Intraoperative ultrasound-directed resection of pituitary tumors

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✓ Microadenomas of the pituitary vary in size, particularly those related to Cushing's disease. They are often not visualized on preoperative magnetic resonance (MR) imaging and may be difficult to find during surgical exploration of the pituitary. To enhance intraoperative localization of pituitary adenomas, we assessed the feasibility of using ultrasound to detect and localize pituitary tumors. Intraoperative ultrasound (IS) in the axial and sagittal planes was performed with an Intrascan system using a 12-MHz mechanically oscillating, end-firing transducer. Interpretation of the scans was performed by two individuals, who were usually blinded to the results of preoperative MR imaging or petrosal sinus sampling.

Twenty-eight patients were examined. Eighteen of these patients had microadenomas (1.5–7 mm), all with Cushing's disease; nine had macroadenomas (10–20 mm), three of which were adrenocorticotropic hormone—secreting, three growth hormone—secreting, two thyroid-stimulating hormone—secreting, and one nonfunctioning; and one patient had an intrasellar craniopharyngioma. Normal sellar and parasellar structures, such as intrapituitary cysts, the intracavernous carotid arteries, and the diaphragma sella were easily visualized. Twenty-three of the 28 tumors, including 13 of the 18 microadenomas, were detected on IS (82% sensitivity). Tumors were seen as hyperechoic masses in 19 patients, mixed echogenicity in three, and isoechoic in one. In most macroadenomas IS allowed visualization of the interface between the tumor and the normal pituitary gland. These results indicate the potential of IS to aid the intraoperative localization and definition of pituitary tumors.

Article Information

Address reprint requests to: Edward H. Oldfield, M.D., Surgical Neurology Branch, NINDS, NIH, 9000 Rockville Pike, Building 10, 5D37, Bethesda, Maryland 20892.

© AANS, except where prohibited by US copyright law.

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Figures

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    Photographs showing a 12-MHz ultrasound probe used for intraoperative ultrasound of the pituitary. An irrigation tube is attached to the probe (upper) to permit filling the gap between the tip of the transducer and the sterile covering of the probe with water (lower).

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    Schematic representation showing the typical appearance of the pituitary gland in the axial (upper) and sagittal (lower) views during pituitary intraoperative ultrasound. Sp = sphenoid sinus; Pit = pituitary gland; St = pituitary stalk; ca = internal carotid artery; CS = cavernous sinus; DS = dorsum sella.

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    Left: Axial view from intraoperative ultrasound in a patient with a thyroid-stimulating hormone—secreting macroadenoma (20 mm). The tumor (long arrow) contained a hemorrhagic cyst (open arrow) and had a well-delineated interface (short arrows) with the adjacent, displaced pituitary gland. Right: Gadolinium-enhanced coronal magnetic resonance (MR) image of the same patient showing the pituitary tumor. However, MR imaging did not indicate the size of the tumor and provided poor definition of the interface between the tumor and adjacent gland. The intratumoral cyst is clearly visualized (arrow).

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    Axial intraoperative ultrasound image from a patient with adrenocorticotropic hormone—secreting macroadenoma showing the well-defined hyperechoic tumor (long arrow). An extension of the tumor is seen within the right cavernous sinus (curved arrow) across from the hypoechoic medial wall of the sinus (short arrow).

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    Upper Left: Gadolinium-enhanced magnetic resonance (MR) images in a patient with Cushing's disease. No tumor can be detected. Upper Center and Right: Axial (upper center) and sagittal (upper right) intraoperative ultrasound images from the same patient revealing the 2-mm hyperechoic adrenocorticotropic hormone—secreting microadenoma within the pituitary gland (arrows). Lower Left and Center: Axial intraoperative ultrasound image (lower left) revealing a well-defined 5-mm hyperechoic microadenoma (long arrow) in another patient with Cushing's disease in whom preoperative MR imaging(lower center) was interpreted as equivocal for detection of an adenoma. Note the hypoechoic rim at the interface of the pseudocapsule of the adenoma and the adjacent pituitary gland, which corresponds to the dissection plane around the adenoma during surgery. The left carotid artery is also visualized in the upper portion of the cavernous sinus (short arrow; lower left).

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    Left: Gadolinium-enhanced magnetic resonance (MR) image in a patient with recurrent Cushing's disease after transsphenoidal surgery. No tumor was seen. Right: Axial intraoperative ultrasound image of the pituitary gland of the same patient showing the hyperechoic tumor (arrow) in the posterior aspect of the sella.

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