Acta Neurochirurgica

, Volume 155, Issue 3, pp 437–448 | Cite as

Intraoperative visualisation of language fascicles by diffusion tensor imaging-based tractography in glioma surgery

  • François Vassal
  • Fabien Schneider
  • Anna Sontheimer
  • Jean-Jacques Lemaire
  • Christophe Nuti
Clinical Article - Neurosurgical Techniques



For gliomas, the goal of surgery is to maximise the extent of resection (EOR) while minimising the postoperative morbidity. The purpose of this study was to evaluate the benefits of a protocol developed for the surgical management of gliomas located in language areas, where tractography-integrated navigation was used in conjunction with direct electrical stimulations (DES).

Methods and materials

The authors included ten patients suffering of gliomas located in language areas. The preoperative planning for multimodal navigation was done by integrating anatomical magnetic resonance images and subcortical pathway volumes generated by diffusion tensor imaging. Six white matter fascicles implicated in language functions were reconstructed in each patient, including fibres for phonological processing (i.e. the arcuate fasciculus), fibres for lexical-semantic processing (i.e. the inferior frontooccipital fasciculus, inferior longitudinal fasciculus and uncinate fasciculus), and two premotor fasciculi involved in the preparation of speech movements (the subcallosal medialis fasciculus and cortical fibres originating from the medial and lateral premotor areas). During surgery, language fascicles were identified by direct visualisation on tractography-integrated navigation images and by observing transient language inhibition after subcortical DES. Language deficits were evaluated preoperatively and postoperatively, and compared with the EOR.


Tractography was successfully performed in all patients, preoperatively demonstrating the relationships between the tumours to resect and the language fascicles to preserve from injury. With the use of the tractography-integrated navigation system and intraoperative DES, language functions were preserved in all patients. The mean volumetric resection was 93.0 ± 10.4 % of the preoperative tumour volume, with a gross total resection in 60 % of patients.


The intraoperative combination of tractography and DES contributed to maximum safe resection of gliomas located in language areas.


Diffusion tensor imaging Fibre tracking Gliomas Language pathways Subcortical stimulation mapping Tractography 


