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A systematic review of functional magnetic resonance imaging and diffusion tensor imaging modalities used in presurgical planning of brain tumour resection

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Abstract

Historically, brain tumour resection has relied upon standardised anatomical atlases and classical mapping techniques for successful resection. While these have provided adequate results in the past, the emergence of new technologies has heralded a wave of less invasive, patient-specific techniques for the mapping of brain function. Functional magnetic resonance imaging (fMRI) and, more recently, diffusion tensor imaging (DTI) are two such techniques. While fMRI is able to highlight localisation of function within the cortex, DTI represents the only technique able to elucidate white matter structures in vivo. Used in conjunction, both of these techniques provide important presurgical information for thorough preoperative planning, as well as intraoperatively via integration into frameless stereotactic neuronavigational systems. Together, these techniques show great promise for improved neurosurgical outcomes. While further research is required for more widespread clinical validity and acceptance, results from the literature provide a clear road map for future research and development to cement these techniques into the clinical setup of neurosurgical departments globally.

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Authors and Affiliations

  1. The Brain and Mind Research Institute, The University of Sydney, 94 Mallet Street, Camperdown, NSW, Australia

    S. Dimou, R. A. Battisti, D. F. Hermens & J. Lagopoulos

  2. The Children’s Hospital Westmead, Westmead, NSW, Australia

    R. A. Battisti

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  1. S. Dimou
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  2. R. A. Battisti
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  3. D. F. Hermens
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  4. J. Lagopoulos
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Correspondence to J. Lagopoulos.

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Comments

Mario Giordano, Hannover, Germany

In the present review the authors deal with a very actual topic in the field of neurosurgery and neuroimaging. Functional magnetic resonance imaging (fMRI) has become fundamental in surgery of intra-axial lesions adjacent to eloquent cortical areas both for preoperative planning and intraoperative guidance. However care should be taken to preserve also white matter connections of these regions in order to avoid postoperative neurological deficits.

In this scenario, diffusion tensor imaging (DTI) provides information about the normal course or the displacement of fibre tracts near the tumour allowing a noninvasive tracing of the main white matter bundles in the human brain.

Combination of both techniques with intraoperative navigation has been applied successfully in many institutions, but its diffusion is still limited. For this reason, is important for the neurosurgical community to be familiar with the basis of these techniques as well as the complete workflow from imaging to surgery. The present review tries to achieve this result in a schematic and simple way describing the technical bases and practical use of both fMRI and DTI techniques. The paper has a ‘textbook’ layout that improves its readability, reaching its educational purpose.

Christopher Nimsky, Marburg, Germany

This review by Dimou et al. gives an overview on current preoperative strategies to locate cortical and subcortical eloquent brain areas. Preoperative fMRI and DTI investigations have become routine in many neurosurgical centres for lesions close to eloquent brain regions.

Integration of these data into a navigation setup leads to so-called functional navigation, allowing intraoperative identification of these eloquent structures. This concept of functional navigation is also open to integrate further modalities like MR spectroscopy, PET, transcranial magnetic stimulation, etc., resulting in the so-called multimodal navigation.

Besides the knowledge on effects related to patient registration accuracy and intraoperative events such as brain shift, all of them decreasing the accuracy of navigation, it is important that the neurosurgical user also has a profound knowledge on the technology behind these data. Otherwise, severe misinterpretations might lead to erroneous tracking results, finally causing unwanted neurological postoperative deficits. It is important to look at the raw data, as well as the strategies on how these data are analysed. The integration of fMRI and DTI packages into commercial navigation systems increases the broad availability; however, the inexperienced user is at risk to reconstruct white matter connections and find fMRI activations that do not relate to the real anatomy. Furthermore, the user has to take into account that the raw data are distorted to some extent. Additional hulls around the reconstructed objects representing major white matter tracts are a possibility to visualise safety margins, which ideally would vary in thickness respective to the quality and reliability of the reconstructed fibre bundle. In case of noisy unreliable data, a thick hull should be added, while in the highly reliable data, the hull could be thinner. The technical, as well as clinical definition of the extent of these safety margins is still under investigation. Maximal safety requires combining electrophysiological brain mapping with functional navigation that integrates fMRI data and DTI-based fibre tracking acquired before and also during surgery.

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Dimou, S., Battisti, R.A., Hermens, D.F. et al. A systematic review of functional magnetic resonance imaging and diffusion tensor imaging modalities used in presurgical planning of brain tumour resection. Neurosurg Rev 36, 205–214 (2013). https://doi.org/10.1007/s10143-012-0436-8

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