Acta Neurochirurgica

, Volume 160, Issue 11, pp 2255–2262 | Cite as

Predicting extent of resection in transsphenoidal surgery for pituitary adenoma

  • Carlo SerraEmail author
  • Victor E. Staartjes
  • Nicolai Maldaner
  • Giovanni Muscas
  • Kevin Akeret
  • David Holzmann
  • Michael B. Soyka
  • Christoph Schmid
  • Luca Regli
Original Article - Pituitaries
Part of the following topical collections:
  1. Pituitaries



The extent of resection (EOR) is a crucial outcome parameter in transsphenoidal pituitary surgery (TSS), and is linked to endocrinological outcome, postoperative morbidity, and mortality. We aimed to build a robust, quantitative, and easily reproducible imaging score able to predict EOR in TSS.


The ratio (R) between the maximum horizontal adenoma diameter and intercarotid distance at the horizontal C4 segment was used to stratify our patient series in four classes: class I R ≤ 0.75, class II 0.75 < R ≤ 1.25, and class III R ≥ 1.25. Class IV included adenomas which completely encased the internal carotid artery. The resulting score was internally validated for robustness.


One hundred sixteen patients were included in the study, of which 96 (83%) for derivation and 20 (17%) for validation. EOR showed significant differences between grades (grade I, 100%; II, 97.9%; III, 94.2%; IV, 87.2%; all P < 0.05). The same applied to residual volume (RV) (grade I, 0 cm3; II, 0.08 cm3; III, 1.11 cm3; IV, 1.63 cm3; all P < 0.05). Differences in gross total resection (GTR) were statistically significant among classes I, II, and III (P < 0.05). The incidence of residual adenoma in the cavernous sinus increased also constantly from grade I up to grade IV although a significant difference was only found between grades III and II (P = 0.004). The score performed equally well in the validation cohort. Inter-observer agreement was high, with intraclass correlation coefficients > 0.89 for measurement of both the horizontal tumor diameter and the ICD among two independent raters (P < 0.001).


The proposed score is a simple and reproducible tool which reliably predicts surgical outcome including EOR, RV, and GTR of pituitary adenoma patients undergoing TSS.


Pituitary surgery Pituitary score Outcome prediction Knosp score Pituitary adenoma Transsphenoidal surgery 



We thank Jorn Fierstra, MD, PhD, and Bas van Niftrik, MD, for their independent measurements used for the assessment of interrater agreement, and Nicola Podda for his graphical work (Fig. 2).

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee (Cantonal Ethics Committee Zürich, KEK St-V-Nr 2015-0142) and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Supplementary material

701_2018_3690_MOESM1_ESM.docx (14 kb)
Supplementary Table 1 Surgical results at 3 months follow up. Values are given separately for both the derivation and validation cohort. IQR, interquartile range; SD, standard deviation; CSS, cavernous sinus space. (DOCX 13 kb)


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Copyright information

© Springer-Verlag GmbH Austria, part of Springer Nature 2018

Authors and Affiliations

  • Carlo Serra
    • 1
    Email author
  • Victor E. Staartjes
    • 1
  • Nicolai Maldaner
    • 1
  • Giovanni Muscas
    • 2
  • Kevin Akeret
    • 1
  • David Holzmann
    • 3
  • Michael B. Soyka
    • 3
  • Christoph Schmid
    • 4
  • Luca Regli
    • 1
  1. 1.Department of Neurosurgery, Clinical Neuroscience Center, University Hospital ZurichUniversity of ZurichZurichSwitzerland
  2. 2.Department of Neurosurgery, Tuscany School of NeurosurgeryUniversity of FirenzeFlorenceItaly
  3. 3.Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital ZurichUniversity of ZurichZurichSwitzerland
  4. 4.Department of Endocrinology and Diabetes, University Hospital ZurichUniversity of ZurichZurichSwitzerland

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