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Case report
peer-reviewed

Automated Whole Brain Tractography Affects Preoperative Surgical Decision Making



Abstract

Surgery in and around eloquent brain structures poses a technical challenge when the goal of surgery is maximal safe resection. Magnetic resonance imaging (MRI) has revolutionized the diagnosis and treatment of neurological disorders, but tractography still remains limited in terms of utility because of the requisite manual labor and time required combined with the high risk of bias and inaccuracy. Automated whole brain tractography (AWBT) has simplified this workflow, overcoming historical barriers, and allowing for integration into modern neuronavigation. However, current literature showing the usefulness of this new technology is limited. In this study, we aimed to illustrate the utility of AWBT during cranial surgery and its ability to affect presurgical and intraoperative clinical decision making. We performed a retrospective chart review of cases that underwent AWBT for one year from July 2016 to July 2017. All patients underwent conventional anatomic MRI with and without contrast sequences, in addition to diffusion tensor imaging (DTI) on a 3 Tesla MRI scanner (Ingenia 3.0T, Philips, Amsterdam NL). Post-hoc AWBT processing was performed on a separate workstation. Patients were subsequently grouped into those that had undergone either language or motor mapping and those that did not. We compared both sets of patients to see any differences in patient age, sex, laterality of surgery, depth of resection from cortical surface, and smallest distance between the lesion and adjacent eloquent white matter tracts. We identified illustrative cases which demonstrated the ability of AWBT to affect surgical decision making. In this single-center series, we identified 73 total patients who underwent AWBT for intracranial surgery, of which 28 patients underwent either speech or language mapping. When comparing mapping to non-mapping patients, we found no difference with respect to age, gender, laterality of surgery, or whether the surgery was a revision. The distance between the lesion and eloquent white matter tracts demonstrated a statistically significant difference between mapping and non-mapping patients, namely in the corticospinal tract (p < 0.0001), the superior longitudinal fasciculus (p < 0.0001), and the arcuate fasciculus (p < 0.004). Patients who underwent mapping were at equal risk for having a postoperative deficit (p = 0.772) but had an improved chance of recovery (p = 0.041) after surgery. We believe this phenomenon is related to increased awareness and avoidance of functional tissue during surgery, which occurs due to the combination of preoperatively identifying white matter tracts with AWBT and intraoperatively testing margins with mapping. We provide two illustrative cases that show the impact of AWBT on patient outcomes. In conclusion, AWBT is relatively simple to perform and provides vital information for surgeons about eloquent white matter tracts that can be used to help improve patient outcomes.



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Case report
peer-reviewed

Automated Whole Brain Tractography Affects Preoperative Surgical Decision Making


Author Information

Hesham Zakaria Corresponding Author

Neurosurgery, Henry Ford Hospital

Sameah Haider

Department of Neurological Surgery, Henry Ford Health Systems

Ian Lee

Neurosurgery, Henry Ford Health System


Ethics Statement and Conflict of Interest Disclosures

Human subjects: Consent was obtained by all participants in this study. Henry Ford Hospital Insitutional Review Board issued approval 9755. Conflicts of interest: The authors have declared the following conflicts of interest: Financial relationships: Ian Lee declare(s) personal fees from Medtronic. Ian Lee declare(s) personal fees from Monteris.

Acknowledgements

Sameah A Haider and Hesham M Zakaria contributed equally to this work. We thank Susan MacPhee for her editing.


Case report
peer-reviewed

Automated Whole Brain Tractography Affects Preoperative Surgical Decision Making


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Case report
peer-reviewed

Automated Whole Brain Tractography Affects Preoperative Surgical Decision Making

  • Author Information
    Hesham Zakaria Corresponding Author

    Neurosurgery, Henry Ford Hospital

    Sameah Haider

    Department of Neurological Surgery, Henry Ford Health Systems

    Ian Lee

    Neurosurgery, Henry Ford Health System


    Ethics Statement and Conflict of Interest Disclosures

    Human subjects: Consent was obtained by all participants in this study. Henry Ford Hospital Insitutional Review Board issued approval 9755. Conflicts of interest: The authors have declared the following conflicts of interest: Financial relationships: Ian Lee declare(s) personal fees from Medtronic. Ian Lee declare(s) personal fees from Monteris.

