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Transsphenoidal resection of sellar tumors using high-field intraoperative magnetic resonance imaging.

ABSTRACT: There has been increasing experience in the utilization of intraoperative magnetic resonance imaging (iMRI) for intracranial surgery. Despite this trend, only a few U.S centers have examined the use of this technology for transsphenoidal resection of tumors of the sella. We present the largest series in North America examining the role of iMRI for pituitary adenoma resection. We retrospectively reviewed our institutional experience of 59-patients who underwent transsphenoidal procedures for sellar and suprasellar tumors with iMRI guidance. Of these, 52 patients had a histological diagnosis of pituitary adenoma. The technical results of this subgroup were examined. A 1.5-T iMRI was integrated with the BrainLAB (Feldkirchen, Germany) neuronavigation system. The majority (94%) of tumors in our series were macroadenomas. Seventeen percent of tumors were confined to the sella, 49% had suprasellar extensions without involvement of the cavernous sinus, 34% had frank cavernous sinus invasion. All patients underwent at least one iMRI, and 19% required one or more additional sets of intraoperative imaging. In 58% of patients, iMRI led to the surgeon attempting more resection. A gross total resection was obtained in 67% of the patients with planned total resections. There was one case of permanent postoperative diabetes insipidus and no other instances of new hormone replacement. In summary, iMRI was most useful for tumors of the sella with and without suprasellar extension where the information from the iMRI extended the complete resection rate from 40 to 72% and 55 to 88%, respectively. As one would expect, it did not substantially increase the rate of resection of tumors with cavernous sinus invasion. Overall, iMRI was particularly useful in guiding resection safely, aiding in clinical decision making, and allowing identification and preservation of the pituitary stalk and normal pituitary gland. Limitations of the iMRI include a need for additional personnel and training as well as additional operative time, which diminishes over time as personnel learn to optimize workflow efficiency. Additional costs are mitigated in part by using the iMRI as an immediate postoperative scan. Other data emerging from our experience suggest that preservation of normal gland and thus avoidance of hypopituitarism may be improved by iMRI use, but longer follow-up periods are required to test this conclusion. iMRI can detect unsuspected complications sooner than routine postoperative imaging, potentially leading to improved outcomes. However, larger studies are needed.

SUBMITTER: Szerlip NJ

PROVIDER: S-EPMC3312115 | biostudies-other | 2011 Jul

REPOSITORIES: biostudies-other

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Project description:Intraoperative magnetic resonance imaging (iMRI) is a tool now commonly used in neurosurgery. Safe and reliable patient care in this (or any other) operating room setting depends on an environment, where electrical noise (EN) does not interfere with the operation of the electronic monitoring or imaging equipment. In this investigation, we evaluated the EN generated by the iMRI system and the anesthesia patient monitor used at this institution that impacts the performance of these two devices.We measured the EN generated by our iMRI-compatible anesthesia patient monitor as detected by the EN analysis algorithm in our iMRI system. We measured the EN generated by our iMRI system during scanning as detected in the electrocardiogram (ECG) waveform of our patient monitor. We analyzed the effects on EN reduction and signal quality of the ECG noise filters provided in our iMRI-compatible anesthesia patient monitor.Our patient monitor generated EN that was detectable by the iMRI EN analysis algorithm; however, this interference was within the iMRI manufacturer's acceptable limits for an iMRI scan (<10% more than background system-level noise). In the clinical case analyzed, the iMRI generated a narrow-band low-frequency (20 Hz) relatively high-energy EN that interfered with the ECG signal of our patient monitor during an iMRI scan. This EN was correlated with the acoustic noise from the iMRI system during the scan and was associated with the radio frequency (RF) and magnetic gradient pulsations of the iMRI system. The integrity of the ECG waveform was nearly entirely lost during a scan. The filters of the ECG monitor diminished but did not entirely eliminate this 20 Hz interference. We found that the filters alter the morphology of the ECG signal, which may make it difficult to identify clinically relevant ECG changes.The EN generated by our anesthesia patient monitor is within acceptable limits for the iMRI system. The iMRI generates EN which renders the ECG unreadable in the most commonly used filter mode. The monitor's filters diminish this noise but also alter the morphology of the ECG waveform. The anesthesiologist must be cognizant of these technical compromises and recognize that adjusting the ECG filters on the monitor is required to obtain a useful ECG signal for patient monitoring during the iMRI scan but that the diagnostic value of the ECG will be reduced.

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Transsphenoidal resection of sellar tumors using high-field intraoperative magnetic resonance imaging.

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