Clinical use of diffusion tensor image-merged functional neuronavigation for brain tumor surgeries: review of preoperative, intraoperative, and postoperative data for 123 cases

The Application of Intraoperative Ultrasound with Burr Hole Probe in Minimally Invasive Diagnosis and Treatment in Neurosurgery

OBJECTIVE

To summarize the preliminary application experience of intraoperative ultrasound with burr hole probe in minimally invasive neurosurgery and to explore its application value.

METHODS

Thirty-one patients who underwent intraoperative ultrasound guided puncture with burr hole probe in our center from August 2018 to May 2024 were collected, including 16 cases of ventriculoperitoneal shunt operation, 6 cases of assisted stereotactic needle biopsy, 3 cases of intracranial pressure probe implantation in lateral ventricle, 3 cases of brain abscess puncture for external drainage, and 3 cases of intracranial cyst puncture and peritoneal drainage. During the procedures, the burr hole probe was used to locate the intracranial targets and guide the puncture. The postoperative computed tomography (CT) scans or combined postoperative pathological results could verify the accuracy of puncture. In addition, the intervention effect and recovery status of patients were also recorded.

RESULTS

The intraoperative ultrasound with burr hole probe could clearly display all the purposed targets and accurately guide the puncture procedures in all cases. All patients achieved satisfactory diagnostic and therapeutic results without new neurological dysfunction and serious complications.

CONCLUSIONS

The intraoperative ultrasound with burr hole probe is an effective device for demonstrating intracranial structures. It not only enables minimally invasive and precise diagnosis or treatment of many neurosurgical diseases, but also is simple and safe to operate, which has important promotional value in the neurosurgery.

Diffusion tensor imaging versus intraoperative subcortical mapping for glioma resection: a systematic review and meta-analysis

Maintaining the integrity of crucial fiber tracts allows functional preservation and improved recovery in patients with glioma resection. Diffusion tensor imaging (DTI) and intraoperative subcortical mapping (ISM) are commonly required for pre- and intraoperative assessment of white matter fibers. This study investigated differences of clinical outcomes in glioma resection aided by DTI or ISM. A comprehensive literature retrieval of the PubMed and Embase databases identified several DTI or ISM studies in 2000-2022. Clinical data, including extent of resection (EOR) and postoperative neurological deficits, was collected and statistically analyzed. Heterogeneity was regressed by a random effect model and the Mann-Whitney U test was used to test statistical significance. Publication bias was assessed by Egger test. A total of 14 studies with a pooled cohort of 1837 patients were included. Patients undergoing DTI-navigated glioma surgery showed a higher rate of gross total resection (GTR) than ISM-assisted surgical resection (67.88%, [95% CI 0.55-0.79] vs. 45.73%, [95% CI 0.29-0.63], P = 0.032). The occurrence of early postoperative functional deficit (35.45%, [95% CI 0.13-0.61] vs. 35.60% [95% CI 0.20-0.53], P = 1.000), late postoperative functional deficit (6.00%, [95% CI 0.02-0.11] vs. 4.91% [95% CI 0.03-0.08], P = 1.000) and severe postoperative functional deficit (2.21%, [95% CI 0-0.08] vs. 5.93% [95% CI 0.01-0.16], P = 0.393) were similar between the DTI and ISM group, respectively. While DTI-navigation resulted in a higher rate of GTR, the occurrence of postoperative neurological deficits between DTI and ISM groups was comparable. Together, these data indicate that both techniques could safely facilitate glioma resection.

Validation of Presurgical Simulation of White Matter Damage Using Diffusion Tensor Imaging

BACKGROUND

The understanding of white matter (WM) was revolutionized by the emergence of tractography based on diffusion tensor imaging (DTI). Currently, DTI simulations are implemented in preoperative planning to optimize surgical approaches. The reliability of these simulations has been questioned and investigated seeking for correlation between neurological performance and anomalies in DTI parameters. However, the ability of preoperative WM simulations to predict a surgical injury has not been thoroughly evaluated. Our objective was to assess the reliability of preoperatively simulated WM injuries for conventional neurosurgical procedures.