    Acknowledgements

    Sameah A Haider and Hesham M Zakaria contributed equally to this work. We thank Susan MacPhee for her editing.


    Article Information

    Published: September 06, 2017

    DOI

    10.7759/cureus.1656

    Cite this article as:

    Zakaria H, Haider S, Lee I (September 06, 2017) Automated Whole Brain Tractography Affects Preoperative Surgical Decision Making. Cureus 9(9): e1656. doi:10.7759/cureus.1656

    Publication history

    Received by Cureus: August 08, 2017
    Peer review began: August 26, 2017
    Peer review concluded: August 31, 2017
    Published: September 06, 2017

    Copyright

    © Copyright 2017
    Zakaria et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 3.0., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

    License

    This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Abstract

Surgery in and around eloquent brain structures poses a technical challenge when the goal of surgery is maximal safe resection. Magnetic resonance imaging (MRI) has revolutionized the diagnosis and treatment of neurological disorders, but tractography still remains limited in terms of utility because of the requisite manual labor and time required combined with the high risk of bias and inaccuracy. Automated whole brain tractography (AWBT) has simplified this workflow, overcoming historical barriers, and allowing for integration into modern neuronavigation. However, current literature showing the usefulness of this new technology is limited. In this study, we aimed to illustrate the utility of AWBT during cranial surgery and its ability to affect presurgical and intraoperative clinical decision making. We performed a retrospective chart review of cases that underwent AWBT for one year from July 2016 to July 2017. All patients underwent conventional anatomic MRI with and without contrast sequences, in addition to diffusion tensor imaging (DTI) on a 3 Tesla MRI scanner (Ingenia 3.0T, Philips, Amsterdam NL). Post-hoc AWBT processing was performed on a separate workstation. Patients were subsequently grouped into those that had undergone either language or motor mapping and those that did not. We compared both sets of patients to see any differences in patient age, sex, laterality of surgery, depth of resection from cortical surface, and smallest distance between the lesion and adjacent eloquent white matter tracts. We identified illustrative cases which demonstrated the ability of AWBT to affect surgical decision making. In this single-center series, we identified 73 total patients who underwent AWBT for intracranial surgery, of which 28 patients underwent either speech or language mapping. When comparing mapping to non-mapping patients, we found no difference with respect to age, gender, laterality of surgery, or whether the surgery was a revision. The distance between the lesion and eloquent white matter tracts demonstrated a statistically significant difference between mapping and non-mapping patients, namely in the corticospinal tract (p < 0.0001), the superior longitudinal fasciculus (p < 0.0001), and the arcuate fasciculus (p < 0.004). Patients who underwent mapping were at equal risk for having a postoperative deficit (p = 0.772) but had an improved chance of recovery (p = 0.041) after surgery. We believe this phenomenon is related to increased awareness and avoidance of functional tissue during surgery, which occurs due to the combination of preoperatively identifying white matter tracts with AWBT and intraoperatively testing margins with mapping. We provide two illustrative cases that show the impact of AWBT on patient outcomes. In conclusion, AWBT is relatively simple to perform and provides vital information for surgeons about eloquent white matter tracts that can be used to help improve patient outcomes.



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Hesham Zakaria

Neurosurgery, Henry Ford Hospital

For correspondence:
hzakari1@hfhs.org

Sameah Haider

Department of Neurological Surgery, Henry Ford Health Systems

Ian Lee

Neurosurgery, Henry Ford Health System

Hesham Zakaria

Neurosurgery, Henry Ford Hospital

For correspondence:
hzakari1@hfhs.org

Sameah Haider

Department of Neurological Surgery, Henry Ford Health Systems

Ian Lee

Neurosurgery, Henry Ford Health System