Identification of tumor residuals in pituitary adenoma surgery with intraoperative MRI: do we need gadolinium?



To evaluate the diagnostic accuracy of high-resolution T2w intraoperative magnetic resonance imaging (iMRI) for detecting pituitary adenoma remnants compared to contrast-enhanced T1-weighted images.


42 patients underwent iMRI-guided resection of large pituitary macroadenomas and fulfilled the inclusion criteria for this retrospective analysis. Intraoperative and postoperative imaging evaluation of tumor residuals and localization were assessed by two experienced neuroradiologists in a blinded fashion. The diagnostic accuracy of T2w and contrast-enhanced T1w images were evaluated.


The diagnostic accuracy for detecting tumor residuals of high-resolution T2w images showed highly significant association to contrast-enhanced T1w images (p < 0.0001). Furthermore, identification rate of tumor remnants in different compartments, e.g., cavernous sinus, was comparable. In total, coronal T2w images provided a diagnostic sensitivity of 97.7% and specificity of 100% compared to the gold standard of contrast-enhanced T1w images. The postoperatively expected extent of resection proved to be true in 97.6% according to MRI 3 months after resection.


High-resolution T2w intraoperative MR images provide excellent diagnostic accuracy for detecting tumor remnants in macroadenoma surgery with highly significant association compared to T1w images with gadolinium. The routine-use and need of gadolinium in these patients should be questioned critically in each case in the future.

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  1. 1.

    Black PM, Moriarty T, Alexander E 3rd, Stieg P, Woodard EJ, Gleason PL, Martin CH, Kikinis R, Schwartz RB, Jolesz FA (1997) Development and implementation of intraoperative magnetic resonance imaging and its neurosurgical applications. Neurosurgery 41(4):831–842 discussion 842–835

    CAS  Article  Google Scholar 

  2. 2.

    Sutherland GR, Kaibara T, Louw D, Hoult DI, Tomanek B, Saunders J (1999) A mobile high-field magnetic resonance system for neurosurgery. Journal of neurosurgery 91(5):804–813.

    CAS  Article  PubMed  Google Scholar 

  3. 3.

    Hall WA, Liu H, Martin AJ, Pozza CH, Maxwell RE, Truwit CL (2000) Safety, efficacy, and functionality of high-field strength interventional magnetic resonance imaging for neurosurgery. Neurosurgery 46(3):632–641 discussion 641–632

    CAS  Article  Google Scholar 

  4. 4.

    Hall WA, Kowalik K, Liu H, Truwit CL, Kucharezyk J (2003) Costs and benefits of intraoperative MR-guided brain tumor resection. Acta neurochirurgica Supplement 85:137–142

    CAS  Article  Google Scholar 

  5. 5.

    Nimsky C, Ganslandt O, Von Keller B, Romstock J, Fahlbusch R (2004) Intraoperative high-field-strength MR imaging: implementation and experience in 200 patients. Radiology 233(1):67–78.

    Article  PubMed  Google Scholar 

  6. 6.

    Nimsky C, Ganslandt O, Fahlbusch R (2005) Comparing 0.2 tesla with 1.5 tesla intraoperative magnetic resonance imaging analysis of setup, workflow, and efficiency. Academic radiology 12(9):1065–1079.

    Article  PubMed  Google Scholar 

  7. 7.

    Schwartz RB, Hsu L, Wong TZ, Kacher DF, Zamani AA, Black PM, Alexander E 3rd, Stieg PE, Moriarty TM, Martin CA, Kikinis R, Jolesz FA (1999) Intraoperative MR imaging guidance for intracranial neurosurgery: experience with the first 200 cases. Radiology 211(2):477–488.

    CAS  Article  PubMed  Google Scholar 

  8. 8.

    Fahlbusch R, Ganslandt O, Nimsky C (2000) Intraoperative imaging with open magnetic resonance imaging and neuronavigation. Child’s nervous system: ChNS: Official Journal of the International Society for Pediatric Neurosurgery 16(10–11):829–831.

    CAS  Article  Google Scholar 

  9. 9.

    Nimsky C, Keller BV, Ganslandt O, Fahlbusch R (2006) Intraoperative high-field magnetic resonance imaging in transsphenoidal surgery of hormonally inactive pituitary macroadenomas. Neurosurgery 59(1):105–114.

    Article  PubMed  Google Scholar 

  10. 10.

    Jones J, Ruge J (2007) Intraoperative magnetic resonance imaging in pituitary macroadenoma surgery: an assessment of visual outcome. Neurosurgical focus 23(5):E12.

    Article  PubMed  Google Scholar 

  11. 11.

    Gerlach R, du Mesnil de Rochemont R, Gasser T, Marquardt G, Reusch J, Imoehl L, Seifert V (2008) Feasibility of Polestar N20, an ultra-low-field intraoperative magnetic resonance imaging system in resection control of pituitary macroadenomas: lessons learned from the first 40 cases. Neurosurgery 63(2):272–284; discussion 284–275.

    Article  PubMed  Google Scholar 

  12. 12.

    Bellut D, Hlavica M, Muroi C, Woernle CM, Schmid C, Bernays RL (2012) Impact of intraoperative MRI-guided transsphenoidal surgery on endocrine function and hormone substitution therapy in patients with pituitary adenoma. Swiss medical weekly 142:w13699.

    Article  PubMed  Google Scholar 

  13. 13.

