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MacFarlane J, Huynh KA, Powlson AS, Kolias AG, Mannion RJ, Scoffings DJ, Mendichovszky IA, Cheow HK, Bashari WA, Jones J, Gillett D, Koulouri O, Gurnell M. Novel imaging techniques in refractory pituitary adenomas. Pituitary 2023:10.1007/s11102-023-01304-9. [PMID: 36971899 DOI: 10.1007/s11102-023-01304-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/20/2023] [Indexed: 04/08/2023]
Abstract
Accurate localization of the site(s) of active disease is key to informing decision-making in the management of refractory pituitary adenomas when autonomous hormone secretion and/or continued tumor growth challenge conventional therapeutic approaches. In this context, the use of non-standard MR sequences, alternative post-acquisition image processing, or molecular (functional) imaging may provide valuable additional information to inform patient management.
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Affiliation(s)
- J MacFarlane
- Cambridge Endocrine Molecular Imaging Group, Metabolic Research Laboratories, Wellcome-MRC Institute of Metabolic Science, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - K A Huynh
- Cambridge Endocrine Molecular Imaging Group, Metabolic Research Laboratories, Wellcome-MRC Institute of Metabolic Science, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - A S Powlson
- Cambridge Endocrine Molecular Imaging Group, Metabolic Research Laboratories, Wellcome-MRC Institute of Metabolic Science, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - A G Kolias
- Department of Neurosurgery, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
- Department of Neurosurgery, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - R J Mannion
- Department of Neurosurgery, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - D J Scoffings
- Department of Radiology, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - I A Mendichovszky
- Department of Radiology, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
- Department of Nuclear Medicine, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
- Department of Radiology, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - H K Cheow
- Department of Nuclear Medicine, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
- Department of Radiology, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - W A Bashari
- Cambridge Endocrine Molecular Imaging Group, Metabolic Research Laboratories, Wellcome-MRC Institute of Metabolic Science, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - J Jones
- Department of Radiology, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - D Gillett
- Cambridge Endocrine Molecular Imaging Group, Metabolic Research Laboratories, Wellcome-MRC Institute of Metabolic Science, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
- Department of Nuclear Medicine, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - O Koulouri
- Cambridge Endocrine Molecular Imaging Group, Metabolic Research Laboratories, Wellcome-MRC Institute of Metabolic Science, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - Mark Gurnell
- Cambridge Endocrine Molecular Imaging Group, Metabolic Research Laboratories, Wellcome-MRC Institute of Metabolic Science, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK.
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Ibrahim B, Mandel M, Ali A, Najera E, Obrzut M, Adada B, Borghei-Razavi H. Pituitary Adenomas: Classification, Clinical Evaluation and Management. Skull Base Surg 2022. [DOI: 10.5772/intechopen.103778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Pituitary adenomas are one of the most common brain tumors. They represent approximately 18% of all intracranial, and around 95% of sellar neoplasms. In recent years, our understanding of the pathophysiology and the behavior of these lesions has led to better control and higher curative rates. The treatment decision is largely dependent on type of the adenoma, clinical presentation, and the size of the lesion. In addition, incidental pituitary lesions add uncertainty in the decision-making process, especially for pituitary adenomas that can be medically managed. When surgery is indicated, the endoscopic endonasal transsphenoidal approach is the technique of choice, but open standard craniotomy approaches can also be the option in selected cases. The following chapter will review the classification, clinical presentation, pathophysiology, diagnostic work-up, selection of surgical approach, and treatment complications in pituitary adenomas.
