Diffusion-tensor imaging—guided tracking of fibers of the pyramidal tract combined with intraoperative cortical stimulation mapping in patients with gliomas

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Object. The goal of this study was to use diffusion-tensor (DT) magnetic resonance (MR) imaging to track fibers combined with cortical stimulation mapping to delineate descending motor pathways. Subcortical localization of motor pathways in relation to a glioma may provide critical information to guide tumor resection and prevent surgical morbidity.

Methods. Eleven adult patients harboring gliomas underwent MR imaging 1 day prior to image-guided intraoperative cortical motor mapping and tumor resection. Screens depicting 27 cortical motor sites on a surgical navigation system were saved to launch DT imaging of fiber tracks of descending motor pathways. The position and organization of motor tracts were visualized by fiber tracking. Tracks from 16 motor stimulation sites followed descending pathways from the precentral gyrus, through the corona radiata and internal capsule, and into the cerebral peduncle. These tracks were also observed on DT images to diverge along crossing white matter bundles (four patients) and to terminate or deviate in regions of peritumoral vasogenic edema (five patients).

Conclusions. The use of precise intraoperative cortical mapping information and DT images of fiber tracks can reveal the course of motor pathways beneath the cortex. The subcortical fiber tracks generated are consistent with the known anatomical course and somatotopic organization of the motor tract in relation to its cortical origins. Tracking fibers by using DT imaging in combination with functional localization has the potential to reduce surgical morbidity by revealing subcortical connections of the functional cortex.

Article Information

Address reprint requests to: Roland G. Henry, Ph.D., University of California, San Francisco, Department of Radiology, 185 Berry Street, Suite 350, San Francisco, California 94143–0946. email: henry@mrsc.ucsf.edu.

© AANS, except where prohibited by US copyright law.

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Figures

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    Case 11. Fiber tracking from a stereotactically identified motor site. A: Surgical navigation screen demonstrating a tongue motor site in a patient. The center of the cross-hairs indicates the position of the stereotactic probe tip on T2-weighted FSE MR images. B: Corresponding axial echo planar image from the DT imaging set revealing the square starting region (arrow) and 3D fiber tracks (white). C: Coronal projection of fiber tracks connecting the cortex with the cerebral peduncle. The outline of the regions drawn in the cerebral peduncle for filtering the fiber tracks is shown (arrow).

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    Case 9. Subcortical organization of fiber tracks demonstrated on DT imaging. Fiber tracks are shown intersecting different axial levels. Tracks from shoulder (red) and wrist (blue) motor cortex stimulation sites descend to the cerebral peduncle. Overlapping voxels appear in yellow. a: Level of shoulder stimulation site. The wrist stimulation site was superior to the shoulder site. b: Motor tracks passing by the border of the tumor. The corticospinal tract is deviated posterolaterally by the tumor mass. c: Corticospinal tracts descend through the centrum semiovale. The DT imaging fiber tracks have rotated, with the shoulder track situated directly posterior to the wrist track. d: The shoulder track lies medial to the wrist track in the cerebral peduncle. e: Three-dimensional view of fiber tracks in relation to the tumor (green). The two tracks are seen twisting around each other as they descend through the internal capsule.

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    Case 10. Coronal slice obtained through fiber tracks (white) terminating at the SLF. Directionality of the primary eigenvector is color coded: anteroposterior, green; left—right, red; and inferosuperior, blue. The anteroposteriorly directed fibers of the SLF appear as green triangular regions (arrows) in both the left and right hemispheres. The descending motor pathway tracks (hand no. 2, depicted in white) intersects or passes very closely to the SLF, preventing DT imaging—demonstrated fiber tracking from entering the internal capsule.

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    Case 2. Diffusion-tensor MR images demonstrating fiber track divergence in regions of edema. a: Fiber tracks (arrow) from a wrist/finger motor site initially descend through the precentral gyrus. b: Fiber tracks (arrows) descend parallel to the tumor border and enter a hyperintense region of edema (c). d: The tracks (arrow) are deviated posteriorly and are not consistent with the known location of the pyramidal tract at this level.

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