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Kram L, Schroeder A, Meyer B, Krieg SM, Ille S. Function-guided differences of arcuate fascicle and inferior fronto-occipital fascicle tractography as diagnostic indicators for surgical risk stratification. Brain Struct Funct 2024:10.1007/s00429-024-02787-3. [PMID: 38597941 DOI: 10.1007/s00429-024-02787-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Accepted: 03/05/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND Several patients with language-eloquent gliomas face language deterioration postoperatively. Persistent aphasia is frequently associated with damage to subcortical language pathways. Underlying mechanisms still need to be better understood, complicating preoperative risk assessment. This study compared qualitative and quantitative functionally relevant subcortical differences pre- and directly postoperatively in glioma patients with and without aphasia. METHODS Language-relevant cortical sites were defined using navigated transcranial magnetic stimulation (nTMS) language mapping in 74 patients between 07/2016 and 07/2019. Post-hoc nTMS-based diffusion tensor imaging tractography was used to compare a tract's pre- and postoperative visualization, volume and fractional anisotropy (FA), and the preoperative distance between tract and lesion and postoperative overlap with the resection cavity between the following groups: no aphasia (NoA), tumor- or previous resection induced aphasia persistent pre- and postoperatively (TIA_P), and surgery-induced transient or permanent aphasia (SIA_T or SIA_P). RESULTS Patients with NoA, TIA_P, SIA_T, and SIA_P showed distinct fasciculus arcuatus (AF) and inferior-fronto-occipital fasciculus (IFOF) properties. The AF was more frequently reconstructable, and the FA of IFOF was higher in NoA than TIA_P cases (all p ≤ 0.03). Simultaneously, SIA_T cases showed higher IFOF fractional anisotropy than TIA_P cases (p < 0.001) and the most considerable AF volume loss overall. While not statistically significant, the four SIA_P cases showed complete loss of ventral language streams postoperatively, the highest resection-cavity-AF-overlap, and the shortest AF to tumor distance. CONCLUSION Functionally relevant qualitative and quantitative differences in AF and IFOF provide a pre- and postoperative pathophysiological and clinically relevant diagnostic indicator that supports surgical risk stratification.
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Affiliation(s)
- Leonie Kram
- Department of Neurosurgery, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Munich, Germany
- Department of Neurosurgery, Heidelberg University Hospital, Ruprecht-Karls-University, Heidelberg, Germany
| | - Axel Schroeder
- Department of Neurosurgery, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Munich, Germany
| | - Sandro M Krieg
- Department of Neurosurgery, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Munich, Germany
- Department of Neurosurgery, Heidelberg University Hospital, Ruprecht-Karls-University, Heidelberg, Germany
| | - Sebastian Ille
- Department of Neurosurgery, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Munich, Germany.
- Department of Neurosurgery, Heidelberg University Hospital, Ruprecht-Karls-University, Heidelberg, Germany.
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Liang R, Schwendner M, Grziwotz M, Wiestler B, Wostrack M, Meyer B, Krieg SM, Ille S. Improving tractography in brainstem cavernoma patients by distortion correction. BRAIN & SPINE 2023; 3:102685. [PMID: 38021010 PMCID: PMC10668098 DOI: 10.1016/j.bas.2023.102685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 09/16/2023] [Accepted: 10/04/2023] [Indexed: 12/01/2023]
Abstract
Introduction The resection of brainstem cerebral cavernous malformations (CCM) harbors the risk of damaging the corticospinal tract (CST) and other major tracts. Hence, visualization of eloquent fiber tracts supports pre- and intraoperative planning. However, diffusion tensor imaging fiber tracking at brainstem level suffers from distortion due to field inhomogeneities and eddy currents by steep diffusion gradients. Research question This study aims to analyze the effect of distortion correction for CST tractography in brainstem CCM patients. Material and methods 25 patients who underwent resection of brainstem CCM were enrolled, 24 suffered from hemorrhage. We performed an anatomically based tractography of the CST with a mean minimal fractional anisotropy of 0.22 ± 0.04 before and after cranial distortion correction (CDC). Accuracy was measured by anatomical plausibility and aberrant fibers. Results CDC led to a more precise CST tractography, further approximating its assumed anatomical localization in all cases. CDC resulted in a significantly more ventral location of the CST of 1.5 ± 0.6 mm (6.1 ± 2.7 mm before CDC vs. 4.6 ± 2.1 mm after CDC; p < .0001) as measured by the distance to the basilar artery and of 1.7 ± 0.6 mm (8.9 ± 2.7 mm vs. 7.2 ± 2.1 mm; p < .0001) in relation to the clivus. Aberrant fibers were reduced by CDC in 44% of cases. We found a mean difference in CST volume of 0.6 ± 0.8 ccm. We could not detect motor deficits after resection of irregular fibers. Discussion and conclusion CDC effectively corrects tractography for distortion at brainstem level, especially in patients suffering from brainstem CCM, further approximating its actual anatomical localization.
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Affiliation(s)
- Raimunde Liang
- Department of Neurosurgery, Klinikum Rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Maximilian Schwendner
- Department of Neurosurgery, Klinikum Rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Marc Grziwotz
- Department of Neurosurgery, Klinikum Rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Benedikt Wiestler
- Department of Diagnostic and Interventional Neuroradiology, Klinikum Rechts der Isar, School of Medicine, Technische Universität München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Maria Wostrack
- Department of Neurosurgery, Klinikum Rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum Rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Sandro M. Krieg
- Department of Neurosurgery, Klinikum Rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Sebastian Ille
- Department of Neurosurgery, Klinikum Rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, Munich, Germany
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Diehl CD, Rosenkranz E, Schwendner M, Mißlbeck M, Sollmann N, Ille S, Meyer B, Combs SE, Krieg SM. Dose Reduction to Motor Structures in Adjuvant Fractionated Stereotactic Radiotherapy of Brain Metastases: nTMS-Derived DTI-Based Motor Fiber Tracking in Treatment Planning. Cancers (Basel) 2022; 15:cancers15010282. [PMID: 36612277 PMCID: PMC9818359 DOI: 10.3390/cancers15010282] [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: 11/09/2022] [Revised: 12/07/2022] [Accepted: 12/19/2022] [Indexed: 01/03/2023] Open
Abstract
Background: Resection of brain metastases (BM) close to motor structures is challenging for treatment. Navigated transcranial magnetic stimulation (nTMS) motor mapping, combined with diffusion tensor imaging (DTI)-based fiber tracking (DTI-FTmot.TMS), is a valuable tool in neurosurgery to preserve motor function. This study aimed to assess the practicability of DTI-FTmot.TMS for local adjuvant radiotherapy (RT) planning of BM. Methods: Presurgically generated DTI-FTmot.TMS-based corticospinal tract (CST) reconstructions (FTmot.TMS) of 24 patients with 25 BM resected during later surgery were incorporated into the RT planning system. Completed fractionated stereotactic intensity-modulated RT (IMRT) plans were retrospectively analyzed and adapted to preserve FTmot.TMS. Results: In regular plans, mean dose (Dmean) of complete FTmot.TMS was 5.2 ± 2.4 Gy. Regarding planning risk volume (PRV-FTTMS) portions outside of the planning target volume (PTV) within the 17.5 Gy (50%) isodose line, the DTI-FTmot.TMS Dmean was significantly reduced by 33.0% (range, 5.9−57.6%) from 23.4 ± 3.3 Gy to 15.9 ± 4.7 Gy (p < 0.001). There was no significant decline in the effective treatment dose, with PTV Dmean 35.6 ± 0.9 Gy vs. 36.0 ± 1.2 Gy (p = 0.063) after adaption. Conclusions: The DTI-FTmot.TMS-based CST reconstructions could be implemented in adjuvant IMRT planning of BM. A significant dose reduction regarding motor structures within critical dose levels seems possible.
