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Brainstem cavernoma surgery with the support of pre- and postoperative diffusion tensor imaging: initial experiences and clinical course of 23 patients

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Abstract

The spatial complexity of highly vulnerable structures makes surgical resection of brainstem cavernomas (BSC) a challenging procedure. Diffusion tensor imaging (DTI) allows for the visualization of white matter tracts and enables a better understanding of the anatomical location of corticospinal and sensory tracts before and after surgery.We investigated the feasibility and clinical usefulness of DTI-based fiber tractography in patients with BSC.Pre- and postoperative DTI visualization of corticospinal and sensory tracts were retrospectively analyzed in 23 individuals with BSC. Preoperative and postoperative DTI-fiber accuracy were associated to the neurological findings. Preoperatively, the corticospinal tracts were visualized in 90 % of the cases and the sensory tracts were visualized in 74 % of the cases. Postoperatively, the corticospinal tracts were visualized in 97 % of the cases and the sensory tracts could be visualized in 80 % of the cases. In all cases, the BSC had caused displacement, thinning, or interruption of the fiber tracts to various degrees. Tract visualization was associated with pre- and postoperative neurological findings. Postoperative damage of the corticospinal tracts was observed in two patients. On follow-up, the Patzold Rating (PR) improved in 19 out of 23 patients (83 %, p = 0.0002).This study confirms that DTI tractography allows accurate and detailed white matter tract visualization in the brainstem, even when an intraaxial lesion affects this structure. Furthermore, visualizing the tracts adjacent to the lesion adds to our understanding of the distorted intrinsic brainstem anatomy and it may assists in planning the surgical approach in specific cases.

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Acknowledgments

We thank Peter Roth from the Department of Neurosurgery at the University Hospital Zurich for providing expert support for illustrations in our illustrative cases.

Disclosure

The authors have no personal financial or institutional interest in any of the materials or devices described in this article.

Conflict of interests

There are no competing interests.

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Authors and Affiliations

  1. Department of Neurosurgery, University Hospital, University of Zurich, Frauenklinikstr.10, 8091, Zurich, Switzerland

    Nils H. Ulrich, David Bellut, Oliver Bozinov, Jan-Karl Burkhardt & Johannes Sarnthein

  2. Department of Neurosurgery, Hirslanden Hospital, Zurich, Switzerland

    Ralf A. Kockro

  3. Department of Neuroradiology, University Hospital, University of Zurich, Zurich, Switzerland

    Christina Amaxopoulou & Spyros S. Kollias

  4. International Neuroscience Institute, INI, Hannover, Germany

    Helmut Bertalanffy

Authors
  1. Nils H. Ulrich
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  2. Ralf A. Kockro
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  3. David Bellut
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  4. Christina Amaxopoulou
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  5. Oliver Bozinov
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  6. Jan-Karl Burkhardt
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  7. Johannes Sarnthein
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  8. Spyros S. Kollias
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  9. Helmut Bertalanffy
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Corresponding author

Correspondence to Nils H. Ulrich.

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Comments

Vini G. Khurana, Canberra, Australia

This is a beautifully written manuscript that reports a very thoughtfully and elegantly executed study of tractography in brainstem cavernous malformation surgery. The work represents a very helpful contribution to our understanding of how relatively high-risk surgery might be made more accurate and safe through a more "visible" and intuitive modality such as DTI compared with electrophysiology and neuronavigation alone. The five illustrative cases provide an elegant and almost tangible insight into the authors' exploration of this exciting frontier. I congratulate Doctor Ulrich and his colleagues on their inspirational work.

Nils H. Ulrich and Ralf A. Kockro contributed equally to this work.

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Ulrich, N.H., Kockro, R.A., Bellut, D. et al. Brainstem cavernoma surgery with the support of pre- and postoperative diffusion tensor imaging: initial experiences and clinical course of 23 patients. Neurosurg Rev 37, 481–492 (2014). https://doi.org/10.1007/s10143-014-0550-x

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  • DOI: https://doi.org/10.1007/s10143-014-0550-x

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