The evolution of Harvey Cushing's surgical approach to pituitary tumors from transsphenoidal to transfrontal

2005 ◽  
Vol 103 (2) ◽  
pp. 372-377 ◽  
Author(s):  
Aaron A. Cohen-Gadol ◽  
Edward R. Laws ◽  
Dennis D. Spencer ◽  
Antonio A. F. De Salles
Keyword(s):  
Transsphenoidal Surgery ◽  
Pituitary Tumors ◽  
Optic Chiasm ◽  
Content Type ◽  
Intracranial Surgery ◽  
Sellar Lesions ◽  
Transsphenoidal Adenomectomy ◽  
Adequate Decompression ◽  
Tumor Recurrence Rate

✓ The evolution of transsphenoidal surgery represents a special chapter in the progress of neurosurgery. Although Cushing initially advocated a transsphenoidal approach to pituitary tumors, he became disenchanted with this approach, ultimately favoring the subfrontal or “transfrontal” route late in his career. Other neurosurgeons followed Cushing's example, and the fate of transsphenoidal surgery entered a dark era in 1929. A review of Cushing's patients' records reveals that his abandonment of the transsphenoidal route was primarily related to the limitations of this approach in providing effective resection of large pituitary lesions—the symptomatic tumor recurrence rate after this procedure was substantial. Furthermore, given the preoperative uncertainty about the suprasellar extension of pituitary tumors prior to modern neuroimaging, the transfrontal route assured Cushing an adequate decompression of the optic chiasm. By 1927, Cushing's mastery of intracranial surgery was accompanied by the use of electrosurgical methods that enabled him to remove sellar lesions through the transfrontal route safely and with timely and effective restoration of visual loss. Transsphenoidal surgery remained relatively dormant, awaiting the efforts and enthusiasm of Norman Dott who bridged the gap between Cushing and Gerard Guiot, the surgeon who revitalized transsphenoidal adenomectomy for future generations of pituitary surgeons.

Rhinological Consequences of Microsurgical Endonasal-Transsphenoidal Surgery for Pituitary Tumors

2020 ◽  
Author(s):  
Nikolaos Hondronikos ◽  
Ali Alomari ◽  
Martin Schrader ◽  
Ulrich J. Knappe
Keyword(s):  
Transsphenoidal Surgery ◽  
Pituitary Tumors ◽  
Final Visit ◽  
Saddle Nose ◽  
Nasal Breathing ◽  
Nasal Airways ◽  
Sellar Lesions ◽  
Saddle Nose Deformity ◽  
Almost All ◽  
Smell Function

Abstract Background Transsphenoidal surgery for sellar lesions may affect patency and function of the nasal airways, smell and sinonasal quality of life. Below is our report on otorhinolaryngological data garnered from patients undergoing endonasal transsphenoidal pituitary microsurgery. Methods In a prospective study, 68 patients scheduled for transsphenoidal operations (32 female, 36 male, age 17–72 years) underwent otorhinolaryngological evaluation of their nasal morphology, a standardized smell test (sniffin’ sticks) and rhinomanometry to analyse nasal breathing function preoperatively, 3–5 days postoperatively (without rhinomanometry), after 3–4 months and after 9 months. Results Immediately after surgery, a reduction in smell sensation was detected in almost all patients. Within 3 months, this impairment resolved in all cases except one. In 2 patients (3%) with preoperative anosmia, improvement of smell function to>6 out of 12 sniffin’ sticks was observed. At final visit no patient was noted to have new anosmia. Within 3 months, the results of the rhinomanometry revealed that all patients except one, regained their preoperative nasal breathing function. In 6 patients (8.8%) an improvement in their nose breathing abilities compared to the preoperative state was found. Three patients (4.4%) underwent a LASER transection of mucosal synechiae. In one case with persistent nasal obstruction (1.5%), secondary septoplasty had to be performed. There was no case in which perforation of the nasal septum, nasal tip deflection, or saddle nose deformity was observed. Conclusion Microsurgical resection of pituitary tumors via the endonasal transsphenoidal approach poses an acceptable risk with regards to sinonasal complications. The incidence of secondary rhinosurgical interventions is low. Standardized comparative studies between endoscopic and microsurgical transsphenoidal operations should be undertaken.

