Abstract
Surgery for pituitary adenomas still remains a mainstay in their treatment, despite all advances in sophisticated medical treatments and radiotherapy. Total tumor excision is often attempted, but there are limitations in the intraoperative assessment of the radicalism of tumor resection by the neurosurgeon. Standard postoperative imaging is usually performed with a few months delay from the surgical intervention. The purpose of this report is to review briefly the facilities and kinds of intraoperative magnetic resonance imaging for all physician and surgeons involved in the management of pituitary adenomas on the basis of current literature. To date, there are several low- and high-field magnetic resonance imaging systems available for intraoperative use and depiction of the extent of tumor removal during surgery. Recovery of vision and the morphological result of surgery can be largely predicted from the intraoperative images. A variety of studies document that depiction of residual tumor allows targeted attack of the remnant and extent the resection. Intraoperative magnetic resonance imaging offers an immediate feedback to the surgeon and is a perfect quality control for pituitary surgery. It is also used as a basis of datasets for intraoperative navigation which is particularly useful in any kind of anatomical variations and repeat operations in which primary surgery has distorted the normal anatomy. However, setting up the technology is expensive and some systems even require extensive remodeling of the operation theatre. Intraoperative imaging prolongs the operation, but may also depict evolving problems, such as hematomas in the tumor cavity. There are several artifacts in intraoperative MR images possible that must be considered. The procedures are not associated with an increased complication rate.
Similar content being viewed by others
References
R.J. Bohinski, R.E. Warnick, M.F. Gaskill-Shipley, M. Zuccarello, H.R. van Loveren, D.W. Kormos, J.M. Tew Jr, Intraoperative magnetic resonance imaging to determine the extent of resection of pituitary macroadenomas during transsphenoidal microsurgery. Neurosurgery 49(5), 1133–1143 (2001); discussion 1134–1143
M. Buchfelder, Treatment of pituitary tumors: surgery. Endocrine 28(1), 67–75 (2005). doi:10.1385/ENDO:28:1:067
M. Buchfelder, S. Schlaffer, Surgical treatment of pituitary tumours. Best practice & research. Clin. Endocrinol. Metab. 23(5), 677–692 (2009). doi:10.1016/j.beem.2009.05.002
J. Hardy, S.M. Wigser, Trans-sphenoidal surgery of pituitary fossa tumors with televised radiofluoroscopic control. J. Neurosurg. 23(6), 612–619 (1965). doi:10.3171/jns.1965.23.6.0612
R. Nesbakken, S. Reinlie, O.P. Eldevik, Intraoperative gas cisternography and gas dissection in the operative treatment of pituitary tumors. A methodological description. Eur. Surg. Res. 16(Suppl 2), 73–79 (1984)
N.F. Maartens, The history of the treatment of pituitary adenomas. Endocrine 28(1), 9–26 (2005). doi:10.1385/ENDO:28:1:009
H. Okudera, T. Takemae, S. Kobayashi, Intraoperative computed tomographic scanning during transsphenoidal surgery: technical note. Neurosurgery 32(6), 1041–1043 (1993)
K. Arita, K. Kurisu, A. Tominaga, H. Kawamoto, K. Iida, T. Mizoue, B. Pant, T. Uozumi, Trans-sellar color Doppler ultrasonography during transsphenoidal surgery. Neurosurgery 42(1), 81–85 (1998); discussion 86
J.L. Atkinson, J.L. Kasperbauer, E.M. James, J.I. Lane, T.B. Nippoldt, Transcranial-transdural real-time ultrasonography during transsphenoidal resection of a large pituitary tumor. Case report. J. Neurosurg. 93(1), 129–131 (2000). doi:10.3171/jns.2000.93.1.0129
