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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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Sharma M, Plou PL, Gunawan K, Ivan M, Chen CC. Survey Assessment of Utility in Preoperative Magnetic Resonance (MR) Tractography Surgical Planning. World Neurosurg 2023; 180:e468-e473. [PMID: 37774789 DOI: 10.1016/j.wneu.2023.09.091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 09/20/2023] [Accepted: 09/21/2023] [Indexed: 10/01/2023]
Abstract
BACKGROUND Although tractography-guided surgery is used by many surgeons, there is controversy in the published literature as it relates to its clinical utility. Here we adopted a survey-based approach with the goal of attaining a broader view of how tractography influence preoperative planning in a sampling of practicing neurosurgeons. METHODS Three cases were prepared where the presence of a tumor distorted the optic radiation (case 1), arcuate fasciculus (case 2), and corticospinal tract (case 3). This survey was administered at the Medtronic Cranial Consortium attended by 20 practicing neurosurgeons. To avoid commercial bias, we used both the Brainlab and Medtronic platform to compute tractography. Each participant is asked to vote on a surgical trajectory before and after seeing the tractography images, as well as whether tractography added value in validating their surgical approach. RESULTS In the 3 cases surveyed, 16%-44% of the surgeons changed the surgical corridor selected after seeing the tractography images. The most common finding associated with a change in surgical corridor involved intersection of the surgical corridor with visualized tracts. Consistently, >80% of the surgeons surveyed felt that tractography added value in their surgical planning. CONCLUSIONS The clinical utility of tractography in preoperative planning varies as a function of surgeon and the tumor anatomy, with >80% of the participating surgeons believing that tractography added value in preoperative surgical planning.
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Affiliation(s)
- Mayur Sharma
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Pedro L Plou
- Neurosurgery Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Kevin Gunawan
- Department of Neurosurgery, Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia
| | - Michael Ivan
- Department of Neurosurgery, University of Miami, Miller SOM, Miami, Florida, USA
| | - Clark C Chen
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA.
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Campbell JM, Habibalahi A, Handley S, Agha A, Mahbub SB, Anwer AG, Goldys EM. Emerging clinical applications in oncology for non-invasive multi- and hyperspectral imaging of cell and tissue autofluorescence. JOURNAL OF BIOPHOTONICS 2023; 16:e202300105. [PMID: 37272291 DOI: 10.1002/jbio.202300105] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 05/02/2023] [Accepted: 05/16/2023] [Indexed: 06/06/2023]
Abstract
Hyperspectral and multispectral imaging of cell and tissue autofluorescence is an emerging technology in which fluorescence imaging is applied to biological materials across multiple spectral channels. This produces a stack of images where each matched pixel contains information about the sample's spectral properties at that location. This allows precise collection of molecularly specific data from a broad range of native fluorophores. Importantly, complex information, directly reflective of biological status, is collected without staining and tissues can be characterised in situ, without biopsy. For oncology, this can spare the collection of biopsies from sensitive regions and enable accurate tumour mapping. For in vivo tumour analysis, the greatest focus has been on oral cancer, whereas for ex vivo assessment head-and-neck cancers along with colon cancer have been the most studied, followed by oral and eye cancer. This review details the scope and progress of research undertaken towards clinical translation in oncology.
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Affiliation(s)
- Jared M Campbell
- Graduate School of Biomedical Engineering, University of New South Wales, Sydney, New South Wales, Australia
- Australian Research Council Centre of Excellence for Nanoscale BioPhotonics, The University of Adelaide, Adelaide, South Australia, Australia
| | - Abbas Habibalahi
- Graduate School of Biomedical Engineering, University of New South Wales, Sydney, New South Wales, Australia
- Australian Research Council Centre of Excellence for Nanoscale BioPhotonics, The University of Adelaide, Adelaide, South Australia, Australia
| | - Shannon Handley
- Graduate School of Biomedical Engineering, University of New South Wales, Sydney, New South Wales, Australia
- Australian Research Council Centre of Excellence for Nanoscale BioPhotonics, The University of Adelaide, Adelaide, South Australia, Australia
| | - Adnan Agha
- Graduate School of Biomedical Engineering, University of New South Wales, Sydney, New South Wales, Australia
- Australian Research Council Centre of Excellence for Nanoscale BioPhotonics, The University of Adelaide, Adelaide, South Australia, Australia
| | - Saabah B Mahbub
- Graduate School of Biomedical Engineering, University of New South Wales, Sydney, New South Wales, Australia
- Australian Research Council Centre of Excellence for Nanoscale BioPhotonics, The University of Adelaide, Adelaide, South Australia, Australia
| | - Ayad G Anwer
- Graduate School of Biomedical Engineering, University of New South Wales, Sydney, New South Wales, Australia
- Australian Research Council Centre of Excellence for Nanoscale BioPhotonics, The University of Adelaide, Adelaide, South Australia, Australia
| | - Ewa M Goldys
- Graduate School of Biomedical Engineering, University of New South Wales, Sydney, New South Wales, Australia
- Australian Research Council Centre of Excellence for Nanoscale BioPhotonics, The University of Adelaide, Adelaide, South Australia, Australia
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4
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Ius T, Sabatino G, Panciani PP, Fontanella MM, Rudà R, Castellano A, Barbagallo GMV, Belotti F, Boccaletti R, Catapano G, Costantino G, Della Puppa A, Di Meco F, Gagliardi F, Garbossa D, Germanò AF, Iacoangeli M, Mortini P, Olivi A, Pessina F, Pignotti F, Pinna G, Raco A, Sala F, Signorelli F, Sarubbo S, Skrap M, Spena G, Somma T, Sturiale C, Angileri FF, Esposito V. Surgical management of Glioma Grade 4: technical update from the neuro-oncology section of the Italian Society of Neurosurgery (SINch®): a systematic review. J Neurooncol 2023; 162:267-293. [PMID: 36961622 PMCID: PMC10167129 DOI: 10.1007/s11060-023-04274-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 02/20/2023] [Indexed: 03/25/2023]
Abstract
PURPOSE The extent of resection (EOR) is an independent prognostic factor for overall survival (OS) in adult patients with Glioma Grade 4 (GG4). The aim of the neuro-oncology section of the Italian Society of Neurosurgery (SINch®) was to provide a general overview of the current trends and technical tools to reach this goal. METHODS A systematic review was performed. The results were divided and ordered, by an expert team of surgeons, to assess the Class of Evidence (CE) and Strength of Recommendation (SR) of perioperative drugs management, imaging, surgery, intraoperative imaging, estimation of EOR, surgery at tumor progression and surgery in elderly patients. RESULTS A total of 352 studies were identified, including 299 retrospective studies and 53 reviews/meta-analysis. The use of Dexamethasone and the avoidance of prophylaxis with anti-seizure medications reached a CE I and SR A. A preoperative imaging standard protocol was defined with CE II and SR B and usefulness of an early postoperative MRI, with CE II and SR B. The EOR was defined the strongest independent risk factor for both OS and tumor recurrence with CE II and SR B. For intraoperative imaging only the use of 5-ALA reached a CE II and SR B. The estimation of EOR was established to be fundamental in planning postoperative adjuvant treatments with CE II and SR B and the stereotactic image-guided brain biopsy to be the procedure of choice when an extensive surgical resection is not feasible (CE II and SR B). CONCLUSIONS A growing number of evidences evidence support the role of maximal safe resection as primary OS predictor in GG4 patients. The ongoing development of intraoperative techniques for a precise real-time identification of peritumoral functional pathways enables surgeons to maximize EOR minimizing the post-operative morbidity.
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Affiliation(s)
- Tamara Ius
- Division of Neurosurgery, Head-Neck and NeuroScience Department, University Hospital of Udine, Udine, Italy
| | - Giovanni Sabatino
- Institute of Neurosurgery, Fondazione Policlinico Gemelli, Catholic University, Rome, Italy
- Unit of Neurosurgery, Mater Olbia Hospital, Olbia, Italy
| | - Pier Paolo Panciani
- Division of Neurosurgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy.
| | - Marco Maria Fontanella
- Department of Neuro-Oncology, University of Turin and City of Health and Science Hospital, 10094, Torino, Italy
| | - Roberta Rudà
- Department of Neuro-Oncology, University of Turin and City of Health and Science Hospital, 10094, Torino, Italy
- Neurology Unit, Hospital of Castelfranco Veneto, 31033, Castelfranco Veneto, Italy
| | - Antonella Castellano
- Department of Neuroradiology, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Giuseppe Maria Vincenzo Barbagallo
- Department of Medical and Surgical Sciences and Advanced Technologies (G.F. Ingrassia), Neurological Surgery, Policlinico "G. Rodolico - San Marco" University Hospital, University of Catania, Catania, Italy
- Interdisciplinary Research Center On Brain Tumors Diagnosis and Treatment, University of Catania, Catania, Italy
| | - Francesco Belotti
- Division of Neurosurgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | | | - Giuseppe Catapano
- Division of Neurosurgery, Department of Neurological Sciences, Ospedale del Mare, Naples, Italy
| | | | - Alessandro Della Puppa
- Neurosurgical Clinical Department of Neuroscience, Psychology, Pharmacology and Child Health, Careggi Hospital, University of Florence, Florence, Italy
| | - Francesco Di Meco
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Johns Hopkins Medical School, Baltimore, MD, USA
| | - Filippo Gagliardi
- Department of Neurosurgery and Gamma Knife Radiosurgery, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Diego Garbossa
- Department of Neuroscience "Rita Levi Montalcini," Neurosurgery Unit, University of Turin, Torino, Italy
| | | | - Maurizio Iacoangeli
- Department of Neurosurgery, Università Politecnica Delle Marche, Azienda Ospedali Riuniti, Ancona, Italy
| | - Pietro Mortini
- Department of Neurosurgery and Gamma Knife Radiosurgery, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | | | - Federico Pessina
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090, Milan, Italy
- Neurosurgery Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Milan, Italy
| | - Fabrizio Pignotti
- Institute of Neurosurgery, Fondazione Policlinico Gemelli, Catholic University, Rome, Italy
- Unit of Neurosurgery, Mater Olbia Hospital, Olbia, Italy
| | - Giampietro Pinna
- Unit of Neurosurgery, Department of Neurosciences, Hospital Trust of Verona, 37134, Verona, Italy
| | - Antonino Raco
- Division of Neurosurgery, Department of NESMOS, AOU Sant'Andrea, Sapienza University, Rome, Italy
| | - Francesco Sala
- Department of Neurosciences, Biomedicines and Movement Sciences, Institute of Neurosurgery, University of Verona, 37134, Verona, Italy
| | - Francesco Signorelli
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, Neurosurgery Unit, University "Aldo Moro", 70124, Bari, Italy
| | - Silvio Sarubbo
- Department of Neurosurgery, Santa Chiara Hospital, Azienda Provinciale Per I Servizi Sanitari (APSS), Trento, Italy
| | - Miran Skrap
- Division of Neurosurgery, Head-Neck and NeuroScience Department, University Hospital of Udine, Udine, Italy
| | | | - Teresa Somma
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università Degli Studi Di Napoli Federico II, Naples, Italy
| | | | | | - Vincenzo Esposito
- Department of Neurosurgery "Giampaolo Cantore"-IRCSS Neuromed, Pozzilli, Italy
- Department of Human, Neurosciences-"Sapienza" University of Rome, Rome, Italy
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Yang Z, Zhao C, Zong S, Piao J, Zhao Y, Chen X. A review on surgical treatment options in gliomas. Front Oncol 2023; 13:1088484. [PMID: 37007123 PMCID: PMC10061125 DOI: 10.3389/fonc.2023.1088484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 02/24/2023] [Indexed: 03/17/2023] Open
Abstract
Gliomas are one of the most common primary central nervous system tumors, and surgical treatment remains the principal role in the management of any grade of gliomas. In this study, based on the introduction of gliomas, we review the novel surgical techniques and technologies in support of the extent of resection to achieve long-term disease control and summarize the findings on how to keep the balance between cytoreduction and neurological morbidity from a list of literature searched. With modern neurosurgical techniques, gliomas resection can be safely performed with low morbidity and extraordinary long-term functional outcomes.
