Harvey Cushing’s craniopharyngioma treatment: Part 2. Surgical strategies and results of his pioneering series

OBJECTIVEHarvey Cushing (1869–1939) developed pioneering surgical techniques for craniopharyngioma (CP) removal. This study exhaustively analyzes the pathological variables and surgical strategies that influenced Cushing’s results in his entire series of CP patients.METHODSThe CP records from Cushing’s Brain Tumor Registry were carefully reviewed, as were his CP cases published in medical monographs and scientific reports.RESULTSOne hundred twenty-four tumors with characteristics typical of CP comprise Cushing’s entire series (CP124). Cushing performed 198 surgical procedures in the patients in whom these tumors were treated, with a 23% mortality rate within the first 2 months after surgery. Three periods in Cushing’s CP surgical career can be differentiated: an early period (1901–1917, 39 patients) characterized by his use of the transsphenoidal approach and limited cyst drainage procedures, an intermediate period (1919–1925, 42 patients) in which the subfrontal approach was the standard procedure and maximal removal was attempted, and a late period (1926–1932, 43 patients) characterized by the use of air ventriculography for topographical diagnosis and limited resections via a transventricular approach. Among Cushing’s CP series were 92 cases that were pathologically verified (CP92). In this subcohort, the unilateral subfrontal approach was predominantly used (72% of cases), followed by the transsphenoidal (15%) and frontal transcortical-transventricular (8%) approaches. Drainage of the CP cystic component or partial excision of the solid component was achieved in 61% of the cases, subtotal removal in 23%, and macroscopic total removal in 10%. Satisfactory outcomes were obtained in 55% of the patients in CP92, whereas poor outcomes and/or death related to hypothalamic injury was observed in 28%. Postoperative symptoms related to hypothalamic dysfunction occurred 53% of the time. The subfrontal approach yielded the highest rates of radical removal (p < 0.001) and good outcomes (p = 0.01). Partial removals were associated with the highest rates of poor outcomes, including death (p = 0.009). Cushing’s removal of CPs with a primary infundibulo-tuberal topography or showing third ventricle invasion was associated with the highest rates of hypothalamic injury (p < 0.001) and the worst outcomes (p = 0.009).CONCLUSIONSHarvey Cushing’s techniques and surgical philosophy varied substantially throughout his career. The experience he gained with this large CP series made him aware of the importance of limiting the extent of tumor removal and leaving untouched the tumor portion strongly adhered to the hypothalamus.

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Charles H. Frazier’s craniopharyngioma treatment: the pivotal role of the transfrontal approach

Journal of Neurosurgery ◽

10.3171/2019.8.jns191508 ◽

2020 ◽

Vol 133 (6) ◽

pp. 1739-1752 ◽

Cited By ~ 1

Author(s):

Ruth Prieto ◽

José María Pascual ◽

Laura Barrios

Keyword(s):

Third Ventricle ◽

Intractable Pain ◽

Conservative Strategy ◽

The Us ◽

Hypothalamic Injury ◽

Rathke's Cleft ◽

Subfrontal Approach ◽

Neurovascular Structures ◽

Complete Account

Charles H. Frazier (1870–1936), one of the pioneers of neurosurgery in the US, is known worldwide for devising surgical procedures to relieve trigeminal neuralgia and intractable pain. Less well-known are his substantial contributions to understanding and treating pituitary and parahypophyseal lesions. Along with Bernard Alpers, he defined Rathke’s cleft tumors as a different pathological entity from adenomas and hypophyseal stalk tumors (craniopharyngiomas [CPs]). The surgical challenge posed by CPs piqued Frazier’s interest in these lesions, although he never published a complete account of his CP series. An examination of the Charles Frazier papers at the College of Physicians of Philadelphia allowed the authors to identify 54 CPs that he had treated during his career. In the early 1910s, Frazier developed the subfrontal approach, which would become the primary surgical route to access these lesions, providing better control of the adjacent vital neurovascular structures than the transsphenoidal route hitherto used. Nevertheless, strong adhesions between CPs and the third ventricle floor, the major reason underlying Frazier’s disappointing results, moved him to advocate incomplete tumor removal followed by radiotherapy to reduce both the risk of hypothalamic injury and CP recurrence. This conservative strategy remains a judicious treatment for CPs to this day.