J.L. Doppman, Z. Ram, T.H. Shawker, E.H. Oldfield, Intraoperative US of the pituitary gland. Work in progress. Radiology 192(1), 111–115 (1994)
W.J. Elias, J.B. Chadduck, T.D. Alden, E.R. Laws Jr, Frameless stereotaxy for transsphenoidal surgery. Neurosurgery 45(2), 271–275 (1999); discussion 275–277
J.A. Jane Jr, K. Thapar, T.D. Alden, E.R. Laws Jr, Fluoroscopic frameless stereotaxy for transsphenoidal surgery. Neurosurgery 48(6), 1302–1307 (2001); discussion 1307–1308
A. Kacker, A. Komisar, J. Huo, J. Mangiardi, Transsphenoidal surgery utilizing computer-assisted stereotactic guidance. Rhinology 39(4), 207–210 (2001)
G. Lasio, P. Ferroli, G. Felisati, G. Broggi, Image-guided endoscopic transnasal removal of recurrent pituitary adenomas. Neurosurgery 51(1), 132–136 (2002); discussion 136–137
U.W. Thomale, J.F. Stover, A.W. Unterberg, The use of neuronavigation in transnasal transsphenoidal pituitary surgery. Zentralbl. Neurochir. 66(3), 126–132 (2005). doi:10.1055/s-2005-836602; discussion 132
D.G. Walker, C. Ohaegbulam, P.M. Black, Frameless stereotaxy as an alternative to fluoroscopy for transsphenoidal surgery: use of the InstaTrak-3000 and a novel headset. J. Clin. Neurosci. 9(3), 294–297 (2002)
M. Buchfelder, S.M. Schlaffer, Modern imaging of pituitary adenomas. Frontier Horm. Res. 38, 109–120 (2010). doi:10.1159/000318500
P.M. Black, T. Moriarty, E. Alexander III, P. Stieg, E.J. Woodard, P.L. Gleason, C.H. Martin, R. Kikinis, R.B. Schwartz, F.A. Jolesz, Development and implementation of intraoperative magnetic resonance imaging and its neurosurgical applications. Neurosurgery 41(4), 831–842 (1997); discussion 842–835
R.S. Pergolizzi Jr, A. Nabavi, R.B. Schwartz, L. Hsu, T.Z. Wong, C. Martin, P.M. Black, F.A. Jolesz, Intra-operative MR guidance during trans-sphenoidal pituitary resection: preliminary results. J. Magn. Reson. Imaging 13(1), 136–141 (2001)
R.B. Schwartz, L. Hsu, T.Z. Wong, D.F. Kacher, A.A. Zamani, P.M. Black, E. Alexander III, P.E. Stieg, T.M. Moriarty, C.A. Martin, R. Kikinis, F.A. Jolesz, Intraoperative MR imaging guidance for intracranial neurosurgery: experience with the first 200 cases. Radiology 211(2), 477–488 (1999)
C. Nimsky, O. Ganslandt, R. Fahlbusch, Comparing 0.2 tesla with 1.5 tesla intraoperative magnetic resonance imaging analysis of setup, workflow, and efficiency. Acad. Radiol. 12(9), 1065–1079 (2005). doi:10.1016/j.acra.2005.05.020
C. Nimsky, O. Ganslandt, B. Von Keller, J. Romstock, R. Fahlbusch, Intraoperative high-field-strength MR imaging: implementation and experience in 200 patients. Radiology 233(1), 67–78 (2004). doi:10.1148/radiol.2331031352
R. Steinmeier, R. Fahlbusch, O. Ganslandt, C. Nimsky, M. Buchfelder, M. Kaus, T. Heigl, G. Lenz, R. Kuth, W. Huk, Intraoperative magnetic resonance imaging with the magnetom open scanner: concepts, neurosurgical indications, and procedures: a preliminary report. Neurosurgery 43(4), 739–747 (1998); discussion 747–738
V. Benes, D. Netuka, F. Kramar, S. Ostry, T. Belsan, Multifunctional surgical suite (MFSS) with 3.0 T iMRI: 17 months of experience. Acta Neurochir. Suppl. 109, 145–149 (2011). doi:10.1007/978-3-211-99651-5_22
A. Jankovski, F. Francotte, G. Vaz, E. Fomekong, T. Duprez, M. Van Boven, M.A. Docquier, L. Hermoye, G. Cosnard, C. Raftopoulos, Intraoperative magnetic resonance imaging at 3-T using a dual independent operating room-magnetic resonance imaging suite: development, feasibility, safety, and preliminary experience. Neurosurgery 63(3), 412–424 (2008). doi:10.1227/01.NEU.0000324897.59311.1C; discussion 416–424
