Acta Neurochirurgica

, Volume 161, Issue 10, pp 2107–2115 | Cite as

The Zurich Pituitary Score predicts utility of intraoperative high-field magnetic resonance imaging in transsphenoidal pituitary adenoma surgery

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



It is currently unclear if there are subsets of patients undergoing transsphenoidal surgery (TSS) in which intraoperative high-field magnetic resonance imaging (3T-iMRI) is particularly advantageous. We aimed to investigate whether a radiological grading scale predicts the utility of 3T-iMRI in pituitary adenoma (PA) TSS.


From a prospective registry, patients who underwent endoscopic TSS for PA using 3T-iMRI were identified. Adenomas were graded using the Zurich Pituitary Score (ZPS). We assessed improvement after 3T-iMRI in terms of gross total resection (GTR), residual volume (RV), and extent of resection (EOR).


Among 95 patients, rates of conversion to GTR after 3T-iMRI decreased steadily from 33% for grade I to 0% for grade IV adenomas, with a statistically significant conversion rate only for grade I (p = 0.008) and grade II (p < 0.001). All grade I adenomas were completely resected after 3T-iMRI. Median RV change was statistically significant for grades I to III, but not for grade IV (p = 0.625). EOR improvement ranged from a median change of 0.0% (IQR 0.0–4.5%) for grade I to 4.4% (IQR 0.0–9.0%) for grade IV, with a significant improvement only for grades I to III (p < 0.05).


Interestingly, this study shows that clinical utility of 3T-iMRI is highest in the more “simple” adenomas (ZPS grades I–II) than for the more “complex” ones (ZPS grade III–IV). Grade I adenomas are amenable to GTR if 3T-iMRI is implemented. In grade III adenomas, EOR and RV can be improved to clinically relevant levels. Conversely, in grade IV adenomas, 3T-iMRI may be of limited use.


Intraoperative imaging Magnetic resonance imaging Zurich Pituitary Score Gross total resection Extent of resection Outcome prediction 


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_2019_4018_MOESM1_ESM.r (17 kb)
Supplementary Methods 1 Supplementary Content 1. R Code for the statistical analysis and figure rendering. The code was executed in R Version 3.5.1 (The R Foundation for Statistical Computing, Vienna, Austria) on a machine running Windows 10 (Microsoft Corp., Redmond, WA, USA). (R 17 kb)
701_2019_4018_MOESM2_ESM.jpg (8.1 mb)
Supplementary Figure 1 Extent of resection (EOR) in percent as measured (A) on intraoperative magnetic resonance imaging (MRI) and (B) on the 3-month follow-up MRI, stratified by Zurich Pituitary Score. An extreme outlier (Grade II) presenting with an intraoperative EOR of 19.6% is not depicted in order to preserve scale. (JPG 8296 kb)


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Copyright information

© Springer-Verlag GmbH Austria, part of Springer Nature 2019

Authors and Affiliations

  • Victor E. Staartjes
    • 1
  • Carlo Serra
    • 1
    Email author
  • Nicolai Maldaner
    • 1
  • Giovanni Muscas
    • 2
  • Oliver Tschopp
    • 3
  • Michael B. Soyka
    • 4
  • David Holzmann
    • 4
  • Luca Regli
    • 1
  1. 1.Department of Neurosurgery, Clinical Neuroscience CenterUniversity Hospital Zurich, University of ZurichZurichSwitzerland
  2. 2.Department of Neurosurgery, Tuscany School of NeurosurgeryUniversity of FirenzeFlorenceItaly
  3. 3.Department of Endocrinology, Diabetes, and Clinical NutritionUniversity Hospital Zurich, University of ZurichZurichSwitzerland
  4. 4.Department of Otolaryngology, Head and Neck SurgeryUniversity Hospital Zurich, University of ZurichZurichSwitzerland

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