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Surgical Treatment of Diffuse Idiopathic Skeletal Hyperostosis (DISH) Involving the Cervical Spine: Technical Nuances and Outcome of a Multicenter Experience

Global Spine Journal ◽

10.1177/2192568220988272 ◽

2021 ◽

pp. 219256822098827

Author(s):

Giorgio Lofrese ◽

Alba Scerrati ◽

Massimo Balsano ◽

Roberto Bassani ◽

Michele Cappuccio ◽

...

Keyword(s):

Cervical Spine ◽

Clinical Outcome ◽

Waiting Times ◽

Diffuse Idiopathic Skeletal Hyperostosis ◽

Surgical Techniques ◽

Rare Condition ◽

Surgical Strategies ◽

Bone Removal ◽

Mild Dysphagia

Study Design: Retrospective multicenter. Objectives: diffuse idiopathic skeletal hyperostosis (DISH) involving the cervical spine is a rare condition determining disabling aero-digestive symptoms. We analyzed impact of preoperative settings and intraoperative techniques on outcome of patients undergoing surgery for DISH. Methods: Patients with DISH needing for anterior cervical osteophytectomy were collected. Swallow studies and endoscopy supported imaging in targeting bone decompression. Patients characteristics, clinico-radiological presentation, outcome and surgical strategies were recorded. Impact on clinical outcome of duration and time to surgery and different surgical techniques was evaluated through ANOVA. Results: 24 patients underwent surgery. No correlation was noted between specific spinal levels affected by DISH and severity of pre-operative dysphagia. A trend toward a full clinical improvement was noted preferring the chisel ( P = 0.12) to the burr ( P = 0.65), and whenever C2-C3 was decompressed, whether hyperostosis included that level ( P = 0.15). Use of curved chisel reduced the surgical times ( P = 0.02) and, together with the nasogastric tube, the risk of complications, while bone removal involving 3 levels or more ( P = 0.04) and shorter waiting times for surgery ( P < 0.001) positively influenced a complete swallowing recovery. Early decompressions were preferred, resulting in 66.6% of patients reporting disappearance of symptoms within 7 days. One and two recurrences respectively at clinical and radiological follow-up were registered 18-30 months after surgery. Conclusion: The “age of DISH” counts more than patients’ age with timeliness of decompression being crucial in determining clinical outcome even with a preoperative mild dysphagia. Targeted bone resections could be reasonable in elderly patients, while in younger ones more extended decompressions should be preferred.

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Experimental Third Ventriculostomy Performed Using Endovascular Surgical Techniques and Their Adaptation to Percutaneous Intradural Neuronavigation: Proof of Concept Cadaver Study

Neurosurgery ◽

10.1227/01.neu.0000073535.48663.ac ◽

2003 ◽

Vol 53 (2) ◽

pp. 387-392 ◽

Cited By ~ 8

Author(s):

Michael B. Horowitz ◽

Kamal Ramzipoor ◽

Ajit Nair ◽

Susan Miller ◽

George Rappard ◽

...

Keyword(s):

Third Ventricle ◽

Surgical Techniques ◽

Cadaver Study ◽

Brain Parenchyma ◽

Third Ventriculostomy ◽

General Anesthetic ◽

The Third ◽

Noncommunicating Hydrocephalus ◽

Pass Through ◽

The Brain

Abstract OBJECTIVE Endoscopic third ventriculostomy has developed into a therapeutic alternative to shunting for the management of carefully selected patients with primarily noncommunicating hydrocephalus. This procedure, however, requires a general anesthetic and necessitates violation of the brain parenchyma and manipulation near vital neural structures to access the floor of the third ventricle. Using two cadavers and off-the-shelf angiographic catheters, we sought to determine whether it was possible to navigate a catheter, angioplasty balloon, and stent percutaneously through the subarachnoid space from the thecal sac into the third ventricle so as to perform a third ventriculostomy from below. METHODS Using biplane angiography and off-the-shelf angiographic catheters along with angioplasty balloons and stents, we were able to pass a stent coaxially from the thecal sac to and across the floor of the third ventricle so as to achieve a third ventriculostomy from below. RESULTS Coaxial catheter techniques allowed for the percutaneous insertion of a stent across the floor of the third ventricle. Ventriculostomy was confirmed by injecting contrast medium into the lateral ventricle and seeing it pass through the stent and into the chiasmatic cistern. CONCLUSION We describe the performance of third ventriculostomies in two cadavers by use of the new concept of percutaneous intradural neuronavigation. This procedure may obviate the need for general anesthetic and minimize the potential for brain and vascular injury, especially if ultimately combined with magnetic resonance fluoroscopy.

