The Usefulness of Diffusion Tensor Imaging and Tractography in Surgery of Brainstem Cavernous Malformations.
BACKGROUND
Diffusion tensor imaging (DTI) estimates the course and connectivity patterns of white matter tracts. The objective of this study is to evaluate whether findings in the brain stem modify the preoperative surgical trajectory planning or postoperative outcome in patients with brain stem cavernous malformations.


METHODS
Ten patients with symptomatic brainstem cavernous malformation underwent surgical resection. Five patients received preoperative DTI evaluation and the remaining 5 did not. Reconstructed DTI tracts consisted of corticospinal, medial lemnisci, and cerebellar peduncles. The surgical planning and postoperative outcome were evaluated.


RESULTS
In 5 patients with no preoperative DTI evaluation, surgical planning was based on anatomic landmark and the 2-point technique. The other 5 patients underwent preoperative DTI, and findings were factored into the selection of the surgical approach. In 3 of the 5 cases with DTI evaluation, the 2-point technique suggested a similar trajectory. In the other 2, the DTI findings suggested a different approach to avoid damage to the white matter tract. Two patients in the group with no DTI had immediate postoperative new or worsened deficit, which improved at long-term follow-up. No patient in the DTI group had a new neurologic deficit.


CONCLUSIONS
Compared with the standard magnetic resonance imaging, DTI provided improved visualization of cavernous malformation involvement in eloquent fiber tracts of the brainstem. This additional information might help in selecting a more appropriate surgical trajectory in selected lesions. Larger patient cohorts are needed to assess the effect of this modality in patients' outcome.
Department of Neurosurgery, Cushing Neuroscience Institute, Hofstra Northwell School of Medicine, Manhasset, New York, USA. Electronic address: jjanuszew@nshs.edu.
Jacob
J
Januszewski
Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA.
Lauren
L
Albert
Department of Neuroradiology, Hofstra Northwell School of Medicine, Manhasset, New York, USA.
Karen
K
Black
Department of Neurosurgery, Cushing Neuroscience Institute, Hofstra Northwell School of Medicine, Manhasset, New York, USA.
Amir R
AR
Dehdashti
D000293:Adolescent; D000328:Adult; D000368:Aged; D001933:Brain Stem; D020295:Brain Stem Neoplasms / Q000000981:diagnostic imaging* / Q000601:surgery*; D002648:Child; D056324:Diffusion Tensor Imaging / Q000379:methods*; D005260:Female; D020786:Hemangioma, Cavernous, Central Nervous System / Q000000981:diagnostic imaging* / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011300:Preoperative Care / Q000379:methods; D015203:Reproducibility of Results; D012189:Retrospective Studies; D012680:Sensitivity and Specificity; D025321:Surgery, Computer-Assisted / Q000379:methods*; D016896:Treatment Outcome; D055815:Young Adult
Brainstem; Cavernous malformation; Diffusion tensor imaging; Diffusion tensor tractography; Outcome; Vascular malformations