METHODS

WM surgical damage was preoperatively simulated by creating a 3-dimensional volume representing the endoscope or the surgical trajectory. This volume was used as an additional region of interest in the fascicle reconstruction to be subtracted from the original fascicle. Simulated, injured fascicles were compared in terms of the number of fibers and volume to those created from postoperative DTI studies. Reliability was assimilated into the correlation between the simulation and the postoperative reconstruction; evaluated using the intraclass correlation coefficient or Lin's Concordance correlation coefficient (CCC), and represented on Bland-Altman plots.

RESULTS

The preoperative and postoperative DTI studies of 30 patients undergoing various neurosurgical approaches were processed. The correlation between simulated injuries and postoperative studies was high in terms of fibers (Concordance correlation coefficient = Rho.C = 0.989 [95% confidence interval = 0.979-0.995]) and volume (intraclass correlation coefficient = 0.95 [95% CI = 0.89-0.97]). Bland-Altman plots demonstrated that the great majority of cases fell within the mean ± 2 Standard deviations.

CONCLUSIONS

Presurgical simulation of WM fascicles based on DTI is consistent with postoperative DTI studies. These findings require further validation by neurophysiological and clinical correlation.

MRI tractography reveals the human olfactory nerve map connecting the olfactory epithelium and olfactory bulb

The olfactory nerve map describes the topographical neural connections between the olfactory epithelium in the nasal cavity and the olfactory bulb. Previous studies have constructed the olfactory nerve maps of rodents using histological analyses or transgenic animal models to investigate olfactory nerve pathways. However, the human olfactory nerve map remains unknown. Here, we demonstrate that high-field magnetic resonance imaging and diffusion tensor tractography can be used to visualize olfactory sensory neurons while maintaining their three-dimensional structures. This technique allowed us to evaluate the olfactory sensory neuron projections from the nasal cavities to the olfactory bulbs and visualize the olfactory nerve maps of humans, marmosets and mice. The olfactory nerve maps revealed that the dorsal-ventral and medial-lateral axes were preserved between the olfactory epithelium and olfactory bulb in all three species. Further development of this technique might allow it to be used clinically to facilitate the diagnosis of olfactory dysfunction.

Combined high-field MRI and DTI analyses in post-mortem mouse, marmoset, and human samples provide insight into the neural connections between nasal cavities and olfactory bulbs.

Utility of multi-material three-dimensional print model in preoperative simulation for glioma surgery

Although the three-dimensional (3D) printing technology has spread in the field of neurosurgery, the use of 3D print models concerning glioma surgery has rarely reported. For glioma surgery, some preoperative and intraoperative assistive methods have been developed to avoid injury to the cortex and fiber that are related to the neurological function. Furthermore, in order to perform preoperative simulation of glioma surgery, we created a 3D print model using a multi-material 3D printer that provided the flexibility of adjusting the color, hardness, and translucency of each structure arbitrarily. The use of 3D print model was demonstrated in one case involving an intramedullary tumor in the right temporal lobe. The tumor, optic radiation, brain parenchyma, tentorium, ventricle, and sinus were constructed in a single model in one printing process. Design of the degree of resection, insertion of the fence-post, and tumor resection paying attention to the optic radiation were simulated preoperatively using this model. The surgery was performed generally as the simulation and gross total removal of the tumor was achieved. This model was useful for understanding the degree of resection, adequate insertion of the fence-post, and the relationship of the tumor with other important structures. A variety of printing materials contributed to make the model realistic and to understand anatomical relationship. In conclusion, the 3D print model can supplement an image of some portions that are not visible perioperatively and serve as a preoperative assistant modality.

Efficacy of Whole-Ventricular Radiotherapy in Patients Undergoing Maximal Tumor Resection for Glioblastomas Involving the Ventricle

Background and Purpose

Patients with glioblastoma (GBM) involving the ventricles are at high risk of ventricle opening during surgery and potential ventricular tumor spread. We evaluated the effectiveness of whole-ventricular radiotherapy (WVRT) in reducing intraventricular seeding in patients with GBM and identified patients who could benefit from this approach.

Methods and Materials

We retrospectively reviewed the data of 382 patients with GBM who underwent surgical resection and temozolomide-based chemoradiotherapy. Propensity score matching was performed to compensate for imbalances in characteristics between patients who did [WVRT (+); n=59] and did not [WVRT (–); n=323] receive WVRT. Local, outfield, intraventricular, and leptomeningeal failure rates were compared.