Transsphenoidal extracapsular approach to pituitary tumors

1986 ◽  
Vol 64 (1) ◽  
pp. 16-20 ◽  
Author(s):  
Nobuo Hashimoto ◽  
Hajime Handa ◽  
Tatsuhito Yamagami
Keyword(s):  
Pituitary Adenomas ◽  
Transsphenoidal Surgery ◽  
Pituitary Tumors ◽  
Hormonal Control ◽  
Arachnoid Membrane ◽  
Content Type ◽  
Tumor Capsule ◽  
Suprasellar Extension ◽  
Fine Print ◽  
Transsphenoidal Resection

✓ Two years' experience with an extracapsular transsphenoidal approach to pituitary adenomas is presented. Some pituitary tumors contain an inordinate amount of connective tissue that often makes transsphenoidal resection difficult. By opening the tumor capsule and adjacent arachnoid membrane, such tumors with suprasellar extension can be safely removed. In some cases of functioning adenoma, resection of the diaphragma sellae and adjacent arachnoid membrane results in hormonal control. Among 62 cases of transsphenoidal surgery for pituitary adenomas, eight cases required this procedure. The surgical procedure is described and the cases are summarized. The indication and limitations of this procedure are discussed.

Selective excision of adenomas originating in or extending into the pituitary stalk with preservation of pituitary function

1997 ◽  
Vol 87 (3) ◽  
pp. 343-351 ◽  
Author(s):  
R. Bryan Mason ◽  
Lynnette K. Nieman ◽  
John L. Doppman ◽  
Edward H. Oldfield
Keyword(s):  
Cushing’S Disease ◽  
Pituitary Tumors ◽  
Optic Chiasm ◽  
Anterior Lobe ◽  
Pituitary Function ◽  
Pituitary Stalk ◽  
Cushing's Disease ◽  
Content Type ◽  
Suprasellar Cistern ◽  
Fine Print

✓ When the surgeon identifies an adenoma within the gland and selectively excises it, endocrine-active pituitary tumors are usually cured and pituitary function is preserved. Occasionally ectopic adenomas arise primarily in the pituitary stalk or arise superiorly in the midportion of the anterior lobe and extend upward within the stalk. To determine if these tumors can be selectively excised with preservation of pituitary function, the authors examined the outcome of selective adenomectomy in 10 patients with Cushing's disease with an ectopic adenoma originating in, and confined to, the stalk (four microadenomas) or an adenoma extending superiorly through the diaphragma sella and into the stalk (five microadenomas and one macroadenoma) from an operative series of 516 patients with Cushing's disease. To reach the adenoma transsphenoidally in these patients, the diaphragma sella was incised anteroposteriorly in the midline to the anterior edge of the stalk, the suprasellar cistern was entered, and the adenoma was selectively excised using care to limit injury to the infundibulum. After selective adenomectomy, Cushing's disease remitted in all patients. All patients were hypocortisolemic immediately after surgery and required hydrocortisone for up to 21 months. Apart from the adrenal axis, pituitary function was normal in five patients in the immediate postoperative period, including two patients with tumors confined to the stalk and three patients with preoperative hypothyroidism (one patient) and/or hypogonadism (three patients). Three others with transient postoperative hypothyroidism (one patient) or diabetes insipidus (two patients) had normal pituitary function within 7 months of surgery. One patient with hypothyroidism and one with hypogonadism before surgery had panhypopituitarism postoperatively. A patient with a microadenoma located high in the stalk next to the optic chiasm had bitemporal hemianopsia postoperatively. These results demonstrate the feasibility of achieving curative transsphenoidal resection and preservation of pituitary function in cases of pituitary adenomas that are confined to the pituitary stalk or tumors that extend superiorly within the stalk from an intrasellar origin.