M.J. Lang, J.J. Kelly, G.R. Sutherland, A moveable 3-T intraoperative magnetic resonance imaging system. Neurosurgery 68(1 Suppl Operative), 168–179 (2011). doi:10.1227/NEU.0b013e3182045803
M.N. Pamir, 3 T ioMRI: the Istanbul experience. Acta Neurochir. Suppl. 109, 131–137 (2011). doi:10.1007/978-3-211-99651-5_20
R. Fahlbusch, B. Keller, O. Ganslandt, J. Kreutzer, C. Nimsky, Transsphenoidal surgery in acromegaly investigated by intraoperative high-field magnetic resonance imaging. Eur. J. Endocrinol. 153(2), 239–248 (2005). doi:10.1530/eje.1.01970
C. Nimsky, B. von Keller, O. Ganslandt, R. Fahlbusch, Intraoperative high-field magnetic resonance imaging in transsphenoidal surgery of hormonally inactive pituitary macroadenomas. Neurosurgery 59(1), 105–114 (2006). doi:10.1227/01.NEU.0000219198.38423.1E; discussion 105–114
R. Fahlbusch, O. Ganslandt, M. Buchfelder, W. Schott, C. Nimsky, Intraoperative magnetic resonance imaging during transsphenoidal surgery. J. Neurosurg. 95(3), 381–390 (2001). doi:10.3171/jns.2001.95.3.0381
C. Nimsky, O. Ganslandt, B. Hofmann, R. Fahlbusch, Limited benefit of intraoperative low-field magnetic resonance imaging in craniopharyngioma surgery. Neurosurgery 53(1), 72–80 (2003); discussion 71–80
T.S. Dina, S.H. Feaster, E.R. Laws Jr, D.O. Davis, MR of the pituitary gland postsurgery: serial MR studies following transsphenoidal resection. AJNR Am. J. Neuroradiol. 14(3), 763–769 (1993)
M.M. Teng, C.I. Huang, T. Chang, The pituitary mass after transsphenoidal hypophysectomy. AJNR Am. J. Neuroradiol. 9(1), 23–26 (1988)
T. Kilic, G. Ekinci, A. Seker, I. Elmaci, C. Erzen, M.N. Pamir, Determining optimal MRI follow-up after transsphenoidal surgery for pituitary adenoma: scan at 24 hours postsurgery provides reliable information. Acta Neurochir. 143(11), 1103–1126 (2001). doi:10.1007/s007010100002
E.J. Zirkzee, E.P. Corssmit, N.R. Biermasz, P.A. Brouwer, F.T. Wiggers-De Bruine, L.J. Kroft, M.A. Van Buchem, F. Roelfsema, A.M. Pereira, J.W. Smit, J.A. Romijn, Pituitary magnetic resonance imaging is not required in the postoperative follow-up of acromegalic patients with long-term biochemical cure after transsphenoidal surgery. J. Clin. Endocrinol. Metab. 89(9), 4320–4324 (2004). doi:10.1210/jc.2003-032141
V. Rajaraman, M. Schulder, Postoperative MRI appearance after transsphenoidal pituitary tumor resection. Surg. Neurol. 52(6), 592–598 (1999); discussion 598–599
O. Rodriguez, B. Mateos, R. de la Pedraja, R. Villoria, J.I. Hernando, A. Pastor, I. Pomposo, J. Aurrecoechea, Postoperative follow-up of pituitary adenomas after trans-sphenoidal resection: MRI and clinical correlation. Neuroradiology 38(8), 747–754 (1996)
A. Giustina, P. Chanson, M.D. Bronstein, A. Klibanski, S. Lamberts, F.F. Casanueva, P. Trainer, E. Ghigo, K. Ho, S. Melmed, Acromegaly consensus, G.: a consensus on criteria for cure of acromegaly. J. Clin. Endocrinol. Metab. 95(7), 3141–3148 (2010). doi:10.1210/jc.2009-2670
A. Giustina, G. Mazziotti, V. Torri, M. Spinello, I. Floriani, S. Melmed, Meta-analysis on the effects of octreotide on tumor mass in acromegaly. PLoS One 7(5), e36411 (2012). doi:10.1371/journal.pone.0036411
S. Melmed, A. Colao, A. Barkan, M. Molitch, A.B. Grossman, D. Kleinberg, D. Clemmons, P. Chanson, E. Laws, J. Schlechte, M.L. Vance, K. Ho, A. Giustina, Acromegaly consensus, G.: Guidelines for acromegaly management: an update. J. Clin. Endocrinol. Metab. 94(5), 1509–1517 (2009). doi:10.1210/jc.2008-2421