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Feng T, Fang Y, Pei Z, Li Z, Chen H, Hou P, Wei L, Wang R, Wang S. A Convolutional Neural Network Model for Detecting Sellar Floor Destruction of Pituitary Adenoma on Magnetic Resonance Imaging Scans. Front Neurosci 2022; 16:900519. [PMID: 35860294 PMCID: PMC9289618 DOI: 10.3389/fnins.2022.900519] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 05/30/2022] [Indexed: 11/29/2022] Open
Abstract
Objective Convolutional neural network (CNN) is designed for image classification and recognition with a multi-layer neural network. This study aimed to accurately assess sellar floor invasion (SFI) of pituitary adenoma (PA) using CNN. Methods A total of 1413 coronal and sagittal magnetic resonance images were collected from 695 patients with PAs. The enrolled images were divided into the invasive group (n = 530) and the non-invasive group (n = 883) according to the surgical observation of SFI. Before model training, 100 images were randomly selected for the external testing set. The remaining 1313 cases were randomly divided into the training and validation sets at a ratio of 80:20 for model training. Finally, the testing set was imported to evaluate the model performance. Results A CNN model with a 10-layer structure (6-layer convolution and 4-layer fully connected neural network) was constructed. After 1000 epoch of training, the model achieved high accuracy in identifying SFI (97.0 and 94.6% in the training and testing sets, respectively). The testing set presented excellent performance, with a model prediction accuracy of 96%, a sensitivity of 0.964, a specificity of 0.958, and an area under the receptor operator curve (AUC-ROC) value of 0.98. Four images in the testing set were misdiagnosed. Three images were misread with SFI (one with conchal type sphenoid sinus), and one image with a relatively intact sellar floor was not identified with SFI. Conclusion This study highlights the potential of the CNN model for the efficient assessment of PA invasion.
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Affiliation(s)
- Tianshun Feng
- Department of Neurosurgery, Dongfang Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Yi Fang
- Department of Neurosurgery, Fuzhou 900th Hospital, Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, China
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhijie Pei
- Department of Neurosurgery, Fuzhou 900th Hospital, Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, China
| | - Ziqi Li
- Department of Neurosurgery, Dongfang Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Hongjie Chen
- Department of Neurosurgery, Fuzhou 900th Hospital, Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, China
| | - Pengwei Hou
- Department of Neurosurgery, Fuzhou 900th Hospital, Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, China
| | - Liangfeng Wei
- Department of Neurosurgery, Fuzhou 900th Hospital, Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, China
| | - Renzhi Wang
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- *Correspondence: Renzhi Wang,
| | - Shousen Wang
- Department of Neurosurgery, Dongfang Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
- Department of Neurosurgery, Fuzhou 900th Hospital, Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, China
- Shousen Wang,
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Fang Y, Pei Z, Chen H, Wang R, Feng M, Wei L, Li J, Zhang H, Wang S. Diagnostic value of Knosp grade and modified Knosp grade for cavernous sinus invasion in pituitary adenomas: a systematic review and meta-analysis. Pituitary 2021; 24:457-464. [PMID: 33491163 DOI: 10.1007/s11102-020-01122-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/31/2020] [Indexed: 12/23/2022]
Abstract
OBJECTIVE This study aimed to examine the reliability of existing Knosp grade (KG) and modified KG for cavernous sinus invasion (CSI). METHODS A thorough search of literature from 1993 to 2020 in six databases was performed. Studies that reported the intraoperative confirmation of CSI using KG and/or modified KG were included. The pooled estimates were calculated by meta-analysis with a bivariate mixed-effect model and the assessment of heterogeneity with I2 statistic. RESULTS The final search yielded 12 eligible studies, which enrolled 3006 patients assessed with KG and 1315 patients assessed with modified KG. The results of the area under the receiver operating characteristic curve showed the good discriminative abilities of grades 2-4 (0.90), 3-4 (0.86) and 3B-4 (0.91) in predicting CSI. Grade 3A showed a remarkably lower CSI rate (44% versus 81%) and incomplete resection rate (26% versus 52%) than grade 3B. Grades 0 and 1 showed a low CSI rate. CSI and incomplete resection rates in grade 2 (30% and 21%, respectively) were close to those in grade 3A. CONCLUSIONS Modifying the KG improved its prognostic role in CSI and gross total resection. However, these grading systems cannot be used as the group standard for invasive and non-invasive pituitary adenomas (PAs) because of the weak reliability of the scale's middle grades (grades 2 and 3A). Authors of future PA studies should consider reporting KG as high (grades 3B and 4), medium (grades 2 and 3A) and low (grades 0 and 1) to optimise the application of the scale.