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Craniopharyngioma adherence: a comprehensive topographical categorization and outcome-related risk stratification model based on the methodical examination of 500 tumors

Neurosurgical FOCUS ◽

10.3171/2016.9.focus16304 ◽

2016 ◽

Vol 41 (6) ◽

pp. E13 ◽

Cited By ~ 40

Author(s):

Ruth Prieto ◽

José María Pascual ◽

Maria Rosdolsky ◽

Inés Castro-Dufourny ◽

Rodrigo Carrasco ◽

...

Keyword(s):

Adhesion Strength ◽

Surgical Outcomes ◽

Third Ventricle ◽

Optic Chiasm ◽

Anatomical Location ◽

Brain Invasion ◽

Model Based ◽

Related Risk ◽

Hypothalamic Injury ◽

Tumor Consistency

OBJECTIVE Craniopharyngioma (CP) adherence strongly influences the potential for achieving a radical and safe surgical treatment. However, this factor remains poorly addressed in the scientific literature. This study provides a rational, comprehensive description of CP adherence that can be used for the prediction of surgical risks associated with the removal of these challenging lesions. METHODS This study retrospectively analyzes the evidence provided in pathological, neuroradiological, and surgical CP reports concerning 3 components of the CP attachment: 1) the intracranial structures attached to the tumor; 2) the morphology of the adhesion; and 3) the adhesion strength. From a total of 1781 CP reports published between 1857 and 2016, a collection of 500 CPs providing the best information about the type of CP attachment were investigated. This cohort includes autopsy studies (n = 254); surgical studies with a detailed description or pictorial evidence of CP adherence (n = 298); and surgical CP videos (n = 61) showing the technical steps for releasing the attachment. A predictive model of CP adherence in hierarchical severity levels correlated with surgical outcomes was generated by multivariate analysis. RESULTS The anatomical location of the CP attachment occurred predominantly at the third ventricle floor (TVF) (54%, n = 268), third ventricle walls (23%, n = 114), and pituitary stalk (19%, n = 94). The optic chiasm was involved in 56% (n = 281). Six morphological patterns of CP attachment were identified: 1) fibrovascular pedicle (5.4%); 2) sessile or patch-like (21%); 3) cap-like (over the CP top, 14%); 4) bowl-like (around the CP bottom, 13.5%); 5) ring-like (encircling central band, 19%); and 6) circumferential (enveloping the entire CP, 27%). Adhesion strength was classified in 4 grades: 1) loose (easily dissectible, 8%); 2) tight (requires sharp dissection, 32%); 3) fusion (no clear cleavage plane, 40%); and 4) replacement (loss of brain tissue integrity, 20%). The types of CP attachment associated with the worst surgical outcomes are the ring-like, bowl-like, and circumferential ones with fusion to the TVF or replacement of this structure (p < 0.001). The CP topography is the variable that best predicts the type of CP attachment (p < 0.001). Ring-like and circumferential attachments were observed for CPs invading the TVF (secondary intraventricular CPs) and CPs developing within the TVF itself (infundibulo-tuberal CPs). Brain invasion and peritumoral gliosis occurred predominantly in the ring-like and circumferential adherence patterns (p < 0.001). A multivariate model including the variables CP topography, tumor consistency, and the presence of hydrocephalus, infundibulo-tuberal syndrome, and/or hypothalamic dysfunction accurately predicts the severity of CP attachment in 87% of cases. CONCLUSIONS A comprehensive descriptive model of CP adherence in 5 hierarchical levels of increased severity—mild, moderate, serious, severe, and critical—was generated. This model, based on the location, morphology, and strength of the attachment can be used to anticipate the surgical risk of hypothalamic injury and to plan the degree of removal accordingly.

