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Koga SF, Hodges WB, Adamyan H, Hayes T, Fecci PE, Tsvankin V, Pradilla G, Hoang KB, Lee IY, Sankey EW, Codd PJ, Huie D, Zacharia BE, Verma R, Baboyan VG. Preoperative validation of edema-corrected tractography in neurosurgical practice: translating surgeon insights into novel software implementation. Front Neurol 2024; 14:1322815. [PMID: 38259649 PMCID: PMC10801029 DOI: 10.3389/fneur.2023.1322815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 12/19/2023] [Indexed: 01/24/2024] Open
Abstract
Background Peritumoral edema alters diffusion anisotropy, resulting in false negatives in tractography reconstructions negatively impacting surgical decision-making. With supratotal resections tied to survival benefit in glioma patients, advanced diffusion modeling is critical to visualize fibers within the peritumoral zone to prevent eloquent fiber transection thereafter. A preoperative assessment paradigm is therefore warranted to systematically evaluate multi-subject tractograms along clinically meaningful parameters. We propose a novel noninvasive surgically-focused survey to evaluate the benefits of a tractography algorithm for preoperative planning, subsequently applied to Synaptive Medical's free-water correction algorithm developed for clinically feasible single-shell DTI data. Methods Ten neurosurgeons participated in the study and were presented with patient datasets containing histological lesions of varying degrees of edema. They were asked to compare standard (uncorrected) tractography reconstructions overlaid onto anatomical images with enhanced (corrected) reconstructions. The raters assessed the datasets in terms of overall data quality, tract alteration patterns, and the impact of the correction on lesion definition, brain-tumor interface, and optimal surgical pathway. Inter-rater reliability coefficients were calculated, and statistical comparisons were made. Results Standard tractography was perceived as problematic in areas proximal to the lesion, presenting with significant tract reduction that challenged assessment of the brain-tumor interface and of tract infiltration. With correction applied, significant reduction in false negatives were reported along with additional insight into tract infiltration. Significant positive correlations were shown between favorable responses to the correction algorithm and the lesion-to-edema ratio, such that the correction offered further clarification in increasingly edematous and malignant lesions. Lastly, the correction was perceived to introduce false tracts in CSF spaces and - to a lesser degree - the grey-white matter interface, highlighting the need for noise mitigation. As a result, the algorithm was modified by free-water-parameterizing the tractography dataset and introducing a novel adaptive thresholding tool for customizable correction guided by the surgeon's discretion. Conclusion Here we translate surgeon insights into a clinically deployable software implementation capable of recovering peritumoral tracts in edematous zones while mitigating artifacts through the introduction of a novel and adaptive case-specific correction tool. Together, these advances maximize tractography's clinical potential to personalize surgical decisions when faced with complex pathologies.
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Affiliation(s)
- Sebastian F. Koga
- Franciscan Missionaries of Our Lady Health System, Baton Rouge, LA, United States
| | | | | | - Tim Hayes
- Synaptive Medical Inc., Toronto, ON, Canada
| | - Peter E. Fecci
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, United States
| | - Vadim Tsvankin
- Colorado Brain and Spine Institute, Englewood, CO, United States
| | - Gustavo Pradilla
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, United States
| | - Kimberly B. Hoang
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, United States
| | - Ian Y. Lee
- Department of Neurosurgery, Henry Ford Health System, Detroit, MI, United States
| | - Eric W. Sankey
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, United States
| | - Patrick J. Codd
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, United States
| | - David Huie
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, United States
| | - Brad E. Zacharia
- Department of Neurosurgery, Penn State Hershey Medical Center, Hershey, PA, United States
| | - Ragini Verma
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, United States
- Cohen Veterans Bioscience, New York, NY, United States
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Neurological outcomes following awake and asleep craniotomies with motor mapping for eloquent tumor resection. Clin Neurol Neurosurg 2022; 213:107128. [DOI: 10.1016/j.clineuro.2022.107128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 01/05/2022] [Accepted: 01/10/2022] [Indexed: 12/13/2022]