Results

All patients in the WVRT (+) group had tumor ventricular involvement and ventricle opening during surgery. In the matched cohort, the WVRT (+) group exhibited a significantly lower 2-year intraventricular failure rate than the WVRT (–) group (2.1% vs. 11.8%; P=0.045), with no difference in other outcomes. Recursive partitioning analysis stratified the patients in the WVRT (–) group at higher intraventricular failure risk (2-year survival, 14.2%) due to tumor ventricular involvement, MGMT unmethylation, and ventricle opening. WVRT reduced the intraventricular failure rate only in high-risk patients (0% vs. 14.2%; P=0.054) or those with MGMT-unmethylated GBM in the matched cohort (0% vs. 17.3%; P=0.036).

Conclusions

WVRT reduced the intraventricular failure rate in patients with tumor ventricular involvement and ventricle opening during surgery. The MGMT-methylation status may further stratify patients who could benefit from WVRT. Further prospective evaluation of WVRT in GBM is warranted.

Tractography in Neurosurgery: A Systematic Review of Current Applications

The ability to visualize the brain's fiber connections noninvasively in vivo is relatively young compared with other possibilities of functional magnetic resonance imaging. Although many studies showed tractography to be of promising value for neurosurgical care, the implications remain inconclusive. An overview of current applications is presented in this systematic review. A search was conducted for (("tractography" or "fiber tracking" or "fibre tracking") and "neurosurgery") that produced 751 results. We identified 260 relevant articles and added 20 more from other sources. Most publications concerned surgical planning for resection of tumors (n = 193) and vascular lesions (n = 15). Preoperative use of transcranial magnetic stimulation was discussed in 22 of these articles. Tractography in skull base surgery presents a special challenge (n = 29). Fewer publications evaluated traumatic brain injury (TBI) (n = 25) and spontaneous intracranial bleeding (n = 22). Twenty-three articles focused on tractography in pediatric neurosurgery. Most authors found tractography to be a valuable addition in neurosurgical care. The accuracy of the technique has increased over time. There are articles suggesting that tractography improves patient outcome after tumor resection. However, no reliable biomarkers have yet been described. The better rehabilitation potential after TBI and spontaneous intracranial bleeding compared with brain tumors offers an insight into the process of neurorehabilitation. Tractography and diffusion measurements in some studies showed a correlation with patient outcome that might help uncover the neuroanatomical principles of rehabilitation itself. Alternative corticofugal and cortico-cortical networks have been implicated in motor recovery after ischemic stroke, suggesting more complex mechanisms in neurorehabilitation that go beyond current models. Hence tractography may potentially be able to predict clinical deficits and rehabilitation potential, as well as finding possible explanations for neurologic disorders in retrospect. However, large variations of the results indicate a lack of data to establish robust diagnostical concepts at this point. Therefore, in vivo tractography should still be interpreted with caution and by experienced surgeons.

The Use of Osirix for Surgical Planning Using Cranial Measures and Region of Interest Tools: Technical Note

Background:

During the surgery for intrinsic brain lesions, it is important to plan the proper site of the craniotomy and to identify the relations with the gyri and superficial veins. This might be a challenge, especially in small subcortical lesions and when there is a distortion of the cortical anatomy.

Materials and Methods:

Using the free computer software Osirix, we have created a 3-dimensional reconstruction of the head and cerebral showing the gyri and superficial veins. With the aid of some tools, it is possible to create a colored image of the lesion and also to calculate the distance between the areas of interest and some easily identifiable structure, making it easier to plan the site of the craniotomy identify the topography of the lesion.

Results:

The reconstructions were compared to the intraoperative view. We found this technique to be useful to help identify the gyri and cortical veins and use them to find the lesions. The use of a region of interest to show better the lesion under the cortical surface and in the three-dimensional reconstruction of the head was also helpful.

Conclusions:

This is a low-cost and easy technique that can be quickly learned and performed before every surgery. It helps the surgeon to plan a safe craniotomy and lesionectomy.

