Arcuate fasciculus tractography integrated into Gamma Knife surgery

Clinical article

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Object

To prevent speech disturbances after Gamma Knife surgery (GKS), the authors integrated arcuate fasciculus (AF) tractography based on diffusion tensor (DT) MR imaging into treatment planning for GKS.

Methods

Arcuate fasciculus tractography was retrospectively integrated into planning that had been previously performed by neurosurgeons and radiation oncologists. This technique was retrospectively applied to 12 patients with arteriovenous malformations adjacent to the AF. Diffusion tensor images were acquired before the frame was affixed to the patient's head and DT tractography images of the AF were created using the authors' original software. The data from DT tractography and stereotactic 3D imaging studies obtained after frame fixation were transported to a treatment planning workstation for GKS and coregistered so that the delivered doses and incidence of posttreatment aphasia could be assessed.

Results

The AF could not be depicted in 2 patients who initially presented with motor aphasia caused by hemorrhaging from arteriovenous malformations. During the median follow-up period of 29 months after GKS, aphasia developed in 2 patients: 30 Gy delivered to the frontal portion of the AF caused conduction aphasia in 1 patient, and 9.6 Gy to the temporal portion led to motor aphasia in the other. Speech dysfunction was not observed after a maximum radiation dose of 10.0–16.8 Gy was delivered to the frontal fibers in 4 patients, and 3.6–5.2 Gy to the temporal fibers in 3.

Conclusions

The authors found that administration of a 10-Gy radiation dose during GKS was tolerated in the frontal but not the temporal fibers of the AF. The authors recommend confirmation of the dose by integration of AF tractography with GKS, especially in lesions located near the temporal language fibers.

Abbreviations used in this paper: AF = arcuate fasciculus; AVM = arteriovenous malformation; DICOM = Digital Imaging and Communications in Medicine; DT = diffusion tensor; GKS = Gamma Knife surgery.

Article Information

Address correspondence to: Keisuke Maruyama, M.D., Ph.D., Department of Neurosurgery, The University of Tokyo Hospital,7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan. email: kskmaru-tky@umin.ac.jp.

Please include this information when citing this paper: published online November 21, 2008; DOI: 10.3171/2008.4.17521.

© AANS, except where prohibited by US copyright law.

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Figures

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    Axial (A), coronal (B), 3D reconstruction image (C), and sagittal (D) radiosurgical dosimetry studies on T2-weighted MR images showing the results of integrating the AF tractography (with the AF shown in orange) in a 48-year-old man who developed conduction aphasia 1 month after GKS. The maximum dose to the AF was 30.0 Gy. The spatial relationship between the dose distribution and the AF is clearly demonstrated in the 3D MR reconstruction. The yellow object in C represents the volume that received 20 Gy. The green and light blue mesh correspond to the volumes that received 10 and 5 Gy, respectively. Comparison of image obtained before GKS (E) with that obtained 1 month postoperatively (F) demonstrates a mild adverse radiation effect.

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    Axial (A), coronal (B), 3D reconstruction image (C), and sagittal (D) radiosurgical dosimetry studies on T2-weighted MR images showing the results of AF tractography integration with GKS planning in a 45-year-old man who developed Broca aphasia 10 months postoperatively. The maximum dose to the AF was 9.6 Gy. In the 3D reconstruction (C), the yellow object represents the volume that received 20 Gy. The green and light blue mesh correspond to the volumes that received 10 and 5 Gy, respectively. Comparison of the image obtained before GKS (E) with that obtained 10 months postoperatively (F) demonstrates a severe adverse radiation effect.

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    A–D: Radiosurgical dosimetry studies on T2-weighted MR images showing the results of AF tractography integration in a 27-year-old woman with a left frontal AVM who received a maximum dose of 10.0 Gy to the AF (orange). The patient experienced no complications during 17 months of follow-up after GKS. In the 3D reconstruction (C), the yellow object represents the volume that received 20 Gy. The green mesh and the light blue mesh correspond to the volumes that received 10 and 5 Gy, respectively.

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