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Affiliation(s)
- Yi Fang
- Department of Neurosurgery, Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, Fujian, China
| | - Zhijie Pei
- Department of Neurosurgery, Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, Fujian, China
| | - Hongjie Chen
- Department of Neurosurgery, Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, Fujian, China
| | - Renzhi Wang
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Ming Feng
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Liangfeng Wei
- Department of Neurosurgery, Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, Fujian, China
| | - Jun Li
- Department of Neurosurgery, Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, Fujian, China
| | - Heng Zhang
- Department of Neurosurgery, Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, Fujian, China
| | - Shousen Wang
- Department of Neurosurgery, Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, Fujian, China.
- Department of Neurosurgery, Fuzhou 900th Hospital, Fuzong Clinical Medical College of Fujian Medical University, No. 156, Xi'erhuanbei Road, Fuzhou, Fujian, China.
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Borghei-Razavi H, Lee J, Ibrahim B, Muhsen BA, Raghavan A, Wu I, Poturalski M, Stock S, Karakasis C, Adada B, Kshettry V, Recinos P. Accuracy and Interrater Reliability of CISS Versus Contrast-Enhanced T1-Weighted VIBE for the Presence of Optic Canal Invasion in Tuberculum Sellae Meningiomas. World Neurosurg 2021; 148:e502-e507. [PMID: 33444830 DOI: 10.1016/j.wneu.2021.01.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 01/04/2021] [Accepted: 01/05/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND The magnetic resonance imaging sequence used to assess optic canal invasion by tuberculum sella meningiomas (TSMs) has not been standardized. Both constructive interference in steady state (CISS) and contrast-enhanced T1-weighted volume-interpolated breath-hold examination (VIBE) sequences are frequently used. The aim of the present study was to compare the accuracy and interrater reliability of these sequences in predicting optic canal invasion by TSMs. METHODS In the present retrospective study of 27 patients (54 optic canals) who had undergone endoscopic transtuberculum transplanum resection of TSMs, images from preoperative CISS and contrast-enhanced T1-weighted VIBE sequences were assessed by 5 neuroradiologists who were unaware of the operative findings. The readers evaluated the optic canal in 4 quadrants at 2 locations (the posterior tip of the anterior clinoid process and the optic strut). A quadrant was considered positive for tumor invasion if invasion was present at either of these 2 locations. The reference standard was intraoperative observation of gross optic canal invasion. RESULTS The interrater agreement was good for the presence or absence of tumor involvement in a particular quadrant (CISS, 0.635; VIBE, 0.643; 95% confidence interval for the difference, -0.086 to 0.010). The mean sensitivity and specificity for optic nerve invasion were 0.643 and 0.438 with CISS and 0.643 and 0.454 with VIBE, respectively. No significant differences were seen between the sequences in terms of reader accuracy when the intraoperative findings were used as the reference standard. CONCLUSION CISS and VIBE sequences both have good accuracy in predicting for optic canal tumor invasion by TMEs.
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Affiliation(s)
- Hamid Borghei-Razavi
- Department of Neurosurgery, Cleveland Clinic Florida Egil and Pauline Braathen Center, Neurological Institute, Cleveland Clinic, Weston, Florida, USA.
| | - Jonathan Lee
- Department of Diagnostic Radiology, Imaging Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Bilal Ibrahim
- Department of Neurosurgery, Cleveland Clinic Florida Egil and Pauline Braathen Center, Neurological Institute, Cleveland Clinic, Weston, Florida, USA
| | - Baha'eddin A Muhsen
- Department of Neurosurgery, Cleveland Clinic Florida Egil and Pauline Braathen Center, Neurological Institute, Cleveland Clinic, Weston, Florida, USA
| | - Alankrita Raghavan
- Department of Diagnostic Radiology, Imaging Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ingrid Wu
- Department of Diagnostic Radiology, Imaging Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Matthew Poturalski
- Department of Diagnostic Radiology, Imaging Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Sarah Stock
- Department of Diagnostic Radiology, Imaging Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Christopher Karakasis
- Department of Diagnostic Radiology, Imaging Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Badih Adada
- Department of Neurosurgery, Cleveland Clinic Florida Egil and Pauline Braathen Center, Neurological Institute, Cleveland Clinic, Weston, Florida, USA
| | - Varun Kshettry
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Pablo Recinos
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Micko A, Hosmann A, Marik W, Bartsch S, Weber M, Knosp E, Wolfsberger S. Optimizing MR imaging for intraoperative image guidance in sellar pathologies. Pituitary 2020; 23:266-272. [PMID: 32170516 PMCID: PMC7181417 DOI: 10.1007/s11102-020-01035-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Alexander Micko
- Department of Neurosurgery, Medical University of Vienna, Waehringer Guertel 18-20, 1097, Vienna, Austria
| | - Arthur Hosmann
- Department of Neurosurgery, Medical University of Vienna, Waehringer Guertel 18-20, 1097, Vienna, Austria
| | - Wolfgang Marik
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Sophie Bartsch
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Michael Weber
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Engelbert Knosp
- Department of Neurosurgery, Medical University of Vienna, Waehringer Guertel 18-20, 1097, Vienna, Austria
| | - Stefan Wolfsberger
- Department of Neurosurgery, Medical University of Vienna, Waehringer Guertel 18-20, 1097, Vienna, Austria.
