Combined use of tractography-integrated functional neuronavigation and direct fiber stimulation

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Object. The aim of this study was better preoperative planning and direct application to intraoperative procedures through accurate coregistration of diffusion-tensor (DT) imaging—based tractography results and anatomical three-dimensional magnetic resonance images and subsequent importation of the combined images to a neuronavigation system (functional neuronavigation).

Methods. Six patients with brain lesions adjacent to the corticospinal tract (CST) were studied. During surgery, direct fiber stimulation was used to evoke motor responses to confirm the accuracy of CST depicted on functional neuronavigation. In three patients, stimulation of the supposed CST elicited the expected motor evoked potentials. In the other three, stimulation at the resection borders more than 1 cm away from the supposed CST showed no motor response. All patients underwent appropriate tumor resection with preservation of the CST.

Conclusions. Integration of the DT imaging—based tractography information into a traditional neuronavigation system demonstrated spatial relationships between lesions and the CST, allowing for the avoidance of tract injury during lesion resection. Direct fiber stimulation was used for real-time reliable white matter mapping, which served to adjust for any discrepancy between the neuronavigation system data and potentially shifted positions of the brain structures. The combination of these techniques enabled the authors to identify accurate positions of the CST during surgery and to accomplish optimal tumor resections.

Article Information

Address reprint requests to: Kyousuke Kamada, M.D., Department of Neurosurgery, The University of Tokyo, 7–3–1 Hongo, Bunkyo-ku, Tokyo 113–8655, Japan. email: kamady-k@umin.ac.jp.

© AANS, except where prohibited by US copyright law.

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Figures

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    Case 1. A: Diffusion-tensor imaging-based tractography data indicating that the CST has shifted anteriorly. B: Three-dimensionally reconstructed CST voxels clearly demonstrating the CST profiles in both hemispheres.

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    Case 1. A: Transverse (left) and coronal (right) T1-weighted 3D MR images with Gd-DTPA enhancement. B: Marked voxels of the CST on DT imaging—based tractography in the same orientations as those featured in A. C: Results of 3D MR imaging fused with those of DT imaging—based tractography, revealing the anterior shift of the CST.

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    Case 1. Three-dimensionally reconstructed whole-head MR imaging data on the neuronavigation system, both the plain mode (A) and the cut mode (B), displaying the CST (green). White arrows indicate the surgical route for approaching the thalamic tumor.

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    Case 1. A: A T1-weighted MR image demonstrating the electrode position for fiber stimulation at the anterior wall of the resection cavity (white cross). B: Intraoperative photograph illustrating placement of an electrode (arrow) at the anterior wall of the tumor cavity. C: Electromyogram demonstrating the MEPs elicited by direct fiber stimulation at the anterior wall of the tumor cavity. D: A T1-weighted MR image exhibiting the electrode position at the posterior wall of the cavity (white cross). E: Intraoperative photograph displaying placement of an electrode (arrow) at the posterior wall of the tumor cavity. F: Electromyogram revealing no MEP on stimulation of the posterior cavity wall.

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    Case 1. Postoperative T2-weighted MR images with the superimposed CST demonstrating that the preserved CST remains anterior to the tumor cavity.

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    Case 4. A: Three-dimensionally reconstructed whole-head MR data on neuronavigation images revealing the tumor (yellow) and the CST (green). B: A transverse neuronavigation image demonstrating the anterior border of the resection (green cross) separated from the CST (white area). Fiber stimulation evoked no MEP.

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    Case 6. A: Diffusion-tensor imaging—based tractography data indicating that the CST has shifted anteriorly. B: A T1-weighted MR image from the functional neuronavigation system revealing the electrode position for fiber stimulation at the anterior wall of the resection cavity (green cross). C: Electromyogram demonstrating the MEPs in the palm and sole elicited by direct fiber stimulation at the anterior cavity wall. D: Postoperative T2-weighted MR image with the superimposed CST demonstrating that the preserved CST remains anterior to the cavity.

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