Novel closure technique for the endonasal transsphenoidal approach

2004 ◽  
Vol 100 (1) ◽  
pp. 161-164 ◽  
Author(s):  
James K. Liu ◽  
Richard R. Orlandi ◽  
Ronald I. Apfelbaum ◽  
William T. Couldwell
Keyword(s):  
Transsphenoidal Surgery ◽  
Nasal Packing ◽  
Transsphenoidal Approach ◽  
Closure Technique ◽  
Content Type ◽  
Submucosal Dissection ◽  
Sellar Lesions ◽  
Parasellar Region ◽  
Transsphenoidal Microsurgery ◽  
Fine Print

✓ Transsphenoidal microsurgery has been the standard approach to sellar lesions since the repopularization of the technique with modifications by Dott, Guiot, and Hardy. The endonasal transseptal transsphenoidal approach, as introduced by Hirsch, is still commonly used by pituitary surgeons to remove lesions of the sellar and parasellar region. One disadvantage of this approach is that the submucosal dissection requires postoperative nasal packing, which is a source of discomfort in patients who undergo transsphenoidal surgery. The authors describe a novel closure technique for the unilateral endonasal transsphenoidal approach that eliminates the need for full nasal packing, minimizing postoperative rhinological morbidity. This technique has been performed in 67 patients harboring sellar and parasellar lesions. All patients recovered rapidly without significant rhinological sequelae.

Significant headache improvement after transsphenoidal surgery in patients with small sellar lesions

2009 ◽  
Vol 110 (2) ◽  
pp. 354-358 ◽  
Author(s):  
Maria Fleseriu ◽  
Christine Yedinak ◽  
Caitlin Campbell ◽  
Johnny B. Delashaw
Keyword(s):  
Retrospective Study ◽  
Postoperative Complications ◽  
Brain Tumors ◽  
Retrospective Review ◽  
Transsphenoidal Surgery ◽  
Imaging Techniques ◽  
Pituitary Tumors ◽  
Cushing Disease ◽  
Sellar Lesions ◽  
Oregon Health

Object Pituitary adenomas represent a large proportion of brain tumors that are increasing in incidence because of improved imaging techniques. Headache is the primary symptom in patients with large tumors (macroadenomas), but is also a symptom in patients with small tumors (microadenomas, tumors < 1.0 cm). The prevalence and optimal treatment of headaches associated with pituitary tumors is still unclear, particularly in cases of microadenoma. If conventional medical management fails, transsphenoidal surgery (TSS) may be considered as an alternative treatment for intractable headaches. Methods The authors conducted a retrospective review of 512 patients who underwent TSS at Oregon Health & Science University between 2001 and 2007; patients with Cushing disease were excluded. The authors identified 41 patients with small pituitary tumors who underwent TSS, and retrospectively evaluated the resolution and/or treatment of headache. Results Ninety percent of patients who presented with nonfunctioning microadenomas and Rathke cleft cysts experienced resolution or improvement in their headaches after TSS, and 56% of patients who presented with hyperfunctioning pituitary microadenomas had improvement in their headaches. There were no postoperative complications. Conclusions In this retrospective study, the authors demonstrate the efficacy of TSS in the treatment of intractable headaches in patients who present with pituitary microadenomas (nonsecreting and hypersecretory) and Rathke cleft cysts.