  1. 1.
    Basser PJ, Pajevic S, Pierpaoli C, Duda J, Aldroubi A (2000) In vivo fiber tractography using DT-MRI data. Magn Reson Med 44:625–632PubMedCrossRefGoogle Scholar
  2. 2.
    Beaulieu C (2002) The basis of anisotropic water diffusion in the nervous system—a technical review. NMR Biomed 15:435–455PubMedCrossRefGoogle Scholar
  3. 3.
    Bello L, Gambini A, Castellano A, Carraba G, Acerbi F, Fava E, Giussani C, Cadioli M, Blasi V, Casarotti A, Papagano C, Gupta AK, Gaini S, Scotti G, Falini A (2008) Motor and language DTI fiber tracking combined with intraoperative subcortical mapping for surgical removal of gliomas. Neuroimage 39:369–382PubMedCrossRefGoogle Scholar
  4. 4.
    Bello L, Castellano A, Fava E, Casaceli G, Riva M, Scotti G, Gaini SM, Falini A (2010) Intraoperative use of diffusion tensor imaging fiber tractography and subcortical mapping for resection of gliomas: technical considerations. Neurosurg Focus 28:E6PubMedCrossRefGoogle Scholar
  5. 5.
    Berman JI, Berger MS, Mukherjee P, Henry RG (2004) Diffusion-tensor imaging-guided tracking of fibers of the pyramidal tract combined with intraoperative cortical stimulation mapping in patients with gliomas. J Neurosurg 101:66–72PubMedCrossRefGoogle Scholar
  6. 6.
    Berman J, Berger M, Chung S, Nagarajan S, Henry R (2007) Accuracy of diffusion tensor magnetic resonance imaging tractography assessed using intraoperative subcortical stimulation mapping and magnetic source imaging. J Neurosurg 107:488–494PubMedCrossRefGoogle Scholar
  7. 7.
    Catani M, Howard RJ, Pajevic S, Jones DK (2002) Virtual in vivo interactive dissection of white matter fasciculi in the human brain. Neuroimage 17:77–94PubMedCrossRefGoogle Scholar
  8. 8.
    Coenen VA, Krings T, Axer H, Weidemann J, Kränzlein H, Fans FJ, Thron A, Gilsbach JM, Rohde V (2003) Intraoperative three-dimensional visualization of the pyramidal tract in a neuronavigation system (PTV) reliably predicts true position of principal motor pathways. Surg Neurol 60:381–390PubMedCrossRefGoogle Scholar
  9. 9.
    Delmaire C, Krainik A, Lethuc V, Reyns N, Duffau H, Capelle L, Lehéricy S (2007) Functional magnetic resonance imaging: physiopathology, techniques, and applications. J Radiol 88:497–509PubMedCrossRefGoogle Scholar
  10. 10.
    Duffau H, Capelle L, Sichez N, Denvil D, Lopes M, Sichez JP, Bitar A, Fohanno D (2002) Intraoperative mapping of the subcortical language pathways using direct stimulations. An anatomofunctional study. Brain 125:199–214PubMedCrossRefGoogle Scholar
  11. 11.
    Duffau H, Capelle L, Denvil D, Sichez N, Gatignol P, Taillandier L, Lopes M, Mitchell MC, Roche S, Muller JC, Bitar A, Sichez JP, van Effentere R (2003) Usefulness of intraoperative electrical subcortical mapping during surgery for low-grade gliomas located within eloquent brain regions: functional results in a consecutive series of 103 patients. J Neurosurg 98:764–778PubMedCrossRefGoogle Scholar
  12. 12.
    Duffau H, Gatignol P, Mandonnet E, Peruzzi P, Tzourio-Mazoyer N, Capelle L (2005) New insights into the anatomo-functional connectivity of the semantic system: a study using cortico-subcortical electrostimulations. Brain 128:797–810PubMedCrossRefGoogle Scholar
  13. 13.
    Duffau H, Gatignol P, Mandonnet E, Capelle L, Taillandier L (2008) Intraoperative mapping of language pathways in a consecutive series of 115 patients with grade II glioma in the left dominant hemisphere. J Neurosurg 109:461–471PubMedCrossRefGoogle Scholar
  14. 14.
    Gonzalez-Darder JM, Gonzales-Lopez P, Talamantes F, Quilis V, Cortes V, Garcia-March G, Roldan P (2010) Multimodal navigation in the functional microsurgical resection of intrinsic brain tumors located in eloquent motor areas: role of tractography. Neurosurg Focus 28:E5PubMedCrossRefGoogle Scholar
  15. 15.
    Hickok G, Poeppel D (2004) Dorsal and ventral streams: a framework for understanding aspects of the functional anatomy of language. Cognition 92:67–99PubMedCrossRefGoogle Scholar
  16. 16.
    Kamada K, Todo T, Masutani Y, Aoki S, Ino K, Takano T, Kirino T, Kawahara N, Morita A (2005) Combined use of tractography-integrated functional neuronavigation and direct fiber stimulation. J Neurosurg 102:664–672PubMedCrossRefGoogle Scholar
  17. 17.
    Kamada K, Todo T, Masutani Y, Aoki S, Ino K, Morita A, Saito N (2007) Visualization of the frontotemporal language fibers by tractography combined with functional magnetic resonance imaging and magnetoencephalography. J Neurosurg 106:90–98PubMedCrossRefGoogle Scholar
  18. 18.
    Kamada K, Todo T, Ota T, Ino K, Masutani Y, Aoki S, Takeuchi F, Kawai K, Saito N (2009) The motor-evoked potential threshold evaluated by tractography and electrical stimulation. J Neurosurg 111:785–795PubMedCrossRefGoogle Scholar
  19. 19.
    Keles GE, Chang EF, Lamborn KR, Tihan T, Chang CJ, Chang SM, Berger MS (2006) Volumetric extent of resection and residual contrast enhancement on initial surgery as predictors of outcome in adult patients with hemispheric anaplastic astrocytoma. J Neurosurg 105:34–40PubMedCrossRefGoogle Scholar
