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Virtual reality presurgical planning for cerebral gliomas adjacent to motor pathways in an integrated 3-D stereoscopic visualization of structural MRI and DTI tractography

  • Clinical Article
  • Published:
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Abstract

Objective

Resection of gliomas invading primary motor cortex and subcortical motor pathway is difficult in both surgical decision-making and functional outcome prediction. In this study, magnetic resonance (MR) diffusion tensor imaging (DTI) data were used to perform tractography to visualize pyramidal tract (PT) along its whole length in a stereoscopic virtual reality (VR) environment. The potential value of its clinical application was evaluated.

Methods

Both three-dimensional (3-D) magnetic resonance imaging (MRI) and DTI datasets were obtained from 45 eligible patients with suspected cerebral gliomas and then transferred to the VR system (Dextroscope; Volume Interactions Pte. Ltd., Singapore). The cortex and tumor were segmented and reconstructed via MRI, respectively, while the tractographic PTs were reconstructed via DTI. All those were presented in a stereoscopic 3-D display synchronously, for the purpose of patient-specific presurgical planning and surgical simulation in each case. The relationship between increasing amplitude of the number of effective fibers of PT (EPT) at affected sides and the patients’ Karnofsky Performance Scale (KPS) at 6 months was addressed out.

Results

In VR presurgical planning for gliomas, surgery was aided by stereoscopic 3-D visualizing the relative position of the PTs and a tumor. There was no significant difference between pre- and postsurgical EPT in this population. A positive relationship was proved between EPT increasing amplitude and 6-month KPS.

Conclusions

3-D stereoscopic visualization of tractography in this VR environment enhances the operators to well understand the anatomic information of intra-axial tumor contours and adjacent PT, results in surgical trajectory optimization initially, and maximal safe tumor resection finally. In accordance to the EPT increasing amplitude, surgeon can predict the long-term motor functional outcome.

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Abbreviations

DEC:

Directionally encoded color

DTI:

Diffusion tensor imaging

EPT:

Effective fibers of pyramidal tract

fMRI:

Functional magnetic resonance imaging

HGG:

High-grade glioma

KPS:

Karnofsky Performance Scale

LGG:

Low-grade glioma

MRI:

Magnetic resonance imaging

PT:

Pyramidal tract

ROI:

Region of interest

VR:

Virtual reality

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Acknowledgments

We sincerely thank Mr. Jian-bing Shi for technical support in the MRI manipulation. This project was sponsored by the Ministry of Health of China (2007–2009) and Shanghai government, P. R. China (NO. 07QA14008).

Statement of authorship

This prospective clinical study was approved by local ethics committee before commencing.

Disclosure

We have no personal financial interest regarding the DTI-based Virtual Reality System described in this paper. None of the authors has received any funding from Dextroscope, Volume Interactions.

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Authors and Affiliations

  1. Shanghai Neurosurgical Center, Department of Neurosurgery, Huashan Hospital, Shanghai Medical School, Fudan University, 12#, Wulumuqi Zhong Road, Shanghai, 200040, People’s Republic of China

    Tian-ming Qiu, Yi Zhang, Jin-Song Wu, Yao Zhao, Zhi-Guang Pan, Ying Mao & Liang-Fu Zhou

  2. Department of Radiology, Huashan Hospital,Shanghai Medical College, Fudan University, Shanghai, China

    Wei-Jun Tang

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  1. Tian-ming Qiu
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Correspondence to Ying Mao or Liang-Fu Zhou.

Additional information

Comment

This article demonstrates the use the authors have found for preoperative planning and rehearsing of surgery of intra-axial cerebral tumors based on virtual reality technology.These are exciting times for Neurosurgery. Developing technology applied to obtaining information regarding not only shear anatomy of the brain but mostly its inherent functions has significantly impacted with the way surgery for these invasive tumors is conducted.

Most information regarding preoperative location of cerebral function is provided by MRI-based technology. That is the case for DTI, tractography, functional MRI, and all adjuncts being developed from here on.

The Dextroscope is an interesting add-on. It enables us to preoperatively reconstruct the anatomy of the lesion to be approached in relationship to the actual cranial and cerebral anatomy of the patient. What has been done here is to add up the information depicting the anatomy of the white matter tracts of the brain namely the pyramidal tracts. The authors then preoperatively assess the EPTs, that is, the number of fibers actually conveying information in a continuous way along the whole cerebral motor pathway and compare this number before and after surgery. Not unexpectedly, patients who end up with higher EPTs seem to fare better from the motor standpoint.

As the authors point out, there are several limitations to the transposition of this information directly into surgery. Fiber tracking technology is still quite dependent on the mathematic algorithm chosen for its representation. Secondly, there is no way one can depend exclusively on this information during surgery because of the shift produced by the manipulation of the brain and the CSF spaces. This aspect can only be circumvented with the use of intraoperative MRI done with the purpose of reacquiring the same sequences enabling the re-reconstruction of the white matter fibers as surgery goes along. This is still a morose and complex technique, and it was not applied in the current series.

Finally, there is nothing in this technique which enables the surgeon to better differentiate between normal and abnormal tissue and certainly nothing updating him on the level of function of the tissue being manipulated. This can only be pursued with the use of DBS.All in all, this virtual reality technology seems to play an interesting part in teaching residents as well as in helping out surgeons actually plan their best trajectory and strategy for a specific case. However, the same comments which apply to the use of neuronavigation are also appropriate regarding this technology. These techniques demonstrate the immense steps taken to help localize anatomy and function within the brain. Their use is ever so more important if based on a sound and strong traditional apprenticeship of the anatomy of the brain based on repeated laboratory cadaver dissections.

For all the above reasons, I think it is a little far-fetched to try to pass the idea that the use of the Dextroscope separates from intraoperative functional imaging and deep brain simulation is a recommendable solution for patients with this type of tumors. Just out of curiosity I would ask the authors to explain what they think is the application of this technique for aneurysms, as stated in the text.

The authors should consider shortening the length of the text and clearing some of the issues raised above.

Maybe this can be turned into a technical report. As it is I think the article does not add much to previous articles published on the matter and has the risk of conveying the idea that the use of the Dextroscope is a safe way to avoid intraoperative injury to deep eloquent areas of the brain. I think we should wait for possible changes and reconsider then.

Manuel Cunha e Sa

Almada, Portugal

Tian-ming Qiu and Yi Zhang contributed to this paper equally.

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Qiu, Tm., Zhang, Y., Wu, JS. et al. Virtual reality presurgical planning for cerebral gliomas adjacent to motor pathways in an integrated 3-D stereoscopic visualization of structural MRI and DTI tractography. Acta Neurochir 152, 1847–1857 (2010). https://doi.org/10.1007/s00701-010-0739-x

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  • DOI: https://doi.org/10.1007/s00701-010-0739-x

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