D.G. Walker, P.M. Black, Use of intraoperative MRI in pituitary surgery. Oper. Tech. Neurosurg. 5(4), 231–238 (2002). doi:10.1053/otns.2002.32496
M. Bernstein, A.R. Al-Anazi, W. Kucharczyk, P. Manninen, M. Bronskill, M. Henkelman, Brain tumor surgery with the Toronto open magnetic resonance imaging system: preliminary results for 36 patients and analysis of advantages, disadvantages, and future prospects. Neurosurgery 46(4), 900–907 (2000); discussion 907–909
C.R. Wirtz, M. Knauth, A. Staubert, M.M. Bonsanto, K. Sartor, S. Kunze, V.M. Tronnier, Clinical evaluation and follow-up results for intraoperative magnetic resonance imaging in neurosurgery. Neurosurgery 46(5), 1112–1120 (2000); discussion 1120–1112
J.S. Lewin, S.G. Nour, M.L. Meyers, A.K. Metzger, R.J. Maciunas, M. Wendt, J.L. Duerk, A. Oppelt, W.R. Selman, Intraoperative MRI with a rotating, tiltable surgical table: a time use study and clinical results in 122 patients. AJR Am. J. Roentgenol. 189(5), 1096–1103 (2007). doi:10.2214/AJR.06.1247
B.J. Darakchiev, J.M. Tew Jr, R.J. Bohinski, R.E. Warnick, Adaptation of a standard low-field (0.3-T) system to the operating room: focus on pituitary adenomas. Neurosurg. Clin. N. Am. 16(1), 155–164 (2005). doi:10.1016/j.nec.2004.07.003
J.Y. Ahn, J.Y. Jung, J. Kim, K.S. Lee, S.H. Kim, How to overcome the limitations to determine the resection margin of pituitary tumours with low-field intra-operative MRI during trans-sphenoidal surgery: usefulness of gadolinium-soaked cotton pledgets. Acta Neurochir. 150(8), 763–771 (2008). doi:10.1007/s00701-008-1505-1; discussion 771
V.K. Anand, T.H. Schwartz, D.H. Hiltzik, A. Kacker, Endoscopic transphenoidal pituitary surgery with real-time intraoperative magnetic resonance imaging. Am. J. Rhinol. 20(4), 401–405 (2006)
F. Baumann, C. Schmid, R.L. Bernays, Intraoperative magnetic resonance imaging-guided transsphenoidal surgery for giant pituitary adenomas. Neurosurg. Rev. 33(1), 83–90 (2010). doi:10.1007/s10143-009-0230-4
D. Bellut, M. Hlavica, C. Schmid, R.L. Bernays, Intraoperative magnetic resonance imaging-assisted transsphenoidal pituitary surgery in patients with acromegaly. Neurosurg. Focus 29(4), E9 (2010). doi:10.3171/2010.7.FOCUS10164
S. Berkmann, J. Fandino, B. Muller, L. Remonda, H. Landolt, Intraoperative MRI and endocrinological outcome of transsphenoidal surgery for non-functioning pituitary adenoma. Acta Neurochir. 154(4), 639–647 (2012). doi:10.1007/s00701-012-1285-5
S. Berkmann, J. Fandino, S. Zosso, H.E. Killer, L. Remonda, H. Landolt, Intraoperative magnetic resonance imaging and early prognosis for vision after transsphenoidal surgery for sellar lesions. J. Neurosurg. 115(3), 518–527 (2011). doi:10.3171/2011.4.JNS101568
O. De Witte, O. Makiese, D. Wikler, M. Levivier, A. Vandensteene, P. Pandin, D. Baleriaux, J. Brotchi, Transsphenoidal approach with low field MRI for pituitary adenoma. Neurochirurgie 51(6), 577–583 (2005)
R. Gerlach, R. du Mesnil de Rochemont, T. Gasser, G. Marquardt, J. Reusch, L. Imoehl, V. Seifert, Feasibility of Polestar N20, an ultra-low-field intraoperative magnetic resonance imaging system in resection control of pituitary macroadenomas: lessons learned from the first 40 cases. Neurosurgery 63(2), 272–284 (2008). doi:10.1227/01.NEU.0000312362.63693.78; discussion 284-275
J. Jones, J. Ruge, Intraoperative magnetic resonance imaging in pituitary macroadenoma surgery: an assessment of visual outcome. Neurosurg. Focus 23(5), E12 (2007). doi:10.3171/FOC-07/11/E12
