Comparison of diffusion tensor imaging tractography of language tracts and intraoperative subcortical stimulations

Clinical article

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Object

Diffusion tensor (DT) imaging tractography is increasingly used to map fiber tracts in patients with surgical brain lesions to reduce the risk of postoperative functional deficit. There are few validation studies of DT imaging tractography in these patients. The aim of this study was to compare DT imaging tractography of language fiber tracts by using intraoperative subcortical electrical stimulations.

Methods

The authors included 10 patients with low-grade gliomas or dysplasia located in language areas. The MR imaging examination included 3D T1-weighted images for anatomical coregistration, FLAIR, and DT images. Diffusion tensors and fiber tracts were calculated using in-house software. Four tracts were reconstructed in each patient including the arcuate fasciculus, the inferior occipitofrontal fasciculus, and 2 premotor fasciculi (the subcallosal medialis fiber tract and cortical fibers originating from the medial and lateral premotor areas). The authors compared fiber tracts reconstructed using DT imaging with those evidenced using intraoperative subcortical language mapping.

Results

Seventeen (81%) of 21 positive stimulations were concordant with DT imaging fiber bundles (located within 6 mm of a fiber tract). Four positive stimulations were not located in the vicinity of a DT imaging fiber tract. Stimulations of the arcuate fasciculus mostly induced articulatory and phonemic/syntactic disorders and less frequently semantic paraphasias. Stimulations of the inferior occipitofrontal fasciculus induced semantic paraphasias. Stimulations of the premotor-related fasciculi induced dysarthria and articulatory planning deficit.

Conclusions

There was a good correspondence between positive stimulation sites and fiber tracts, suggesting that DT imaging fiber tracking is a reliable technique but not yet optimal to map language tracts in patients with brain lesions. Negative tractography does not rule out the persistence of a fiber tract, especially when invaded by the tumor. Stimulations of the different tracts induced variable language disorders that were specific to each fiber tract.

Abbreviations used in this paper: DT = diffusion tensor; FA = fractional anisotropy; LGG = low-grade glioma; ROI = region of interest; SMA = supplementary motor area; VAC = vertical anterior commissural.

Article Information

Address correspondence to: Delphine Leclercq, M.D., Ph.D., Service de Neuroradiologie, Bâtiment Babinski, Hôpital de la Pitié-Salpêtrière, 47 boulevard de l'Hôpital, 75651 Paris CEDEX 13, France. email: dlecl_99@yahoo.fr.

Please include this information when citing this paper: published online September 11, 2009; DOI: 10.3171/2009.8.JNS09558.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Reconstructed images. A: Tracts were reconstructed using 1 cortical (left) and 1 subcortical (right) ROI. B: Reconstructed tracts coregistered onto preoperative T1-weighted images. The arcuate fasciculus appears turquoise; the inferior occipitofrontal fasciculus, blue; the subcallosal medials fasciculus, green; and the premotor fibers, yellow.

  • View in gallery

    Examples of positive correlation. Three-dimensional reconstructions of language fiber tracts in 3 different patients (A–C) superimposed onto postoperative 3D T1-weighted images (A, B, and C1) and corresponding intraoperative photograph (C2). Positive stimulations sites are indicated by arrows. A: Sagittal view obtained in a patient with a frontoinsular tumor, showing the arcuate fasciculus (light blue) and 2 positive stimulation sites in contact with the anterior and posterior parts of the fasciculus. B: Sagittal view obtained in a patient with a frontoinsular tumor, showing the premotor fibers (yellow) originating from the ventral and dorsal premotor cortex and 1 positive stimulation site in contact with the anterior part of the fasciculus. C1 and C2: Correlation between the subcallosal medialis fasciculus on a sagittal image (C1) and operative view (C2). The positive stimulation site labeled 50 in the operative view (C2) adjoined the fasciculus (green area in the MR image). The top of the patient's head is located in the inferior part of the image; anterior is to the left.

  • View in gallery

    Examples of incomplete reconstruction related to low local anisotropy. Coronal views of the premotor fibers on the directional color map with projection of the main eigenvector and corresponding tracts coregistered onto preoperative T1-weighted images. The tumor was responsible for a low anisotropy locally (arrows). A: A tumor located in the SMA. The premotor fibers originating from the SMA in green in the color-coded image were missing (arrow). In the right panel, neither these fibers (arrow) nor the subcallosal medialis was reconstructed. B: A tumor located in the ventrolateral premotor area. The fibers originating from the premotor cortex (blue in the color-coded image) were missing. On the right panel, these fibers were not reconstructed.

  • View in gallery

    Example of impossible reconstruction related to the disorganization of the vector orientation. Coronal view of the subcallosal medialis fibers on the directional color map with projection of the main eigenvector (left) and corresponding view on T2-weighted DT imaging (right). The tumor was responsible for a disorganization of the vector orientation in the area of the missing tract (fat arrows) compared with the contralateral fibers seen in green (small arrow). In this case, the subcallosal medialis fasciculus could not be reconstructed by tractography.

  • View in gallery

    Example of incomplete reconstruction. A: Sagittal view of the arcuate fasciculus (arrow) on the directional color map with projection of the main eigenvector. B: Reconstructed arcuate fasciculus coregistered onto a preoperative T1-weighted image. The anterior part of the left fasciculus, which is visible in the normal hemisphere (thin arrow), is missing in the pathological hemisphere (fat arrow). Positive stimulations were recorded in the area of the missing tract.

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