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Affiliation(s)
- Zhongxi Yang
- Department of Neurosurgery, The First Hospital of Jilin University, Jilin, China
| | - Chen Zhao
- Department of Neurosurgery, The First Hospital of Jilin University, Jilin, China
| | - Shan Zong
- Department of Gynecology Oncology, The First Hospital of Jilin University, Jilin, China
| | - Jianmin Piao
- Department of Neurosurgery, The First Hospital of Jilin University, Jilin, China
| | - Yuhao Zhao
- Department of Neurosurgery, The First Hospital of Jilin University, Jilin, China
| | - Xuan Chen
- Department of Neurosurgery, The First Hospital of Jilin University, Jilin, China
- *Correspondence: Xuan Chen,
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Lalgudi Srinivasan H, Pedro Lavrador J, Tambirajoo K, Pang G, Patel S, Gullan R, Vergani F, Bhangoo R, Shapey J, Vasan AK, Ashkan K. Tractography-Enhanced Biopsy of Central Core Motor Eloquent Tumours: A Simulation-Based Study. J Pers Med 2023; 13:jpm13030467. [PMID: 36983649 PMCID: PMC10051818 DOI: 10.3390/jpm13030467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 02/25/2023] [Accepted: 02/27/2023] [Indexed: 03/08/2023] Open
Abstract
Safe Trajectory planning for navigation guided biopsy (nBx) of motor eloquent tumours (METs) is important to minimise neurological morbidity. Preliminary clinical data suggest that visualisation of the corticospinal tract (CST) and its relation to the tumour may aid in planning a safe trajectory. In this article we assess the impact of tractography in nBx planning in a simulation-based exercise. This single centre cross-sectional study was performed in March 2021 including 10 patients with METs divided into 2 groups: (1) tractography enhanced group (T-nBx; n = 5; CST merged with volumetric MRI); (2) anatomy-based group (A-nBx; n = 5; volumetric MRI only). A biopsy target was chosen on each tumour. Volunteer neurosurgical trainees had to plan a suitable biopsy trajectory on a Stealth S8® workstation for all patients in a single session. A trajectory safety index (TSI) was devised for each trajectory. Data collection and analysis included a comparison of trajectory planning time, trajectory/lobe changes and TSI. A total of 190 trajectories were analysed based on participation from 19 trainees. Mean trajectory planning time for the entire cohort was 225.1 ± 21.97 s. T-nBx required shorter time for planning (p = 0.01). Mean trajectory changes and lobe changes made per biopsy were 3.28 ± 0.29 and 0.45 ± 0.08, respectively. T-nBx required fewer trajectory/lobe changes (p = 0.01). TSI was better in the presence of tractography than A-nBx (p = 0.04). Neurosurgical experience of trainees had no significant impact on the measured parameters despite adjusted analysis. Irrespective of the level of neurosurgical training, surgical planning of navigation guided biopsy for METs may be achieved in less time with a safer trajectory if tractography imaging is available.
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Affiliation(s)
| | - Jose Pedro Lavrador
- Department of Neurosurgery, King’s College Hospital, London SE5 9RS, UK
- King’s NeuroLab, King’s College Hospital, London WC2R 2LS, UK
| | | | - Graeme Pang
- Department of Neurosurgery, King’s College Hospital, London SE5 9RS, UK
| | - Sabina Patel
- Department of Neurosurgery, King’s College Hospital, London SE5 9RS, UK
| | - Richard Gullan
- Department of Neurosurgery, King’s College Hospital, London SE5 9RS, UK
| | - Francesco Vergani
- Department of Neurosurgery, King’s College Hospital, London SE5 9RS, UK
| | - Ranjeev Bhangoo
- Department of Neurosurgery, King’s College Hospital, London SE5 9RS, UK
| | - Jonathan Shapey
- Department of Neurosurgery, King’s College Hospital, London SE5 9RS, UK
- King’s NeuroLab, King’s College Hospital, London WC2R 2LS, UK
- Department of Surgical Intervention and Engineering, School of Biomedical Engineering and Imaging Sciences, King’s College London, London WC2R 2LS, UK
| | - Ahilan Kailaya Vasan
- Department of Neurosurgery, King’s College Hospital, London SE5 9RS, UK
- King’s NeuroLab, King’s College Hospital, London WC2R 2LS, UK
| | - Keyoumars Ashkan
- Department of Neurosurgery, King’s College Hospital, London SE5 9RS, UK
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Prediction of the Topography of the Corticospinal Tract on T1-Weighted MR Images Using Deep-Learning-Based Segmentation. Diagnostics (Basel) 2023; 13:diagnostics13050911. [PMID: 36900055 PMCID: PMC10000710 DOI: 10.3390/diagnostics13050911] [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: 01/29/2023] [Revised: 02/23/2023] [Accepted: 02/27/2023] [Indexed: 03/04/2023] Open
Abstract
INTRODUCTION Tractography is an invaluable tool in the planning of tumor surgery in the vicinity of functionally eloquent areas of the brain as well as in the research of normal development or of various diseases. The aim of our study was to compare the performance of a deep-learning-based image segmentation for the prediction of the topography of white matter tracts on T1-weighted MR images to the performance of a manual segmentation. METHODS T1-weighted MR images of 190 healthy subjects from 6 different datasets were utilized in this study. Using deterministic diffusion tensor imaging, we first reconstructed the corticospinal tract on both sides. After training a segmentation model on 90 subjects of the PIOP2 dataset using the nnU-Net in a cloud-based environment with graphical processing unit (Google Colab), we evaluated its performance using 100 subjects from 6 different datasets. RESULTS Our algorithm created a segmentation model that predicted the topography of the corticospinal pathway on T1-weighted images in healthy subjects. The average dice score was 0.5479 (0.3513-0.7184) on the validation dataset. CONCLUSIONS Deep-learning-based segmentation could be applicable in the future to predict the location of white matter pathways in T1-weighted scans.
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Yao S, Yang R, Du C, Jiang C, Wang Y, Peng C, Bai H. Maximal safe resection of diffuse lower grade gliomas primarily within central lobe using cortical/subcortical direct electrical stimulation under awake craniotomy. Front Oncol 2023; 13:1089139. [PMID: 36895476 PMCID: PMC9990258 DOI: 10.3389/fonc.2023.1089139] [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: 11/03/2022] [Accepted: 02/07/2023] [Indexed: 02/23/2023] Open
Abstract
Background Diffuse lower-grade glioma (DLGG) in the central lobe is a challenge for safe resection procedures. To improve the extent of resection and reduce the risk of postoperative neurological deficits, we performed an awake craniotomy with cortical-subcortical direct electrical stimulation (DES) mapping for patients with DLGG located primarily within the central lobe. We investigated the outcomes of cortical-subcortical brain mapping using DES in an awake craniotomy for central lobe DLGG resection. Methods We performed a retrospective analysis of clinical data of a cohort of consecutively treated patients from February 2017 to August 2021 with diffuse lower-grade gliomas located primarily within the central lobe. All patients underwent awake craniotomy with DES for cortical and subcortical mapping of eloquent brain areas, neuronavigation, and/or ultrasound to identify tumor location. Tumors were removed according to functional boundaries. Maximum safe tumor resection was the surgical objective for all patients. Results Thirteen patients underwent 15 awake craniotomies with intraoperative mapping of eloquent cortices and subcortical fibers using DES. Maximum safe tumor resection was achieved according to functional boundaries in all patients. The pre-operative tumor volumes ranged from 4.3 cm3 to 137.3 cm3 (median 19.2 cm3). The mean extent of tumor resection was 94.6%, with eight cases (53.3%) achieving total resection, four (26.7%) subtotal and three (20.0%) partial. The mean tumor residue was 1.2 cm3. All patients experienced early postoperative neurological deficits or worsening conditions. Three patients (20.0%) experienced late postoperative neurological deficits at the 3-month follow-up, including one moderate and two mild neurological deficits. None of the patients experienced late onset severe neurological impairments post-operatively. Ten patients with 12 tumor resections (80.0%) had resumed activities of daily living at the 3-month follow-up. Among 14 patients with pre-operative epilepsy, 12 (85.7%) were seizure-free after treatment with antiepileptic drugs 7 days after surgery up to the last follow-up. Conclusions DLGG located primarily in the central lobe deemed inoperable can be safely resected using awake craniotomy with intraoperative DES without severe permanent neurological sequelae. Patients experienced an improved quality of life in terms of seizure control.
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Affiliation(s)
- Shujing Yao
- Department of Neurosurgery, General Hospital of Southern Theater Command of PLA, Guangzhou, China
| | - Ruixin Yang
- Department of Neurosurgery, General Hospital of Southern Theater Command of PLA, Guangzhou, China
| | - Chenggang Du
- Department of Neurosurgery, General Hospital of Southern Theater Command of PLA, Guangzhou, China
| | - Che Jiang
- Department of Neurosurgery, General Hospital of Southern Theater Command of PLA, Guangzhou, China
| | - Yang Wang
- Department of Neurosurgery, General Hospital of Southern Theater Command of PLA, Guangzhou, China
| | - Chongqi Peng
- Department of Neurosurgery, General Hospital of Southern Theater Command of PLA, Guangzhou, China
| | - Hongmin Bai
- Department of Neurosurgery, General Hospital of Southern Theater Command of PLA, Guangzhou, China
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9
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Yang JYM, Chen J, Alexander B, Schilling K, Kean M, Wray A, Seal M, Maixner W, Beare R. Assessment of intraoperative diffusion EPI distortion and its impact on estimation of supratentorial white matter tract positions in pediatric epilepsy surgery. Neuroimage Clin 2022; 35:103097. [PMID: 35759887 PMCID: PMC9250069 DOI: 10.1016/j.nicl.2022.103097] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 05/18/2022] [Accepted: 06/20/2022] [Indexed: 10/26/2022]
Abstract
The effectiveness of correcting diffusion Echo Planar Imaging (EPI) distortion and its impact on tractography reconstruction have not been adequately investigated in the intraoperative MRI setting, particularly for High Angular Resolution Diffusion Imaging (HARDI) acquisition. In this study, we evaluated the effectiveness of EPI distortion correction using 27 legacy intraoperative HARDI datasets over two consecutive surgical time points, acquired without reverse phase-encoded data, from 17 children who underwent epilepsy surgery at our institution. The data was processed with EPI distortion correction using the Synb0-Disco technique (Schilling et al., 2019) and without distortion correction. The corrected and uncorrected b0 diffusion-weighted images (DWI) were first compared visually. The mutual information indices between the original T1-weighted images and the fractional anisotropy images derived from corrected and uncorrected DWI were used to quantify the effect of distortion correction. Sixty-four white matter tracts were segmented from each dataset, using a deep-learning based automated tractography algorithm for the purpose of a standardized and unbiased evaluation. Displacement was calculated between tracts generated before and after distortion correction. The tracts were grouped based on their principal morphological orientations to investigate whether the effects of EPI distortion vary with tract orientation. Group differences in tract distortion were investigated both globally, and regionally with respect to proximity to the resecting lesion in the operative hemisphere. Qualitatively, we observed notable improvement in the corrected diffusion images, over the typically affected brain regions near skull-base air sinuses, and correction of additional distortion unique to intraoperative open cranium images, particularly over the resection site. This improvement was supported quantitatively, as mutual information indices between the FA and T1-weighted images were significantly greater after the correction, compared to before the correction. Maximum tract displacement between the corrected and uncorrected data, was in the range of 7.5 to 10.0 mm, a magnitude that would challenge the safety resection margin typically tolerated for tractography-informed surgical guidance. This was particularly relevant for tracts oriented partially or fully in-line with the acquired diffusion phase-encoded direction. Portions of these tracts passing close to the resection site demonstrated significantly greater magnitude of displacement, compared to portions of tracts remote from the resection site in the operative hemisphere. Our findings have direct clinical implication on the accuracy of intraoperative tractography-informed image guidance and emphasize the need to develop a distortion correction technique with feasible intraoperative processing time.
