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Chirag D. Gandhi and Kalmon D. Post

Over the past century pituitary surgery has undergone multiple revolutions in surgical technique and technological advancements that have resulted in what is now recognized as modern transsphenoidal surgery. Although the procedure is well established in the current neurosurgical literature, the historical maze that led to its development continues to be of interest because it allows us to appreciate better the unique contributions made by the pioneers of the technique as well as the innovative spirit that continues to fuel neurosurgery. The early events in the history of transsphenoidal surgery have already been well documented. Therefore, the authors summarize the major early transitions along the timeline and then further describe more recent advancements in transsphenoidal surgery such as the surgical microscope, fluoroscopy, endoscopy, intraoperative neuroimaging, frameless image guidance, and radioimmunoassay. The story of these innovations is unique because each was developed as a response to certain needs of the surgeon. An understanding of these more recent contributions coupled with the early history provides a more complete perspective on modern transsphenoidal surgery.

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Michael A. Chorney, Chirag D. Gandhi and Charles J. Prestigiacomo

Craniotomies are among the oldest neurosurgical procedures, as evidenced by early human skulls discovered with holes in the calvaria. Though devices change, the principles to safely transgress the skull are identical. Modern neurosurgeons regularly use electric power drills in the operating theater; however, nonelectric trephining instruments remain trusted by professionals in certain emergent settings in the rare instance that an electric drill is unavailable. Until the late Middle Ages, innovation in craniotomy instrumentation remained stunted without much documented redesign. Jacopo Berengario da Carpi's (c. 1457–1530 CE) text Tractatus de Fractura Calvae sive Cranei depicts a drill previously unseen in a medical volume. Written in 1518 CE, the book was motivated by defeat over the course of Lorenzo II de'Medici's medical care. Berengario's interchangeable bit with a compound brace (“vertibulum”), known today as the Hudson brace, symbolizes a pivotal device in neurosurgery and medical tool design. This drill permitted surgeons to stock multiple bits, perform the craniotomy faster, and decrease equipment costs during a period of increased incidence of cranial fractures, and thus the need for craniotomies, which was attributable to the introduction of gunpowder. The inspiration stemmed from a school of thought growing within a population of physicians trained as mathematicians, engineers, and astrologers prior to entering the medical profession. Berengario may have been the first to record the use of such a unique drill, but whether he invented this instrument or merely adapted its use for the craniotomy remains clouded.

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Chirag D. Gandhi, Lana D. Christiano and Charles J. Prestigiacomo

The management of stroke has progressed significantly over the past 2 decades due to successful treatment protocols including intravenous and intraarterial options. The intravenous administration of tissue plasminogen activator within an established treatment window has been proven in large, well-designed studies. The evolution of endovascular strategies for acute stroke has been prompted by the limits of the intravenous treatment, as well as by the desire to demonstrate improved recanalization rates and improved long-term outcomes. The interventional treatment options available today are the intraarterial administration of tissue plasminogen activator and newer antiplatelet agents, mechanical thrombectomy with the MERCI device and the Penumbra system, and intracranial angioplasty and stent placement. In this review the authors outline the major studies that have defined the current field of acute stroke management and discuss the basic treatment paradigms that are commonly used today.

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Christopher Doe, Pinakin R. Jethwa, Chirag D. Gandhi and Charles J. Prestigiacomo

The treatment of asymptomatic carotid artery stenosis (ACAS) has continued to evolve for the past 3 decades. With rapidly advancing technology, the results of old trials have become obsolete. While there has been little change in the efficacy of carotid endarterectomy, there have been vast improvements in both medical management and carotid angioplasty with stenting. Finding the best therapy for a given patient can therefore be difficult. In this article, the authors review the current literature regarding treatment options for ACAS and the methods available for stratifying patients who would benefit from surgical versus medical treatment.

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E. Jesus Duffis, Zaid Al-Qudah, Charles J. Prestigiacomo and Chirag Gandhi

Early treatment of ischemic stroke with thrombolytics is associated with improved outcomes, but few stroke patients receive thrombolytic treatment in part due to the 3-hour time window. Advances in neuroimaging may help to aid in the selection of patients who may still benefit from thrombolytic treatment beyond conventional time-based guidelines. In this article the authors review the available literature in support of using advanced neuroimaging to select patients for treatment beyond the 3-hour time window cutoff and explore potential applications and limitations of perfusion imaging in the treatment of acute ischemic stroke.