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Affiliation(s)
- Christian D. Diehl
- Department of Radiation Oncology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
- Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, 85764 Neuherberg, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), DKTK Partner Site, 81675 Munich, Germany
- Correspondence:
| | - Enrike Rosenkranz
- Department of Radiation Oncology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
- Department of Neurosurgery, School of Medicine, Klinikum rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
| | - Maximilian Schwendner
- Department of Neurosurgery, School of Medicine, Klinikum rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
| | - Martin Mißlbeck
- Department of Radiation Oncology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
| | - Nico Sollmann
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
- TUM-Neuroimaging Center, Klinikum rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
- Department of Diagnostic and Interventional Radiology, University Hospital Ulm, 89081 Ulm, Germany
| | - Sebastian Ille
- Department of Neurosurgery, School of Medicine, Klinikum rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, School of Medicine, Klinikum rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
| | - Stephanie E. Combs
- Department of Radiation Oncology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
- Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, 85764 Neuherberg, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), DKTK Partner Site, 81675 Munich, Germany
| | - Sandro M. Krieg
- Department of Neurosurgery, School of Medicine, Klinikum rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
- TUM-Neuroimaging Center, Klinikum rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
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Zhang W, Ille S, Schwendner M, Wiestler B, Meyer B, Krieg SM. Tracking motor and language eloquent white matter pathways with intraoperative fiber tracking versus preoperative tractography adjusted by intraoperative MRI-based elastic fusion. J Neurosurg 2022; 137:1114-1123. [PMID: 35213839 DOI: 10.3171/2021.12.jns212106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 12/09/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Preoperative fiber tracking (FT) enables visualization of white matter pathways. However, the intraoperative accuracy of preoperative image registration is reduced due to brain shift. Intraoperative FT is currently considered the standard of anatomical accuracy, while intraoperative imaging can also be used to correct and update preoperative data by intraoperative MRI (ioMRI)-based elastic fusion (IBEF). However, the use of intraoperative tractography is restricted due to the need for additional acquisition of diffusion imaging in addition to scanner limitations, quality factors, and setup time. Since IBEF enables compensation for brain shift and updating of preoperative FT, the aim of this study was to compare intraoperative FT with IBEF of preoperative FT. METHODS Preoperative MRI (pMRI) and ioMRI, both including diffusion tensor imaging (DTI) data, were acquired between February and November 2018. Anatomy-based DTI FT of the corticospinal tract (CST) and the arcuate fascicle (AF) was reconstructed at various fractional anisotropy (FA) values on pMRI and ioMRI, respectively. The intraoperative DTI FT, as a baseline tractography, was fused with original preoperative FT and IBEF-compensated FT, processes referred to as rigid fusion (RF) and elastic fusion (EF), respectively. The spatial overlap index (Dice coefficient [DICE]) and distances of surface points (average surface distance [ASD]) of fused FT before and after IBEF were analyzed and compared in operated and nonoperated hemispheres. RESULTS Seventeen patients with supratentorial brain tumors were analyzed. On the operated hemisphere, the overlap index of pre- and intraoperative FT of the CST by DICE significantly increased by 0.09 maximally after IBEF. A significant decrease by 0.5 mm maximally in the fused FT presented by ASD was observed. Similar improvements were found in IBEF-compensated FT, for which AF tractography on the tumor hemispheres increased by 0.03 maximally in DICE and decreased by 1.0 mm in ASD. CONCLUSIONS Preoperative tractography after IBEF is comparable to intraoperative tractography and can be a reliable alternative to intraoperative FT.
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Affiliation(s)
| | | | | | - Benedikt Wiestler
- 2Diagnostic and Interventional Neuroradiology, Technical University of Munich School of Medicine, Munich, Germany
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5
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Retif P, Djibo Sidikou A, Mathis C, Letellier R, Verrecchia-Ramos E, Dupres R, Michel X. Evaluation of the ability of the Brainlab Elements Cranial Distortion Correction algorithm to correct clinically relevant MRI distortions for cranial SRT. Strahlenther Onkol 2022; 198:907-918. [PMID: 35980455 DOI: 10.1007/s00066-022-01988-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 07/10/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE Cranial stereotactic radiotherapy (SRT) requires highly accurate lesion delineation. However, MRI can have significant inherent geometric distortions. We investigated how well the Elements Cranial Distortion Correction algorithm of Brainlab (Munich, Germany) corrects the distortions in MR image-sets of a phantom and patients. METHODS A non-distorted reference computed tomography image-set of a CIRS Model 603-GS (CIRS, Norfolk, VA, USA) phantom was acquired. Three-dimensional T1-weighted images were acquired with five MRI scanners and reconstructed with vendor-derived distortion correction. Some were reconstructed without correction to generate heavily distorted image-sets. All MR image-sets were corrected with the Brainlab algorithm relative to the computed tomography acquisition. CIRS Distortion Check software measured the distortion in each image-set. For all uncorrected and corrected image-sets, the control points that exceeded the 0.5-mm clinically relevant distortion threshold and the distortion maximum, mean, and standard deviation were recorded. Empirical cumulative distribution functions (eCDF) were plotted. Intraclass correlation coefficient (ICC) was calculated. The algorithm was evaluated with 10 brain metastases using Dice similarity coefficients (DSC). RESULTS The algorithm significantly reduced mean and standard deviation distortion in all image-sets. It reduced the maximum distortion in the heavily distorted image-sets from 2.072 to 1.059 mm and the control points with > 0.5-mm distortion fell from 50.2% to 4.0%. Before and especially after correction, the eCDFs of the four repeats were visually similar. ICC was 0.812 (excellent-good agreement). The algorithm increased the DSCs for all patients and image-sets. CONCLUSION The Brainlab algorithm significantly and reproducibly ameliorated MRI distortion, even with heavily distorted images. Thus, it increases the accuracy of cranial SRT lesion delineation. After further testing, this tool may be suitable for SRT of small lesions.