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Affiliation(s)
- Joseph Yuan-Mou Yang
- Department of Neurosurgery, Neuroscience Advanced Clinical Imaging Service (NACIS), The Royal Children's Hospital, Melbourne, Australia; Developmental Imaging, Murdoch Children's Research Institute, Melbourne, Australia; Neuroscience Research, Murdoch Children's Research Institute, Melbourne, Australia; Department of Paediatrics, The University of Melbourne, Melbourne, Australia.
| | - Jian Chen
- Developmental Imaging, Murdoch Children's Research Institute, Melbourne, Australia
| | - Bonnie Alexander
- Department of Neurosurgery, Neuroscience Advanced Clinical Imaging Service (NACIS), The Royal Children's Hospital, Melbourne, Australia; Developmental Imaging, Murdoch Children's Research Institute, Melbourne, Australia
| | - Kurt Schilling
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Centre, Nashville, USA
| | - Michael Kean
- Developmental Imaging, Murdoch Children's Research Institute, Melbourne, Australia; Department of Paediatrics, The University of Melbourne, Melbourne, Australia; Medical Imaging, The Royal Children's Hospital, Melbourne, Australia
| | - Alison Wray
- Department of Neurosurgery, Neuroscience Advanced Clinical Imaging Service (NACIS), The Royal Children's Hospital, Melbourne, Australia; Neuroscience Research, Murdoch Children's Research Institute, Melbourne, Australia
| | - Marc Seal
- Developmental Imaging, Murdoch Children's Research Institute, Melbourne, Australia; Department of Paediatrics, The University of Melbourne, Melbourne, Australia
| | - Wirginia Maixner
- Department of Neurosurgery, Neuroscience Advanced Clinical Imaging Service (NACIS), The Royal Children's Hospital, Melbourne, Australia; Neuroscience Research, Murdoch Children's Research Institute, Melbourne, Australia
| | - Richard Beare
- Developmental Imaging, Murdoch Children's Research Institute, Melbourne, Australia; Peninsula Clinical School, Faculty of Medicine, Monash University, Melbourne, Australia
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10
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Accurate Preoperative Identification of Motor Speech Area as Termination of Arcuate Fasciculus Depicted by Q-ball Imaging Tractography. World Neurosurg 2022; 164:e764-e771. [PMID: 35595046 DOI: 10.1016/j.wneu.2022.05.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 05/09/2022] [Accepted: 05/10/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Tractography is one way to predict the distribution of cortical functional domains preoperatively. Diffusion tensor tractography (DTT) is commonly used in clinical practice but is known to have limitations in delineating crossed fibers, which can be overcome by q-ball imaging tractography (QBT). In this study, we aimed to compare the reliability of these two methods, based on the spatial correlation between the arcuate fasciculus depicted by tractography and direct cortical stimulation (DCS) during awake surgery. METHODS Fifteen patients with glioma underwent awake surgery with DCS. Tractography was depicted in a 3D computer graphic model preoperatively, which was integrated with the photograph of the actual brain cortex using our novel mixed-reality technology. The termination of the arcuate fasciculus depicted by either DTT or QBT and the results of DCS were compared, and sensitivity and specificity were calculated in speech-associated brain gyri: pars triangularis, pars opercularis, ventral precentral gyrus, and middle frontal gyrus. RESULTS QBT had significantly better sensitivity and lower false positive rate than DTT in the pars orpercularis. The same trend was noted for the other gyri. CONCLUSIONS QBT is more reliable than DTT in identification of the motor speech area and may be clinically useful in brain tumor surgery.
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11
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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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12
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Yeh FC, Irimia A, Bastos DCDA, Golby AJ. Tractography methods and findings in brain tumors and traumatic brain injury. Neuroimage 2021; 245:118651. [PMID: 34673247 PMCID: PMC8859988 DOI: 10.1016/j.neuroimage.2021.118651] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 10/05/2021] [Accepted: 10/11/2021] [Indexed: 12/31/2022] Open
Abstract
White matter fiber tracking using diffusion magnetic resonance imaging (dMRI) provides a noninvasive approach to map brain connections, but improving anatomical accuracy has been a significant challenge since the birth of tractography methods. Utilizing tractography in brain studies therefore requires understanding of its technical limitations to avoid shortcomings and pitfalls. This review explores tractography limitations and how different white matter pathways pose different challenges to fiber tracking methodologies. We summarize the pros and cons of commonly-used methods, aiming to inform how tractography and its related analysis may lead to questionable results. Extending these experiences, we review the clinical utilization of tractography in patients with brain tumors and traumatic brain injury, starting from tensor-based tractography to more advanced methods. We discuss current limitations and highlight novel approaches in the context of these two conditions to inform future tractography developments.
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Affiliation(s)
- Fang-Cheng Yeh
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA; Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
| | - Andrei Irimia
- Ethel Percy Andrus Gerontology Center, Leonard Davis School of Gerontology, University of Southern California, Los Angeles, California, USA; Corwin D. Denney Research Center, Department of Biomedical Engineering, Viterbi School of Engineering, University of Southern California, Los Angeles, California, USA
| | | | - Alexandra J Golby
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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13
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Wu C, Ferreira F, Fox M, Harel N, Hattangadi-Gluth J, Horn A, Jbabdi S, Kahan J, Oswal A, Sheth SA, Tie Y, Vakharia V, Zrinzo L, Akram H. Clinical applications of magnetic resonance imaging based functional and structural connectivity. Neuroimage 2021; 244:118649. [PMID: 34648960 DOI: 10.1016/j.neuroimage.2021.118649] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 09/24/2021] [Accepted: 10/10/2021] [Indexed: 12/23/2022] Open
Abstract
Advances in computational neuroimaging techniques have expanded the armamentarium of imaging tools available for clinical applications in clinical neuroscience. Non-invasive, in vivo brain MRI structural and functional network mapping has been used to identify therapeutic targets, define eloquent brain regions to preserve, and gain insight into pathological processes and treatments as well as prognostic biomarkers. These tools have the real potential to inform patient-specific treatment strategies. Nevertheless, a realistic appraisal of clinical utility is needed that balances the growing excitement and interest in the field with important limitations associated with these techniques. Quality of the raw data, minutiae of the processing methodology, and the statistical models applied can all impact on the results and their interpretation. A lack of standardization in data acquisition and processing has also resulted in issues with reproducibility. This limitation has had a direct impact on the reliability of these tools and ultimately, confidence in their clinical use. Advances in MRI technology and computational power as well as automation and standardization of processing methods, including machine learning approaches, may help address some of these issues and make these tools more reliable in clinical use. In this review, we will highlight the current clinical uses of MRI connectomics in the diagnosis and treatment of neurological disorders; balancing emerging applications and technologies with limitations of connectivity analytic approaches to present an encompassing and appropriate perspective.
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Affiliation(s)
- Chengyuan Wu
- Department of Neurological Surgery, Vickie and Jack Farber Institute for Neuroscience, Thomas Jefferson University, 909 Walnut Street, Third Floor, Philadelphia, PA 19107, USA; Jefferson Integrated Magnetic Resonance Imaging Center, Department of Radiology, Thomas Jefferson University, 909 Walnut Street, First Floor, Philadelphia, PA 19107, USA.
| | - Francisca Ferreira
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, 33 Queen Square, London WC1N 3BG, UK; Unit of Functional Neurosurgery, UCL Queen Square Institute of Neurology, 33 Queen Square, London WC1N 3BG, UK.
| | - Michael Fox
- Center for Brain Circuit Therapeutics, Departments of Neurology, Psychiatry, Radiology, and Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA 02115, USA.
| | - Noam Harel
- Center for Magnetic Resonance Research, University of Minnesota, 2021 Sixth Street S.E., Minneapolis, MN 55455, USA.
| | - Jona Hattangadi-Gluth
- Department of Radiation Medicine and Applied Sciences, Center for Precision Radiation Medicine, University of California, San Diego, 3855 Health Sciences Drive, La Jolla, CA 92037, USA.
| | - Andreas Horn
- Neurology Department, Movement Disorders and Neuromodulation Section, Charité - University Medicine Berlin, Charitéplatz 1, D-10117, Berlin, Germany.
| | - Saad Jbabdi
- Wellcome Centre for Integrative Neuroimaging, Centre for Functional MRI of the Brain, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford OX3 9DU, UK.
| | - Joshua Kahan
- Department of Neurology, Weill Cornell Medicine, 525 East 68th Street, New York, NY, 10065, USA.
| | - Ashwini Oswal
- Medical Research Council Brain Network Dynamics Unit, University of Oxford, Mansfield Rd, Oxford OX1 3TH, UK.
| | - Sameer A Sheth
- Department of Neurosurgery, Baylor College of Medicine, 7200 Cambridge, Ninth Floor, Houston, TX 77030, USA.
| | - Yanmei Tie
- Center for Brain Circuit Therapeutics, Departments of Neurology, Psychiatry, Radiology, and Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA 02115, USA; Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA 02115, USA.
| | - Vejay Vakharia
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, 33 Queen Square, London WC1N 3BG, UK.
| | - Ludvic Zrinzo
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, 33 Queen Square, London WC1N 3BG, UK; Unit of Functional Neurosurgery, UCL Queen Square Institute of Neurology, 33 Queen Square, London WC1N 3BG, UK.
| | - Harith Akram
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, 33 Queen Square, London WC1N 3BG, UK; Unit of Functional Neurosurgery, UCL Queen Square Institute of Neurology, 33 Queen Square, London WC1N 3BG, UK.
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14
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Luzzi S, Giotta Lucifero A, Martinelli A, Maestro MD, Savioli G, Simoncelli A, Lafe E, Preda L, Galzio R. Supratentorial high-grade gliomas: maximal safe anatomical resection guided by augmented reality high-definition fiber tractography and fluorescein. Neurosurg Focus 2021; 51:E5. [PMID: 34333470 DOI: 10.3171/2021.5.focus21185] [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: 03/26/2021] [Accepted: 05/13/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The theoretical advantages of augmented reality (AR) with diffusion tensor imaging (DTI)-based high-definition fiber tractography (HDFT) and sodium fluorescein (F) in high-grade glioma (HGG) surgery have not been investigated in detail. In this study, the authors aimed to evaluate the safety and efficacy profiles of HDFT-F microscope-based AR cytoreductive surgery for newly diagnosed supratentorial HGGs. METHODS Data of patients with newly diagnosed supratentorial HGGs who underwent surgery using the AR HDFT-F technique were reviewed and compared with those of a cohort of patients who underwent conventional white-light surgery assisted by infrared neuronavigation. The safety and efficacy of the techniques were reported based on the postoperative Neurological Assessment in Neuro-Oncology (NANO) scores, extent of resection (EOR), and Kaplan-Meier curves, respectively. The chi-square test was conducted for categorical variables. A p value < 0.05 was considered statistically significant. RESULTS A total of 54 patients underwent surgery using the AR HDFT-F technique, and 63 underwent conventional white-light surgery assisted by infrared neuronavigation. The mean postoperative NANO scores were 3.8 ± 2 and 5.2 ± 4 in the AR HDFT-F group and control group, respectively (p < 0.05). The EOR was higher in the AR HDFT-F group (p < 0.05) than in the control group. With a mean follow-up of 12.2 months, the rate of progression-free survival (PFS) was longer in the study group (log-rank test, p = 0.006) than in the control group. Moreover, the complication rates were 9.2% and 9.5% in the study and control groups, respectively. CONCLUSIONS Overall, AR HDFT-F-assisted surgery is safe and effective in maximizing the EOR and PFS rate for patients with newly diagnosed supratentorial HGGs, and in optimizing patient functional outcomes.
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Affiliation(s)
- Sabino Luzzi
- 1Neurosurgery Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia.,2Neurosurgery Unit, Department of Surgical Sciences, Fondazione IRCCS Policlinico San Matteo, Pavia
| | - Alice Giotta Lucifero
- 1Neurosurgery Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia
| | - Andrea Martinelli
- 3Department of Science and High Technology, University of Insubria, Como
| | - Mattia Del Maestro
- 4PhD School in Experimental Medicine, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia
| | - Gabriele Savioli
- 4PhD School in Experimental Medicine, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia.,5Emergency Department, IRCCS Policlinico San Matteo, Pavia; and
| | - Anna Simoncelli
- 6Department of Diagnostic Radiology and Interventional Radiology and Neuroradiology, University of Pavia, IRCCS Policlinico San Matteo Foundation, Pavia; and
| | - Elvis Lafe
- 6Department of Diagnostic Radiology and Interventional Radiology and Neuroradiology, University of Pavia, IRCCS Policlinico San Matteo Foundation, Pavia; and
| | - Lorenzo Preda
- 6Department of Diagnostic Radiology and Interventional Radiology and Neuroradiology, University of Pavia, IRCCS Policlinico San Matteo Foundation, Pavia; and
| | - Renato Galzio
- 7Neurosurgery Unit, Maria Cecilia Hospital, Cotignola, Italy
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15
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Yang JYM, Yeh CH, Poupon C, Calamante F. Diffusion MRI tractography for neurosurgery: the basics, current state, technical reliability and challenges. Phys Med Biol 2021; 66. [PMID: 34157706 DOI: 10.1088/1361-6560/ac0d90] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Accepted: 06/22/2021] [Indexed: 01/20/2023]
Abstract
Diffusion magnetic resonance imaging (dMRI) tractography is currently the only imaging technique that allows for non-invasive delineation and visualisation of white matter (WM) tractsin vivo,prompting rapid advances in related fields of brain MRI research in recent years. One of its major clinical applications is for pre-surgical planning and intraoperative image guidance in neurosurgery, where knowledge about the location of WM tracts nearby the surgical target can be helpful to guide surgical resection and optimise post-surgical outcomes. Surgical injuries to these WM tracts can lead to permanent neurological and functional deficits, making the accuracy of tractography reconstructions paramount. The quality of dMRI tractography is influenced by many modifiable factors, ranging from MRI data acquisition through to the post-processing of tractography output, with the potential of error propagation based on decisions made at each and subsequent processing steps. Research over the last 25 years has significantly improved the anatomical accuracy of tractography. An updated review about tractography methodology in the context of neurosurgery is now timely given the thriving research activities in dMRI, to ensure more appropriate applications in the clinical neurosurgical realm. This article aims to review the dMRI physics, and tractography methodologies, highlighting recent advances to provide the key concepts of tractography-informed neurosurgery, with a focus on the general considerations, the current state of practice, technical challenges, potential advances, and future demands to this field.