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Repair of Protruding Bilateral Cleft Lip and Palate With Staged Premaxilla Setback Osteotomy, Cheiloplasty, and Palatoplasty in Trisomy 17p Patient: A Review of Syndromic Clinical Characteristic

The Cleft Palate-Craniofacial Journal ◽

10.1177/10556656211069820 ◽

2021 ◽

pp. 105566562110698

Author(s):

Kristaninta Bangun ◽

Jessica Halim ◽

Vika Tania

Keyword(s):

Cleft Lip ◽

Cleft Lip And Palate ◽

Surgical Techniques ◽

Chromosome 17 ◽

Long Term Effects ◽

Surgical Strategies ◽

Increased Risk ◽

The Cost

Chromosome 17 duplication is correlated with an increased risk of developmental delay, birth defects, and intellectual disability. Here, we reported a female patient with trisomy 17 on the whole short arm with bilateral complete cleft lip and palate (BCLP). This study will review the surgical strategies to reconstruct the protruding premaxillary segment, cleft lip, and palate in trisomy 17p patient. The patient had heterozygous pathogenic duplication of chromosomal region chr17:526-18777088 on almost the entire short arm of chromosome 17. Beside the commonly found features of trisomy 17p, the patient also presented with BCLP with a prominent premaxillary portion. Premaxillary setback surgery was first performed concomitantly with cheiloplasty. The ostectomy was performed posterior to the vomero-premaxillary suture (VPS). The premaxilla was firmly adhered to the lateral segment and the viability of philtral flap was not compromised. Two-flap palatoplasty with modified intravelar veloplasty (IVV) was performed 4 months after. Successful positioning of the premaxilla segment, satisfactory lip aesthetics, and vital palatal flap was obtained from premaxillary setback, primary cheiloplasty, and subsequent palatoplasty in our trisomy 17p patient presenting with BLCP. Postoperative premaxillary stability and patency of the philtral and palatal flap were achieved. Longer follow-up is needed to evaluate the long-term effects of our surgical techniques on inhibition of midfacial growth. However, the benefits that the patient received from the surgery in improving feeding capacity and facial appearance early in life outweigh the cost of possible maxillary retrusion.

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Different Surgical Techniques in Tubo-ovarian Abscess Management

Gynecology Obstetrics and Reproductive Medicine ◽

10.21613/gorm.2016.639 ◽

2017 ◽

pp. 1

Author(s):

Hale GÖKSEVER ÇELİK ◽

Engin Çelik ◽

Semra Yüksel ◽

Ercan Baştu ◽

Hasan Cemal Ark

Keyword(s):

Surgical Techniques ◽

Operation Technique ◽

Blood Cell Count ◽

Abscess Drainage ◽

Mean Values ◽

Surgical Methods ◽

Training And Research ◽

Poor Outcomes ◽

One Year ◽

Ovarian Abscess

Objectıve: Tubo-ovarian abscess is mostly a consequence of pelvic inflammatory disease. We aimed to compare success of the different surgical methods in tubo-ovarian abscess treatment. Study Design: 53 patients with Tubo-ovarian abscess that were hospitalized and operated in the Department of Obstetrics and Gynecology at Kanuni Sultan Suleyman Training and Research Hospital during one year were included. Patients who had underwent salpingectomy/salpingo-oophorectomy and only abscess drainage were compared. Results: Salpingectomy/salpingo-oophorectomy had been done in 74.5% of cases and only drainage had been applied in 25.5% of cases. Difference in mean values between 2 groups were not observed except white blood cell count. Conclusıon: Treatment of Tubo-ovarian abscess must be a combination of parenteral antibiotics and early surgical procedure to prevent poor outcomes. There is not any difference between different surgical techniques. But additionally more studies are needed to better understand which operation technique is more effective and less complicated.

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COLLOID CYST OF THE THIRD VENTRICLE

The Professional Medical Journal ◽

10.29309/tpmj/2010.17.01.2206 ◽

2010 ◽

Vol 17 (01) ◽

pp. 156-163

Author(s):

NAVEED ASHRAF ◽

MUHAMMAD AKMAL AZEEMI ◽

FAUZIA SAJJAD ◽

Asma Ghouri

Keyword(s):