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Affiliation(s)
- Paul Retif
- Medical Physics Unit, CHR Metz-Thionville, Metz, France. .,Université de Lorraine, CNRS, CRAN, 54000, Nancy, France.
| | | | | | | | | | - Rémi Dupres
- Medical Imaging Department, CHR Metz-Thionville, Metz, France
| | - Xavier Michel
- Radiation Therapy Department, CHR Metz-Thionville, Metz, France
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Kim JT, Di L, Etame AB, Olson S, Vogelbaum MA, Tran ND. Use of virtual magnetic resonance imaging to compensate for brain shift during image-guided surgery: illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2022; 3:CASE21683. [PMID: 35733635 PMCID: PMC9204912 DOI: 10.3171/case21683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 04/20/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Maximal safe resection is the paramount objective in the surgical management of malignant brain tumors. It is facilitated through use of image-guided neuronavigation. Intraoperative image guidance systems use preoperative magnetic resonance imaging (MRI) as the navigational map. The accuracy of neuronavigation is limited by intraoperative brain shift and can become less accurate over the course of the procedure. Intraoperative MRI can compensate for dynamic brain shift but requires significant space and capital investment, often unavailable at many centers. OBSERVATIONS The authors described a case in which an image fusion algorithm was used in conjunction with an intraoperative computed tomography (CT) system to compensate for brain shift during resection of a brainstem hemorrhagic melanoma metastasis. Following initial debulking of the hemorrhagic metastasis, intraoperative CT was performed to ascertain extent of resection. An elastic image fusion (EIF) algorithm was used to create virtual MRI relative to both the intraoperative CT scan and preoperative MRI, which facilitated complete resection of the tumor while preserving critical brainstem anatomy. LESSONS EIF algorithms can be used with multimodal images (preoperative MRI and intraoperative CT) and create an updated virtual MRI data set to compensate for brain shift in neurosurgery and aid in maximum safe resection of malignant brain tumors.
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Affiliation(s)
- John T. Kim
- Department of Neurosurgery, University of South Florida, Tampa, Florida; and
| | - Long Di
- Department of Neurosurgery, University of South Florida, Tampa, Florida; and
| | - Arnold B. Etame
- Department of Neurosurgery, University of South Florida, Tampa, Florida; and
- Department of Neuro-Oncology, Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Sarah Olson
- Department of Neuro-Oncology, Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Michael A. Vogelbaum
- Department of Neurosurgery, University of South Florida, Tampa, Florida; and
- Department of Neuro-Oncology, Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Nam D. Tran
- Department of Neurosurgery, University of South Florida, Tampa, Florida; and
- Department of Neuro-Oncology, Moffitt Cancer Center and Research Institute, Tampa, Florida
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7
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Diehl C, Rosenkranz E, Mißlbeck M, Schwendner M, Sollmann N, Ille S, Meyer B, Combs S, Bernhardt D, Krieg S. nTMS-derived DTI-based motor fiber tracking in radiotherapy treatment planning of high-grade gliomas for avoidance of motor structures. Radiother Oncol 2022; 171:189-197. [DOI: 10.1016/j.radonc.2022.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 04/08/2022] [Accepted: 04/10/2022] [Indexed: 10/18/2022]
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TMS Seeded Diffusion Tensor Imaging Tractography Predicts Permanent Neurological Deficits. Cancers (Basel) 2022; 14:cancers14020340. [PMID: 35053503 PMCID: PMC8774180 DOI: 10.3390/cancers14020340] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 01/01/2022] [Accepted: 01/06/2022] [Indexed: 02/04/2023] Open
Abstract
Simple Summary For brain tumor patients, surgeons must resect as much of the tumor as possible while preserving the patient’s function and quality of life. This requires preoperative imaging that accurately identifies important parts of the brain. Transcranial magnetic stimulation is a way of preoperatively finding the areas of the brain connected to motor function. However, few studies have investigated the accuracy and clinical relevance of the data. In this study, we examine the functional outcomes of patients who had TMS points resected and patients who did not. We aim to address key technical barriers to performing this analysis. We also aim to discern the appropriate role of TMS tractography in preoperative diagnostic imaging. Insights gained from this study can be used to select the right patients and plan for the optimal surgeries. Abstract Surgeons must optimize the onco-functional balance by maximizing the extent of resection and minimizing postoperative neurological morbidity. Optimal patient selection and surgical planning requires preoperative identification of nonresectable structures. Transcranial magnetic stimulation is a method of noninvasively mapping the cortical representations of the speech and motor systems. Despite recent promising data, its clinical relevance and appropriate role in a comprehensive mapping approach remains unknown. In this study, we aim to provide direct evidence regarding the clinical utility of transcranial magnetic stimulation by interrogating the eloquence of TMS points. Forty-two glioma patients were included in this retrospective study. We collected motor function outcomes 3 months postoperatively. We overlayed the postoperative MRI onto the preoperative MRI to visualize preoperative TMS points in the context of the surgical cavity. We then generated diffusion tensor imaging tractography to identify meaningful subsets of TMS points. We correlated the resection of preoperative imaging features with clinical outcomes. The resection of TMS-positive points was significantly predictive of permanent deficits (p = 0.05). However, four out of eight patients had TMS-positive points resected without a permanent deficit. DTI tractography at a 75% FA threshold identified which TMS points are essential and which are amenable to surgical resection. TMS combined with DTI tractography shows a significant prediction of postoperative neurological deficits with both a high positive predictive value and negative predictive value.
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Predicting the Extent of Resection of Motor-Eloquent Gliomas Based on TMS-Guided Fiber Tracking. Brain Sci 2021; 11:brainsci11111517. [PMID: 34827516 PMCID: PMC8615964 DOI: 10.3390/brainsci11111517] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 11/05/2021] [Accepted: 11/13/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Surgical planning with nTMS-based tractography is proven to increase safety during surgery. A preoperative risk stratification model has been published based on the M1 infiltration, RMT ratio, and tumor to corticospinal tract distance (TTD). The correlation of TTD with corticospinal tract to resection cavity distance (TRD) and outcome is needed to further evaluate the validity of the model. Aim of the study: To use the postop MRI-derived resection cavity to measure how closely the resection cavity approximated the preoperatively calculated corticospinal tract (CST) and how this correlates with the risk model and the outcome. Methods: We included 183 patients who underwent nTMS-based DTI and surgical resection for presumed motor-eloquent gliomas. TTD, TRD, and motor outcome were recorded and tested for correlations. The intraoperative monitoring documentation was available for a subgroup of 48 patients, whose responses were correlated to TTD and TRD. Results: As expected, TTD and TRD showed a good correlation (Spearman’s ρ = 0.67, p < 0.001). Both the TTD and the TRD correlated significantly with the motor outcome at three months (Kendall’s Tau-b 0.24 for TTD, 0.31 for TRD, p < 0.001). Interestingly, the TTD and TRD correlated only slightly with residual tumor volume, and only after correction for outliers related to termination of resection due to intraoperative monitoring events or the proximity of other eloquent structures (TTD ρ = 0.32, p < 0.001; TRD ρ = 0.19, p = 0.01). This reflects the fact that intraoperative monitoring (IOM) phenomena do not always correlate with preoperative structural analysis, and that additional factors influence the intraoperative decision to abort resection, such as the adjacency of other vulnerable structures. The TTD was also significantly correlated with variations in motor evoked potential (MEP) responses (no/reversible decrease vs. irreversible decrease; p = 0.03). Conclusions: The TTD approximates the TRD well, confirming the best predictive parameter and giving strength to the nTMS-based risk stratification model. Our analysis of TRD supports the use of the nTMS-based TTD measurement to estimate the resection preoperatively, also confirming the 8 mm cutoff. Nevertheless, the TRD proved to have a slightly stronger correlation with the outcome as the surgeon’s experience, anatomofunctional knowledge, and MEP observations influence the expected EOR.
