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Updated: Dec 26, 2025
Role of Diffusion MRI Tractography in Endoscopic Endonasal Skull Base Surgery
Published on: July 5, 2021
Optimizing MR imaging for intraoperative image guidance in sellar pathologies
Alexander Micko1, Arthur Hosmann1, Wolfgang Marik2
1Department of Neurosurgery, Medical University of Vienna, Waehringer Guertel 18-20, 1097, Vienna, Austria.
Purpose:
With the advancement of extended endonasal approaches, the ability to surgically reach parasellar tumor extensions increase. The aim of the study was to propose an optimized imaging protocol for surgical guidance in the cavernous sinus (CS) for proper visualization structures at risk.
Methods:
Prospective case control analysis of 20 consecutive pituitary adenoma patients scheduled for endoscopic transnasal surgery. Assessment of the capability of three different MRI sequences (MPRAGE, VIBE, CISS) by 4 investigators to correctly visualize sellar and parasellar structures. Invasiveness and position of the normal pituitary gland were compared with the intraoperative findings.
Results:
The consensus between the 4 examiners to achieve the same results for all modalities was 40% for MPRAGE, 70% for VIBE and 60% for CISS sequences (p = 0.155). A consensus of Knosp Grade per patient was 80% for MPRAGE, 100% for VIBE and 90% for CISS (overall kappa 0.60). A higher Knosp Grade was found in MPRAGE sequences compared to the other sequences. Intraoperative status of invasiveness was correctly identified in 12/20 (60%) with MPRAGE, 19/20 (95%) with VIBE and 11/20 (55%) with CISS sequences. The position of the normal pituitary gland was most frequent evaluable in 15/20 (75%) and correctly identified in 12/15 (80%) cases.
Conclusion:
Our data showed that VIBE sequences obtain the highest degree of consensus with intraoperative findings of invasiveness and position of the normal pituitary gland. VIBE sequences, due to their high spatial resolution and at the same time fast image acquisition could provide improved imaging for neuronavigation.
Insights
VIBE MRI sequences offer superior visualization of cavernous sinus structures for pituitary adenoma surgery. This optimized imaging protocol enhances surgical guidance and improves accuracy in identifying tumor invasiveness and pituitary gland position.
Area of Science:
- Neurosurgery
- Radiology
- Medical Imaging
Background:
- Extended endonasal approaches enable surgical access to parasellar tumor extensions.
- Accurate visualization of structures at risk in the cavernous sinus (CS) is crucial for surgical planning.
Purpose of the Study:
- To propose an optimized imaging protocol for surgical guidance in the CS.
- To evaluate MRI sequences for visualizing sellar and parasellar structures.
Main Methods:
- Prospective analysis of 20 pituitary adenoma patients undergoing endoscopic transnasal surgery.
- Comparison of MPRAGE, VIBE, and CISS MRI sequences for visualizing sellar/parasellar structures.
- Assessment of invasiveness and pituitary gland position against intraoperative findings.
Main Results:
- VIBE sequences demonstrated the highest consensus (70%) among investigators for visualizing structures.
- 100% consensus was achieved for Knosp Grade using VIBE sequences.
- Intraoperative invasiveness was correctly identified in 95% of cases with VIBE, significantly higher than MPRAGE (60%) and CISS (55%).
Conclusions:
- VIBE sequences provide the highest consensus with intraoperative findings for invasiveness and pituitary gland position.
- High spatial resolution and fast acquisition make VIBE sequences ideal for neuronavigation.
