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A standardised evaluation of pre-surgical imaging of the corticospinal tract: where to place the seed ROI

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Abstract

The aim of the study was to compare the different approaches of pre-operative diffusion-tensor-imaging-based fibre tracking (FT) of the corticospinal tract (CST) focusing on the positioning of the seeding region of interest (seed ROI). Thirty-nine patients with brain lesions in the vicinity of the CST were evaluated pre-operatively. Imaging comprised a 3D T1-weighted sequence, a gradient echo echo-planar imaging sequence for functional magnetic resonance imaging (fMRI), and a diffusion-weighted sequence for diffusion tensor (DT) tractography. DT tractography was performed with two different procedures to track the corticospinal fibres: one downwards and one upwards. Downward FT was started with the seed ROI in the pre-central gyrus subjacent to the maximal fMRI activity while for the upward FT seed ROI was placed in the cerebral peduncle. In 16 patients, tracking results were individually compared with the unaffected contralateral hemisphere. Results were correlated with fractional anisotropy (FA) values and other factors potentially influencing fibre tracking results. On the side with the space-occupying lesion, downward FT yielded more positive tracking results (tracked fibres > 0) than the upward FT. On both the affected and the unaffected side, downward FT reconstructed fewer fibres than upward FT. For none of the two methods did the tracking results (number and volume of fibres) correlate with FA values or with other clinical data. FA values for tracts ipsilateral to the lesion correlated with age and lesion entity. We conclude that the sequence of ROI positioning influences significantly the tracking results. Upward FT may fail to track fibres, whereas the successful tracking results may be superior to downward FT. Hence, upward FT of the CST should be preferred in patients with space-occupying lesions. Downward FT should be performed if upward FT fails.

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Conflict of interest Statement

The authors have no conflicts of interest in the subject matter of their manuscript.

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Authors and Affiliations

  1. Institute of Neuroradiology, J.W. Goethe University, Schleusenweg 2-16, Frankfurt/Main, 60528, Germany

    Elke Hattingen, Alina Jurcoane, Stefan Weidauer & Friedhelm E. Zanella

  2. Department of Neurosurgery, J.W. Goethe University, Frankfurt/Main, Germany

    Julian Rathert, Andrea Szelényi, Volker Seifert & Thomas Gasser

  3. BrainLab AG, Feldkirchen, Germany

    George Ogrezeanu

Authors
  1. Elke Hattingen
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  2. Julian Rathert
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  3. Alina Jurcoane
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  4. Stefan Weidauer
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  5. Andrea Szelényi
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  6. George Ogrezeanu
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  8. Friedhelm E. Zanella
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Correspondence to Elke Hattingen.

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Comments

Christopher Nimsky, Marburg, Germany

Diffusion tensor imaging (DTI) is increasingly applied in pre-operative neurosurgical evaluation to delineate the course of major white matter tracts, mostly the pyramidal tract. This information is then used intraoperatively to localise the white matter tract of interest to preserve neurological function.

Standard DTI is probably no longer the most elegant method to reconstruct major white matter tracts because, besides of spatial distortions of the raw data, which cause some inaccuracies, when these data are used in a navigation/stereotactic setup, there are some distinct challenges and inconsistencies when tracking algorithms are applied. Areas of white matter tract crossings cannot be resolved reliably by standard DTI; also, tracking that is initiated at different areas/volumes in the three-dimensional diffusion data set does not result in the identical anatomical structure. Ideally, a tracking algorithm strategy that starts in a part of the pyramidal tract should be able to reconstruct the pyramidal tract independent of the placement of the seed region.

The paper by Hattingen et al. highlights these problems by analysing the effects of seed region placement when applying a standard DTI tracking approach. It clearly demonstrates that distinct strategies on how to perform a multi-step tracking process have to be established. This is also of special importance, when the data are to be used for comparisons in larger patient groups. Furthermore, it has to be emphasised that a profound knowledge of how the original diffusion data are measured, what kind of sequences are used, and what kind of tracking algorithms are implemented and how they are optimally used is necessary if tractography is used in a clinical setting. Otherwise, tractography might not increase the safety for the neurosurgeon but result in increased risks for the patients.

Michael Nelles, Horst Urbach, Bonn, Germany

The combination of pre-surgical MRI as one of the most common examinations in clinical routine and diffusion tensor tractography (DTT) imposes the task of registering EPI-based sequences to “conventional” sequences for anatomic reference. The combination of fMRI with DTT yields additional information concerning a starting step for DTT in the primary motor area. Multi-step tracking can reduce unwanted tract contributions when the general trajectory of the tract of interest is known.

Size and location of the seeding ROIs affect, however, amongst different other factors, tractography results with respect to which of the displayed trajectories can be regarded as “true positive” or “negative”. Systematic evaluations of these factors and their inferences on fibre tracking results are still rare. The above-mentioned EPI-related artefacts (as well as patient motion) may lead to further erroneously “small” calculation of CST fibre bundles. An unguided placement of ROIs is prone to errors which adds to the general inter-observer variability of ROI-based DTT post-processing.

This study compares different approaches of fibre tracking of the CST in patients with intra-cranial mass lesions in the vicinity of the CST. A relatively thin-sectioned 1.6 × 1.6 × 1.6-mm isotropic sequence with whole-brain coverage and 12 encoding directions is used. Rigid registration fusion with high-resolution T1-weighted anatomical data and fMRI is used to allow for a guided placement of tracking seeds.

A particular focus is laid on the positioning of these seeding ROIs, as well as determination of the intra- and inter-rater variability of the tracking protocol. Systematic comparison of CST tractographies between affected and unaffected hemispheres contributes to the detection of fibre reduction due to technical issues (and thus missing fibre visualisation in a stereotactic setting). This paper hence provides essential data to improve the accuracy of pre-surgical DTT in terms of reproducibility and precision.

Elke Hattingen and Julian Rathert contributed equally to this work.

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Hattingen, E., Rathert, J., Jurcoane, A. et al. A standardised evaluation of pre-surgical imaging of the corticospinal tract: where to place the seed ROI. Neurosurg Rev 32, 445–456 (2009). https://doi.org/10.1007/s10143-009-0197-1

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  • DOI: https://doi.org/10.1007/s10143-009-0197-1

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