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10
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Ort J, Hamou HA, Kernbach JM, Hakvoort K, Blume C, Lohmann P, Galldiks N, Heiland DH, Mottaghy FM, Clusmann H, Neuloh G, Langen KJ, Delev D. 18F-FET-PET-guided gross total resection improves overall survival in patients with WHO grade III/IV glioma: moving towards a multimodal imaging-guided resection. J Neurooncol 2021; 155:71-80. [PMID: 34599479 PMCID: PMC8545732 DOI: 10.1007/s11060-021-03844-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 09/08/2021] [Indexed: 11/15/2022]
Abstract
Purpose PET using radiolabeled amino acid [18F]-fluoro-ethyl-L-tyrosine (FET-PET) is a well-established imaging modality for glioma diagnostics. The biological tumor volume (BTV) as depicted by FET-PET often differs in volume and location from tumor volume of contrast enhancement (CE) in MRI. Our aim was to investigate whether a gross total resection of BTVs defined as < 1 cm3 of residual BTV (PET GTR) correlates with better oncological outcome. Methods We retrospectively analyzed imaging and survival data from patients with primary and recurrent WHO grade III or IV gliomas who underwent FET-PET before surgical resection. Tumor overlap between FET-PET and CE was evaluated. Completeness of FET-PET resection (PET GTR) was calculated after superimposition and semi-automated segmentation of pre-operative FET-PET and postoperative MRI imaging. Survival analysis was performed using the Kaplan–Meier method and the log-rank test. Results From 30 included patients, PET GTR was achieved in 20 patients. Patients with PET GTR showed improved median OS with 19.3 compared to 13.7 months for patients with residual FET uptake (p = 0.007; HR 0.3; 95% CI 0.12–0.76). This finding remained as independent prognostic factor after performing multivariate analysis (HR 0.19, 95% CI 0.06–0.62, p = 0.006). Other survival influencing factors such as age, IDH-mutation, MGMT promotor status, and adjuvant treatment modalities were equally distributed between both groups. Conclusion Our results suggest that PET GTR improves the OS in patients with WHO grade III or IV gliomas. A multimodal imaging approach including FET-PET for surgical planning in newly diagnosed and recurrent tumors may improve the oncological outcome in glioma patients. Supplementary Information The online version contains supplementary material available at 10.1007/s11060-021-03844-1.
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Affiliation(s)
- Jonas Ort
- Department of Neurosurgery, Medical Faculty, RWTH Aachen University, 52074, Aachen, Germany. .,NAILA-Neurosurgical Artificial Intelligence Laboratory Aachen, Aachen, Germany. .,Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Aachen, Germany.
| | - Hussam Aldin Hamou
- Department of Neurosurgery, Medical Faculty, RWTH Aachen University, 52074, Aachen, Germany.,Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Aachen, Germany
| | - Julius M Kernbach
- Department of Neurosurgery, Medical Faculty, RWTH Aachen University, 52074, Aachen, Germany.,NAILA-Neurosurgical Artificial Intelligence Laboratory Aachen, Aachen, Germany.,Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Aachen, Germany
| | - Karlijn Hakvoort
- Department of Neurosurgery, Medical Faculty, RWTH Aachen University, 52074, Aachen, Germany.,NAILA-Neurosurgical Artificial Intelligence Laboratory Aachen, Aachen, Germany.,Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Aachen, Germany
| | - Christian Blume
- Department of Neurosurgery, Medical Faculty, RWTH Aachen University, 52074, Aachen, Germany.,Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Aachen, Germany
| | - Philipp Lohmann
- Institute of Neuroscience and Medicine (INM-3, INM-4), Research Center Juelich, Juelich, Germany.,Department of Stereotaxy and Functional Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Norbert Galldiks
- Institute of Neuroscience and Medicine (INM-3, INM-4), Research Center Juelich, Juelich, Germany.,Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany.,Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Aachen, Germany
| | - Dieter Henrik Heiland
- Department of Neurosurgery, Medical Center, University of Freiburg, Freiburg, Germany.,Faculty of Medicine, Freiburg University, Freiburg, Germany
| | - Felix M Mottaghy
- Department of Nuclear Medicine, Medical Faculty, RWTH Aachen University, 52074, Aachen, Germany.,JARA-Juelich Aachen Research Alliance, Juelich, Germany.,Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Aachen, Germany
| | - Hans Clusmann
- Department of Neurosurgery, Medical Faculty, RWTH Aachen University, 52074, Aachen, Germany.,Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Aachen, Germany
| | - Georg Neuloh
- Department of Neurosurgery, Medical Faculty, RWTH Aachen University, 52074, Aachen, Germany.,Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Aachen, Germany
| | - Karl-Josef Langen
- Institute of Neuroscience and Medicine (INM-3, INM-4), Research Center Juelich, Juelich, Germany.,Department of Nuclear Medicine, Medical Faculty, RWTH Aachen University, 52074, Aachen, Germany.,JARA-Juelich Aachen Research Alliance, Juelich, Germany.,Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Aachen, Germany
| | - Daniel Delev
- Department of Neurosurgery, Medical Faculty, RWTH Aachen University, 52074, Aachen, Germany.,NAILA-Neurosurgical Artificial Intelligence Laboratory Aachen, Aachen, Germany.,Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Aachen, Germany
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11
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Rosenstock T, Häni L, Grittner U, Schlinkmann N, Ivren M, Schneider H, Raabe A, Vajkoczy P, Seidel K, Picht T. Bicentric validation of the navigated transcranial magnetic stimulation motor risk stratification model. J Neurosurg 2021; 136:1194-1206. [PMID: 34534966 DOI: 10.3171/2021.3.jns2138] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 03/23/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The authors sought to validate the navigated transcranial magnetic stimulation (nTMS)-based risk stratification model. The postoperative motor outcome in glioma surgery may be preoperatively predicted based on data derived by nTMS. The tumor-to-tract distance (TTD) and the interhemispheric resting motor threshold (RMT) ratio (as a surrogate parameter for cortical excitability) emerged as major factors related to a new postoperative deficit. METHODS In this bicentric study, a consecutive prospectively collected cohort underwent nTMS mapping with diffusion tensor imaging (DTI) fiber tracking of the corticospinal tract prior to surgery of motor eloquent gliomas. The authors analyzed whether the following items were associated with the patient's outcome: patient characteristics, TTD, RMT value, and diffusivity parameters (fractional anisotropy [FA] and apparent diffusion coefficient [ADC]). The authors assessed the validity of the published risk stratification model and derived a new model. RESULTS A new postoperative motor deficit occurred in 36 of 165 patients (22%), of whom 20 patients still had a deficit after 3 months (13%; n3 months = 152). nTMS-verified infiltration of the motor cortex as well as a TTD ≤ 8 mm were confirmed as risk factors. No new postoperative motor deficit occurred in patients with TTD > 8 mm. In contrast to the previous risk stratification, the RMT ratio was not substantially correlated with the motor outcome, but high RMT values of both the tumorous and healthy hemisphere were associated with worse motor outcome. The FA value was negatively associated with worsening of motor outcome. Accuracy analysis of the final model showed a high negative predictive value (NPV), so the preoperative application may accurately predict the preservation of motor function in particular (day of discharge: sensitivity 47.2%, specificity 90.7%, positive predictive value [PPV] 58.6%, NPV 86.0%; 3 months: sensitivity 85.0%, specificity 78.8%, PPV 37.8%, NPV 97.2%). CONCLUSIONS This bicentric validation analysis further improved the model by adding the FA value of the corticospinal tract, demonstrating the relevance of nTMS/nTMS-based DTI fiber tracking for clinical decision making.
