 28% or a sinus with the major septum well off midline in 47%; and 8) a presellar type of sphenoid sinus with no obvious bulge of the sellar floor into the sphenoid sinus in 20%. Variants considered disadvantageous to the transfrontal approach were found as follows: 1) a prefixed chiasm in 10% and a normal chiasm with 2 mm or less between the chiasm and tuberculum sellae in 14%; 2) an acute angle between the optic nerves as they entered the chiasm in 25%; 3) a prominent tuberculum sella protruding above a line connecting the optic nerves as they entered the optic canals in 44%; and 4) carotid arteries approaching within 4 mm of midline within or above the sella turcica in 12%.

Primary pituitary aspergillosis responding to transsphenoidal surgery and combined therapy with amphotericin-B and 5-fluorocytosine

1981 ◽  
Vol 54 (6) ◽  
pp. 839-841 ◽  
Author(s):  
Angelita Ramos-Gabatin ◽  
Richard M. Jordan
Keyword(s):  
Cerebrospinal Fluid ◽  
Amphotericin B ◽  
Transsphenoidal Surgery ◽  
Combined Therapy ◽  
Sella Turcica ◽  
Single Patient ◽  
Pituitary Abscess ◽  
Content Type ◽  
Elevated Protein ◽  
Fine Print

✓ Pituitary abscess is an unusual cause of sella turcica enlargement. Because its presentation closely mimics that of a pituitary tumor, the condition is seldom recognized preoperatively. Most cases have been of bacterial etiology; however, a single patient with a primary mycotic pituitary abscess secondary to Aspergillus species has been reported. That patient died of diffuse Aspergillus meningoencephalitis following a transfrontal craniotomy. In the present case, a woman with primary pituitary aspergillosis survived her infection with virtually intact pituitary function following a transsphenoidal approach which avoided contamination of cerebrospinal fluid. Postoperative amphotericin-B and 5-fluorocytosine therapy probably contributed greatly to her survival. Factors that should alert the clinician to the presence of a pituitary abscess in a patient with sella turcica enlargement are prior episodes of meningitis, sinusitis, or cerebrospinal fluid abnormalities, including pleocytosis, depressed glucose, and elevated protein.

Ectopic intracavernous sinus adrenocorticotropic hormone—secreting microadenoma: could this be a common cause of failed transsphenoidal surgery in Cushing disease?

2003 ◽  
Vol 98 (6) ◽  
pp. 1312-1317 ◽  
Author(s):  
Louis J. Kim ◽  
Jeffrey D. Klopfenstein ◽  
Ming Cheng ◽  
Murugasu Nagul ◽  
Stephen Coons ◽  
...  
Keyword(s):  
Transsphenoidal Surgery ◽  
Adrenocorticotropic Hormone ◽  
Sella Turcica ◽  
Cardiac Events ◽  
Cushing Disease ◽  
Rapid Reduction ◽  
Content Type ◽  
Negative Findings ◽  
Acth Secreting ◽  
Fine Print

✓ Despite diagnostic advances, it remains difficult to identify intrasellar and ectopic parasellar adrenocorticotropic hormone (ACTH)—secreting microadenomas. The authors present the case of a 61-year-old woman with Cushing disease in whom a significant central-to-peripheral and lateralized right-sided ACTH gradient was demonstrated on inferior petrosal sinus sampling; no discernible abnormality was seen on magnetic resonance imaging. She underwent transnasal transsphenoidal surgery. No tumor was found on sellar exploration and a total hypophysectomy was performed, yet her hypercortisolemia persisted. The patient died of cardiac events 17 days postsurgery. Autopsy revealed an isolated, right-sided, intracavernous ACTH-secreting adenoma with no intrasellar communication. This case represents the first failed transsphenoidal surgery for Cushing disease in which there is postmortem confirmation of a suspected intracavernous sinus lesion. It supports the hypothesis that Cushing disease associated with nondiagnostic imaging studies, a strong ACTH gradient on venography, and negative findings on sellar exploration may be caused by an ectopic intracavernous ACTH-secreting adenoma. There are no premortem means of confirming the presence of such lesions, but these tumors could underlie similar cases of failed surgery. Radiation therapy targeting the sella turcica and both cavernous sinuses, possibly supplemented with medical treatment, is suggested for similar patients in whom transsphenoidal hypophysectomy has failed. Adrenalectomy may also be appropriate if a rapid reduction in ACTH is necessary.

Modification of a nasal speculum for transsphenoidal surgery

2000 ◽  
Vol 92 (2) ◽  
pp. 359-360 ◽  
Author(s):  
Hiroji Miyake ◽  
Tomio Ohta
Keyword(s):  
Transsphenoidal Surgery ◽  
Sphenoid Sinus ◽  
Anterior Wall ◽  
Surgical Instruments ◽  
Content Type ◽  
Inferior Portion ◽  
Surgical Field ◽  
The Individual ◽  
Inferior Edge ◽  
Fine Print

✓ The authors modified a Hardy nasal speculum to improve the access to surgical fields and the handling of various instruments during transsphenoidal surgery. A section of the inferior edge of the speculum was cut out 2 cm from its orifice on both sides. The thickness of the tip of the speculum was also reduced. The authors are prepared to operate using a variety of speculum lengths (the distance between the tip and the cutting level), and this length is selected depending on the distance between the anterior wall of the sphenoid sinus and the surface of the gingiva in the individual patient.A modified nasal speculum was used in transsphenoidal surgery for a pituitary adenoma. With use of this device, the protrusion of the speculum above the gingiva was markedly decreased. Because most instruments are inserted into the inferior portion of the speculum orifice, this approach facilitated the handling of all surgical instruments through the modified nasal speculum. The actual surgical field became shallow and wide, and the long surgical instruments that are generally used for transsphenoidal surgery were unnecessary in most cases.