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Mato D, Velasquez C, Gómez E, Marco de Lucas E, Martino J. Predicting the Extent of Resection in Low-Grade Glioma by Using Intratumoral Tractography to Detect Eloquent Fascicles Within the Tumor. Neurosurgery 2021; 88:E190-E202. [PMID: 33313812 DOI: 10.1093/neuros/nyaa463] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 08/12/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND An early maximal safe surgical resection is the current treatment paradigm for low-grade glioma (LGG). Nevertheless, there are no reliable methods to accurately predict the axonal intratumoral eloquent areas and, consequently, to predict the extent of resection. OBJECTIVE To describe the functional predictive value of eloquent white matter tracts within the tumor by using a pre- and postoperative intratumoral diffusion tensor imaging (DTI) tractography protocol in patients with LGG. METHODS A preoperative intratumoral DTI-based tractography protocol, using the tumor segmented volume as the only seed region, was used to assess the tracts within the tumor boundaries in 22 consecutive patients with LGG. The reconstructed tracts were correlated with intraoperative electrical stimulation (IES)-based language and motor subcortical mapping findings and the extent of resection was assessed by tumor volumetrics. RESULTS Identification of intratumoral language and motor tracts significantly predicted eloquent areas within the tumor during the IES mapping: the positive predictive value for the pyramidal tract, the inferior fronto-occipital fasciculus, the arcuate fasciculus and the inferior longitudinal fasciculus positive was 100%, 100%, 33%, and 80%, respectively, whereas negative predictive value was 100% for all of them. The reconstruction of at least one of these tracts within the tumor was significantly associated with a lower extent of resection (67%) as opposed to the extent of resection in the cases with a negative intratumoral tractography (100%) (P < .0001). CONCLUSION Intratumoral DTI-based tractography is a simple and reliable method, useful in assessing glioma resectability based on the analysis of intratumoral eloquent areas associated with motor and language tracts within the tumor.
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Affiliation(s)
- David Mato
- Department of Neurological Surgery, Hospital Universitario Marqués de Valdecilla and Fundación Instituto de Investigación Valdecilla, Santander, Spain
| | - Carlos Velasquez
- Department of Neurological Surgery, Hospital Universitario Marqués de Valdecilla and Fundación Instituto de Investigación Valdecilla, Santander, Spain
| | - Elsa Gómez
- Deparment of Psychiatry, Hospital Universitario Marqués de Valdecilla and Fundación Instituto de Investigación Valdecilla, Santander, Spain
| | - Enrique Marco de Lucas
- Deparment of Radiology, Hospital Universitario Marqués de Valdecilla and Fundación Instituto de Investigación Valdecilla, Santander, Spain
| | - Juan Martino
- Department of Neurological Surgery, Hospital Universitario Marqués de Valdecilla and Fundación Instituto de Investigación Valdecilla, Santander, Spain
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Giammalva GR, Brunasso L, Costanzo R, Paolini F, Umana GE, Scalia G, Gagliardo C, Gerardi RM, Basile L, Graziano F, Gulì C, Messina D, Pino MA, Feraco P, Tumbiolo S, Midiri M, Iacopino DG, Maugeri R. Brain Mapping-Aided SupraTotal Resection (SpTR) of Brain Tumors: The Role of Brain Connectivity. Front Oncol 2021; 11:645854. [PMID: 33738262 PMCID: PMC7960910 DOI: 10.3389/fonc.2021.645854] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 01/18/2021] [Indexed: 11/13/2022] Open
Abstract
Brain gliomas require a deep knowledge of their effects on brain connectivity. Understanding the complex relationship between tumor and functional brain is the preliminary and fundamental step for the subsequent surgery. The extent of resection (EOR) is an independent variable of surgical effectiveness and it correlates with the overall survival. Until now, great efforts have been made to achieve gross total resection (GTR) as the standard of care of brain tumor patients. However, high and low-grade gliomas have an infiltrative behavior and peritumoral white matter is often infiltrated by tumoral cells. According to these evidences, many efforts have been made to push the boundary of the resection beyond the contrast-enhanced lesion core on T1w MRI, in the so called supratotal resection (SpTR). SpTR is aimed to maximize the extent of resection and thus the overall survival. SpTR of primary brain tumors is a feasible technique and its safety is improved by intraoperative neuromonitoring and advanced neuroimaging. Only transient cognitive impairments have been reported in SpTR patients compared to GTR patients. Moreover, SpTR is related to a longer overall and progression-free survival along with preserving neuro-cognitive functions and quality of life.