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Affiliation(s)
- Tizian Rosenstock
- 1Department of Neurosurgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin.,2Berlin Institute of Health at Charité-Universitätsmedizin Berlin, Germany
| | - Levin Häni
- 3Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Ulrike Grittner
- 4Institute of Biometry and Clinical Epidemiology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin; and
| | - Nicolas Schlinkmann
- 1Department of Neurosurgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin
| | - Meltem Ivren
- 1Department of Neurosurgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin
| | - Heike Schneider
- 1Department of Neurosurgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin
| | - Andreas Raabe
- 3Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Peter Vajkoczy
- 1Department of Neurosurgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin
| | - Kathleen Seidel
- 3Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Thomas Picht
- 1Department of Neurosurgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin.,5Cluster of Excellence: "Matters of Activity. Image Space Material," Humboldt University, Berlin, Germany
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12
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Li M, Zhang Q, Yang K. Role of MRI-Based Functional Imaging in Improving the Therapeutic Index of Radiotherapy in Cancer Treatment. Front Oncol 2021; 11:645177. [PMID: 34513659 PMCID: PMC8429950 DOI: 10.3389/fonc.2021.645177] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 07/30/2021] [Indexed: 02/05/2023] Open
Abstract
Advances in radiation technology, such as intensity-modulated radiation therapy (IMRT), have largely enabled a biological dose escalation of the target volume (TV) and reduce the dose to adjacent tissues or organs at risk (OARs). However, the risk of radiation-induced injury increases as more radiation dose utilized during radiation therapy (RT), which predominantly limits further increases in TV dose distribution and reduces the local control rate. Thus, the accurate target delineation is crucial. Recently, technological improvements for precise target delineation have obtained more attention in the field of RT. The addition of functional imaging to RT can provide a more accurate anatomy of the tumor and normal tissues (such as location and size), along with biological information that aids to optimize the therapeutic index (TI) of RT. In this review, we discuss the application of some common MRI-based functional imaging techniques in clinical practice. In addition, we summarize the main challenges and prospects of these imaging technologies, expecting more inspiring developments and more productive research paths in the near future.
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Affiliation(s)
- Mei Li
- Department of Gynecology and Obstetrics, Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, China.,West China School of Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Qin Zhang
- West China School of Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Kaixuan Yang
- Department of Gynecology and Obstetrics, Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, China
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13
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Silva LL, Tuncer MS, Vajkoczy P, Picht T, Rosenstock T. Distinct approaches to language pathway tractography: comparison of anatomy-based, repetitive navigated transcranial magnetic stimulation (rTMS)-based, and rTMS-enhanced diffusion tensor imaging-fiber tracking. J Neurosurg 2021; 136:589-600. [PMID: 34330091 DOI: 10.3171/2020.12.jns204028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 12/21/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Visualization of subcortical language pathways by means of diffusion tensor imaging-fiber tracking (DTI-FT) is evolving as an important tool for surgical planning and decision making in patients with language-suspect brain tumors. Repetitive navigated transcranial magnetic stimulation (rTMS) cortical language mapping noninvasively provides additional functional information. Efforts to incorporate rTMS data into DTI-FT are promising, but the lack of established protocols makes it hard to assess clinical utility. The authors performed DTI-FT of important language pathways by using five distinct approaches in an effort to evaluate the respective clinical usefulness of each approach. METHODS Thirty patients with left-hemispheric perisylvian lesions underwent preoperative rTMS language mapping and DTI. FT of the principal language tracts was conducted according to different strategies: Ia, anatomical landmark based; Ib, lesion-focused landmark based; IIa, rTMS based; IIb, rTMS based with postprocessing; and III, rTMS enhanced (based on a combination of structural and functional data). The authors analyzed the respective success of each method in revealing streamlines and conducted a multinational survey with expert clinicians to evaluate aspects of clinical utility. RESULTS The authors observed high usefulness and accuracy ratings for anatomy-based approaches (Ia and Ib). Postprocessing of rTMS-based tractograms (IIb) led to more balanced perceived information content but did not improve the usefulness for surgical planning and risk assessment. Landmark-based tractography (Ia and Ib) was most successful in delineating major language tracts (98% success), whereas rTMS-based tractography (IIa and IIb) frequently failed to reveal streamlines and provided less complete tractograms than the landmark-based approach (p < 0.001). The lesion-focused landmark-based (Ib) and the rTMS-enhanced (III) approaches were the most preferred methods. CONCLUSIONS The lesion-focused landmark-based approach (Ib) achieved the best ratings and enabled visualization of the principal language tracts in almost all cases. The rTMS-enhanced approach (III) was positively evaluated by the experts because it can reveal cortico-subcortical connections, but the functional relevance of these connections is still unclear. The use of regions of interest derived solely from cortical rTMS mapping (IIa and IIb) leads to cluttered images that are of limited use in clinical practice.
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Affiliation(s)
- Luca L Silva
- Departments of1Neurosurgery and.,2Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin
| | | | | | - Thomas Picht
- Departments of1Neurosurgery and.,3Cluster of Excellence: "Matters of Activity. Image Space Material"-Humboldt University, Berlin; and
| | - Tizian Rosenstock
- Departments of1Neurosurgery and.,4Berlin Institute of Health (BIH) at Charité - Universitätsmedizin Berlin, Germany
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14
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Sollmann N, Krieg SM, Säisänen L, Julkunen P. Mapping of Motor Function with Neuronavigated Transcranial Magnetic Stimulation: A Review on Clinical Application in Brain Tumors and Methods for Ensuring Feasible Accuracy. Brain Sci 2021; 11:brainsci11070897. [PMID: 34356131 PMCID: PMC8305823 DOI: 10.3390/brainsci11070897] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 06/29/2021] [Accepted: 07/02/2021] [Indexed: 12/15/2022] Open
Abstract
Navigated transcranial magnetic stimulation (nTMS) has developed into a reliable non-invasive clinical and scientific tool over the past decade. Specifically, it has undergone several validating clinical trials that demonstrated high agreement with intraoperative direct electrical stimulation (DES), which paved the way for increasing application for the purpose of motor mapping in patients harboring motor-eloquent intracranial neoplasms. Based on this clinical use case of the technique, in this article we review the evidence for the feasibility of motor mapping and derived models (risk stratification and prediction, nTMS-based fiber tracking, improvement of clinical outcome, and assessment of functional plasticity), and provide collected sets of evidence for the applicability of quantitative mapping with nTMS. In addition, we provide evidence-based demonstrations on factors that ensure methodological feasibility and accuracy of the motor mapping procedure. We demonstrate that selection of the stimulation intensity (SI) for nTMS and spatial density of stimuli are crucial factors for applying motor mapping accurately, while also demonstrating the effect on the motor maps. We conclude that while the application of nTMS motor mapping has been impressively spread over the past decade, there are still variations in the applied protocols and parameters, which could be optimized for the purpose of reliable quantitative mapping.