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Affiliation(s)
- Joseph Yuan-Mou Yang
- Department of Neurosurgery, The Royal Children's Hospital, Melbourne, Australia.,Neuroscience Research, Murdoch Children's Research Institute, Melbourne, Australia.,Developmental Imaging, Murdoch Children's Research Institute, Melbourne, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, Australia
| | - Chun-Hung Yeh
- Institute for Radiological Research, Chang Gung University and Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Department of Child and Adolescent Psychiatry, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
| | - Cyril Poupon
- NeuroSpin, Frédéric Joliot Life Sciences Institute, CEA, CNRS, Paris-Saclay University, Gif-sur-Yvette, France
| | - Fernando Calamante
- The University of Sydney, Sydney Imaging, Sydney, Australia.,The University of Sydney, School of Biomedical Engineering, Sydney, Australia
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16
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Duffau H. Neural Connectivity: How to Reinforce the Bidirectional Synapse Between Basic Neuroscience and Routine Neurosurgical Practice? Front Neurol 2021; 12:705135. [PMID: 34354668 PMCID: PMC8336871 DOI: 10.3389/fneur.2021.705135] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 05/10/2021] [Indexed: 11/29/2022] Open
Affiliation(s)
- Hugues Duffau
- Department of Neurosurgery, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France.,Team "Plasticity of Central Nervous System, Stem Cells and Glial Tumors," National Institute for Health and Medical Research (INSERM), U1191 Laboratory, Institute of Functional Genomics, University of Montpellier, Montpellier, France
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17
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You H, Qiao H. Intraoperative Neuromonitoring During Resection of Gliomas Involving Eloquent Areas. Front Neurol 2021; 12:658680. [PMID: 34248818 PMCID: PMC8260928 DOI: 10.3389/fneur.2021.658680] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 05/18/2021] [Indexed: 11/23/2022] Open
Abstract
In the case of resection of gliomas involving eloquent areas, equal consideration should be given to maintain maximal extent of resection (EOR) and neurological protection, for which the intraoperative neuromonitoring (IONM) proves an effective and admirable approach. IONM techniques applied in clinical practice currently consist of somatosensory evoked potential (SSEP), direct electrical stimulation (DES), motor evoked potential (MEP), electromyography (EMG), and electrocorticography (ECoG). The combined use of DES and ECoG has been adopted widely. With the development of technology, more effective IONM tactics and programs would be proposed. The ultimate goal would be strengthening the localization of eloquent areas and epilepsy foci, reducing the incidence of postoperative dysfunction and epilepsy improving the life quality of patients.
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Affiliation(s)
- Hao You
- Department of Neurophysiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Hui Qiao
- Department of Neurophysiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
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18
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Germann J, Elias GJB, Neudorfer C, Boutet A, Chow CT, Wong EHY, Parmar R, Gouveia FV, Loh A, Giacobbe P, Kim SJ, Jung HH, Bhat V, Kucharczyk W, Chang JW, Lozano AM. Potential optimization of focused ultrasound capsulotomy for obsessive compulsive disorder. Brain 2021; 144:3529-3540. [PMID: 34145884 DOI: 10.1093/brain/awab232] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 02/19/2021] [Accepted: 05/21/2021] [Indexed: 11/13/2022] Open
Abstract
Obsessive-compulsive disorder is a debilitating and often refractory psychiatric disorder. Magnetic resonance-guided focused ultrasound is a novel, minimally invasive neuromodulatory technique that has shown promise in treating this condition. We investigated the relationship between lesion location and long-term outcome in obsessive-compulsive disorder patients treated with focused ultrasound to discern the optimal lesion location and elucidate the efficacious network underlying symptom alleviation. Postoperative images of eleven patients who underwent focused ultrasound capsulotomy were used to correlate lesion characteristics with symptom improvement at one year follow-up. Normative resting-state functional MRI and normative diffusion MRI-based tractography analyses were used to determine the networks associated with successful lesions. Obsessive-compulsive disorder patients treated with inferior thalamic peduncle deep brain stimulation (n = 5) and lesions from the literature implicated in obsessive-compulsive disorder (n = 18) were used for external validation. Successful long-term relief of obsessive-compulsive disorder was associated with lesions that included a specific area in the dorsal anterior limb of the internal capsule. Normative resting-state functional MRI analysis showed that lesion engagement of areas 24 and 46 was significantly associated with clinical outcomes (R = 0.79, p = 0.004). The key role of areas 24 and 46 was confirmed by (1) normative diffusion MRI-based tractography analysis showing that streamlines associated with better outcome projected to these areas, (2) association of these areas with inferior thalamic peduncle deep brain stimulation patients' outcome (R = 0.83, p = 0.003); (3) the connectedness of these areas to obsessive-compulsive disorder-causing lesions, as identified using literature-based lesion network mapping. These results provide considerations for target improvement, outlining the specific area of the internal capsule critical for successful magnetic resonance-guided focused ultrasound outcome and demonstrating that discrete frontal areas are involved in symptom relief. This could help refine focused ultrasound treatment for obsessive-compulsive disorder and provide a network-based rationale for potential alternative targets.
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Affiliation(s)
- Jürgen Germann
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Canada
| | - Gavin J B Elias
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Canada
| | - Clemens Neudorfer
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Canada
| | - Alexandre Boutet
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Canada.,Joint Department of Medical Imaging, University of Toronto, Toronto, Canada
| | - Clement T Chow
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Canada
| | - Emily H Y Wong
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Canada
| | - Roohie Parmar
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Canada
| | - Flavia Venetucci Gouveia
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Aaron Loh
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Canada
| | - Peter Giacobbe
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Se Joo Kim
- Department of Psychiatry, Yonsei University College of Medicine, Seoul, Korea
| | - Hyun Ho Jung
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea
| | - Venkat Bhat
- Centre for Mental Health and Krembil Research Centre, University Health Network, Toronto, Canada
| | - Walter Kucharczyk
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Canada.,Joint Department of Medical Imaging, University of Toronto, Toronto, Canada
| | - Jin Woo Chang
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea
| | - Andres M Lozano
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Canada
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19
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Eichberg DG, Cajigas I. Commentary: A Novel Intraoperative Brain Mapping Integrated Task-Presentation Platform. Oper Neurosurg (Hagerstown) 2021; 20:E340-E341. [PMID: 33548925 DOI: 10.1093/ons/opaa482] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 11/27/2020] [Indexed: 11/14/2022] Open
Affiliation(s)
- Daniel G Eichberg
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Iahn Cajigas
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida
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20
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Rossi M, Sciortino T, Conti Nibali M, Gay L, Viganò L, Puglisi G, Leonetti A, Howells H, Fornia L, Cerri G, Riva M, Bello L. Clinical Pearls and Methods for Intraoperative Motor Mapping. Neurosurgery 2021; 88:457-467. [PMID: 33476393 PMCID: PMC7884143 DOI: 10.1093/neuros/nyaa359] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 04/26/2020] [Indexed: 12/13/2022] Open
Abstract
Resection of brain tumors involving motor areas and pathways requires the identification and preservation of various cortical and subcortical structures involved in motor control at the time of the procedure, in order to maintain the patient's full motor capacities. The use of brain mapping techniques has now been integrated into clinical practice for many years, as they help the surgeon to identify the neural structures involved in motor functions. A common definition of motor function, as well as knowledge of its neural organization, has been continuously evolving, underlining the need for implementing intraoperative strategies at the time of the procedure. Similarly, mapping strategies have been subjected to continuous changes, enhancing the likelihood of preservation of full motor capacities. As a general rule, the motor mapping strategy should be as flexible as possible and adapted strictly to the individual patient and clinical context of the tumor. In this work, we present an overview of current knowledge of motor organization, indications for motor mapping, available motor mapping, and monitoring strategies, as well as their advantages and limitations. The use of motor mapping improves resection and outcomes in patients harboring tumors involving motor areas and pathways, and should be considered the gold standard in the resection of this type of tumor.
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Affiliation(s)
- Marco Rossi
- Neurosurgery , Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milano, Italy
| | - Tommaso Sciortino
- Neurosurgery , Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milano, Italy
| | - Marco Conti Nibali
- Neurosurgery , Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milano, Italy
| | - Lorenzo Gay
- Neurosurgery , Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milano, Italy
| | - Luca Viganò
- Neurosurgery , Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milano, Italy
| | - Guglielmo Puglisi
- Neurosurgery , Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milano, Italy.,Laboratory of Motor Control, Department of Biotechnology and Translational Medicine, Università degli Studi di Milano Milano, Italy
| | - Antonella Leonetti
- Neurosurgery , Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milano, Italy.,Laboratory of Motor Control, Department of Biotechnology and Translational Medicine, Università degli Studi di Milano Milano, Italy
| | - Henrietta Howells
- Laboratory of Motor Control, Department of Biotechnology and Translational Medicine, Università degli Studi di Milano Milano, Italy
| | - Luca Fornia
- Laboratory of Motor Control, Department of Biotechnology and Translational Medicine, Università degli Studi di Milano Milano, Italy
| | - Gabriella Cerri
- Laboratory of Motor Control, Department of Biotechnology and Translational Medicine, Università degli Studi di Milano Milano, Italy
| | - Marco Riva
- Neurosurgery , Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milano, Italy
| | - Lorenzo Bello
- Neurosurgery , Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milano, Italy
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Morsy AA, Ismail AM, Nasr YM, Waly SH, Abdelhameed EA. Predictors of stimulation-induced seizures during perirolandic glioma resection using intraoperative mapping techniques. Surg Neurol Int 2021; 12:117. [PMID: 33880222 PMCID: PMC8053429 DOI: 10.25259/sni_873_2020] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 02/20/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Intraoperative mapping techniques maximize safety and efficacy during perirolandic glioma resection but may induce seizures and limit the procedure. We aim to report the incidence and predictors of stimulation-induced seizures during mapping either patient is awake or under general anesthesia (GA). METHODS Retrospective analysis of 64 patients (40 awake and 24 GA) with perirolandic glioma underwent resection using intraoperative mapping techniques between 2014 and 2019. Preoperative data, operative details, postoperative neurological status, and extent of resection (EOR) were analyzed. Predictors of intraoperative seizures were assessed. RESULTS The mean cortical and subcortical stimulation intensities needed to evoke motor responses were significantly lower in awake cases than in GA patients (4.9 ± 0.42 vs. 8.9 ± 1.2 mA) and (8.3 ± 0.62 vs. 12.1 ± 1.1 mA), respectively (P = 0.01). Incidence of intraoperative seizures was lower but statistically non-significant in awake cases (10% vs. 12.5%) (P = 0.76). Preoperative multiple antiepileptic drugs (AEDs) (P = 0.03) and low-grade glioma (P = 0.04) were statistically significant predictors for intraoperative seizures. Mean EOR in awake cases was 92.03% and 90.05% in GA cases (P = 0.23). Postoperative deficits were permanent after 3 months only in 5% of awake patients versus 8.3% of GA group (P = 0.59). CONCLUSION Awake craniotomy with intraoperative mapping can be done safely for perirolandic gliomas with lower but statistically nonsignificant incidence of intraoperative seizures and this could be attributed to statistically significant lower stimulation intensities required for mapping. Preoperative multiple AEDs and low-grade glioma are significant predictors for intraoperative seizures.
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Affiliation(s)
- Ahmed A Morsy
- Department of Neurosurgery, Zagazig University, Zagazig, Alsharkia, Egypt
| | - Ayman M Ismail
- Department of Neurosurgery, Zagazig University, Zagazig, Alsharkia, Egypt
| | - Yasser M Nasr
- Department of Anesthesia and Surgical Intensive Care, Zagazig University, Zagazig, Alsharkia, Egypt
| | - Salwa H Waly
- Department of Anesthesia and Surgical Intensive Care, Zagazig University, Zagazig, Alsharkia, Egypt
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22
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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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23
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Isolan GR, Campero A, Ajler PM, Farina EM, Frigeri TM, Dini LI. El lóbulo de la ínsula: Parte 2 - anatomía microquirúrgica y correlación clínico-quirúrgica. Surg Neurol Int 2020. [DOI: 10.25259/sni_679_2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Antecedentes:
El conocimiento profundo de la anatomía microquirúrgica del lóbulo de la ínsula es crucial para operar pacientes con tumores en esta región. El objetivo de la segunda parte de este estudio es correlacionar la anatomía microquirúrgica con casos ilustrativos retirados de nuestra casuística de 35 pacientes en los cuales fueron realizados 44 cirugías de tumores en relación con el lóbulo de la ínsula.