Presurgical simulation for neuroendoscopic procedures: Virtual study of the integrity of neurological pathways using diffusion tensor imaging tractography

Background:

White matter (WM) transgression is an unexplored concept in neuroendoscopy. Diffusion tensor image (DTI) tractography could be implemented as a planning and postoperative evaluation tool in functional disconnection procedures (FDPs), which are, currently, the subject of technological innovations. We intend to prove the usefulness of this planning method focused on the assessment of WM injury that is suitable for planning FDPs.

Methods:

Ten cranial magnetic resonance studies (20 sides) without pathological findings were processed. Fascicles were defined by two regions of interest (ROIs) using the fiber assignment method by the continuous tracking approach. Using three-dimensional (3D) simulation and DTI tractography, we created an 8-mm virtual endoscope and an uninjured inferior fronto-occipital fasciculus (IFOF) from two ROIs. The injured tract was generated using a third ROI built from the 3D model of the intersection of the oriented trajectory of the endoscope with the fascicle. Data and images were quantitatively and qualitatively analyzed.

Results:

The average percentage of the injured fibers was 32.0% (range: 12.4%–70%). The average intersected volume was 1.1 cm³ (range: 0.3–2.3 cm³). Qualitative analysis showed the inferior medial quadrant of the inferior fronto-occipital fasciculus (IFOF) as the most frequently injured region. No hemispherical asymmetry was found (P > 0.5).

Conclusion:

DTI tractography is a useful surgical planning tool that could be implemented in several endoscopic procedures. Together with a functional atlas, the presented technique provides a noninvasive method to assess the potential sequelae and thus to optimize the surgical route. The suggested method could be implemented to analyze pathological WM fascicles and to assess the surgical results of FDP such as hemispherotomy or amygdalohippocampectomy. More studies are needed to overcome the limitations of the tractography based information and to develop more anatomically and functionally reliable planning systems.

Effectiveness of navigation-guided cyst aspiration before resection of large cystic brain tumors: a proof of concept for more radical surgery

BACKGROUND

Resection of tumors close to the corticospinal tract (CST) carries a high risk of damage to the CST. For cystic tumors, aspirating the cyst before resection may reduce the risk of damage to vital structures. This study evaluated the effectiveness of cyst aspiration, by comparing the results before and after aspiration of diffusion tensor image (DTI) tractography.

METHODS

This study enrolled 23 patients with large cystic brain tumors (>20 cm³) between 2012 and 2016. All underwent magnetic resonance imaging (MRI), including DTI tractography, followed by navigation-guided aspiration of the cyst and subsequent tumor resection via craniotomy. Distances between the tumor margin and CST before and after cyst aspiration, volume reduction, and postoperative outcomes were assessed.

RESULTS

Median tumor volume decreased from 88 cm³ (range, 25-153) to 29 cm³ (range, 20-80) and distances between tumor margins and the CST increased from 5.7 mm (range, 0.6-22.0) to 14.8 mm (range, 0.6-41.4) after aspiration. Neurological symptoms of patients immediately improved after cyst aspiration. All patients, except for one with a secondary glioblastoma, underwent gross total resection of the tumor. No neurological deterioration was observed after tumor resection.

CONCLUSIONS

Navigation-guided cyst aspiration followed by resection is a useful and safe procedure for brain tumors with large cystic components. Cyst aspiration resulted in expansion of the compressed brain tissue between the tumor margins and vital structures, making maximal safe resection possible.

Microstructure-informed slow diffusion tractography in humans enhances visualisation of fibre pathways

