Intraoperative MRI for endoscopic endonasal transsphenoidal surgery in children

Abstract

Objective: The use of intraoperative MRI (iMRI) has been well described for endoscopic endonasal transsphenoidal surgery (EETS) in adults. However, literature on its use for EETS in pediatric patients is lacking. The objective of this study was to evaluate the usefulness, efficacy, and safety of iMRI for EETS in the pediatric population.

Methods: A retrospective review of patient medical records and imaging was performed for all patients younger than 18 years of age who underwent EETS at a single institution from January 2005 to December 2024. Based on whether iMRI was used, cases were divided into two groups and compared. Collected data included the preoperative goal of the surgery (biopsy, debulking/decompression, subtotal resection [STR], and gross-total resection [GTR]) and the iMRI timing (predissection, intradissection, and postdissection), purpose, and findings, as well as how these findings impacted intraoperative surgical management and whether the preoperative goal of the surgery was met. Additional demographic and clinical variables were assessed, including age at surgery, surgery duration, hospital length of stay (LOS), whether postoperative MRI was performed during the same admission, repeat surgery, histopathological diagnosis, complications, long-term tumor progression/recurrence, and use of adjuvant therapy.

Results: Twenty-two EETS procedures were performed among 21 patients with sellar/suprasellar pathologies; iMRI was used in 13 of 22 cases (12 patients, age range 6-17 years) including 4 predissection, 8 pre- and intradissection, and 1 postdissection iMRI evaluations. Pathologies included mostly craniopharyngiomas (46.2%) and pituitary adenomas (38.5%). Surgical goals included biopsy (n = 2), debulking/decompression (n = 3), STR (n = 1), and GTR (n = 7) and were achieved in 12 of 13 cases (92.3%). The mean operative duration was 6.1 hours, mean LOS was 2.9 days, and mean follow-up was 4.3 years. The rate of complications was 38.5% (4 pituitary insufficiency/diabetes insipidus [DI] and 1 CSF leak). Two adenomas recurred and required repeat surgery. For the 9 patients (age range 5-17 years) in the non-iMRI EETS group, the most common pathologies were Rathke cleft cyst (33.3%), craniopharyngioma (22.2%), and adenoma (22.2%). The surgical goal was achieved in 66.6%, with no statistically significant difference compared with the iMRI group (p = 0.264). The operative time (mean 5.8 hours), LOS (mean 4.3 days), and complication rate (22.2%) were similar between the non-iMRI and iMRI groups. Three patients in the non-iMRI group (2 with craniopharyngiomas and 1 with a Rathke cyst) required reoperation for recurrence.

Conclusions: For pediatric EETS, iMRI showed promise as an effective and safe surgical adjunct to help verify, in the same setting, that the goals of surgery had been met. However, the outcome measures studied herein were not better than those achieved without the use of iMRI.

Keywords: children; endoscopic endonasal transsphenoidal surgery; intraoperative MRI; pituitary surgery; tumor.