J.S. Wu, X.F. Shou, C.J. Yao, Y.F. Wang, D.X. Zhuang, Y. Mao, S.Q. Li, L.F. Zhou, Transsphenoidal pituitary macroadenomas resection guided by PoleStar N20 low-field intraoperative magnetic resonance imaging: comparison with early postoperative high-field magnetic resonance imaging. Neurosurgery 65(1), 63–70 (2009). doi:10.1227/01.NEU.0000348549.26832.51; discussion 61–70
G.R. Sutherland, T. Kaibara, D. Louw, D.I. Hoult, B. Tomanek, J. Saunders, A mobile high-field magnetic resonance system for neurosurgery. J. Neurosurg. 91(5), 804–813 (1999). doi:10.3171/jns.1999.91.5.0804
W.A. Hall, W. Galicich, T. Bergman, C.L. Truwit, 3-T intraoperative MR imaging for neurosurgery. J. Neurooncol. 77(3), 297–303 (2006). doi:10.1007/s11060-005-9046-4
M.L. Hlavin, J.S. Lewin, B.M. Arafah, Intraoperative magnetic resonance imaging for assessment of chiasmatic decompression and tumour resection during transsphenoidal pituitary surgery. Tech. Neurosurg. 6, 282–288 (2000)
C.H. Martin, R. Schwartz, F. Jolesz, P.M. Black, Transsphenoidal resection of pituitary adenomas in an intraoperative MRI unit. Pituitary 2(2), 155–162 (1999)
T.H. Schwartz, P.E. Stieg, V.K. Anand, Endoscopic transsphenoidal pituitary surgery with intraoperative magnetic resonance imaging. Neurosurgery 58(1 Suppl), ONS44–51; discussion ONS44–51 (2006)
P.V. Theodosopoulos, J. Leach, R.G. Kerr, L.A. Zimmer, A.M. Denny, B. Guthikonda, S. Froelich, J.M. Tew, Maximizing the extent of tumor resection during transsphenoidal surgery for pituitary macroadenomas: can endoscopy replace intraoperative magnetic resonance imaging? J. Neurosurg. 112(4), 736–743 (2010). doi:10.3171/2009.6.JNS08916
T.W. Vitaz, K.E. Inkabi, C.J. Carrubba, Intraoperative MRI for transphenoidal procedures: short-term outcome for 100 consecutive cases. Clin. Neurol. Neurosurg. 113(9), 731–735 (2011). doi:10.1016/j.clineuro.2011.07.025
J.C. Dort, G.R. Sutherland, Intraoperative magnetic resonance imaging for skull base surgery. Laryngoscope 111(9), 1570–1575 (2001). doi:10.1097/00005537-200109000-00014
X.H. Meng, B.N. Xu, S.B. Wei, T. Zhou, X.L. Chen, X.G. Yu, D.B. Zhou, H.Y. Tong, J.S. Zhang, Y. Zhao, Y.Z. Hou, High-field intraoperative magnetic resonance imaging suite with neuronavigation system: implementation and preliminary experience in the pituitary adenoma operation with transsphenoidal approach. Zhonghua wai ke za zhi [Chin. J. Surg.] 49(8), 703–706 (2011)
D. Netuka, V. Masopust, T. Belsan, F. Kramar, V. Benes, One year experience with 3.0 T intraoperative MRI in pituitary surgery. Acta Neurochir. Suppl. 109, 157–159 (2011). doi:10.1007/978-3-211-99651-5_24
W.A. Hall, C.L. Truwit, Intraoperative MR imaging. Magn. Reson. Imaging Clin. N. Am. 13(3), 533–543 (2005). doi:10.1016/j.mric.2005.04.001
N.J. Szerlip, Y.C. Zhang, D.G. Placantonakis, M. Goldman, K.B. Colevas, D.G. Rubin, E.J. Kobylarz, S. Karimi, M. Girotra, V. Tabar, Transsphenoidal resection of sellar tumors using high-field intraoperative magnetic resonance imaging. Skull Base 21(4), 223–232 (2011). doi:10.1055/s-0031-1277262
J.A. Jane Jr, E.R. Laws Jr, Endoscopy versus MR imaging. J. Neurosurg. 112(4), 734 (2010). doi:10.3171/2009.7.JNS091042; discussion 735
Conflicts of interest
The authors declare that they have no conflict of interest.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Buchfelder, M., Schlaffer, SM. Intraoperative magnetic resonance imaging during surgery for pituitary adenomas: pros and cons. Endocrine 42, 483–495 (2012). https://doi.org/10.1007/s12020-012-9752-6
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s12020-012-9752-6