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Affiliation(s)
- Nico Sollmann
- Department of Diagnostic and Interventional Radiology, University Hospital Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Germany
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675 Munich, Germany
- TUM-Neuroimaging Center, Klinikum rechts der Isar, Technical University of Munich, 81675 Munich, Germany;
- Department of Radiology and Biomedical Imaging, University of California San Francisco, 185 Berry Street, San Francisco, CA 94143, USA
- Correspondence:
| | - Sandro M. Krieg
- TUM-Neuroimaging Center, Klinikum rechts der Isar, Technical University of Munich, 81675 Munich, Germany;
- Department of Neurosurgery, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Laura Säisänen
- Department of Clinical Neurophysiology, Kuopio University Hospital, 70029 Kuopio, Finland; (L.S.); (P.J.)
- Department of Applied Physics, University of Eastern Finland, 70211 Kuopio, Finland
| | - Petro Julkunen
- Department of Clinical Neurophysiology, Kuopio University Hospital, 70029 Kuopio, Finland; (L.S.); (P.J.)
- Department of Applied Physics, University of Eastern Finland, 70211 Kuopio, Finland
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15
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Rosenstock T, Tuncer MS, Münch MR, Vajkoczy P, Picht T, Faust K. Preoperative nTMS and Intraoperative Neurophysiology - A Comparative Analysis in Patients With Motor-Eloquent Glioma. Front Oncol 2021; 11:676626. [PMID: 34094981 PMCID: PMC8175894 DOI: 10.3389/fonc.2021.676626] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 04/23/2021] [Indexed: 01/26/2023] Open
Abstract
Background The resection of a motor-eloquent glioma should be guided by intraoperative neurophysiological monitoring (IOM) but its interpretation is often difficult and may (unnecessarily) lead to subtotal resection. Navigated transcranial magnetic stimulation (nTMS) combined with diffusion-tensor-imaging (DTI) is able to stratify patients with motor-eloquent lesion preoperatively into high- and low-risk cases with respect to a new motor deficit. Objective To analyze to what extent preoperative nTMS motor risk stratification can improve the interpretation of IOM phenomena. Methods In this monocentric observational study, nTMS motor mapping with DTI fiber tracking of the corticospinal tract was performed before IOM-guided surgery for motor-eloquent gliomas in a prospectively collected cohort from January 2017 to October 2020. Descriptive analyses were performed considering nTMS data (motor cortex infiltration, resting motor threshold (RMT), motor evoked potential (MEP) amplitude, latency) and IOM data (transcranial MEP monitoring, intensity of monopolar subcortical stimulation (SCS), somatosensory evoked potentials) to examine the association with the postoperative motor outcome (assessed at day of discharge and at 3 months). Results Thirty-seven (56.1%) of 66 patients (27 female) with a median age of 48 years had tumors located in the right hemisphere, with glioblastoma being the most common diagnosis with 39 cases (59.1%). Three patients (4.9%) had a new motor deficit that recovered partially within 3 months and 6 patients had a persistent deterioration (9.8%). The more risk factors of the nTMS risk stratification model (motor cortex infiltration, tumor-tract distance (TTD) ≤8mm, RMTratio <90%/>110%) were detected, the higher was the risk for developing a new postoperative motor deficit, whereas no patient with a TTD >8mm deteriorated. Irreversible MEP amplitude decrease >50% was associated with worse motor outcome in all patients, while a MEP amplitude decrease ≤50% or lower SCS intensities ≤4mA were particularly correlated with a postoperative worsened motor status in nTMS-stratified high-risk cases. No patient had postoperative deterioration of motor function (except one with partial recovery) when intraoperative MEPs remained stable or showed only reversible alterations. Conclusions The preoperative nTMS-based risk assessment can help to interpret ambiguous IOM phenomena (such as irreversible MEP amplitude decrease ≤50%) and adjustment of SCS stimulation intensity.
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Affiliation(s)
- Tizian Rosenstock
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.,Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Biomedical Innovation Academy, Berlin, Germany
| | - Mehmet Salih Tuncer
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Max Richard Münch
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Thomas Picht
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.,Cluster of Excellence: "Matters of Activity. Image Space Material", Humboldt University, Berlin, Germany
| | - Katharina Faust
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
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16
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Ille S, Schwendner M, Zhang W, Schroeder A, Meyer B, Krieg SM. Tractography for Subcortical Resection of Gliomas Is Highly Accurate for Motor and Language Function: ioMRI-Based Elastic Fusion Disproves the Severity of Brain Shift. Cancers (Basel) 2021; 13:cancers13081787. [PMID: 33918598 PMCID: PMC8068819 DOI: 10.3390/cancers13081787] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 03/29/2021] [Accepted: 04/04/2021] [Indexed: 02/07/2023] Open
Abstract
Simple Summary Tractography enables the visualization of eloquent white matter pathways. Inaccuracies due to brain shift might occur intraoperatively. The aim of this study was to evaluate the impact of intraoperative magnetic resonance imaging (MRI)-based elastic fusion on preoperative tractography for subcortical resection of gliomas. We confirmed the high accuracy of tractography during the whole course of surgery. Abstract When using preoperative tractography intraoperatively, inaccuracies due to brain shift might occur. Intraoperative tractography is rarely performed. Elastic fusion (EF) is a tool developed to compensate for brain shift, gravity, and tissue resection based on intraoperative images. Our hypothesis was that preoperative tractography is accurate and adjustments of tractography by intraoperative magnetic resonance imaging (ioMRI)-based EF (IBEF) compensate for brain shift. Between February 2018 and June 2019, 78 patients underwent eloquent (46 motor, 32 language) glioma resection in our department using intraoperative MRI. Mean distances between the resection cavity and tractography were analyzed and correlated with clinical outcomes. The mean ± standard deviation (range) distance after the application of IBEF was 5.0 ± 2.9 mm (0–10 mm) in patients without surgery-related motor deficits compared with 1.1 ± 1.6 mm (0–5 mm) in patients who showed new permanent surgery-related motor deficits postoperatively (p < 0.001). For language, the distance was 0.7 ± 1.2 mm (0–2 mm) in patients with new permanent deficits compared with 3.1 ± 4.5 mm (0–14 mm) in patients without new permanent surgery-related language deficits (p = 0.541). Preoperative tractography corrected by IBEF for subcortical resection of gliomas is highly accurate. However, at least for such subcortical anatomy, the severity of brain shift was considerably overestimated in the past.