    Buchfelder M, Schlaffer SM (2012) Intraoperative magnetic resonance imaging during surgery for pituitary adenomas: pros and cons. Endocrine 42(3):483–495.

    CAS  Article  PubMed  Google Scholar 

  14. 14.

    Coburger J, Konig R, Seitz K, Bazner U, Wirtz CR, Hlavac M (2014) Determining the utility of intraoperative magnetic resonance imaging for transsphenoidal surgery: a retrospective study. J Neurosurg 120(2):346–356.

    Article  PubMed  Google Scholar 

  15. 15.

    Dort JC, Sutherland GR (2001) Intraoperative magnetic resonance imaging for skull base surgery. The Laryngoscope 111(9):1570–1575.

    CAS  Article  PubMed  Google Scholar 

  16. 16.

    Fahlbusch R, Keller B, Ganslandt O, Kreutzer J, Nimsky C (2005) Transsphenoidal surgery in acromegaly investigated by intraoperative high-field magnetic resonance imaging. Eur J Endocrinol 153(2):239–248.

    CAS  Article  PubMed  Google Scholar 

  17. 17.

    Netuka D, Masopust V, Belsan T, Kramar F, Benes V (2011) One year experience with 3.0 T intraoperative MRI in pituitary surgery. Acta Neurochirurgica Supplement 109:157–159.

    Article  PubMed  Google Scholar 

  18. 18.

    Sylvester PT, Evans JA, Zipfel GJ, Chole RA, Uppaluri R, Haughey BH, Getz AE, Silverstein J, Rich KM, Kim AH, Dacey RG, Chicoine MR (2015) Combined high-field intraoperative magnetic resonance imaging and endoscopy increase extent of resection and progression-free survival for pituitary adenomas. Pituitary 18(1):72–85.

    Article  PubMed  PubMed Central  Google Scholar 

  19. 19.

    Kanda T, Fukusato T, Matsuda M, Toyoda K, Oba H, Kotoku J, Haruyama T, Kitajima K, Furui S (2015) Gadolinium-based contrast agent accumulates in the brain even in subjects without severe renal dysfunction: evaluation of autopsy brain specimens with inductively coupled plasma mass spectroscopy. Radiology 276(1):228–232.

    Article  PubMed  Google Scholar 

  20. 20.

    Knosp E, Steiner E, Kitz K, Matula C (1993) Pituitary adenomas with invasion of the cavernous sinus space: a magnetic resonance imaging classification compared with surgical findings. Neurosurgery 33(4):610–617; discussion 617–618.

    CAS  Article  PubMed  Google Scholar 

  21. 21.

    Serra C, Staartjes VE, Maldaner N, Muscas G, Akeret K, Holzmann D, Soyka MB, Schmid C, Regli L (2018) Predicting extent of resection in transsphenoidal surgery for pituitary adenoma. Acta Neurochir (Wien) 160(11):2255–2262.

    Article  Google Scholar 

  22. 22.

    Faul F, Erdfelder E, Lang AG, Buchner A (2007) G*Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav Res Methods 39(2):175–191

    Article  Google Scholar 

  23. 23.

    Hlavac M, Konig R, Halatsch M, Wirtz CR (2012) Intraoperative magnetic resonance imaging. Fifteen years’ experience in the neurosurgical hybrid operating suite. Der Unfallchirurg 115(2):121–124.

    CAS  Article  PubMed  Google Scholar 

  24. 24.

    Patel KS, Yao Y, Wang R, Carter BS, Chen CC (2016) Intraoperative magnetic resonance imaging assessment of non-functioning pituitary adenomas during transsphenoidal surgery. Pituitary 19(2):222–231.

    Article  PubMed  Google Scholar 

  25. 25.

    Elmholdt TR, Jorgensen B, Ramsing M, Pedersen M, Olesen AB (2010) Two cases of nephrogenic systemic fibrosis after exposure to the macrocyclic compound gadobutrol. NDT Plus 3(3):285–287.

    Article  PubMed  PubMed Central  Google Scholar 

  26. 26.

    Gulani V, Calamante F, Shellock FG, Kanal E, Reeder SB, International Society for Magnetic Resonance in M (2017) Gadolinium deposition in the brain: summary of evidence and recommendations. Lancet Neurol 16(7):564–570.

    Article  PubMed  Google Scholar 

  27. 27.

    Roder C, Breitkopf M, Ms BS, Freitas Rda S, Dimostheni A, Ebinger M, Wolff M, Tatagiba M, Schuhmann MU (2016) Beneficial impact of high-field intraoperative magnetic resonance imaging on the efficacy of pediatric low-grade glioma surgery. Neurosurgical focus 40(3):E13.

    Article  PubMed  Google Scholar 

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Correspondence to Benjamin Bender.

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The authors declare that they have no conflict of interest.

Ethical approval

The study was approved by the local institutional review board (Project 208/2019/BO2).

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In accordance with local privacy protection laws (§13(1) LDSG-Anpassungsgesetz) and EU regulation 2016/679 Art. 5, 6, 9, and 89, informed consent was waived for this retrospective evaluation of clinical data.

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Gohla, G., Bender, B., Tatagiba, M. et al. Identification of tumor residuals in pituitary adenoma surgery with intraoperative MRI: do we need gadolinium?. Neurosurg Rev 43, 1623–1629 (2020).

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  • Pituitary adenoma
  • Intraoperative MRI
  • High-resolution MRI
  • Gadolinium