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Affiliation(s)
- Giuseppe Roberto Giammalva
- Unit of Neurosurgery, Department of Biomedicine, Neuroscience and Advanced Diagnostics, Post Graduate Residency Program in Neurosurgery, University of Palermo, Palermo, Italy
| | - Lara Brunasso
- Unit of Neurosurgery, Department of Biomedicine, Neuroscience and Advanced Diagnostics, Post Graduate Residency Program in Neurosurgery, University of Palermo, Palermo, Italy
| | - Roberta Costanzo
- Unit of Neurosurgery, Department of Biomedicine, Neuroscience and Advanced Diagnostics, Post Graduate Residency Program in Neurosurgery, University of Palermo, Palermo, Italy
| | - Federica Paolini
- Unit of Neurosurgery, Department of Biomedicine, Neuroscience and Advanced Diagnostics, Post Graduate Residency Program in Neurosurgery, University of Palermo, Palermo, Italy
| | | | | | - Cesare Gagliardo
- Section of Radiological Sciences, Department of Biomedicine, Neuroscience and Advanced Diagnostics, University of Palermo, Palermo, Italy
| | - Rosa Maria Gerardi
- Unit of Neurosurgery, Department of Biomedicine, Neuroscience and Advanced Diagnostics, Post Graduate Residency Program in Neurosurgery, University of Palermo, Palermo, Italy
| | - Luigi Basile
- Unit of Neurosurgery, Department of Biomedicine, Neuroscience and Advanced Diagnostics, Post Graduate Residency Program in Neurosurgery, University of Palermo, Palermo, Italy
| | | | - Carlo Gulì
- Unit of Neurosurgery, Department of Biomedicine, Neuroscience and Advanced Diagnostics, Post Graduate Residency Program in Neurosurgery, University of Palermo, Palermo, Italy
| | - Domenico Messina
- Unit of Neurosurgery, Department of Biomedicine, Neuroscience and Advanced Diagnostics, Post Graduate Residency Program in Neurosurgery, University of Palermo, Palermo, Italy
| | - Maria Angela Pino
- Unit of Neurosurgery, Department of Biomedicine, Neuroscience and Advanced Diagnostics, Post Graduate Residency Program in Neurosurgery, University of Palermo, Palermo, Italy
| | - Paola Feraco
- Neuroradiology Unit, S. Chiara Hospital, Trento, Italy
| | - Silvana Tumbiolo
- Department of Neurosurgery, Villa Sofia Hospital, Palermo, Italy
| | - Massimo Midiri
- Unit of Neurosurgery, Department of Biomedicine, Neuroscience and Advanced Diagnostics, Post Graduate Residency Program in Neurosurgery, University of Palermo, Palermo, Italy
| | - Domenico Gerardo Iacopino
- Unit of Neurosurgery, Department of Biomedicine, Neuroscience and Advanced Diagnostics, Post Graduate Residency Program in Neurosurgery, University of Palermo, Palermo, Italy
| | - Rosario Maugeri
- Unit of Neurosurgery, Department of Biomedicine, Neuroscience and Advanced Diagnostics, Post Graduate Residency Program in Neurosurgery, University of Palermo, Palermo, Italy
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Ni C, Qin D, Cheng H, Zhou M, Luo D. Effect Evaluation of Combined Application of Magnetic Resonance Diffusion Tensor Imaging and Brain Function Imaging in Radiation Therapy of Brain Tumours Involving Motor Pathways. JOURNAL OF MEDICAL IMAGING AND HEALTH INFORMATICS 2021. [DOI: 10.1166/jmihi.2021.3329] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
This study is an attempt to find a way for functional imaging information to be applied clinically in radiation therapy. The basal nucleus is a collective term for a group of neural nucleus in the central nervous system that connects the pontine, brainstem, and cerebral cortex, including