Conventional fibre tractography methods based on diffusion tensor imaging exploit diffusion anisotropy and directionality in the range of low diffusion weightings (b-values). High b-value Biexponential Diffusion Tensor Analysis reported previously has demonstrated that fractional anisotropy of the slow diffusion component is essentially higher than that of conventional diffusion tensor imaging whereas popular compartment models associate this slow diffusion component with axonal water fraction. One of the primary aims of this study is to elucidate the feasibility and potential benefits of "microstructure-informed" whole-brain slow-diffusion fibre tracking (SDIFT) in humans. In vivo diffusion-weighted images in humans were acquired in the extended range of diffusion weightings≤6000smm^-2 at 3T. Fast and slow diffusion tensors were reconstructed using the bi-exponential tensor decomposition, and a detailed statistical analysis of the relevant whole-brain tensor metrics was performed. We visualised three-dimensional fibre tracts in in vivo human brains using deterministic streamlining via the major eigenvector of the slow diffusion tensor. In particular, we demonstrated that slow-diffusion fibre tracking provided considerably higher fibre counts of long association fibres and allowed one to reconstruct more short association fibres than conventional diffusion tensor imaging. SDIFT is suggested to be useful as a complimentary method capable to enhance reliability and visualisation of the evaluated fibre pathways. It is especially informative in precortical areas where the uncertainty of the mono-exponential tensor evaluation becomes too high due to decreased anisotropy of low b-value diffusion in these areas. Benefits can be expected in assessment of the residual axonal integrity in tissues affected by various pathological conditions, in surgical planning, and in evaluation of cortical connectivity, in particular, between Brodmann's areas.

Assessment of White Matter Transgression During Neuroendoscopic Procedures Using Diffusion Tensor Image Fiber Tracking

BACKGROUND

Presurgical planning allows anticipating intraoperative difficulties, increasing efficiency, and reducing risks. Neuroendoscopy is a minimally invasive technique whose related complications have been focused on cortical function and surface vessels injury. However, white matter disruption has been insufficiently acknowledged.

OBJECTIVE

To present a new surgical planning method based on diffusion tensor image that allows quantifying subcortical transgression and optimizing neuroendoscopic trajectories.

METHODS

Ten cranial magnetic resonance studies (20 sides) without pathologic findings were anonymized and processed. A standard transcortical approach to the frontal horn was used to study the transgression of the corpus callosum (CC) and cingulum (Ci) caused by a virtual endoscope (VE) oriented from the Kocher point to the foramen of Monro. An 8-mm VE model was created, oriented, and coregistered. VE-CC and VE-Ci intersections were segmented. The number and volume of injured fibers were measured, intersections were quantified, and the percentage of tract transgression was calculated. The areas damaged by the VE were also recorded.

RESULTS

Among the CC fibers, 16.4% were injured (range: 3.3%-37%) and 26.7% of fibers on Ci (rank: 0%-73.4%). The average intersected volumes were 19.1% (range: 4.2%-53.2%) for CC and 33.2% for Ci (range: 0%-73.7%). Qualitative analysis showed the lateral aspect of both tracts as the most frequently injured region. No hemispherical asymmetry was found (P > 0.05).

CONCLUSION

This method using tractography and oriented models of surgical instruments allows assessing white matter transgression, both qualitatively and quantitatively, for a deep brain trajectory. Thus our method permits surgeons to optimize safety and avoid transgression of eloquent tracts during surgical planning. Nevertheless, more studies are necessary.

Stereotactic diffusion tensor imaging tractography for Gamma Knife radiosurgery

OBJECTIVE The integration of modern neuroimaging into treatment planning has increased the therapeutic potential and safety of stereotactic radiosurgery. The authors report their method of integrating stereotactic diffusion tensor imaging (DTI) tractography into conventional treatment planning for Gamma Knife radiosurgery (GKRS). The aim of this study was to demonstrate the feasibility of this technique and to address some of the technical limitations of previously reported techniques. METHODS Twenty patients who underwent GKRS composed the study cohort. They consisted of 1 initial test case (a patient with a vestibular schwannoma), 5 patients with arteriovenous malformations, 9 patients with cerebral metastases, 1 patient with parasagittal meningioma, and 4 patients with vestibular schwannoma. DT images were obtained at the time of standard GKRS protocol MRI (T1 and T2 weighted) for treatment, with the patient's head secured by a Leksell stereotactic frame. All studies were performed using a 1.5-T magnet with a single-channel head coil. DTI was performed with diffusion gradients in 32 directions and coregistered with the volumetric T1-weighted study. DTI postprocessing by means of commercially available software allowed tensor computation and the creation of directionally encoded color-, apparent diffusion coefficient-, and fractional anisotropy-mapped sequences. In addition, the software allowed visualized critical tracts to be exported as a structural volume and integrated into GammaPlan as an "organ at risk" during shot planning. Combined images were transferred to GammaPlan and integrated into treatment planning. RESULTS Stereotactic DT images were successfully acquired in all patients, with generation of correct directionally encoded color images. Tract generation with the software was straightforward and reproducible, particularly for axial tracts such as the optic radiation and the arcuate fasciculus. Corticospinal tract visualization was hampered by some artifacts from the base of the stereotactic frame, but this was overcome by a combination of frame/MRI volume adjustment and DTI seeding parameters. Coregistration of the DTI series with the T1-weighted treatment volume at the time of imaging was essential for the generation of correct tensor data. All patients with the exception of the vestibular schwannoma cases had treatment pathology in the vicinity of eloquent tracts and/or the cortex. No new neurological deficits due to radiation were recorded at the short-term follow-up. CONCLUSIONS Recent reports in the medical literature have suggested that white matter tracts (particularly the optic radiation and arcuate fasciculus) are more vulnerable to radiation during stereotactic radiosurgery than previously thought. Integration of stereotactic tractography into GKRS represents a promising tool for preventing GKRS complications by reduction in radiation doses to functional organs at risk, including critical cortical areas and subcortical white matter tracts.