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Affiliation(s)
- Sebastian Ille
- Department of Neurosurgery, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, 81675 Munich, Germany; (S.I.); (M.S.); (W.Z.); (A.S.); (B.M.)
- TUM Neuroimaging Center, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, 81675 Munich, Germany
| | - Maximilian Schwendner
- Department of Neurosurgery, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, 81675 Munich, Germany; (S.I.); (M.S.); (W.Z.); (A.S.); (B.M.)
- TUM Neuroimaging Center, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, 81675 Munich, Germany
| | - Wei Zhang
- Department of Neurosurgery, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, 81675 Munich, Germany; (S.I.); (M.S.); (W.Z.); (A.S.); (B.M.)
| | - Axel Schroeder
- Department of Neurosurgery, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, 81675 Munich, Germany; (S.I.); (M.S.); (W.Z.); (A.S.); (B.M.)
- TUM Neuroimaging Center, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, 81675 Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, 81675 Munich, Germany; (S.I.); (M.S.); (W.Z.); (A.S.); (B.M.)
| | - Sandro M. Krieg
- Department of Neurosurgery, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, 81675 Munich, Germany; (S.I.); (M.S.); (W.Z.); (A.S.); (B.M.)
- TUM Neuroimaging Center, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, 81675 Munich, Germany
- Correspondence: ; Tel.: +49-89-4140-2151
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17
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Bopp MHA, Emde J, Carl B, Nimsky C, Saß B. Diffusion Kurtosis Imaging Fiber Tractography of Major White Matter Tracts in Neurosurgery. Brain Sci 2021; 11:brainsci11030381. [PMID: 33802710 PMCID: PMC8002557 DOI: 10.3390/brainsci11030381] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 03/08/2021] [Accepted: 03/14/2021] [Indexed: 01/31/2023] Open
Abstract
Diffusion tensor imaging (DTI)-based fiber tractography is routinely used in clinical applications to visualize major white matter tracts, such as the corticospinal tract (CST), optic radiation (OR), and arcuate fascicle (AF). Nevertheless, DTI is limited due to its capability of resolving intra-voxel multi-fiber populations. Sophisticated models often require long acquisition times not applicable in clinical practice. Diffusion kurtosis imaging (DKI), as an extension of DTI, combines sophisticated modeling of the diffusion process with short acquisition times but has rarely been investigated in fiber tractography. In this study, DTI- and DKI-based fiber tractography of the CST, OR, and AF was investigated in healthy volunteers and glioma patients. For the CST, significantly larger tract volumes were seen in DKI-based fiber tractography. Similar results were obtained for the OR, except for the right OR in patients. In the case of the AF, results of both models were comparable with DTI-based fiber tractography showing even significantly larger tract volumes in patients. In the case of the CST and OR, DKI-based fiber tractography contributes to advanced visualization under clinical time constraints, whereas for the AF, other models should be considered.
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Affiliation(s)
- Miriam H. A. Bopp
- Department of Neurosurgery, University of Marburg, Baldingerstrasse, 35043 Marburg, Germany; (J.E.); (B.C.); (C.N.); (B.S.)
- Center for Mind, Brain and Behavior (CMBB), 35043 Marburg, Germany
- Correspondence:
| | - Julia Emde
- Department of Neurosurgery, University of Marburg, Baldingerstrasse, 35043 Marburg, Germany; (J.E.); (B.C.); (C.N.); (B.S.)
| | - Barbara Carl
- Department of Neurosurgery, University of Marburg, Baldingerstrasse, 35043 Marburg, Germany; (J.E.); (B.C.); (C.N.); (B.S.)
- Department of Neurosurgery, Helios Dr. Horst Schmidt Kliniken, Ludwig-Erhard-Strasse 100, 65199 Wiesbaden, Germany
| | - Christopher Nimsky
- Department of Neurosurgery, University of Marburg, Baldingerstrasse, 35043 Marburg, Germany; (J.E.); (B.C.); (C.N.); (B.S.)
- Center for Mind, Brain and Behavior (CMBB), 35043 Marburg, Germany
| | - Benjamin Saß
- Department of Neurosurgery, University of Marburg, Baldingerstrasse, 35043 Marburg, Germany; (J.E.); (B.C.); (C.N.); (B.S.)
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18
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Oh K, Oh IS, Le VNT, Lee DW. Deep Anatomical Context Feature Learning for Cephalometric Landmark Detection. IEEE J Biomed Health Inform 2021; 25:806-817. [PMID: 32750939 DOI: 10.1109/jbhi.2020.3002582] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
In the past decade, anatomical context features have been widely used for cephalometric landmark detection and significant progress is still being made. However, most existing methods rely on handcrafted graphical models rather than incorporating anatomical context during training, leading to suboptimal performance. In this study, we present a novel framework that allows a Convolutional Neural Network (CNN) to learn richer anatomical context features during training. Our key idea consists of the Local Feature Perturbator (LFP) and the Anatomical Context loss (AC loss). When training the CNN, the LFP perturbs a cephalometric image based on prior anatomical distribution, forcing the CNN to gaze relevant features more globally. Then AC loss helps the CNN to learn the anatomical context based on spatial relationships between the landmarks. The experimental results demonstrate that the proposed framework makes the CNN learn richer anatomical representation, leading to increased performance. In the performance comparisons, the proposed scheme outperforms state-of-the-art methods on the ISBI 2015 Cephalometric X-ray Image Analysis Challenge.
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19
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Ille S, Schroeder A, Wagner A, Negwer C, Kreiser K, Meyer B, Krieg SM. Intraoperative MRI-based elastic fusion for anatomically accurate tractography of the corticospinal tract: correlation with intraoperative neuromonitoring and clinical status. Neurosurg Focus 2021; 50:E9. [PMID: 33386010 DOI: 10.3171/2020.10.focus20774] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Accepted: 10/26/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Tractography is a useful technique that is standardly applied to visualize subcortical pathways. However, brain shift hampers tractography use during the course of surgery. While intraoperative MRI (ioMRI) has been shown to be beneficial for use in oncology, intraoperative tractography can rarely be performed due to scanner, protocol, or head clamp limitations. Elastic fusion (EF), however, enables adjustment for brain shift of preoperative imaging and even tractography based on intraoperative images. The authors tested the hypothesis that adjustment of tractography by ioMRI-based EF (IBEF) correlates with the results of intraoperative neuromonitoring (IONM) and clinical outcome and is therefore a reliable method. METHODS In 304 consecutive patients treated between June 2018 and March 2020, 8 patients, who made up the basic study cohort, showed an intraoperative loss of motor evoked potentials (MEPs) during motor-eloquent glioma resection for a subcortical lesion within the corticospinal tract (CST) as shown by ioMRI. The authors preoperatively visualized the CST using tractography. Also, IBEFs of pre- and intraoperative images were obtained and the location of the CST was compared in relation to a subcortical lesion. In 11 patients (8 patients with intraoperative loss of MEPs, one of whom also showed loss of MEPs on IBEF evaluation, plus 3 additional patients with loss of MEPs on IBEF evaluation), the authors examined the location of the CST by direct subcortical stimulation (DSCS). The authors defined the IONM results and the functional outcome data as ground truth for analysis. RESULTS The maximum mean ± SD correction was 8.8 ± 2.9 (range 3.8-12.0) mm for the whole brain and 5.3 ± 2.4 (range 1.2-8.7) mm for the CST. The CST was located within the lesion before IBEF in 3 cases and after IBEF in all cases (p = 0.0256). All patients with intraoperative loss of MEPs suffered from surgery-related permanent motor deficits. By approximation, the location of the CST after IBEF could be verified by DSCS in 4 cases. CONCLUSIONS The present study shows that tractography after IBEF accurately correlates with IONM and patient outcomes and thus demonstrates reliability in this initial study.
