title: Clinical application of motor pathway mapping using diffusion tensor imaging tractography and intraoperative direct subcortical stimulation in cerebral glioma surgery:  a prospective cohort study.
abstract: BACKGROUND
  Glioma surgery in eloquent areas remains a challenge because of the risk of postoperative motor deficits.
  
  
  OBJECTIVE
  To prospectively evaluate the efficiency of using a combination of diffusion tensor imaging (DTI) tractography functional neuronavigation and direct subcortical stimulation (DsCS) to yield a maximally safe resection of cerebral glioma in eloquent areas.
  
  
  METHODS
  A prospective cohort study was conducted in 58 subjects with an initial diagnosis of primary cerebral glioma within or adjacent to the pyramidal tract (PT). The white matter beneath the resection cavity was stimulated along the PT, which was visualized with DTI tractography. The intercept between the PT border and DsCS site was measured. The sensitivity and specificity of DTI tractography for PT mapping were evaluated. The efficiency of the combined use of both techniques on motor function preservation was assessed.
  
  
  RESULTS
  Postoperative analysis showed gross total resection in 40 patients (69.0%). Seventeen patients (29.3%) experienced postoperative worsening; 1-month motor deficit was observed in 6 subjects (10.3%). DsCS verified a high concordance rate with DTI tractography for PT mapping. The sensitivity and specificity of DTI were 92.6% and 93.2%, respectively. The intercepts between positive DsCS sites and imaged PTs were 2.0 to 14.7 mm (5.2 ± 2.2 mm). The 6-month Karnofsky performance scale scores in 50 postoperative subjects were significantly increased compared with their preoperative scores.
  
  
  CONCLUSIONS
  DTI tractography is effective but not completely reliable in delineating the descending motor pathways. Integration of DTI and DsCS favors patient-specific surgery for cerebral glioma in eloquent areas.
authors.affiliation: Shanghai Medical College, Fudan University, Shanghai, China.
authors.forename: Feng-Ping
authors.initials: FP
authors.lastname: Zhu
authors.forename: Jin-Song
authors.initials: JS
authors.lastname: Wu
authors.forename: Yan-Yan
authors.initials: YY
authors.lastname: Song
authors.forename: Cheng-Jun
authors.initials: CJ
authors.lastname: Yao
authors.forename: Dong-Xiao
authors.initials: DX
authors.lastname: Zhuang
authors.forename: Geng
authors.initials: G
authors.lastname: Xu
authors.forename: Wei-Jun
authors.initials: WJ
authors.lastname: Tang
authors.forename: Zhi-Yong
authors.initials: ZY
authors.lastname: Qin
authors.forename: Ying
authors.initials: Y
authors.lastname: Mao
authors.forename: Liang-Fu
authors.initials: LF
authors.lastname: Zhou
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001931:Brain Mapping; D001932:Brain Neoplasms / Q000473:pathology / Q000601:surgery*; D002648:Child; D015331:Cohort Studies; D056324:Diffusion Tensor Imaging; D004525:Efferent Pathways / Q000503:physiopathology* / Q000601:surgery; D004558:Electric Stimulation; D004576:Electromyography; D019054:Evoked Potentials, Motor / Q000502:physiology; D005260:Female; D005910:Glioma / Q000473:pathology / Q000601:surgery*; D006801:Humans; D021621:Imaging, Three-Dimensional; D008297:Male; D008875:Middle Aged; D016343:Monitoring, Intraoperative; D038361:Neuronavigation; D019635:Neurosurgical Procedures / Q000379:methods*; D055815:Young Adult