the caudate nucleus, the bean-shaped nucleus, the screen-shaped nucleus, and the amygdala. It is difficult to find the exact position of these neural nuclei on the computed tomography (CT) image or the T1 or T2 sequence of magnetic resonance. However, the development of neurosurgery has partially
confirmed that these functional nuclei are involved in advanced cognitive functions such as memory, emotion, and learning. Neurosurgery has tried to avoid damaging these nucleus groups during surgery to improve the quality of life of patients, and there is currently no clear strategy for this
in radiotherapy. Because CT and magnetic resonance spin echo (SE) sequences are difficult to find the anatomical location of the nucleus, it is difficult to have any strategy to protect these functions in radiotherapy planning. This article uses diffusion tensor imaging (DTI) images and fiber
bundle tracking to obtain a more accurate anatomical position of the nerve nucleus on the image, and provides some available strategies for radiotherapy to protect patients’ brain function. The conclusion of this paper is that the combined application of DTI and functional magnetic resonance
imaging (fMRI) can better observe the relationship among tumours, functional areas and white matter fibers, and guide the designation of radiotherapy plans.
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Affiliation(s)
- Cheng Ni
- The Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, En Shi 445000, China
| | - Daming Qin
- The Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, En Shi 445000, China
| | - Hong Cheng
- The Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, En Shi 445000, China
| | - Meng Zhou
- The Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, En Shi 445000, China
| | - Dandan Luo
- The Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, En Shi 445000, China
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Elastic Fusion Enables Fusion of Intraoperative Magnetic Resonance Imaging Data with Preoperative Neuronavigation Data. World Neurosurg 2020; 142:e223-e228. [PMID: 32599196 DOI: 10.1016/j.wneu.2020.06.166] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 06/19/2020] [Accepted: 06/21/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Intraoperative magnetic resonance imaging (iMRI) has been shown to optimize the extent of resection of parenchymal brain tumors. To facilitate the use of preoperative treatment plans after an intraoperative navigation update via iMRI, an elastic image fusion (EIF) algorithm was developed. METHODS Ten MRI-iMRI data pairs of patients with brain tumor were evaluated and typical anatomic landmarks were assessed. The pre- and iMRI scans were elastically fused by using a prototype EIF software (Elements Virtual iMRI [Brainlab AG]). For each landmark pair, the Euclidean distance was calculated for rigidly and elastically fused image data. RESULTS The Euclidean distance was 2.67 ± 2.62 mm using standard rigid image fusion and 1.8 ± 1.57 mm using our EIF algorithm (P = 0.005). For landmarks near the resected lesion, which were subject to higher anatomic distortion, the Euclidian distances were 4.38 ± 2.51 and 2.52 ± 1.9 mm (P = 0.003). CONCLUSIONS This feasibility study shows that EIF can compensate for surgery-related brain shift in a highly significant manner even in this small number of cases. The establishment of an easy applicable and reliable EIF tool integrated in the clinical workflow could open a large variety of new options for image-guided tumor surgery.