  20. 20.
    Kuhnt D, Bauer MA, Becker A, Merhof D, Zolal A, Richter M, Grummich P, Ganslandt O, Buchfelder M, Nimsky C (2012) Intraoperative visualization of fiber tracking based reconstruction of language pathways in glioma surgery. Neurosurgery 70:911–920PubMedCrossRefGoogle Scholar
  21. 21.
    Lehéricy S, Cohen L, Bazin B, Samson S, Giacomini E, Rougeret R, Hertz-Pannier L, Le Bihan D, Marsault C, Baulac M (2000) Functional MR evaluation of temporal and frontal language dominance compared with the Wada test. Neurology 54:1625–1633PubMedCrossRefGoogle Scholar
  22. 22.
    Lu X, Suo S, Liu H, Zhang S (2012) Three-dimensional multimodal image non-rigid registration and fusion in a high intensity focused ultrasound system. Comput Aided Surg 17:1–12PubMedCrossRefGoogle Scholar
  23. 23.
    Martino J, Brogna C (2011) Anatomy of the white matter pathways. In: Duffau H (ed) Human brain mapping. From neural basis of cognition to surgical applications. Springer, Wien, pp 27–41Google Scholar
  24. 24.
    Mesulam MM (1990) Large scale neurocognitive networks and distributed processing for attention, language, and memory. Ann Neurol 28:597–613PubMedCrossRefGoogle Scholar
  25. 25.
    Nimsky C, Ganslandt O, Hastreiter P, Wang R, Benner T, Sorensen AG, Fahlbusch R (2005) Preoperative and intraoperative diffusion tensor imaging-based fiber tracking in glioma surgery. Neurosurgery 56:130–137PubMedGoogle Scholar
  26. 26.
    Nimsky C, Grummich P, Sorensen AG, Fahlbusch R, Ganslandt O (2005) Visualization of the pyramidal tract in glioma surgery by integrating diffusion tensor imaging in functional neuronavigation. Zentralbl Neurochir 66:133–141PubMedCrossRefGoogle Scholar
  27. 27.
    Nimsky C, von Keller B, Schlaffer S, Kuhnt D, Weigel D, Ganslandt O, Buchfelder M (2009) Updating navigation with intraoperative image data. Top Magn Reson Imaging 19:197–204PubMedCrossRefGoogle Scholar
  28. 28.
    Ohue S, Kohno S, Inoue A, Yamashita D, Harada H, Kumon Y, Kikuchi K, Miki H, Ohnishi T (2012) Accuracy of diffusion tensor magnetic resonance imaging-based tractography for surgery of gliomas near the pyramidal tract: a significant correlation between sucortical electrical stimulation and postoperative tractography. Neurosurgery 70:283–294PubMedCrossRefGoogle Scholar
  29. 29.
    Oldfield RC (1971) The assessment and analysis of handedness: the Edinburgh inventory. Neuropsychologia 9:97–113PubMedCrossRefGoogle Scholar
  30. 30.
    Price CJ (2000) The anatomy of language: contribution from functional neuroimaging. J Anat 197:335–359PubMedCrossRefGoogle Scholar
  31. 31.
    Roux FE, Ibarrola D, Tremoulet M, Lazorthes Y, Henry P, Sol JC, Berry I (2001) Methodological and technical issues for integrating functional magnetic resonance imaging data in a neuronavigational system. Neurosurgery 49:1145–1156PubMedGoogle Scholar
  32. 32.
    Roux FE, Boulanouar K, Lotterie JA, Mejdoubi M, Lesage JP, Berry I (2003) Language functional magnetic resonance imaging in preoperative assessment of language areas: correlation with direct cortical stimulation. Neurosurgery 52:1335–1337PubMedCrossRefGoogle Scholar
  33. 33.
    Sanai N, Berger MS (2008) Glioma extent of resection and its impact on patient outcome. Neurosurgery 62:753–764PubMedCrossRefGoogle Scholar
  34. 34.
    Saur D, Kreher BW, Schnell S, Kümmerer D, Kellmeyer P, Vry MS, Umarova R, Musso M, Glauche V, Abel S, Huber W, Rijntjes M, Hennig J, Weiller C (2008) Ventral and dorsal pathways for language. Proc Nati Acad Sci USA 105:18035–18040CrossRefGoogle Scholar
  35. 35.
    Stadlbauer A, Nimsky C, Buslei R, Salomonowitz E, Hammen T, Buchfelder M, Moser E, Ernst-Stecken A, Ganslandt O (2007) Diffusion tensor imaging and optimized fiber tracking in glioma patients: histopathologic evaluation of tumor-invaded white matter structures. NeuroImage 34:949–956PubMedCrossRefGoogle Scholar
  36. 36.
    Wang MN, Song ZJ (2011) Classification and analysis of the errors in neuronavigation. Neurosurgery 68:1131–1143PubMedGoogle Scholar

Copyright information

© Springer-Verlag Wien 2012

Authors and Affiliations

  • François Vassal
    • 1
    • 4
    • 5
  • Fabien Schneider
    • 2
  • Anna Sontheimer
    • 4
  • Jean-Jacques Lemaire
    • 3
    • 4
  • Christophe Nuti
    • 1
  1. 1.Neurosurgery Service, Hôpital NordCentre Hospitalier Universitaire de Saint-EtienneSaint-EtienneFrance
  2. 2.Neuroradiology Unit, Hôpital NordCentre Hospitalier Universitaire de Saint-EtienneSaint-EtienneFrance
  3. 3.Neurosurgery Service A, Hôpital Gabriel MontpiedCentre Hospitalier Universitaire de Clermont-FerrandClermont-FerrandFrance
  4. 4.Medical Imagery Research Team-IGCNC (Image-Guided Clinical Neurosciences and Connectomics), Unité de Formation et de Recherche MédecineUniversité Clermont 1Clermont-FerrandFrance
  5. 5.Service de Neurochirurgie, Hôpital NordSaint-Priest en JarezFrance

Personalised recommendations