Superiority of constructive interference in steady-state MRI sequencing over T1-weighted MRI sequencing for evaluating cavernous sinus invasion by pituitary macroadenomas

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Preoperatively determining the extent of parasellar invasion of pituitary macroadenomas is useful for surgical planning and patient counseling. Here, the authors compared constructive interference in steady state (CISS), a T2-weighted gradient-echo MRI sequence, to volume-interpolated breath-hold examination (VIBE), a T1-weighted gradient-echo MRI sequence, for evaluation of cavernous sinus invasion (CSI) by pituitary macroadenomas.


VIBE and CISS images of 98 patients with pituitary macroadenoma were retrospectively analyzed and graded using the modified Knosp classification. The Knosp grades were correlated to surgical findings of CSI, which were determined intraoperatively using 0° and 30° endoscopes. The predictive accuracies for CSI according to the Knosp grades derived from the CISS and VIBE images were compared using receiver operating characteristic (ROC) curves. Postoperative MRI was used to evaluate the gross-total resection (GTR) rates.


The CSI rate by pituitary macroadenomas was 27.6% (27 of 98 cases). Of 196 assessments (left and right sides of 98 macroadenomas), 45 (23.0%) had different Knosp grades when scored using VIBE versus CISS images. For the VIBE images, 0% of Knosp grade 0, 4.5% of grade 1, 23.8% of grade 2, 42.1% of grade 3A, 100% of grade 3B, and 83.3% of grade 4 macroadenomas were found to have CSI intraoperatively. For the CISS images, 0% of Knosp grade 0, 2.1% of grade 1, 31.3% of grade 2, 56.3% of grade 3A, 100% of grade 3B, and 100% of grade 4 macroadenomas were found to have CSI intraoperatively. Two pituitary macroadenomas were classified as grade 4 on VIBE sequences but grades 3A and 2 on CISS sequences; CSI was not observed intraoperatively in both cases. The GTR rate was 64.3% and 60.0% for high-grade (3A, 3B, and 4) macroadenomas classified using VIBE and CISS sequences, respectively. The areas under the ROC curves were 0.94 and 0.97 for VIBE- and CISS-derived Knosp grades (p = 0.007), respectively.


Knosp grades determined using CISS sequence images are better correlated with intraoperative CSI than those determined using VIBE sequence images. CISS sequences may be valuable for the preoperative assessment of pituitary macroadenomas.

ABBREVIATIONS AUC = area under the curve; CISS = constructive interference in steady state; CSI = cavernous sinus invasion; GTR = gross-total resection; ICA = internal carotid artery; ROC = receiver operating characteristic; VIBE = volume-interpolated breath-hold examination.

Article Information

Correspondence Pablo F. Recinos: Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland, OH.

INCLUDE WHEN CITING Published online March 23, 2018; DOI: 10.3171/2017.9.JNS171699.

Disclosures Dr. Recinos is a member of the Scientific Advisory Board of Acera Surgical Inc. and owns stock in Acera Surgical Inc.

© AANS, except where prohibited by US copyright law.



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    Left: Graphic illustration of the Knosp classification system for pituitary macroadenomas. Artist: Joe Pangrace. Copyright Center for Medical Art and Photography, Cleveland Clinic Foundation. Published with permission. Center: Representative coronal VIBE images. Right: Representative coronal CISS images. A: Grade 0. The adenoma is medial to the cavernous sinus and does not pass the medial tangent (line), which passes between the medial aspects of the supra- and intracavernous portions of the ICAs. B: Grade 1. The adenoma passes the medial tangent but does not pass the cross-sectional line (line) drawn between the supra- and intracavernous ICAs. C: Grade 2. The adenoma extends beyond the cross-sectional line but does not pass the lateral tangent (line) drawn between the lateral aspects of the supra- and intracavernous ICAs. D: Grade 3A. The adenoma extends beyond the lateral tangent (line) and into the superior cavernous sinus compartment. E: Grade 3B. The adenoma extends beyond the lateral tangent (line) and into the inferior cavernous sinus compartment. F: Grade 4. The adenoma completely encases the intracavernous ICA (circle). Figure is available in color online only.

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    Two cases of pituitary macroadenoma classified as Knosp grade 4 on VIBE images but without intraoperative findings of CSI. A and B: In the first case, the pituitary macroadenoma appears to fully encase the intracavernous portion of the right ICA (arrows) on VIBE imaging. However, with better visualization of the dural boundaries and the outline of the macroadenoma on CISS imaging, it was clear that the pituitary macroadenoma did not encase the ICA but rather extended into the superior cavernous sinus compartment. CSI was not observed on the right side intraoperatively. C and D: In the second case, the pituitary macroadenoma appears to fully encase the left ICA (arrows) on VIBE imaging but not on CISS imaging. CSI was not observed intraoperatively on the left side.

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    Example of a pituitary macroadenoma with a lower Knosp grade on VIBE (left) than CISS (right) images. The ICAs, pituitary macroadenoma, and sellar anatomy were better visualized on CISS images. The pituitary macroadenoma did not extend past the solid cross-sectional line on the VIBE image (Knosp grade 1) but reached the dashed lateral tangent line on the CISS image (Knosp grade 2). CSI was not observed intraoperatively.

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    Intraoperative findings of CSI plotted against Knosp grades determined using CISS (black bars) and VIBE (gray bars) images. The prevalence of CSI increased with higher Knosp grade, regardless of whether CISS or VIBE images were used for grading. While 100% of grade 4 macroadenomas classified using CISS sequence images were found to be invasive, only 83.3% of grade 4 macroadenomas classified using VIBE sequence images were found to be invasive.

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    ROC curves of Knosp grades derived from CISS (red line) and VIBE (blue line) imaging. The points on the plot were obtained by setting each Knosp grade as the threshold for the diagnosis of CSI. The AUC was significantly greater for the CISS ROC curve than the VIBE ROC curve (0.97 vs 0.94; p = 0.007). Figure is available in color online only.



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