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Affiliation(s)
- Sebastian Ille
- 1Department of Neurosurgery.,2TUM Neuroimaging Center, and
| | - Axel Schroeder
- 1Department of Neurosurgery.,2TUM Neuroimaging Center, and
| | - Arthur Wagner
- 1Department of Neurosurgery.,2TUM Neuroimaging Center, and
| | | | - Kornelia Kreiser
- 3Department of Diagnostic and Interventional Neuroradiology, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Munich, Germany
| | | | - Sandro M Krieg
- 1Department of Neurosurgery.,2TUM Neuroimaging Center, and
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Tuncer MS, Salvati LF, Grittner U, Hardt J, Schilling R, Bährend I, Silva LL, Fekonja LS, Faust K, Vajkoczy P, Rosenstock T, Picht T. Towards a tractography-based risk stratification model for language area associated gliomas. NEUROIMAGE-CLINICAL 2020; 29:102541. [PMID: 33401138 PMCID: PMC7785953 DOI: 10.1016/j.nicl.2020.102541] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 12/04/2020] [Accepted: 12/20/2020] [Indexed: 12/26/2022]
Abstract
Injury to major white matter pathways during language-area associated glioma surgery often results in permanent aphasia. DTI-based tractography of language pathways allows to correlate individual tract injury profiles with functional outcome. Infiltration of the AF is particularly associated with functional deterioration. The temporo-parieto-occipital junction and the temporal stem were confirmed as pivotal functional nodes. Standardized DTI-based tractography can help to determine the individual aphasia risk profile before surgery.
Objectives Injury to major white matter pathways during language-area associated glioma surgery often leads to permanent loss of neurological function. The aim was to establish standardized tractography of language pathways as a predictor of language outcome in clinical neurosurgery. Methods We prospectively analyzed 50 surgical cases of patients with left perisylvian, diffuse gliomas. Standardized preoperative Diffusion-Tensor-Imaging (DTI)-based tractography of the 5 main language tracts (Arcuate Fasciculus [AF], Frontal Aslant Tract [FAT], Inferior Fronto-Occipital Fasciculus [IFOF], Inferior Longitudinal Fasciculus [ILF], Uncinate Fasciculus [UF]) and spatial analysis of tumor and tracts was performed. Postoperative imaging and the resulting resection map were analyzed for potential surgical injury of tracts. The language status was assessed preoperatively, postoperatively and after 3 months using the Aachen Aphasia Test and Berlin Aphasia Score. Correlation analyses, two-step cluster analysis and binary logistic regression were used to analyze associations of tractography results with language outcome after surgery. Results In 14 out of 50 patients (28%), new aphasic symptoms were detected 3 months after surgery. The preoperative infiltration of the AF was associated with functional worsening (cc = 0.314; p = 0.019). Cluster analysis of tract injury profiles revealed two areas particularly related to aphasia: the temporo-parieto-occipital junction (TPO; temporo-parietal AF, middle IFOF, middle ILF) and the temporal stem/peri-insular white matter (middle IFOF, anterior ILF, temporal UF, temporal AF). Injury to these areas (TPO: OR: 23.04; CI: 4.11 – 129.06; temporal stem: OR: 21.96; CI: 2.93 – 164.41) was associated with a higher-risk of persisting aphasia. Conclusions Tractography of language pathways can help to determine the individual aphasia risk profile pre-surgically. The TPO and temporal stem/peri-insular white matter were confirmed as functional nodes particularly sensitive to surgical injuries.
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Affiliation(s)
- Mehmet Salih Tuncer
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | | | - Ulrike Grittner
- Institute of Biometry and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Berlin, Germany; Berlin Institute of Health (BIH), Anna-Louisa-Karsch-Str. 2, 10178 Berlin, Germany
| | - Juliane Hardt
- Institute of Biometry and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Berlin, Germany; Berlin Institute of Health (BIH), Anna-Louisa-Karsch-Str. 2, 10178 Berlin, Germany; Hochschule Hannover - University of Applied Sciences and Arts, Fakultät III, Department Information and Communication, Medical Information Management, Hannover, Germany
| | - Ralph Schilling
- Institute of Biometry and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Berlin, Germany; Berlin Institute of Health (BIH), Anna-Louisa-Karsch-Str. 2, 10178 Berlin, Germany
| | - Ina Bährend
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany; Department of Neurosurgery, Vivantes-Klinikum Neukölln, Berlin, Germany
| | - Luca Leandro Silva
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany; Department of Anaesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Lucius S Fekonja
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany; Cluster of Excellence: "Matters of Activity. Image Space Material", Humboldt University, Berlin, Germany
| | - Katharina Faust
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Tizian Rosenstock
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany; Berlin Institute of Health (BIH), Anna-Louisa-Karsch-Str. 2, 10178 Berlin, Germany.
| | - Thomas Picht
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany; Cluster of Excellence: "Matters of Activity. Image Space Material", Humboldt University, Berlin, Germany
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Ille S, Krieg SM. Functional Mapping for Glioma Surgery, Part 1: Preoperative Mapping Tools. Neurosurg Clin N Am 2020; 32:65-74. [PMID: 33223027 DOI: 10.1016/j.nec.2020.08.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Although intraoperative mapping of brain areas was shown to promote greater extent of resection and reduce functional deficits, this was shown only recently for some noninvasive techniques. Yet, proper surgical planning, indication, and patient consultation require reliable noninvasive techniques. Because functional magnetic resonance imaging, tractography, and neurophysiologic methods like navigated transcranial magnetic stimulation and magnetoencephalography allow identifying eloquent areas prior to resective surgery and tailor the surgical approach, this article provides an overview on the individual strengths and limitations of each modality.
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Affiliation(s)
- Sebastian Ille
- Department of Neurosurgery, Technical University of Munich, Germany, School of Medicine, Klinikum rechts der Isar, Ismaninger Strasse 22, Munich 81675, Germany
| | - Sandro M Krieg
- Department of Neurosurgery, Technical University of Munich, Germany, School of Medicine, Klinikum rechts der Isar, Ismaninger Strasse 22, Munich 81675, Germany.
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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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