Usefulness of subtraction images for accurate diagnosis of pituitary microadenomas in dynamic contrast-enhanced magnetic resonance imaging

Abstract

Background Dynamic contrast-enhanced magnetic resonance imaging (MRI) is the modality of choice for the diagnosis of pituitary microadenomas; however, it may be associated with a relatively high false-negative rate, especially in small lesions. Purpose To evaluate the usefulness of subtraction images for enhancing the visual detection of pituitary microadenomas. Material and Methods In total, 50 patients with clinically established diagnosis hyperprolactinemia, acromegaly, and Cushing's disease were enrolled. Ten patients referred for brain MRI for reasons other than pituitary abnormality were selected as control group. Routine dynamic MRI of the pituitary gland and obtained subtraction MRI scans were scrutinized separately on different sessions by an experienced radiologist blinded to the study design and patient's data. The investigator's opinion on the presence or absence of a lesion and lesion size were collected. Results In patients with pituitary microadenoma, dynamic MRI images were reported positive in 42 (84%) patients and negative in 8 (16%). Subtraction images were described as positive in all patients (100%)—including all patients with negative dynamic MRI—and the difference was statistically significant ( P=0.016). Undetected lesions on dynamic MRI had a mean size of 2.84 ± 1.79 mm (median= 2.20 mm, interquartile range=1.62–4.62 mm) and a significant inverse correlation was noted between lesion size and negative report of dynamic MRI ( P=0.018). Brain MRI scans in the control group were reported negative for pituitary microadenoma in both dynamic contrast-enhanced and subtraction images. Conclusion Subtraction images can successfully identify all lesions detectable with conventional dynamic MRI as well as improving visualization of lesions undetected on dynamic MRI, especially in small lesions.