Impact of Prolactin Hipersecrey on Glucid and Lipid Metabolisms

2019 ◽  
Vol 70 (5) ◽  
pp. 1603-1607
Author(s):  
Elena Ionescu ◽  
Bogdan Virgil Cotoi ◽  
Anca Ganescu
Keyword(s):  
Cranial Nerves ◽  
Pituitary Tumors ◽  
Optic Chiasm ◽  
Anterior Lobe ◽  
Visual Field Defects ◽  
Large Tumor ◽  
Metabolic Complications ◽  
Clinical Onset ◽  
Vision Defects ◽  
Upper Level

Pituitary is a common terrain for the appearance of tumoral changes, representing the origin of about 15% of all intracranial tumors [13]. These tumors are, for the most part, histologically benign, as they arise from hormone secreting cells in the anterior lobe. Therefore, the aim of the paper is to specify the clinical and paraclinical clinical onset characteristics, the evolutionary peculiarities, as well as the metabolic complications secondary to the prolactin hypersecretion. The effects of prolactin-secreting pituitary tumors may occur as a result of mass effects of tumors or even hyperprolactinaemia. Because microadenomas are intrathecal, visual defects may not occur, but headaches occur more often (50%) than normal (27%) [1, 6]. A large tumor that extends beyond the limbs of the turkey can cause headaches and vision defects. The classical presentation is bitemporal hemianopsia due to the compression of the optic chiasm from a tumor that extends to the upper level. If chiasma is prefixed or if the tumor extends posteriorly, compression of a single optical system results in visual field defects similar. The lateral extension in the cavernous sinus can lead to the illness of the oculomotor function involving the cranial nerves III, IV and VI and the branches V1 and V2 of the cranial nerve V, alone or in combinations.

Intraoperative monitoring of brain-stem auditory evoked potentials

1982 ◽  
Vol 57 (3) ◽  
pp. 341-348 ◽  
Author(s):  
Peter A. Raudzens ◽  
Andrew G. Shetter
Keyword(s):  
Evoked Potentials ◽  
Brain Stem ◽  
Auditory Evoked Potentials ◽  
Neurological Deficits ◽  
Additional Patient ◽  
Content Type ◽  
Intracranial Surgery ◽  
Surgical Measures ◽  
Evoked Potential Monitoring ◽  
Operating Surgeon

✓ Intraoperative brain-stem auditory evoked potentials (BAEP's) were monitored in 46 patients undergoing intracranial surgery for a variety of pathological conditions to determine whether this technique was capable of providing useful information to the operating surgeon. Intraoperative BAEP's were unchanged throughout surgery in 34 patients (74%), and these individuals had no postoperative hearing deficits. Four patients (9%) developed an abrupt ipsilateral loss of all waveform components beyond Wave I and had postoperative evidence of a pronounced hearing loss in the affected ear. An additional patient demonstrated BAEP loss contralateral to the side of surgery, and this was associated with subsequent signs of severe brain-stem dysfunction. Seven patients (15%) developed intraoperative delays of BAEP waveform latency values, but maintained recognizable waveforms beyond Wave I. Postoperatively, their hearing was either normal or mildly impaired, and there were no indications of other brain-stem abnormalities. This group represents the individuals who may have been benefited by evoked potential monitoring, since corrective surgical measures were taken when latency delays were observed. Intraoperative BAEP's can be reliably and routinely recorded in an operating room environment. They provide a good predictor of postoperative auditory status, and may have prevented permanent neurological deficits in a small segment of patients by alerting the surgeon to potentially reversible abnormalities.

Surgical treatment of cerebral metastases from lung cancer

1971 ◽  
Vol 35 (4) ◽  
pp. 416-420 ◽  
Author(s):  
Edwin E. MacGee
Keyword(s):  
Lung Cancer ◽  
Surgical Treatment ◽  
Operative Mortality ◽  
Cerebral Metastases ◽  
Cerebral Metastasis ◽  
Metastatic Lung Cancer ◽  
Content Type ◽  
Intracranial Surgery ◽  
Metastatic Lung ◽  
Fine Print

✓ Results in 27 cases of intracranial surgery for metastatic lung cancer are evaluated with regard to both the quality and duration of survival; 56% of the patients lived more than 1 year, with the longest survivor still living 32 months after operation. The operative mortality was 26%. These data suggest that intracranial surgery is worthwhile in patients with lung cancer when the cerebral metastasis is either solitary or single.

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