Comparison of compressed sensing diffusion spectrum imaging and diffusion tensor imaging in patients with intracranial masses

PURPOSE

To compare compressed diffusion spectrum imaging (CS-DSI) with diffusion tensor imaging (DTI) in patients with intracranial masses. We hypothesized that CS-DSI would provide superior visualization of the motor and language tracts.

MATERIALS AND METHODS

We retrospectively analyzed 25 consecutive patients with intracranial masses who underwent DTI and CS-DSI for preoperative planning. Directionally-encoded anisotropy maps, and streamline hand corticospinal motor tracts and arcuate fasciculus language tracts were graded according to a 3-point scale. Tract counts, anisotropy, and lengths were also calculated. Comparisons were made using exact marginal homogeneity, McNemar's and Wilcoxon signed-rank tests.

RESULTS

Readers preferred the CS-DSI over DTI anisotropy maps in 92% of the cases, and the CS-DSI over DTI tracts in 84%. The motor tracts were graded as excellent in 80% of cases for CS-DSI versus 52% for DTI; 58% of the motor tracts graded as acceptable in DTI were graded as excellent in CS-DSI (p=0.02). The language tracts were graded as excellent in 68% for CS-DSI versus none for DTI; 78% of the language tracts graded as acceptable by DTI were graded as excellent by CS-DSI (p<0.001). CS-DSI demonstrated smaller normalized mean differences than DTI for motor tract counts, anisotropy and language tract counts (p≤0.01).

CONCLUSION

CS-DSI was preferred over DTI for the evaluation of motor and language white matter tracts in patients with intracranial masses. Results suggest that CS-DSI may be more useful than DTI for preoperative planning purposes.

Characterization and Correction of Geometric Distortions in 814 Diffusion Weighted Images

Introduction

Diffusion Weighted Imaging (DWI), which is based on Echo Planar Imaging (EPI) protocols, is becoming increasingly important for neurosurgical applications. However, its use in this context is limited in part by significant spatial distortion inherent to EPI.

Method

We evaluated an efficient algorithm for EPI distortion correction (EPIC) across 814 DWI scans from 250 brain tumor patients and quantified the magnitude of geometric distortion for whole brain and multiple brain regions.

Results

Evaluation of the algorithm’s performance revealed significantly higher mutual information between T1-weighted pre-contrast images and corrected b = 0 images than the uncorrected b = 0 images (p < 0.001). The distortion magnitude across all voxels revealed a median EPI distortion effect of 2.1 mm, ranging from 1.2 mm to 5.9 mm, the 5^th and 95^th percentile, respectively. Regions adjacent to bone-air interfaces, such as the orbitofrontal cortex, temporal poles, and brain stem, were the regions most severely affected by DWI distortion.

Conclusion

Using EPIC to estimate the degree of distortion in 814 DWI brain tumor images enabled the creation of a topographic atlas of DWI distortion across the brain. The degree of displacement of tumors boundaries in uncorrected images is severe but can be corrected for using EPIC. Our results support the use of distortion correction to ensure accurate and careful application of DWI to neurosurgical practice.

Merits and Limits of Tractography Techniques for the Uninitiated

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.