Intraoperative magnetic resonance imaging during transsphenoidal surgery

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Object. The aim of this study was to evaluate whether intraoperative magnetic resonance (MR) imaging can increase the efficacy of transsphenoidal microsurgery, primarily in non—hormone-secreting intra- and suprasellar pituitary macroadenomas.

Methods. Intraoperative imaging was performed using a 0.2-tesla MR imager, which was located in a specially designed operating room. The patient was placed supine on the sliding table of the MR imager, with the head placed near the 5-gauss line. A standard flexible coil was placed around the patient's forehead. Microsurgery was performed using MR-compatible instruments. Image acquisition was started after the sliding table had been moved into the center of the magnet. Coronal and sagittal T1-weighted images each required over 8 minutes to acquire, and T2-weighted images were obtained optionally. To assess the reliability of intraoperative evaluation of tumor resection, the intraoperative findings were compared with those on conventional postoperative 1.5-tesla MR images, which were obtained 2 to 3 months after surgery.

Among 44 patients with large intra- and suprasellar pituitary adenomas that were mainly hormonally inactive, intraoperative MR imaging allowed an ultra-early evaluation of tumor resection in 73% of cases; such an evaluation is normally only possible 2 to 3 months after surgery. A second intraoperative examination of 24 patients for suspected tumor remnants led to additional resection in 15 patients (34%).

Conclusions. Intraoperative MR imaging undoubtedly offers the option of a second look within the same surgical procedure, if incomplete tumor resection is suspected. Thus, the rate of procedures during which complete tumor removal is achieved can be improved. Furthermore, additional treatments for those patients in whom tumor removal was incomplete can be planned at an early stage, namely just after surgery.

Article Information

Address reprint requests to: Christopher Nimsky, M.D., Department of Neurosurgery, University of Erlangen—Nürnberg, Schwabachanlage 6, 91054 Erlangen, Germany. email: nimsky@nch.imed.uni-erlangen.de.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Schematic drawing of the intraoperative setup for transsphenoidal surgery. During surgery the patient's head is placed at the 5-gauss (5G) line. conv. mic. = conventional microscope; RF = radiofrequency.

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    Photographs demonstrating the intraoperative setup for transsphenoidal surgery. a: The patient is placed supine on the movable table of the MR imager and the thigh is flexed for removal of some fascia lata for closure of the sellar floor. b: A standard flexible coil is placed around the patient's forehead, just prior to surgery. A titanium needle is inserted into the patient's nose and is used during imaging to show the correct direction to the sellar floor. c: View during surgery, which is performed with the aid of a conventional microscope that is placed outside the 5-gauss line. d: For imaging, the table is moved into the center of the MR magnet.

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    Magnetic resonance images demonstrating a titanium needle (a, arrow) and a gadolinium-filled plastic tube (b, arrow). Either can be used to determine the correct direction to the sphenoid sinus and sellar floor.

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    Decision diagram designed to evaluate the relevance of intraoperative MR imaging in transsphenoidal surgery. It is based on the surgeon's estimation of the extent of the resection, the findings on intraoperative MR imaging, and the conclusions drawn. The total number of patients in each category is shown. Shading in the boxes indicates the following: black squares, highly relevant; gray squares, relevant; white squares, not relevant. c = complete; i = incomplete; ? = undecided.

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    Case 36. Coronal (a–c) and sagittal (d–f) MR images obtained in a 69-year-old man with a large intra-, supra-, and parasellar, endocrinologically asymptomatic pituitary adenoma. a and d: Preoperative images. b and e: Intraoperative images demonstrating nearly complete tumor removal. There is only one area in the right cavernous sinus in which residual tumor was suspected (arrows), but intrasellar interpretation is obscured by some drilling artifacts. c and f: Follow-up MR images confirming the results of the intraoperative imaging. The suspicious area located in the right cavernous sinus has shrunk in size.

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    Case 9. Coronal MR images obtained in a 59-year-old woman with a large intra- and suprasellar, endocrinologically asymptomatic pituitary adenoma. a: Preoperative image. b: Intraoperative image that raises a suspicion of blood in the resection cavity. c: Early postoperative image obtained 1 week after surgery revealing blood in the resection cavity, which now appears hyperintense. d: Follow-up MR image demonstrating complete tumor removal.

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    Case 13. Coronal (a–d) and sagittal (e–h) MR images obtained in a 46-year-old woman with a large, partially cystic, intra- and suprasellar, endocrinologically asymptomatic pituitary adenoma. a and e: Preoperative images. b and f: Intraoperative images that raise the suspicion of remaining tumor. c and g: Because the surgeon was sure he had completely removed the tumor, repeated imaging with a T2-weighted sequence was performed (c). In the meantime, the suprasellar fold had descended, which is confirmed by an additional sagittal T1-weighted image (g). d and h: Follow-up MR images obtained later served to confirm total tumor removal.

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    Case 44. Coronal (a–c) and sagittal (d–f) MR images obtained in a 68-year-old woman with a large intra- and suprasellar, endocrinologically asymptomatic pituitary adenoma. a and d: Preoperative images. b and e: Intraoperative images demonstrating complete tumor removal. c and f: Follow-up images demonstrating complete tumor removal.

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    Case 20. Coronal (a–d) and sagittal (e–h) MR images obtained in a 59-year-old man with a large intra-, para-, and suprasellar, endocrinologically asymptomatic pituitary adenoma. a and e: Preoperative images. b and f: Intraoperative images revealing some remaining tumor (arrows), which led to the surgeon taking a second look and removing the remaining portions of tumor. c and g: Additional images obtained at the end of surgery demonstrating that the remaining adenoma has been removed. d and h: Follow-up MR images confirming that tumor is no longer present.

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