Use of intraoperative intracavitary (direct-contact) ultrasound for resection control in transsphenoidal surgery for pituitary tumors: evaluation of a microsurgical series
- 34 Downloads
Perisellar infiltration may be responsible for incomplete removal of pituitary tumors. Since intraoperative visualization of parasellar structures is difficult during transsphenoidal surgery, we are describing the use of intraoperative direct contact ultrasound (IOUS).
Within 5 years, in 113 transsphenoidal operations (58 male, 55 female, age 14–81 years, 110 pituitary adenomas (mean diameter 26.6 mm, 69 non-secreting adenomas, 41 secreting adenomas), and 1 of each Rathke’s cleft cyst, craniopharyngioma, and xanthogranuloma), IOUS was applied. After wide opening of the sellar floor and removal of the intrasellar tumor portions, a commercially available side fire ultrasound probe is introduced, and in direct contact to the sellar envelope, the perisellar space is scanned perpendicular to the axis of the working channel. We compared the results of IOUS to postoperative MRI after 3–6 months.
Identification of the intracavernous ICA, the anterior optic pathway, and the ACA, was possible, it was safe to operate close to them. In 65 operations (58%), further resection of tumor remnants was performed after IOUS. In this selected series, complete resection of tumors (stated by postoperative MRI after 3–6 months) was achieved in 75 operations (66%) and remission was achieved in 18 operations of secreting adenomas (44%). Compared to MRI after 3 to 6 months, the sensitivity of IOUS was 0.568 and the specificity was 0.907. No complications related to IOUS were seen.
Visualization of the perisellar compartments by IOUS is easy and fast to perform. It allows the surgeon to identify resectable tumor remnants intraoperatively, which otherwise could be missed.
KeywordsIntraoperative ultrasound Pituitary surgery Transsphenoidal surgery Pituitary tumor
Anterior cerebral artery
A1-segment of ACA
Internal carotid artery
Insulin-like growth factor 1
Magnetic resonance imaging
Syndrome of inappropriate ADH secretion
This manuscript contains essential parts of the thesis of Dr. Med. Ali Alomari.
Compliance with ethical standards
Conflict of interest
All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speaker’s bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patient-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee (Ethikkommission der Ärztekammer Westfalen-Lippe, Universität Muenster) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
For this type of study formal consent is not required.
- 6.Bohinski RJ, Warnick RE, Gaskill-Shipley MF, Zuccarello M, van Loveren HR, Kormos DW, Tew JM Jr (2001) Intraoperative magnetic resonance imaging to determine the extent of resection of pituitary macroadenomas during transsphenoidal microsurgery. Neurosurgery 49:1133–1143Google Scholar
- 13.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 63:272–284CrossRefGoogle Scholar
- 20.Jho HD, Park IS, Alfieri A (2000) The future of pituitary surgery. Clin Neurosurg 47:83–98Google Scholar
- 22.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 33:610–617Google Scholar
- 35.Schwartz TH, Stieg PE, Anand VK (2006) Endoscopic transsphenoidal pituitary surgery with intraoperative magnetic resonance imaging. Neurosurgery 58:ONS44–ONS51Google Scholar
- 37.Solheim O, Johansen TF, Cappelen J, Unsgard G, Selbekk T (2016) Transsellar ultrasound in pituitary surgery with a designated probe: early experiences. Oper Neurosurg (Hagerstown) 12:128–134Google Scholar
- 41.van Lindert EJ, Grotenhuis JA (2005) New endoscope shaft for endoscopic transsphenoidal pituitary surgery. Neurosurgery 57:203–206Google Scholar
- 42.Wagenmakers MA, Boogaarts HD, Roerink SH, Timmers HJ, Stikkelbroeck NM, Smit JW, van Lindert EJ, Netea-Maier RT, Grotenhuis JA, Hermus AR (2013) Endoscopic transsphenoidal pituitary surgery: a good and safe primary treatment option for Cushing’s disease, even in case of macroadenomas or invasive adenomas. Eur J Endocrinol 169:329–337CrossRefGoogle Scholar