Métodos:
A lo largo de marzo de 2007 y agosto de 2014, 44 microcirugías fueron realizadas en 35 pacientes portadores de tumores insulares y los hallazgos de las cirugías y mapeo cerebral se correlacionaron con la anatomía microquirúrgica.
Resultados:
De una serie de 44 pacientes con tumores de la ínsula, la mayoría de los casos eran gliomas de bajo grado de malignidad (29 casos). El inicio de los síntomas en 34 pacientes fue epilepsia, siendo esta refractaria al tratamiento medicamentoso en 12 casos. El grado de resección fue subtotal o total en la mayoría de los casos de la serie. La mejoría en la calidad de vida (epilepsia, etc.) estuvo presente en más de la mitad de los pacientes. El dé cit neurológico permanente estuvo presente en tres pacientes.
Conclusión:
En los tumores insulares, es tan importante el conocimiento profundo de la anatomía, como el saber utilizar e interpretar en tiempo real las observaciones de la monitorización neuro siológica intraoperatoria.
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Affiliation(s)
- Gustavo Rassier Isolan
- Department of Surgery, The Center for Advanced Neurology and Neurosurgery, Porto Alegre, Rio Grande do Sul, Brazil,
| | - Alvaro Campero
- Department of Neurosurgery, Hospital Padila, Country Las Yungas, Yerba Buena, Tucumán,
| | - Pablo Marcelo Ajler
- Department of Neurosurgery, Hospital Italiano de Buenos Aires, Perón, Buenos Aires, Argentina,
| | - Edgar Manuel Farina
- Serviço de Neurocirurgia, Hospital Ministro Costa Cavalcanti Sanatório Le Blanc, Rua Joao Rouver, Foz do Iguaçu, Parana,
| | - Thomas More Frigeri
- Department of Neurosurgery, Pontifical Catholic University of Rio Grande do Sul, Luciana de Abreu, Porto Alegre,
| | - Leandro Infantini Dini
- Department of Neurosurgery, Center for Advanced Neurology and Neurosurgery, São Leopoldo, Rio Grande do Sul, Brazil
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24
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Isolan GR, Campero A, Ajler P, Farina EM, Frigeri TM, Dini LI. Parte I: Anatomía microquirúrgica tridimensional de la ínsula. Surg Neurol Int 2020. [DOI: 10.25259/sni_557_2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Antecedentes:
El lóbulo de la ínsula, o ínsula, se encuentra oculto en la super cie lateral del cerebro. La ínsula está localizada profundamente en el surco lateral o cisura silviana, recubierta por los opérculos frontal, parietal y temporal. Estudiar la compleja anatomía del lóbulo de la ínsula, una de las regiones de mayor complejidad quirúrgica del cerebro humano, y su correlación anatómica con casos quirúrgicos.
Métodos:
En la primera parte de este estudio presentamos los resultados de nuestras disecciones microquirúrgicas en fotografías 2 D y 3D; en la segunda parte de nuestro trabajo, la correlación anatómica con una serie de 44 cirugías en pacientes con tumores de la ínsula, principalmente gliomas, operados entre 2007 y 2014.
Resultados:
Extenso conjunto de bras subcorticales, incluyendo el fascículo uncinado, fronto-occipital inferior y el fascículo arcuato, conectan la ínsula a las regiones vecinas. Varias estructuras anatómicas responsables por dé cits neurológicos severos están íntimamente relacionadas con la cirugía de la ínsula, tales como lesiones de la arteria cerebral Media, cápsula interna, áreas del lenguaje en el hemisferio dominante y arterias lenticuloestriadas.
Conclusión:
El entrenamiento en laboratorio de neuroanatomía, estudio de material impreso en 3D, el conocimiento sobre neuro siología intra-operatoria y el uso de armamento neuroquirúrgico moderno son factores que in uencian en los resultados quirúrgicos.
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Affiliation(s)
- Gustavo Rassier Isolan
- Department of Surgery, Center for Advanced Neurology and Neurosurgery, Porto Alegre, Rio Grande do Sul, Brazil,
| | - Alvaro Campero
- Department of Neurosurgery, Hospital Padilla, Country Las Yungas, Yerba Buena, Tucumuán, Argentina,
| | - Pablo Ajler
- Department of Neurosurgery, Hospital Italiano de Buenos Aires, Peron, Buenos Aires, Argentina,
| | - Edgar Manuel Farina
- Department of Serviço de Neurocirurgia, Hospital Ministro Costa Cavalcanti Sanatório Le Blanc, Foz do Iguacu, Paraná, Brazil,
| | - Thomas More Frigeri
- Department of Neurosurgery, Pontificical Catholic University of Rio Grande do Sul, Porto Alegre,
| | - Leandro Infantini Dini
- Department of Neurosurgery, Center for Advanced Neurology and Neurosurgery, São Leopoldo, Rio Grande do Sul, Brazil
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25
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Leroy HA, Lacoste M, Maurage CA, Derré B, Baroncini M, Reyns N, Delmaire C. Anatomo-radiological correlation between diffusion tensor imaging and histologic analyses of glial tumors: a preliminary study. Acta Neurochir (Wien) 2020; 162:1663-1672. [PMID: 32291589 DOI: 10.1007/s00701-020-04323-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 04/02/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND PURPOSE The challenge of the neurosurgical management of gliomas lies in achieving a maximal resection without persistent functional deficit. Diffusion tensor imaging (DTI) allows non-invasive identification of white matter tracts and their interactions with the tumor. Previous DTI validation studies were compared with intraoperative cortical stimulation, but none was performed based on the tumor anatomopathological analysis. This preliminary study evaluates the correlation between the preoperative subcortical DTI tractography and histology in terms of fiber direction as well as potential tumor-related fiber disruption. METHODS Eleven patients harboring glial tumors underwent preoperative DTI images. Correlations were performed between the visual color-coded anisotropy (FA) map analysis and the tumor histology after "en bloc" resection. Thirty-one tumor areas were classified according to the degree of tumor infiltration, the destruction of myelin fibers and neurofilaments, the presence of organized white matter fibers, and their orientation in space. RESULTS After histologic comparison, the DTI sensitivity and specificity to predict disrupted fiber tracts were respectively of 89% and 90%. The positive and negative predicted values of DTI were 80% and 95%. The DTI data were in line with the histologic myelin fiber orientation in 90% of patients. In our series, the prevalence of destructed fiber was 31%. Glioblastoma WHO grade IV harbored a higher proportion of destructed white matter tracts. Lower WHO grades were associated with higher preservation of subcortical fiber tracts. CONCLUSION This DTI/histology study of "en bloc"-resected gliomas reported a high and reproducible concordance of the visual color-coded FA map with the histologic examination to predict subcortical fiber tract disruption. Our series brought consistency to the DTI data that could be performed routinely for glioma surgery to predict the tumor grade and the postoperative clinical outcomes.
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Affiliation(s)
- Henri-Arthur Leroy
- Department of Neurosurgery, CHU Lille, Univ. Lille, F-59000, Lille, France.
- Inserm, CHU Lille, U1189 - ONCO-THAI - Image Assisted Laser Therapy for Oncology, Univ. Lille, F-59000, Lille, France.
| | - M Lacoste
- Department of Neuroradiology, CHU Lille, Univ. Lille, F-59000, Lille, France
| | - C-A Maurage
- Department of Anatomopathology, CHU Lille, Univ. Lille, F-59000, Lille, France
| | - B Derré
- Department of Neurosurgery, CHU Lille, Univ. Lille, F-59000, Lille, France
| | - M Baroncini
- Department of Neurosurgery, CHU Lille, Univ. Lille, F-59000, Lille, France
| | - N Reyns
- Department of Neurosurgery, CHU Lille, Univ. Lille, F-59000, Lille, France
- Inserm, CHU Lille, U1189 - ONCO-THAI - Image Assisted Laser Therapy for Oncology, Univ. Lille, F-59000, Lille, France
| | - C Delmaire
- Department of Neuroradiology, CHU Lille, Univ. Lille, F-59000, Lille, France
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26
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Jordan KM, Keshavan A, Caverzasi E, Osorio J, Papinutto N, Amirbekian B, Berger MS, Henry RG. Longitudinal Disconnection Tractograms to Investigate the Functional Consequences of White Matter Damage: An Automated Pipeline. J Neuroimaging 2020; 30:443-457. [PMID: 32436352 DOI: 10.1111/jon.12713] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 03/27/2020] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND AND PURPOSE Neurosurgical resection is one of the few opportunities researchers have to image the human brain pre- and postfocal damage. A major challenge associated with brains undergoing surgical resection is that they often do not fit brain templates most image-processing methodologies are based on. Manual intervention is required to reconcile the pathology, requiring time investment and introducing reproducibility concerns, and extreme cases must be excluded. METHODS We propose an automatic longitudinal pipeline based on High Angular Resolution Diffusion Imaging acquisitions to facilitate a Pathway Lesion Symptom Mapping analysis relating focal white matter injury to functional deficits. This two-part approach includes (i) automatic segmentation of focal white matter injury from anisotropic power differences, and (ii) modeling disconnection using tractography on the single-subject level, which specifically identifies the disconnections associated with focal white matter damage. RESULTS The advantages of this approach stem from (1) objective and automatic lesion segmentation and tractogram generation, (2) objective and precise segmentation of affected tissue likely to be associated with damage to long-range white matter pathways (defined by anisotropic power), (3) good performance even in the cases of anatomical distortions by use of nonlinear tensor-based registration, which aligns images using an approach sensitive to white matter microstructure. CONCLUSIONS Mapping a system as variable and complex as the human brain requires sample sizes much larger than the current technology can support. This pipeline can be used to execute large-scale, sufficiently powered analyses by meeting the need for an automatic approach to objectively quantify white matter disconnection.
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Affiliation(s)
- Kesshi M Jordan
- UCSF-UC Berkeley Graduate Group in Bioengineering, San Francisco, CA.,Department of Neurology, University of California, San Francisco, CA
| | - Anisha Keshavan
- UCSF-UC Berkeley Graduate Group in Bioengineering, San Francisco, CA.,Department of Neurology, University of California, San Francisco, CA
| | - Eduardo Caverzasi
- Department of Neurology, University of California, San Francisco, CA
| | - Joseph Osorio
- Division of Neurosurgery, Department of Surgery, University of California, San Diego, CA
| | - Nico Papinutto
- Department of Neurology, University of California, San Francisco, CA
| | - Bagrat Amirbekian
- UCSF-UC Berkeley Graduate Group in Bioengineering, San Francisco, CA.,Department of Neurology, University of California, San Francisco, CA
| | - Mitchel S Berger
- Department of Neurosurgery, University of California, San Francisco, CA
| | - Roland G Henry
- UCSF-UC Berkeley Graduate Group in Bioengineering, San Francisco, CA.,Department of Neurology, University of California, San Francisco, CA.,Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA
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27
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Liu X, Kinoshita M, Shinohara H, Hori O, Ozaki N, Nakada M. Does the superior fronto-occipital fascicle exist in the human brain? Fiber dissection and brain functional mapping in 90 patients with gliomas. NEUROIMAGE-CLINICAL 2020; 25:102192. [PMID: 32014826 PMCID: PMC6997620 DOI: 10.1016/j.nicl.2020.102192] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 12/19/2019] [Accepted: 01/20/2020] [Indexed: 01/04/2023]
Abstract
Existence of superior fronto-occipital fascicle (SFOF) in humans is controversial. Fiber dissection in vitro revealed Muratoff and Probst bundles but not SFOF. Direct functional mappings for SFOF were performed in 90 awake craniotomies. Eight of total 453 positive sites were located in the region believed to be SFOF. The anatomo-functional features suggest that SFOF might not exist in human brain.
The presence of the superior fronto-occipital fascicle (SFOF) has been reported in the Rhesus monkey; however, it is a subject of controversy in humans. The aim of this study is to identify the SFOF using both in vitro and in vivo anatomo-functional analyses. This study consisted of two approaches. First, one acallosal brain and 12 normal postmortem hemispheres (five left and seven right sides) were dissected under a microscope using Klingler's fiber dissection technique. We focused on the medial subcallosal area superior to the Muratoff bundle, which has been indicated as a principal target area of the SFOF in previous studies. Second, 90 patients underwent awake craniotomy for gliomas with direct electrical stimulations. Functional examinations for visual, ataxic, and cognitive tasks were performed and 453 positive mapping sites were investigated by voxel-based morphometry analysis to establish the functions of the SFOF. The corticostriatal fibers, or the Muratoff bundle, and thalamic peduncle fibers joined in the area of the caudate nucleus, making thalamic peduncle/ corticostriatal bundles, which ran antero-posteriorly in the anterior subcallosal area and radiated from the caudate superior margin in the posterior subcallosal area. However, no SFOF fiber bundle crossed perpendicular to the thalamic peduncle/ corticostriatal bundles in the posterior subcallosal area. In the acallosal hemispheres, Probst bundles were confirmed and the subcallosal areas did not show a specific organization different from the normal brain. Hence, we could not detect a long and continuous association fascicle connecting the frontal lobe and occipital or parietal lobe in the target areas. Furthermore, in the in vivo functional mappings of awake surgery and voxel-based morphometry analysis, eight positive points on the SFOF were selected from the total 453 positive points, but their functions were not related with visual processing and spatial awareness, as has been reported in previous studies. In conclusion, in the present study we attempted to investigate the existence of the SFOF using an anatomical and functional approach. According to our results, the SFOF may not exist in the human brain.