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Victor M. Sabourin, Ryan Holland, Christine Mau, Chirag D. Gandhi and Charles J. Prestigiacomo

The Civil War era was an age-defining period in the history of the United States of America, the effects of which are still seen in the nation today. In this era, the issue of head injury pervaded society. From the president of the United States, Abraham Lincoln, to the officers and soldiers of the Union and Confederate armies, and to the population at large, head injury and its ramifications gripped the nation. This article focuses on 3 individuals: Major General John Sedgwick, First Lieutenant Alonzo Cushing, and Harriet Tubman, as examples of the impact that head injury had during this era. These 3 individuals were chosen for this article because of their lasting legacies, contributions to society, and interesting connections to one another.

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Prateeka Koul, Christine Mau, Victor M. Sabourin, Chirag D. Gandhi and Charles J. Prestigiacomo

World War I advanced the development of aviation from the concept of flight to the use of aircraft on the battlefield. Fighter planes advanced technologically as the war progressed. Fighter pilot aces Francesco Baracca and Manfred von Richthofen (the Red Baron) were two of the most famous pilots of this time period. These courageous fighter aces skillfully maneuvered their SPAD and Albatros planes, respectively, while battling enemies and scoring aerial victories that contributed to the course of the war. The media thrilled the public with their depictions of the heroic feats of fighter pilots such as Baracca and the Red Baron. Despite their aerial prowess, both pilots would eventually be shot down in combat. Although the accounts of their deaths are debated, it is undeniable that both were victims of traumatic head injury.

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Ryan Holland, Victor M. Sabourin, Chirag D. Gandhi, Peter W. Carmel and Charles J. Prestigiacomo

As his fellow soldiers ran past him, Joseph Warren stood bravely on Bunker Hill. It was June 17, 1775, and British troops were fighting the colonists in one of the early battles of the American Revolution. The British had already attempted two major assaults that day, and the third would end with Warren’s death. He was a medical doctor, public figure, and general who spent his life and last living moments fighting for freedom for the American colonists.

After the battle, there was much confusion about what had happened to Joseph Warren. Some thought he had survived the battle; other accounts differed on how exactly he had died. The details of the events on Bunker Hill remained a mystery until the following year, when Paul Revere helped identify Warren’s body by the false teeth that had been implanted years earlier. Warren’s remains showed that his head had been struck by a bullet.

Analysis of the skull helped to sift through the differing tales of Warren’s death and thus unveil the truth about what occurred that day. The smaller bullet wound in the left maxilla suggests that he was not shot while retreating with the rest of the soldiers. The larger exit wound in the right occiput illustrates that the bullet’s trajectory crossed the midline of the brain and most likely injured the brainstem. Therefore, contrary to rumors that circulated at the time, Joseph Warren most likely was killed instantly at the Battle of Bunker Hill while heroically facing his enemy.

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Christina E. Sarris, Krystal L. Tomei, Peter W. Carmel and Chirag D. Gandhi

Lipomyelomeningocele represents a rare but complex neurological disorder that may present with neurological deterioration secondary to an inherent tethered spinal cord. Radiological testing is beneficial in determining the morphology of the malformation. Specialized testing such as urodynamic studies and neurophysiological testing may be beneficial in assessing for neurological dysfunction secondary to the lipomyelomeningocele. Early surgical intervention may be beneficial in preventing further neurological decline.

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Karen Man, Victor M. Sabourin, Chirag D. Gandhi, Peter W. Carmel and Charles J. Prestigiacomo

Pierre Curie, best known as a Nobel Laureate in Physics for his co-contributions to the field of radioactivity alongside research partner and wife Marie Curie, died suddenly in 1906 from a street accident in Paris. Tragically, his skull was crushed under the wheel of a horse-drawn carriage. This article attempts to honor the life and achievements of Pierre Curie, whose trailblazing work in radioactivity and piezoelectricity set into motion a wide range of technological developments that have culminated in the advent of numerous techniques used in neurological surgery today. These innovations include brachytherapy, Gamma Knife radiosurgery, focused ultrasound, and haptic feedback in robotic surgery.