Impact of Intraoperative MRI on Outcomes in Pituitary Adenoma Surgery: A Systematic Review and Meta-Analysis

The role of intraoperative magnetic resonance imaging (iMRI) in the surgical management of pituitary neuroendocrine tumors (PitNETs) remains debated. While transsphenoidal surgery (TSS) is the gold standard for adenoma resection, the potential benefits of iMRI in improving surgical outcomes have been increasingly recognized. This meta-analysis compares the outcomes of pituitary adenoma (PA) surgeries performed with and without iMRI, focusing on resection rates and complications in 824 patients. A comprehensive database search was conducted until January 6, 2026, to identify studies comparing surgical outcomes in patients with PA who underwent surgery with and without iMRI. The primary outcomes included gross total resection (GTR), the need for additional resection, intraoperative cerebrospinal fluid (CSF) fistulas, postoperative CSF leaks, meningitis, and the presence of a residual tumor within six months postoperatively. Among the 633 articles screened, four cohort studies met the inclusion criteria, encompassing 824 patients with PA. Patients who underwent iMRI had a significantly higher final GTR rate than those who did not (relative risk (RR) 1.71; 95% CI 1.07-2.73; P=0.03). Additionally, the residual tumor rate within six months postoperatively was significantly lower in the iMRI group (RR 0.53; 95% CI 0.35-0.80; P=0.002). Additional resection rates were comparable, with no statistically significant difference (RR 1.99; 95% CI 0.40-9.97; P=0.40). Intraoperative CSF leak rates showed no significant differences between groups (RR 1.00; 95% CI 0.29-3.48; P=1.00). Similarly, postoperative CSF leak rates were comparable (RR 0.81; 95% CI 0.29-2.25; P=0.69), and meningitis rates did not differ significantly (RR 0.62; 95% CI 0.14-2.71; P=0.53). Patients undergoing iMRI-assisted PA surgery achieve significantly higher rates of GTR and lower residual tumors at six months, without increased risk of CSF leaks, meningitis, or other complications. Further studies should assess cost-effectiveness and refine patient selection to maximize the benefits of iMRI.