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Affiliation(s)
- Xiaoliang Liu
- Department of Neurosurgery, Kanazawa University,13-1 Takara-machi, Kanazawa, 920-8641 Japan; Department of Neurosurgery, The First Hospital of Jilin University, China
| | - Masashi Kinoshita
- Department of Neurosurgery, Kanazawa University,13-1 Takara-machi, Kanazawa, 920-8641 Japan.
| | | | - Osamu Hori
- Department of Neuroanatomy, Kanazawa University, Japan
| | - Noriyuki Ozaki
- Department of Functional anatomy, Kanazawa University, Japan
| | - Mitsutoshi Nakada
- Department of Neurosurgery, Kanazawa University,13-1 Takara-machi, Kanazawa, 920-8641 Japan
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28
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Raffa G, Quattropani MC, Germanò A. When imaging meets neurophysiology: the value of navigated transcranial magnetic stimulation for preoperative neurophysiological mapping prior to brain tumor surgery. Neurosurg Focus 2019; 47:E10. [DOI: 10.3171/2019.9.focus19640] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 09/04/2019] [Indexed: 11/06/2022]
Abstract
Maximal safe resection is the modern goal for surgery of intrinsic brain tumors located in or close to brain eloquent areas. Nowadays different neuroimaging techniques provide important anatomical and functional information regarding the brain functional organization that can be used to plan a customized surgical strategy to preserve functional networks, and to increase the extent of tumor resection. Among these techniques, navigated transcranial magnetic stimulation (nTMS) has recently gained great favor among the neurosurgical community for preoperative mapping and planning prior to brain tumor surgery. It represents an advanced neuroimaging technique based on the neurophysiological mapping of the functional cortical brain organization. Moreover, it can be combined with other neuroimaging techniques such as diffusion tensor imaging tractography, thus providing a reliable reconstruction of brain eloquent networks. Consequently, nTMS mapping may provide reliable noninvasive brain functional mapping, anticipating information that otherwise may be available to neurosurgeons only in the operating theater by using direct electrical stimulation. The authors describe the reliability and usefulness of the preoperative nTMS-based approach in neurosurgical practice, and briefly discuss their experience using nTMS as well as currently available evidence in the literature supporting its clinical use. In particular, special attention is reserved for the discussion of the role of nTMS as a novel tool for the preoperative neurophysiological mapping of motor and language networks prior to surgery of intrinsic brain tumors located in or close to eloquent networks, as well as for future and promising applications of nTMS in neurosurgical practice.
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Affiliation(s)
- Giovanni Raffa
- 1Division of Neurosurgery, BIOMORF Department, University of Messina, Italy; and
| | | | - Antonino Germanò
- 1Division of Neurosurgery, BIOMORF Department, University of Messina, Italy; and
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29
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Yang JYM, Beare R, Wu MH, Barton SM, Malpas CB, Yeh CH, Harvey AS, Anderson V, Maixner WJ, Seal M. Optic Radiation Tractography in Pediatric Brain Surgery Applications: A Reliability and Agreement Assessment of the Tractography Method. Front Neurosci 2019; 13:1254. [PMID: 31824251 PMCID: PMC6879599 DOI: 10.3389/fnins.2019.01254] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 11/05/2019] [Indexed: 11/13/2022] Open
Abstract
Background Optic radiation (OR) tractography may help predict and reduce post-neurosurgical visual field deficits. OR tractography methods currently lack pediatric and surgical focus. Purpose We propose a clinically feasible OR tractography strategy in a pediatric neurosurgery setting and examine its intra-rater and inter-rater reliability/agreements. Methods Preoperative and intraoperative MRI data were obtained from six epilepsy and two brain tumor patients on 3 Tesla MRI scanners. Four raters with different clinical experience followed the proposed strategy to perform probabilistic OR tractography with manually drawing anatomical landmarks to reconstruct the OR pathway, based on fiber orientation distributions estimated from high angular resolution diffusion imaging data. Intra- and inter-rater reliabilities/agreements of tractography results were assessed using intraclass correlation coefficient (ICC) and dice similarity coefficient (DSC) across various tractography and OR morphological metrics, including the lateral geniculate body positions, tract volumes, and Meyer's loop position from temporal anatomical landmarks. Results Good to excellent intra- and inter-rater reproducibility was demonstrated for the majority of OR reconstructions (ICC = 0.70-0.99; DSC = 0.84-0.89). ICC was higher for non-lesional (0.82-0.99) than lesional OR (0.70-0.99). The non-lesional OR's mean volume was 22.66 cm3; the mean Meyer's loop position was 29.4 mm from the temporal pole, 5.89 mm behind of and 10.26 mm in front of the temporal ventricular horn. The greatest variations (± 1.00-3.00 mm) were observed near pathology, at the tract edges or at cortical endpoints. The OR tractography were used to assist surgical planning and guide lesion resection in all cases, no patient had new visual field deficits postoperatively. Conclusion The proposed tractography strategy generates reliable and reproducible OR tractography images that can be reliably implemented in the routine, non-emergency pediatric neurosurgical setting.
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Affiliation(s)
- Joseph Yuan-Mou Yang
- Department of Neurosurgery, The Royal Children's Hospital, Melbourne, VIC, Australia.,Developmental Imaging, Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Neuroscience Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
| | - Richard Beare
- Developmental Imaging, Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Department of Medicine, Monash University, Melbourne, VIC, Australia
| | - Michelle Hao Wu
- Medical Imaging, The Royal Children's Hospital, Melbourne, VIC, Australia
| | - Sarah M Barton
- Developmental Imaging, Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Neuroscience Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia.,Department of Neurology, The Royal Children's Hospital, Melbourne, VIC, Australia
| | - Charles B Malpas
- Developmental Imaging, Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Clinical Outcomes Research Unit, Department of Medicine, Royal Melbourne Hospital, The University of Melbourne, Melbourne, VIC, Australia.,Melbourne School of Psychological Sciences, The University of Melbourne, Melbourne, VIC, Australia
| | - Chun-Hung Yeh
- The Florey Institute of Neuroscience and Mental Health, Melbourne, VIC, Australia
| | - A Simon Harvey
- Neuroscience Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia.,Department of Neurology, The Royal Children's Hospital, Melbourne, VIC, Australia
| | - Vicki Anderson
- Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia.,Melbourne School of Psychological Sciences, The University of Melbourne, Melbourne, VIC, Australia.,Brain and Mind, Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Department of Psychology, The Royal Children's Hospital, Melbourne, VIC, Australia
| | - Wirginia J Maixner
- Department of Neurosurgery, The Royal Children's Hospital, Melbourne, VIC, Australia.,Neuroscience Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Marc Seal
- Developmental Imaging, Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
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Modern Treatment of Brain Arteriovenous Malformations Using Preoperative Planning Based on Navigated Transcranial Magnetic Stimulation: A Revisitation of the Concept of Eloquence. World Neurosurg 2019; 131:371-384. [PMID: 31247351 DOI: 10.1016/j.wneu.2019.06.119] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 06/12/2019] [Accepted: 06/13/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Navigated transcranial magnetic stimulation (nTMS) provides a reliable identification of "eloquent" cortical brain areas. Moreover, it can be used for diffusion tensor imaging fiber tracking of eloquent subcortical tracts. We describe the use of nTMS-based cortical mapping and diffusion tensor imaging fiber tracking for defining the "eloquence" of areas surrounding brain arteriovenous malformations (BAVMs), aiming to improve patient stratification and treatment. METHODS We collected data of BAVMs suspected to be in eloquent areas treated between 2017 and 2019, and submitted to nTMS-based reconstruction of motor, language, and visual pathways for the definition of the eloquence of the surrounding brain areas. We describe the nTMS-based approach and analyze its impact on patient stratification and allocation to treatment in comparison with the standard assessment of eloquence based on anatomical landmarks. RESULTS Ten patients were included in the study. Preliminarily, 9 BAVMs were suspected to be located in an eloquent area. After nTMS-based mapping, only 5 BAVMs were confirmed to be close to eloquent structures, thus leading to a change of the score for eloquence and of the final BAVMs grading in 60% of patients. Treatment was customized according to nTMS information, and no cases of neurological worsening were observed. Radiological obliteration was complete in 7 cases microsurgically treated, and accounted for about 70% in the remaining 3 patients 1 year after radiosurgical treatment. CONCLUSIONS The nTMS-based information allows an accurate stratification and allocation of patients with BAVMs to the most effective treatment according to a modern, customized, neurophysiological identification of the adjacent eloquent brain networks.
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Latini F, Fahlström M, Berntsson SG, Larsson EM, Smits A, Ryttlefors M. A novel radiological classification system for cerebral gliomas: The Brain-Grid. PLoS One 2019; 14:e0211243. [PMID: 30677090 PMCID: PMC6345500 DOI: 10.1371/journal.pone.0211243] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Accepted: 01/09/2019] [Indexed: 11/23/2022] Open
Abstract
Purpose Standard radiological/topographical classifications of gliomas often do not reflect the real extension of the tumor within the lobar-cortical anatomy. Furthermore, these systems do not provide information on the relationship between tumor growth and the subcortical white matter architecture. We propose the use of an anatomically standardized grid system (the Brain-Grid) to merge serial morphological magnetic resonance imaging (MRI) scans with a representative tractographic atlas. Two illustrative cases are presented to show the potential advantages of this classification system. Methods MRI scans of 39 patients (WHO grade II and III gliomas) were analyzed with a standardized grid created by intersecting longitudinal lines on the axial, sagittal, and coronal planes. The anatomical landmarks were chosen from an average brain, spatially normalized to the Montreal Neurological Institute (MNI) space and the Talairach space. Major white matter pathways were reconstructed with a deterministic tracking algorithm on a reference atlas and analyzed using the Brain-Grid system. Results In all, 48 brain grid voxels (areas defined by 3 coordinates, axial (A), coronal (C), sagittal (S) and numbers from 1 to 4) were delineated in each MRI sequence and on the tractographic atlas. The number of grid voxels infiltrated was consistent, also in the MNI space. The sub-cortical insula/basal ganglia (A3-C2-S2) and the fronto-insular region (A3-C2-S1) were most frequently involved. The inferior fronto-occipital fasciculus, anterior thalamic radiation, uncinate fasciculus, and external capsule were the most frequently associated pathways in both hemispheres. Conclusions The Brain-Grid based classification system provides an accurate observational tool in all patients with suspected gliomas, based on the comparison of grid voxels on a morphological MRI and segmented white matter atlas. Important biological information on tumor kinetics including extension, speed, and preferential direction of progression can be observed and even predicted with this system. This novel classification can easily be applied to both prospective and retrospective cohorts of patients and increase our comprehension of glioma behavior.
