Validation of diffusion tensor imaging tractography to visualize the dentatorubrothalamic tract for surgical planning

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The dentatorubrothalamic tract (DRTT) has been suggested as the anatomical substrate for deep brain stimulation (DBS)–induced tremor alleviation. So far, little is known about how accurately and reliably tracking results correspond to the anatomical DRTT. The objective of this study was to systematically investigate and validate the results of different tractography approaches for surgical planning.


The authors retrospectively analyzed 4 methodological approaches for diffusion tensor imaging (DTI)–based fiber tracking using different regions of interest in 6 patients with essential tremor. Tracking results were analyzed and validated with reference to MRI-based anatomical landmarks, were projected onto the stereotactic atlas of Morel at 3 predetermined levels (vertical levels −3.6, −1.8, and 0 mm below the anterior commissure–posterior commissure line), and were correlated to clinical outcome.


The 4 different methodologies for tracking the DRTT led to divergent results with respect to the MRI-based anatomical landmarks and when projected onto the stereotactic atlas of Morel. There was a statistically significant difference in the lateral and anteroposterior coordinates at the 3 vertical levels (p < 0.001, 2-way ANOVA). Different fractional anisotropy values ranging from 0.1 to 0.46 were required for anatomically plausible tracking results and led to varying degrees of success. Tracking results were not correlated to postoperative tremor reduction.


Different tracking methods can yield results with good anatomical approximation. The authors recommend using 3 regions of interest including the dentate nucleus of the cerebellum, the posterior subthalamic area, and the precentral gyrus to visualize the DRTT. Tracking results must be cautiously evaluated for anatomical plausibility and accuracy in each patient.

ABBREVIATIONS AC = anterior commissure; AP = anteroposterior; DBS = deep brain stimulation; DRTT = dentatorubrothalamic tract; DTI = diffusion tensor imaging; ET = essential tremor; FA = fractional anisotropy; fct = fasciculus cerebellothalamicus, per the Morel atlas; LAT = lateral; ML = medial lemniscus; ml = medial lemniscus, per the Morel atlas; PC = posterior commissure; PSA = posterior subthalamic area; PT = pyramidal tract; RN = red nucleus; ROI = region of interest; STN = subthalamic nucleus; TRS = Fahn-Tolosa-Marin tremor rating scale; VERT = vertical; Vim = ventral intermediate nucleus; VLp = ventrolateral posterior part of the thalamus.

Article Information

Correspondence Andreas Nowacki: University Hospital Inselspital Bern, University of Bern, Switzerland.

INCLUDE WHEN CITING Published online March 23, 2018; DOI: 10.3171/2017.9.JNS171321.

Disclosures Dr. Debove has received support from Boston Scientific for non–study-related clinical or research efforts.

© AANS, except where prohibited by US copyright law.



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    Cuboid boxes along the axis of the gyrus were constructed as ROIs for the primary motor cortex (A), somatosensory cortex (B), and RN (E). Manual segmentation was performed to define the superior cerebellar peduncle (C), the dentate nucleus (D), the PSA (F), the middle two-thirds of the crus cerebri (G), and the ML (H). All ROIs were selected on T2-weighted images.

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    The PSA was defined as the white matter contained within the parallelogram defined by the medial and lateral margins of the STN and RN. The PSA is known to include the DRTT (fct) based on atlas data (A). The parallelograms were constructed on T2-weighted imaging for analysis purposes in each patient (B). Purple indicates method 2; dark blue, method 3; yellow, method 4; green, method 1; light blue, ML; red, PT. bic = brachium of inferior colliculus; GPi = globus pallidus interna; Hyp = hypothalamus; ic = internal capsule; MCL = midcommissural mammillothalamic tract; MGN = medial geniculate nucleus; mtt = mammillothalamic tract; PCL = posterior commissural line; STh = subthalamic nucleus. Panel A is adapted from Gallay et al: Brain Struct Funct 212:443–463, 2008. Copyright: the authors (Gallay et al.). CC BY-NC (

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    The calculated mean position of the center of the PT (red circle), ML (light blue circle), and method 1 (green circle), method 2 (purple circle), method 3 (navy circle), and method 4 (yellow circle) fiber tracking results, as well their corresponding 95% confidence intervals, are projected onto axial planes of the Morel atlas at the corresponding levels VERT −3.6 mm (A), −1.8 mm (B), and 0 mm (C). Two-way ANOVA revealed significant differences between the mean LAT and AP coordinates among the 4 different tracking methods. Mean differences and corresponding 95% confidence intervals of the LAT (D) and AP (E) coordinates among the 4 methods are presented (post hoc analysis based on Tukey’s multiple comparison test). al = ansa lenticularis; CeM = central medial nucleus; CM = centromedian nucleus; fl = fasciculus lenticularis; frf = fasciculus retroflexus; ft = fasciculus thalamicus; iml = internal medullary lamina; Li = limitans nucleus; MV = medial ventral nucleus; PAG = periaqueductal gray; Pf = parafascicular nucleus; Po = posterior nucleus; PuA = anterior pulvinar; R = reticular thalamic nucleus; VLa = ventral lateral anterior nucleus; VLpv = ventral lateral posteroventral nucleus; VM = ventral medial nucleus; VPI = ventral posterior inferior nucleus; VPLa = ventral posterolateral anterior nucleus; VPLp = ventral posterolateral posterior nucleus; VPM = ventral posteromedial; VPMpc = ventral posteromedial, parvocellular division; SG = suprageniculate nucleus; sPf = subparafascicular nucleus; ZI = zona incerta. See legend of Fig. 1 for additional abbreviations. Panels A–C adapted from Gallay et al: Brain Struct Funct 212:443–463, 2008. Copyright: the authors (Gallay et al.). CC BY-NC (

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    Plausible (A) and implausible (B) fiber tracking results of the 4 methods to display the DRTT in 2 representative patients. Green fibers result from method 1, purple fibers from method 2, blue fibers from method 3, and yellow fibers from method 4. The RN (red) and PSA (blue) were segmented and displayed for better anatomical orientation.

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    Regression analysis and the correlation between unilateral TRS scores, and the distance between the active contact position and the center of the tracked DRTT by method 1 (A), method 2 (B), method 3 (C), and method 4 (D). There was a nonsignificant inverse correlation between the unilateral TRS score, and the distance between the active contact and the tracked DRTT of method 1 and method 2 (Spearman’s r = −0.09, p = 0.76; and Spearman’s r = −0.07, p = 0.88; respectively). There was a slightly positive correlation between the unilateral TRS score, and the distance between the active contact and the tracked DRTT of method 3 and method 4 (Spearman’s r = 0.54, p = 0.71; and Spearman’s r = 0.55, p = 0.06; respectively).



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