Clinical Success ◽

Standard Procedure ◽

Third Ventricle ◽

Colloid Cyst ◽

Invasive Approach ◽

Keyhole Surgery ◽

The Third ◽

Number Of Patients ◽

Colloid Cysts ◽

Microsurgical Resection

Objectives: Cerebrospinal fluid shunting or microsurgical resection of the colloid cysts of the third ventricle have long been a standard treatment. The emergence of neuroendoscopy has lead to its application in various neurosurgical problems. Colloid cyst of the third ventricle is one such pathology where endoscopic treatment has been performed with great clinical success during the past decade. We now Although considered less efficacious than microsurgical excision endoscopic excision is less invasive and much simpler.Objectives: (1) to assess the extent of excision (2) to assess the morbid anatomy of the colloid cyst (3) to assess the risk of complications (4) to assess the functional outcome. Period: Eight years (Jul 2001-June 2009) Materials and Methods: Endoscopic resections of 15 colloid cysts of the third ventricle with obstruction of Foramina of Monroe in all cases. Results: Total removal was achieved in 10 (66.7%) cases. In 5 (33.3%) patients the colloid material was evacuated completely while the remnant of the capsule adherent to its origin was left behind. Two (13.3%) patients developed meningitis one week postoperatively and one diedsubsequently. Nine (60%) patients had excellent recovery as the symptoms were relieved during a period of 3 to 24 months. Five (33.3%) of the total patients required ventriculoperitoneal shunt for obstructivey drocephalus which developed with in 2 weeks after surgery. One out of the total number of patients deteriorated postoperatively on the existing neurological deficit. There has not been any recurrence until now with subtotal excision of the capsule. Conclusions: Keyhole surgery under endoscopic visual control offers an alternative, very effective minimally invasive approach for the excision of colloid cyst of the third ventricle and is likely to replace microsurgical resection as a standard procedure.

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Surgical Strategies in the Management of Tumours of the Anterior Third Ventricle

Modern Neurosurgery 1 ◽

10.1007/978-3-662-08801-2_25 ◽

1982 ◽

pp. 215-224 ◽

Cited By ~ 4

Author(s):

J. L. Antunes ◽

K. Muraszko ◽

D. O. Quest ◽

P. W. Carmel

Keyword(s):

Third Ventricle ◽

Surgical Strategies

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Laparoscopic Hepatectomy for Liver Cancer

Digestive Diseases ◽

10.1159/000438499 ◽

2015 ◽

Vol 33 (5) ◽

pp. 691-698 ◽

Cited By ~ 4

Author(s):

Akishige Kanazawa ◽

Tadashi Tsukamoto ◽

Sadatoshi Shimizu ◽

Satoshi Yamamoto ◽

Akihiro Murata ◽

...

Keyword(s):

Liver Cancer ◽

Standard Procedure ◽

Laparoscopic Hepatectomy ◽

Surgical Techniques ◽

Laparoscopic Approach ◽

Technological Innovations ◽

Rapid Progress ◽

Hepatic Surgery ◽

Novel Approach ◽

Near Future

This chapter covers a range of important topics of laparoscopic hepatectomy as a novel approach toward treatment of liver cancer. Although laparoscopic hepatectomy was performed in a limited number of centers in the 1990s, technological innovations, improvements in surgical techniques and accumulation of experience by surgeons have led to more rapid progress in laparoscopic hepatectomy in the late 2000s for minimally invasive hepatic surgery. Currently, laparoscopic hepatectomy can be performed for all tumor locations and several diseases via several approaches. The laparoscopic approach can be applied to several types of resection, not only for tumors but also for liver transplantation, with equivalent or better results compared with those obtained with open surgery. Therefore, laparoscopic hepatectomy will become a standard procedure for treatment of liver cancer in the near future.

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Lateral skull base malignancies

Neurosurgical FOCUS ◽

10.3171/foc.2002.12.5.9 ◽

2002 ◽

Vol 12 (5) ◽

pp. 1-4 ◽

Cited By ~ 6

Author(s):

Benjamin M. McGrew ◽

C. Gary Jackson ◽

Raquel A. Redtfeldt

Keyword(s):

Skull Base ◽

Postoperative Radiotherapy ◽

Survival Rates ◽

Tumor Resection ◽

Surgical Techniques ◽

Local Tumor Control ◽

Tumor Control ◽

Lateral Skull Base ◽

The Mean ◽

Poor Outcomes

Object Historically poor outcomes have been characteristic in patients with lateral skull base malignancies. As advances in skull base surgical techniques have been made, complete resection has increasingly been achieved. This has resulted in improved survival rates and local tumor control. Methods The authors performed a retrospective review of 95 patients treated for lateral skull base malignancies. The mean age of the patients was 49.4 years. There were 44 females and 51 males. The mean follow-up period was 50 months. Resection was performed in all patients, and postoperative radiotherapy was undertaken in 54% of the cases. Local disease control was maintained in 73% of the patients. Tumor involvement of the facial nerve and intracranial tumor extension did not jeopardize the rate of local control. Conclusions Despite the fact that technical advances in skull base surgery have resulted in a higher incidence of complete tumor resection and improved survival rates, a respect for the poor prognosis historically associated with lateral skull base malignancies should be maintained and treatment should be appropriately aggressive.

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