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Affiliation(s)
- Francesco Latini
- Department of Neuroscience, Neurosurgery, Uppsala University, Uppsala, Sweden
- * E-mail:
| | - Markus Fahlström
- Department of Surgical Sciences, Radiology, Uppsala University, Uppsala, Sweden
| | - Shala G. Berntsson
- Department of Neuroscience, Neurology, Uppsala University, Uppsala, Sweden
| | - Elna-Marie Larsson
- Department of Surgical Sciences, Radiology, Uppsala University, Uppsala, Sweden
| | - Anja Smits
- Department of Neuroscience, Neurology, Uppsala University, Uppsala, Sweden
- Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Mats Ryttlefors
- Department of Neuroscience, Neurosurgery, Uppsala University, Uppsala, Sweden
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Li D, Jiao YM, Wang L, Lin FX, Wu J, Tong XZ, Wang S, Cao Y. Surgical outcome of motor deficits and neurological status in brainstem cavernous malformations based on preoperative diffusion tensor imaging: a prospective randomized clinical trial. J Neurosurg 2019; 130:286-301. [PMID: 29547081 DOI: 10.3171/2017.8.jns17854] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 08/21/2017] [Indexed: 12/18/2022]
Abstract
OBJECTIVE: Surgical management of brainstem lesions is challenging due to the highly compact, eloquent anatomy of the brainstem. This study aimed to evaluate the safety and efficacy of preoperative diffusion tensor imaging (DTI) and diffusion tensor tractography (DTT) in brainstem cavernous malformations (CMs). METHODS: A prospective randomized controlled clinical trial was performed by using stratified blocked randomization. The primary eligibility criterion of the study was being a surgical candidate for brainstem CMs (with informed consent). The study enrolled 23 patients who underwent preoperative DTI/DTT and 24 patients who did not (the control group). The pre- and postoperative muscle strength of both limbs and modified Rankin Scale (mRS) scores were evaluated. Muscle strength of any limb at 12 months after surgery at the clinic visit was the primary outcome; worsened muscle strength was considered to be a poor outcome. Outcome assessors were blinded to patient management. This study reports the preliminary results of the interim analysis. RESULTS: The cohort included 47 patients (22 women) with a mean age of 35.7 years. The clinical baselines between these 2 groups were not significantly different. In the DTI/DTT group, the corticospinal tract was affected in 17 patients (73.9%): it was displaced, deformed/partially interrupted, or completely interrupted in 6, 7, and 4 patients, respectively. The surgical approach and brainstem entry point were adjusted in 3 patients (13.0%) based on DTI/DTT data. The surgical morbidity of the DTI/DTT group (7/23, 30.4%) was significantly lower than that of the control group (19/24, 79.2%, p = 0.001). At 12 months, the mean mRS score (1.1, p = 0.034) and percentage of patients with worsened motor deficits (4.3%, p = 0.006) were significantly lower in the DTI/DTT group than in the control group (1.7% and 37.5%). Multivariate logistic regression identified the absence of preoperative DTI/DTT (OR 0.06, 95% CI 0.01-0.73, p = 0.028) and use of the 2-point method (OR 4.15, 95% CI 1.38-12.49, p = 0.011) as independent adverse factors for a worsened motor deficit. The multivariate model found a significant correlation between poor mRS score and both an increased preoperative mRS score (t = 3.559, p = 0.001) and absence of preoperative DTI/DTT (t = -2.747, p = 0.009). CONCLUSIONS: DTI/DTT noninvasively allowed for visualization of the anatomical relationship between vital tracts and pathologies as well as facilitated the brainstem surgical approach and entry-point decision making. The technique was valuable for complex neurosurgical planning to reduce morbidity. Nonetheless, DTI/DTT data should be interpreted cautiously.■ CLASSIFICATION OF EVIDENCE Type of question: therapeutic; study design: randomized controlled trial; evidence: class I. Clinical trial registration no.: NCT01758211 (ClinicalTrials.gov).
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Bertani GA, Bertulli L, Scola E, Di Cristofori A, Zavanone M, Triulzi F, Rampini PM, Carrabba GG. Optic Radiation Diffusion Tensor Imaging Tractography: An Alternative and Simple Technique for the Accurate Detection of Meyer's Loop. World Neurosurg 2018; 117:e42-e56. [DOI: 10.1016/j.wneu.2018.05.131] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 05/17/2018] [Accepted: 05/18/2018] [Indexed: 12/11/2022]
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Functional brain mapping: overview of techniques and their application to neurosurgery. Neurosurg Rev 2018; 42:639-647. [DOI: 10.1007/s10143-018-1007-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 06/25/2018] [Accepted: 07/06/2018] [Indexed: 10/28/2022]
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Duffau H. The error of Broca: From the traditional localizationist concept to a connectomal anatomy of human brain. J Chem Neuroanat 2018; 89:73-81. [DOI: 10.1016/j.jchemneu.2017.04.003] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 03/06/2017] [Accepted: 04/12/2017] [Indexed: 11/16/2022]
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Abstract
INTRODUCTION Radical glioma resection improves overall survival, both in low-grade and high-grade glial tumors. However, preservation of the quality of life is also crucial. Areas covered: Due to the diffuse feature of gliomas, which invade the central nervous system, and due to considerable variations of brain organization among patients, an individual cerebral mapping is mandatory to solve the classical dilemma between the oncological and functional issues. Because functional neuroimaging is not reliable enough, intraoperative electrical stimulation, especially in awake patients benefiting from a real-time cognitive monitoring, is the best way to increase the extent of resection while sparing eloquent neural networks. Expert commentary: Here, we propose a paradigmatic shift from image-guided resection to functional mapping-guided resection, based on the study of the dynamic distribution of delocalized cortico-subcortical circuits at the individual level, i.e., the investigation of brain connectomics and neuroplastic potential. This surgical philosophy results in an improvement of both oncological outcomes and quality of life. This highlights the need to reinforce the link between glioma surgery and cognitive neurosciences.
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Affiliation(s)
| | - Hugues Duffau
- b Department of Neurosurgery , Gui de Chauliac Hospital, Montpellier University Medical Center , Montpellier , France.,c National Institute for Health and Medical Research (INSERM), U1051 Laboratory, Team "Brain Plasticity, Stem Cells and Glial Tumors", Institute for Neurosciences of Montpellier , Montpellier University Medical Center , Montpellier , France
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Lin Y, Lin F, Kang D, Jiao Y, Cao Y, Wang S. Supratentorial cavernous malformations adjacent to the corticospinal tract: surgical outcomes and predictive value of diffusion tensor imaging findings. J Neurosurg 2018; 128:541-552. [PMID: 28362238 DOI: 10.3171/2016.10.jns161179] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEDiffusion tensor imaging (DTI) findings may facilitate clinical decision making in patients with supratentorial cavernous malformations adjacent to the corticospinal tract (CST-CMs). The objective of this study was to determine the predictive value of preoperative DTI findings for surgical outcomes in patients with CST-CMs.METHODSA prospectively maintained database of patients with CM referred to the authors' hospital between September 2012 and October 2015 was reviewed to identify all consecutive surgically treated patients with CST-CM. All patients had undergone sagittal T1-weighted anatomical imaging and DTI before surgery. Both DTI findings and clinical characteristics of the patients and lesions were analyzed with respect to surgery-related motor deficits. DTI findings included lesion-to-CST distance (LCD) and the alteration (i.e., deviation, interruption, or degeneration due to the CM) of CST on preoperative DTI images. Surgery-related motor deficits at 1 week and the last clinic visit (≥ 3 months) after surgery were defined as short-term and long-term deficits, respectively. Preoperative and final modified Rankin Scale scores were also analyzed to identify the surgical outcomes in these patients.RESULTSA total of 56 patients with 56 CST-CMs were included in this study. The mean LCD was 3.9 ± 3.2 mm, and alterations of the CST were detected in 20 (36.7%) patients. One week after surgery, 21 (37.5%) patients had short-term surgery-related motor deficits, but only 14 (25.0%) patients had long term deficits at the last clinical visit. The mean patient follow-up was 14.7 ± 10.1 months. The difference between preoperative and final modified Rankin Scale scores was not statistically significant (p = 0.490). Multivariate analysis showed that both short-term (p < 0.001) and long-term (p = 0.002) surgery-related motor deficits were significantly associated with LCD. Receiver operating characteristic (ROC) curve results were as follows: for short-term surgery-related motor deficits, the area under the ROC curve (AUC) was 0.860, and the cutoff point was LCD = 2.55 mm; for long-term deficits, the AUC was 0.894, and the cutoff point was LCD = 2.30 mm. Both univariate (p = 0.012) and multivariate (p = 0.049) analyses revealed that CST alteration on preoperative DTI was significantly correlated with short-term surgery-related motor deficits. On univariate analysis, deep location of the CST-CMs was significantly correlated with long-term motor deficits (p = 0.016). Deep location of the CST-CMs had a trend toward significance with long-term motor deficits on the multivariate analysis (p = 0.060).CONCLUSIONSTo facilitate clinical practice, the authors propose that 3.00 mm (2.55 to ∼3.00 mm) may be the safe LCD for surgery in patients with CST-CMs. A CST alteration on preoperative DTI and a deep location of the CST-CM may be risk factors for short- and long-term surgery-related motor deficits, respectively. A randomized controlled trial is needed to demonstrate the predictive value of preoperative DTI findings on surgical outcomes in patients with CST-CMs in future studies.
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Affiliation(s)
- Yuanxiang Lin
- 1Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fujian Medical University, Fujian Province
| | - Fuxin Lin
- 1Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fujian Medical University, Fujian Province
| | - Dezhi Kang
- 1Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fujian Medical University, Fujian Province
| | - Yuming Jiao
- 2Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing
- 3China National Clinical Research Center for Neurological Diseases, Beijing
- 4Center of Stroke, Beijing Institute for Brain Disorders, Beijing; and
- 5Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, People's Republic of China
| | - Yong Cao
- 2Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing
- 3China National Clinical Research Center for Neurological Diseases, Beijing
- 4Center of Stroke, Beijing Institute for Brain Disorders, Beijing; and
- 5Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, People's Republic of China
| | - Shuo Wang
- 2Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing
- 3China National Clinical Research Center for Neurological Diseases, Beijing
- 4Center of Stroke, Beijing Institute for Brain Disorders, Beijing; and
- 5Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, People's Republic of China
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Deslauriers-Gauthier S, Parker D, Rheault F, Deriche R, Brem S, Descoteaux M, Verma R. Edema-Informed Anatomically Constrained Particle Filter Tractography. MEDICAL IMAGE COMPUTING AND COMPUTER ASSISTED INTERVENTION – MICCAI 2018 2018. [DOI: 10.1007/978-3-030-00931-1_43] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
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Duffau H. Awake mapping is not an additional surgical technique but an alternative philosophy in the management of low-grade glioma patients. Neurosurg Rev 2017; 41:689-691. [PMID: 29236183 DOI: 10.1007/s10143-017-0937-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Accepted: 12/06/2017] [Indexed: 01/01/2023]
Affiliation(s)
- Hugues Duffau
- Department of Neurosurgery, Gui de Chauliac Hospital, Montpellier University Medical Center, 80, Avenue Augustin Fliche, 34295, Montpellier, France. .,Institute for Neuroscience of Montpellier, INSERM U1051, Team "Plasticity of Central Nervous System, Human Stem Cells and Glial Tumors," Saint Eloi Hospital, Montpellier University Medical Center, Montpellier, France.
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Vilasboas T, Herbet G, Duffau H. Challenging the Myth of Right Nondominant Hemisphere: Lessons from Corticosubcortical Stimulation Mapping in Awake Surgery and Surgical Implications. World Neurosurg 2017; 103:449-456. [DOI: 10.1016/j.wneu.2017.04.021] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Revised: 04/02/2017] [Accepted: 04/05/2017] [Indexed: 10/19/2022]
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Boissonneau S, Duffau H. Identifying clinical risk in low grade gliomas and appropriate treatment strategies, with special emphasis on the role of surgery. Expert Rev Anticancer Ther 2017; 17:703-716. [PMID: 28608763 DOI: 10.1080/14737140.2017.1342537] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Diffuse low-grade glioma (DLGG) is a chronic tumoral disease that ineluctably grows, migrates along white matter pathways, and progresses to a higher grade of malignancy. Areas covered: To determine the best individualized treatment attitude for each DLGG patient, and to redefine it over the years, i.e. to optimize the 'onco-functional balance' of serial and multimodal therapies, the understanding of the natural history of this chronic disease is crucial but not sufficient. A paradigmatic shift is to tailor the individual management according to the dynamic relationships between DLGG course and neural remodeling. In this spirit, a better knowledge of brain plasticity in a connectomal account of cerebral processing has enabled a dramatic improvement of both oncological and functional outcomes in DLGG patients, by increasing overall survival while preserving (or even improving) the quality of life. Expert commentary: Here, we propose an individualized and recursive therapeutic strategy in DLGG, leading to the concept of a 'personalized functional neuro-oncology', by emphasizing the role of early and maximal safe surgical resection(s) reliably achieved using intraoperative mapping of cortico-subcortical networks in awake patients.