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Wende T, Hoffmann KT, Meixensberger J. Tractography in Neurosurgery: A Systematic Review of Current Applications. J Neurol Surg A Cent Eur Neurosurg 2020; 81:442-455. [PMID: 32176926 DOI: 10.1055/s-0039-1691823] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The ability to visualize the brain's fiber connections noninvasively in vivo is relatively young compared with other possibilities of functional magnetic resonance imaging. Although many studies showed tractography to be of promising value for neurosurgical care, the implications remain inconclusive. An overview of current applications is presented in this systematic review. A search was conducted for (("tractography" or "fiber tracking" or "fibre tracking") and "neurosurgery") that produced 751 results. We identified 260 relevant articles and added 20 more from other sources. Most publications concerned surgical planning for resection of tumors (n = 193) and vascular lesions (n = 15). Preoperative use of transcranial magnetic stimulation was discussed in 22 of these articles. Tractography in skull base surgery presents a special challenge (n = 29). Fewer publications evaluated traumatic brain injury (TBI) (n = 25) and spontaneous intracranial bleeding (n = 22). Twenty-three articles focused on tractography in pediatric neurosurgery. Most authors found tractography to be a valuable addition in neurosurgical care. The accuracy of the technique has increased over time. There are articles suggesting that tractography improves patient outcome after tumor resection. However, no reliable biomarkers have yet been described. The better rehabilitation potential after TBI and spontaneous intracranial bleeding compared with brain tumors offers an insight into the process of neurorehabilitation. Tractography and diffusion measurements in some studies showed a correlation with patient outcome that might help uncover the neuroanatomical principles of rehabilitation itself. Alternative corticofugal and cortico-cortical networks have been implicated in motor recovery after ischemic stroke, suggesting more complex mechanisms in neurorehabilitation that go beyond current models. Hence tractography may potentially be able to predict clinical deficits and rehabilitation potential, as well as finding possible explanations for neurologic disorders in retrospect. However, large variations of the results indicate a lack of data to establish robust diagnostical concepts at this point. Therefore, in vivo tractography should still be interpreted with caution and by experienced surgeons.
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Affiliation(s)
- Tim Wende
- Department of Neurosurgery, University Hospital Leipzig, Leipzig, Germany
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Jakola AS, Sagberg LM, Gulati S, Solheim O. Advancements in predicting outcomes in patients with glioma: a surgical perspective. Expert Rev Anticancer Ther 2020; 20:167-177. [PMID: 32114857 DOI: 10.1080/14737140.2020.1735367] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Introduction: Diffuse glioma is a challenging neurosurgical entity. Although surgery does not provide a cure, it may greatly influence survival, brain function, and quality of life. Surgical treatment is by nature highly personalized and outcome prediction is very complex. To engage and succeed in this balancing act it is important to make best use of the information available to the neurosurgeon.Areas covered: This narrative review provides an update on advancements in predicting outcomes in patients with glioma that are relevant to neurosurgeons.Expert opinion: The classical 'gut feeling' is notoriously unreliable and better prediction strategies for patients with glioma are warranted. There are numerous tools readily available for the neurosurgeon in predicting tumor biology and survival. Predicting extent of resection, functional outcome, and quality of life remains difficult. Although machine-learning approaches are currently not readily available in daily clinical practice, there are several ongoing efforts with the use of big data sets that are likely to create new prediction models and refine the existing models.
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Affiliation(s)
- Asgeir Store Jakola
- Department of Clinical Neuroscience, Institute of Physiology and Neuroscience, Sahlgrenska Academy, Gothenburg, Sweden.,Department of Neurosurgery, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Neuromedicine and Movement Science, NTNU, Trondheim, Norway
| | - Lisa Millgård Sagberg
- Department of Neurosurgery, St.Olavs Hospital, Trondheim, Norway.,Department of Public Health and Nursing, NTNU, Trondheim, Norway
| | - Sasha Gulati
- Department of Neuromedicine and Movement Science, NTNU, Trondheim, Norway.,Department of Neurosurgery, St.Olavs Hospital, Trondheim, Norway
| | - Ole Solheim
- Department of Neuromedicine and Movement Science, NTNU, Trondheim, Norway.,Department of Neurosurgery, St.Olavs Hospital, Trondheim, Norway
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Awake mapping is not an additional surgical technique but an alternative philosophy in the management of low-grade glioma patients. Neurosurg Rev 2018; 41:697-698. [DOI: 10.1007/s10143-018-0960-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 02/21/2018] [Indexed: 10/17/2022]
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