Stereotaxic thrombosis of inaccessible intracranial aneurysms

1977 ◽  
Vol 47 (6) ◽  
pp. 833-839 ◽  
Author(s):  
Randall W. Smith ◽  
John F. Alksne
Keyword(s):  
Brain Stem ◽  
Cavernous Sinus ◽  
Intracranial Aneurysms ◽  
Sphenoid Sinus ◽  
Ophthalmic Artery ◽  
Sella Turcica ◽  
Content Type ◽  
The Brain ◽  
Stereotaxic Technique ◽  
Fine Print

✓ Some intracranial aneurysms that might be considered inoperable by open craniotomy are readily treatable by stereotaxic thrombosis. This is possible because the stereotaxic technique requires only that some point on the fundus of the aneurysm can be punctured with a needle. Illustrative cases are given describing the successful treatment of aneurysms arising at the origin of the ophthalmic artery, within the cavernous sinus, within the sella turcica, and from the vertebrobasilar and the posterior inferior cerebellar arteries ventral to the brain stem. The aneurysms within the sella or cavernous sinus can be approached through the sphenoid sinus, and the aneurysms ventral to the brain stem can be approached through the clivus without opening the dura.

Transsphenoidal surgery of intrasellar germinomas

1983 ◽  
Vol 59 (6) ◽  
pp. 1063-1066 ◽  
Author(s):  
David S. Baskin ◽  
Charles B. Wilson
Keyword(s):  
Diabetes Insipidus ◽  
Transsphenoidal Surgery ◽  
Sella Turcica ◽  
Young Patients ◽  
Content Type ◽  
Patients With Diabetes ◽  
Transsphenoidal Operation ◽  
Diagnostic Possibility ◽  
Fine Print

✓ Two patients with diabetes insipidus, hypopituitarism, and an enlarged sella turcica underwent a transsphenoidal operation for the treatment of intrasellar germinomas. Successful transsphenoidal treatment of such neoplasms has not been reported previously. The cases indicate that the diagnostic possibility of intrasellar germinoma should be considered in young patients with combined diabetes insipidus and hypopituitarism, even when the sella is markedly expanded.

Transsphenoidal decompression of the optic nerve and chiasm

1977 ◽  
Vol 46 (6) ◽  
pp. 717-722 ◽  
Author(s):  
Edward R. Laws ◽  
James C. Trautmann ◽  
Robert W. Hollenhorst
Keyword(s):  
Pituitary Adenoma ◽  
Optic Nerve ◽  
Transsphenoidal Surgery ◽  
Visual Loss ◽  
Sella Turcica ◽  
Recent Experience ◽  
Content Type ◽  
Visual Status ◽  
Fine Print

✓ A review of recent experience with transsphenoidal surgery for lesions in and about the sella turcica establishes the value of this approach for the management of patients with visual loss. The lesions encountered consisted of pituitary adenoma in 45 cases, craniopharyngioma in 10 cases, and miscellaneous tumors involving the sella in the remaining seven cases. Sixty of the 62 patients in this series had quantitative determination of preoperative and postoperative visual status; after surgery, vision was improved in 81%, unchanged in 11%, and worse in 5%. Two patients (3%) died during the immediate postoperative period before their visual status could be evaluated.

Sellar reconstruction with resorbable vicryl patches, gelatin foam, and fibrin glue in transsphenoidal surgery: a 10-year experience with 376 patients

2000 ◽  
Vol 93 (5) ◽  
pp. 762-765 ◽  
Author(s):  
Rolf W. Seiler ◽  
Luigi Mariani
Keyword(s):  
Fibrin Glue ◽  
Transsphenoidal Surgery ◽  
Operating Time ◽  
Sella Turcica ◽  
Morbidity Rate ◽  
Surgical Incision ◽  
Content Type ◽  
Csf Leakage ◽  
Sellar Reconstruction ◽  
Fine Print

Object. Closure of the sella turcica after transsphenoidal surgery is mainly accomplished with autologous muscle fascia and fat or muscle; this requires a second surgical incision. The authors review the results of using resorbable vicryl patches, gelatin foam, and fibrin glue for sellar reconstruction.Methods. A review was conducted of 376 consecutive patients who underwent surgery for pituitary adenomas, cysts, or subdiaphragmatic craniopharyngiomas in the sella turcica that the senior author (R.W.S.) had performed or directly supervised over the last 10 years. The sellar reconstruction was performed with a commercially available, synthetic absorbable patch composed of polyglactin 910/poly-p-dioxanone, gelatin foam, and fibrin glue. The patch is essentially resorbed in 2 to 3 months and replaced by fibrous collagen tissue. There were 117 small, 112 medium-sized, and 147 large lesions. The overall nonendocrine postoperative morbidity rate was 2.8%, and included visual deterioration, meningitis, secondary epistaxis, nasal septum complication, and cerebrospinal fluid (CSF) leakage. Two patients with macroadenomas needed reoperation for persistent CSF leakage, which comprised 0.5% of the whole series or 0.8% of the 259 patients with medium-sized or large lesions. There was no mortality and no morbidity related to the implanted material, and in particular no delayed empty sella syndrome.Conclusions. Closure of the sella turcica with a synthetic absorbable vicryl patch, gelatin foam, and fibrin glue after transsphenoidal surgery is safe and very effective in preventing postoperative CSF fistulas. The use of this technique obviates the need for a second surgical incision and shortens the operating time. Because of the progressive resorption of the substitute material, the interpretation of postoperative magnetic resonance studies was not significantly hindered.

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