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Affiliation(s)
| | - Hugues Duffau
- b Department of Neurosurgery , Gui de Chauliac Hospital, Montpellier University Medical Center , Montpellier , France.,c Team "Plasticity of Central Nervous System, Stem Cells and Glial Tumors," INSERM U1051, Institute for Neurosciences of Montpellier , Montpellier University Medical Center , Montpellier , France
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Liao R, Ning L, Chen Z, Rigolo L, Gong S, Pasternak O, Golby AJ, Rathi Y, O'Donnell LJ. Performance of unscented Kalman filter tractography in edema: Analysis of the two-tensor model. NEUROIMAGE-CLINICAL 2017; 15:819-831. [PMID: 28725549 PMCID: PMC5506885 DOI: 10.1016/j.nicl.2017.06.027] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 06/01/2017] [Accepted: 06/19/2017] [Indexed: 11/30/2022]
Abstract
Diffusion MRI tractography is increasingly used in pre-operative neurosurgical planning to visualize critical fiber tracts. However, a major challenge for conventional tractography, especially in patients with brain tumors, is tracing fiber tracts that are affected by vasogenic edema, which increases water content in the tissue and lowers diffusion anisotropy. One strategy for improving fiber tracking is to use a tractography method that is more sensitive than the traditional single-tensor streamline tractography. We performed experiments to assess the performance of two-tensor unscented Kalman filter (UKF) tractography in edema. UKF tractography fits a diffusion model to the data during fiber tracking, taking advantage of prior information from the previous step along the fiber. We studied UKF performance in a synthetic diffusion MRI digital phantom with simulated edema and in retrospective data from two neurosurgical patients with edema affecting the arcuate fasciculus and corticospinal tracts. We compared the performance of several tractography methods including traditional streamline, UKF single-tensor, and UKF two-tensor. To provide practical guidance on how the UKF method could be employed, we evaluated the impact of using various seed regions both inside and outside the edematous regions, as well as the impact of parameter settings on the tractography sensitivity. We quantified the sensitivity of different methods by measuring the percentage of the patient-specific fMRI activation that was reached by the tractography. We expected that diffusion anisotropy threshold parameters, as well as the inclusion of a free water model, would significantly influence the reconstruction of edematous WM fiber tracts, because edema increases water content in the tissue and lowers anisotropy. Contrary to our initial expectations, varying the fractional anisotropy threshold and including a free water model did not affect the UKF two-tensor tractography output appreciably in these two patient datasets. The most effective parameter for increasing tracking sensitivity was the generalized anisotropy (GA) threshold, which increased the length of tracked fibers when reduced to 0.075. In addition, the most effective seeding strategy was seeding in the whole brain or in a large region outside of the edema. Overall, the main contribution of this study is to provide insight into how UKF tractography can work, using a two-tensor model, to begin to address the challenge of fiber tract reconstruction in edematous regions near brain tumors. Reconstruction of edematous white matter from diffusion MRI is investigated. The performance of two–tensor unscented Kalman filter (UKF) tractography is assessed. The two–tensor model in UKF is analyzed in phantom and patient data experiments. Practical guidance on employing the UKF method in neurosurgical patients is provided
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Affiliation(s)
- Ruizhi Liao
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Lipeng Ning
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Zhenrui Chen
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Laura Rigolo
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Shun Gong
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Shanghai Changzheng Hospital, Shanghai, China
| | - Ofer Pasternak
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Alexandra J Golby
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Yogesh Rathi
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Preoperative prediction of language function by diffusion tensor imaging. Brain Inform 2017; 4:201-205. [PMID: 28474309 PMCID: PMC5563300 DOI: 10.1007/s40708-017-0064-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 04/13/2017] [Indexed: 01/28/2023] Open
Abstract
For surgery of eloquent tumors in language areas, the accepted gold standard is functional mapping through direct cortical stimulation (DCS) in awake patients. Ever since, neuroscientists are searching for reliable noninvasive detection of function in the human brain, with variable success. The potential of diffusion tensor imaging (DTI) in combination with computational cortical parcellation to predict functional areas in language eloquent tumors has not been assessed so far. We present a proof-of-concept report involving awake surgery for a temporodorsal tumor. Postoperatively, the imaging was extensively studied and a predictive value of multimodal MR imaging for the possible extent of resection was analyzed. After resection using DCS, the extent of resection and functional outcome were correlated with the processed imaging. Preoperative imaging of our patient was taken to compute the lesion volume as a seed for tractography (DTI) and combined with a tractography of the entire hemisphere. For better spatial resolution, an elastic image fusion was performed to correct the distortion of DTI data. After subtotal resection and imaging analysis, the status of the superior part of the lesion could be identified and predicted as functional cortex. There was a strong correlation between the tumor remnant during surgery and the imaging parameters of DTI connectivity of the eloquent tissue. A combination of complex DTI processing may be able to predict function in a patient suffering eloquent brain tumors and thus allow estimation of extent of resection.
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Jordan K, Keshavan A, Mandelli ML, Henry R. Cluster-viz: A Tractography QC Tool. RESEARCH IDEAS AND OUTCOMES 2017. [DOI: 10.3897/rio.3.e12394] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Wang L, Lin F, Wu J, Jiao Y, Cao Y, Zhao Y, Wang S. Plasticity of motor function and surgical outcomes in patients with cerebral arteriovenous malformation involving primary motor area: insight from fMRI and DTI. Chin Neurosurg J 2016. [DOI: 10.1186/s41016-016-0030-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Kinoshita M, Miyashita K, Tsutsui T, Furuta T, Nakada M. Critical Neural Networks in Awake Surgery for Gliomas. Neurol Med Chir (Tokyo) 2016; 56:674-686. [PMID: 27250817 PMCID: PMC5221778 DOI: 10.2176/nmc.ra.2016-0069] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
From the embarrassing character commonly infiltrating eloquent brain regions, the surgical resection of glioma remains challenging. Owing to the recent development of in vivo visualization techniques for the human brain, white matter regions can be delineated using diffusion tensor imaging (DTI) as a routine clinical practice in neurosurgery. In confirmation of the results of DTI tractography, a direct electrical stimulation (DES) substantially influences the investigation of cortico-subcortical networks, which can be identified via specific symptoms elicited in the concerned white matter tracts (eg., the arcuate fascicle, superior longitudinal fascicles, inferior fronto-occipital fascicle, inferior longitudinal fascicle, frontal aslant tract, sensori-motor tracts, optic radiation, and so forth). During awake surgery for glioma using DES, it is important to identify the anatomo-functional structure of white matter tracts to identify the surgical boundaries of brain regions not only to achieve maximal resection of the glioma but also to maximally preserve quality of life. However, the risk exists that neurosurgeons may be misled by the inability of DTI to visualize the actual anatomy of the white matter fibers, resulting in inappropriate decisions regarding surgical boundaries. This review article provides information of the critical neuronal network that is necessary to identify and understand in awake surgery for glioma, with special references to white matter tracts and the author's experiences.
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Abstract
The implementation of fiber tracking or tractography modules in commercial navigation systems resulted in a broad availability of visualization possibilities for major white matter tracts in the neurosurgical community. Unfortunately the implemented algorithms and tracking approaches do not represent the state of the art of tractography strategies and may lead to false tracking results. The application of advanced tractography techniques for neurosurgical procedures poses even additional challenges that relate to effects of the individual anatomy that might be altered by edema and tumor, to stereotactic inaccuracies due to image distortion, as well as to registration inaccuracies and brain shift.
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Affiliation(s)
- Christopher Nimsky
- Department of Neurosurgery, University Marburg, Baldingerstrasse, Marburg, 35033, Germany.
| | - Miriam Bauer
- Department of Neurosurgery, University Marburg, Baldingerstrasse, Marburg, 35033, Germany
| | - Barbara Carl
- Department of Neurosurgery, University Marburg, Baldingerstrasse, Marburg, 35033, Germany
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Preoperative Functional Findings and Surgical Outcomes in Patients with Motor Cortical Arteriovenous Malformation. World Neurosurg 2016; 85:273-81. [DOI: 10.1016/j.wneu.2015.10.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Revised: 09/30/2015] [Accepted: 10/01/2015] [Indexed: 10/22/2022]
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Bonney PA, Conner AK, Boettcher LB, Cheema AA, Glenn CA, Smitherman AD, Pittman NA, Sughrue ME. A Simplified Method of Accurate Postprocessing of Diffusion Tensor Imaging for Use in Brain Tumor Resection. Oper Neurosurg (Hagerstown) 2015; 13:47-59. [DOI: 10.1227/neu.0000000000001181] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Accepted: 10/25/2015] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND: Use of diffusion tensor imaging (DTI) in brain tumor resection has been limited in part by a perceived difficulty in implementing the techniques into neurosurgical practice.
OBJECTIVE: To demonstrate a simple DTI postprocessing method performed without a neuroscientist and to share results in preserving patient function while aggressively resecting tumors.
METHODS: DTI data are obtained in all patients with tumors located within presumed eloquent cortices. Relevant white matter tracts are mapped and integrated with neuronavigation by a nonexpert in < 20 minutes. We report operative results in 43 consecutive awake craniotomy patients from January 2014 to December 2014 undergoing resection of intracranial lesions. We compare DTI-expected findings with stimulation mapping results for the corticospinal tract, superior longitudinal fasciculus, and inferior fronto-occipital fasciculus.
RESULTS: Twenty-eight patients (65%) underwent surgery for high-grade gliomas and 11 patients (26%) for low-grade gliomas. Seventeen patients had posterior temporal lesions; 10 had posterior frontal lesions; 8 had parietal-temporal-occipital junction lesions; and 8 had insular lesions. With DTI-defined tracts used as a guide, a combined 65 positive maps and 60 negative maps were found via stimulation mapping. Overall sensitivity and specificity of DTI were 98% and 95%, respectively. Permanent speech worsening occurred in 1 patient (2%), and permanent weakness occurred in 3 patients (7%). Greater than 90% resection was achieved in 32 cases (74%).
CONCLUSION: Accurate DTI is easily obtained, postprocessed, and implemented into neuronavigation within routine neurosurgical workflow. This information aids in resecting tumors while preserving eloquent cortices and subcortical networks.
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Affiliation(s)
- Phillip A. Bonney
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Andrew K. Conner
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Lillian B. Boettcher
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Ahmed A. Cheema
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Chad A. Glenn
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Adam D. Smitherman
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | | | - Michael E. Sughrue
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
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50
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Lin F, Zhao B, Wu J, Wang L, Jin Z, Cao Y, Wang S. Risk factors for worsened muscle strength after the surgical treatment of arteriovenous malformations of the eloquent motor area. J Neurosurg 2015; 125:289-98. [PMID: 26636384 DOI: 10.3171/2015.6.jns15969] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Case selection for the surgical treatment of arteriovenous malformations (AVMs) of the eloquent motor area remains challenging. The aim of this study was to determine the risk factors for worsened muscle strength after surgery in patients with this disorder. METHODS At their hospital the authors retrospectively studied 48 consecutive patients with AVMs involving motor cortex and/or the descending pathway. All patients had undergone preoperative functional MRI (fMRI) and diffusion tensor imaging (DTI), followed by resection. Both functional and angioarchitectural factors were analyzed with respect to the change in muscle strength. Functional factors included lesion-to-corticospinal tract distance (LCD) on DTI and lesion-to-activation area distance (LAD) and cortical reorganization on fMRI. Based on preoperative muscle strength, the changes in muscle strength at 1 week and 6 months after surgery were defined as short-term and long-term surgical outcomes, respectively. Statistical analysis was performed using the statistical package SPSS (version 20.0.0, IBM Corp.). RESULTS Twenty-one patients (43.8%) had worsened muscle strength 1 week after surgery. However, only 10 patients (20.8%) suffered from muscle strength worsening 6 months after surgery. The LCD was significantly correlated with short-term (p < 0.001) and long-term (p < 0.001) surgical outcomes. For long-term outcomes, patients in the 5 mm ≥ LCD > 0 mm (p = 0.009) and LCD > 5 mm (p < 0.001) categories were significantly associated with a lower risk of permanent motor worsening in comparison with patients in the LCD = 0 mm group. No significant difference was found between patients in the 5 mm ≥ LCD > 0 mm group and LCD > 5 mm group (p = 0.116). Nidus size was the other significant predictor of short-term (p = 0.021) and long-term (p = 0.016) outcomes. For long-term outcomes, the area under the ROC curve (AUC) was 0.728, and the cutoff point was 3.6 cm. Spetzler-Martin grade was not associated with short-term surgical outcomes (0.143), although it was correlated with long-term outcomes (0.038). CONCLUSIONS An AVM with a nidus in contact with tracked eloquent fibers (LCD = 0) and having a large size is more likely to be associated with worsened muscle strength after surgery in patients with eloquent motor area AVMs. Surgical treatment in these patients should be carefully considered. In patients with an LCD > 5 mm, radical resection may be considered to eliminate the risk of hemorrhage.
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Affiliation(s)
- Fuxin Lin
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University;,China National Clinical Research Center for Neurological Diseases;,Center of Stroke, Beijing Institute for Brain Disorders;,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease
| | - Bing Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University;,China National Clinical Research Center for Neurological Diseases;,Center of Stroke, Beijing Institute for Brain Disorders;,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease
| | - Jun Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University;,China National Clinical Research Center for Neurological Diseases;,Center of Stroke, Beijing Institute for Brain Disorders;,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease
| | - Lijun Wang
- Department of Neurosurgery, Hongqi Hospital, Mu Dan Jiang Medical University, Mu Dan Jiang, Hei Long Jiang Province, People's Republic of China
| | - Zhen Jin
- Medical Imaging Center, The 306th Hospital of PLA, Beijing; and
| | - Yong Cao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University;,China National Clinical Research Center for Neurological Diseases;,Center of Stroke, Beijing Institute for Brain Disorders;,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University;,China National Clinical Research Center for Neurological Diseases;,Center of Stroke, Beijing Institute for Brain Disorders;,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease
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