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Lang M, Habboub G, Moon D, Bandyopadhyay A, Silva D, Kennedy L, Kshettry VR, Recinos PF. Comparison of Constructive Interference in Steady-State and T1-Weighted MRI Sequence at Detecting Pituitary Adenomas in Cushing's Disease Patients. J Neurol Surg B Skull Base 2018; 79:593-598. [PMID: 30456030 DOI: 10.1055/s-0038-1642032] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 03/03/2018] [Indexed: 10/16/2022] Open
Abstract
Background T1-weighted magnetic resonance imaging (MRI) remains the standard pituitary imaging sequence. However, up to 50% of pituitary adenomas are missed with standard imaging in Cushing's disease (CD) patients. Utility of other imaging sequences needs be explored. Objective To compare a T2-gradient echo sequence, constructive interference in steady state (CISS), with a contrast-enhanced (CE) T1-weighted sequence, volume-interpolated breath-hold examination (VIBE), in the detection of pituitary adenomas in CD patients. Design Retrospective analysis of CD patients who underwent endoscopic transsphenoidal pituitary adenomectomy at our institution. Patients and Measurement Twelve patients were included in the study. Two neuroradiologists, who were blinded to the patients' clinical and surgical findings, independently reviewed the CE-VIBE and CISS images. Localization of pituitary adenoma from imaging was compared with intraoperative localization. Results The averaged sensitivity of detecting pituitary adenoma in CD patients was not significantly different between CE-VIBE sequence (63%) and CISS sequence (54%). The positive predictive value was 75% (Observer A) and 100% (Observer B) with CE-VIBE sequence, and 64% (Observer A) and 100% (Observer B) with CISS sequence. In two patients, pituitary adenoma was easily localized with CISS sequence but hard to detect with CE-VIBE sequence. In two other patients, the adenoma was much better delineated on CE-VIBE sequence. Conclusion In our series, the addition of CISS sequence to T1-weighted MRI imaging protocols improved the detection of pituitary adenomas in CD patients. CISS sequence may be a useful adjunct to T1-weighted pituitary MRI protocols and an appropriate alternative for patients with gadolinium contraindications.
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Affiliation(s)
- Min Lang
- School of Medicine, Case Western Reserve University, Cleveland, Ohio, United States.,Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, United States
| | - Ghaith Habboub
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, United States.,Minimally Invasive Cranial Base and Pituitary Surgery Program, Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio, United States
| | - Doksu Moon
- Department of Diagnostic Radiology, Imaging Institute, Cleveland Clinic, Cleveland, Ohio, United States
| | - Abin Bandyopadhyay
- Department of Diagnostic Radiology, Imaging Institute, Cleveland Clinic, Cleveland, Ohio, United States
| | - Danilo Silva
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, United States.,Minimally Invasive Cranial Base and Pituitary Surgery Program, Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio, United States
| | - Laurence Kennedy
- Department of Endocrinology, Diabetes, and Metabolism, Cleveland Clinic, Cleveland, Ohio, United States
| | - Varun R Kshettry
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, United States.,Minimally Invasive Cranial Base and Pituitary Surgery Program, Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio, United States.,Section of Rhinology, Sinus, and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, United States
| | - Pablo F Recinos
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, United States.,Minimally Invasive Cranial Base and Pituitary Surgery Program, Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio, United States.,Section of Rhinology, Sinus, and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, United States
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