Diffusion Tensor Imaging Tractography Indications

Diffusion tensor imaging for brain tumor resection.

see Diffusion tensor imaging for degenerative cervical myelopathy.

Plasticity of the developing motor tracts is a contributor to recovery of motor function after pediatric stroke. The mechanism of these plastic changes may be functional and/or structural in nature.

In a case of a 3-year-old girl demonstrating reorganization of the pyramidal tracts after an extensive left MCA territory stroke secondary to head trauma. Reorganization is characterized using serial diffusion tensor imaging (DTI) of the pyramidal tracts which contain the CST.

Imaging shows decreased ipsi-lesional fractional anisotropy (FA) suggestive of Wallerian degeneration and increased contralesional FA.

These results point to plastic reorganization of the pyramidal tract post-stroke and the utility of DTI in recognizing these changes 1).

Pulsed arterial spin labeling, DTI, and MR spectroscopy are useful for predicting glioma grade. Additionally, the parameters obtained on DTI and MR spectroscopy closely correlated with the proliferative potential of gliomas 2).

For predicting the consistency of intracranial meningiomas.

DTI parameters, assessed at approximately day 12 after injury, correlated with mortality at 6 months in patients with severe TBI or aSAH. Similar patterns were found for both TBI and aSAH patients. This supports a potential role of DTI as early endpoint for clinical studies and a predictor of late mortality 3).

A retrospective DTI study demonstrated significant WM abnormalities in infants with hydrocephalus in both the corpus callosum and internal capsule. The results also showed evidence that the impact of hydrocephalus on WM was different in the corpus callosum and internal capsule 4).

A study provides initial evidence of DTI's sensitivity to detect subtle WM changes associated with performance improvements in response to a 6-week occupational therapy (OT) intervention in children with surgically treated hydrocephalus (HCP) 5).

DTI may be used for the diagnosis and differentiation of idiopathic normal pressure hydrocephalus (iNPH) from other neurodegenerative diseases with similar imaging findings and clinical symptoms and signs. The goal of a study was to identify and analyze recently published series on the use of DTI as a diagnostic tool. Moreover, Siasios et al., also explored the utility of DTI in identifying patients with iNPH who could be managed by surgical intervention.

The authors performed a literature search of the PubMed database by using any possible combinations of the following terms: “Alzheimer's disease,” “brain,” “cerebrospinal fluid,” “CSF,” “diffusion tensor imaging,” “DTI,” “hydrocephalus,” “idiopathic,” “magnetic resonance imaging,” “normal pressure,” “Parkinson's disease,” and “shunting.” Moreover, all reference lists from the retrieved articles were reviewed to identify any additional pertinent articles.

The literature search retrieved 19 studies in which DTI was used for the identification and differentiation of iNPH from other neurodegenerative diseases. The DTI protocols involved different approaches, such as region of interest (ROI) methods, tract-based spatial statistics, voxel-based analysis, and delta-ADC analysis. The most studied anatomical regions were the periventricular WM areas, such as the internal capsule (IC), the corticospinal tract (CST), and the corpus callosum (CC). Patients with iNPH had significantly higher MD in the periventricular WM areas of the CST and the CC than had healthy controls. In addition, FA and ADCs were significantly higher in the CST of iNPH patients than in any other patients with other neurodegenerative diseases. Gait abnormalities of iNPH patients were statistically significantly and negatively correlated with FA in the CST and the minor forceps. Fractional anisotropy had a sensitivity of 94% and a specificity of 80% for diagnosing iNPH. Furthermore, FA and MD values in the CST, the IC, the anterior thalamic region, the fornix, and the hippocampus regions could help differentiate iNPH from Alzheimer or Parkinson disease. Interestingly, CSF drainage or ventriculoperitoneal shunting significantly modified FA and ADCs in iNPH patients whose condition clinically responded to these maneuvers.

Measurements of FA and MD significantly contribute to the detection of axonal loss and gliosis in the periventricular WM areas in patients with iNPH. Diffusion tensor imaging may also represent a valuable noninvasive method for differentiating iNPH from other neurodegenerative diseases. Moreover, DTI can detect dynamic changes in the WM tracts after lumbar drainage or shunting procedures and could help identify iNPH patients who may benefit from surgical intervention 6).

see Diffusion tensor imaging for trigeminal neuralgia

A number of studies have investigated tractography-guided brain tumour surgery over the past years and reported good clinical results 7).

DTI-based tractography is an increasingly important tool for planning brain surgery in patients suffering from brain tumours. However, there is an ongoing debate which tracking approaches yield the most valid results. Especially the use of functional localizer data such as navigated transcranial magnetic stimulation (nTMS) or functional magnetic resonance imaging (fMRI) seem to improve fibre tracking data in conditions where anatomical landmarks are less informative due to tumour-induced distortions of the gyral anatomy.

Deep brain stimulation

It has been generally accepted that deep brain stimulation (DBS) not only acts in the nucleus where it is being applied, as initially thought, but that chronic stimulation activates axons located in its scope, and that this activation can exert its effects in distant areas. Considering this, DBS target identification should be made based on techniques that identify white matter tracts, such as tractography, rather than only by identifying specific nuclei on conventional magnetic resonance imaging.

A review of the literature on the use of tractography in DBS surgery and provide an overview of the main results.

Tractography has been used in the field of DBS to help clarify relevant aspects in the selection of targets and in evaluating its therapeutic effects in movement disorders, psychiatric diseases and pain.

Studies are scarce so far, but they have provided data that, if confirmed, may optimize DBS surgery. Tractography might become a routine tool for DBS surgery in the near future 8).

Diffusion tensor tractography for preoperative prediction of the location of the facial and vestibulocochlear nerves in relation to vestibular schwannoma

Diffusion tensor tractography (DTT) effectively revealed the location of the facial nerve (FN), including cases in which the FN was membranoid or passed through the interface between an area exhibiting cystic changes and the tumor nodule. Fibers aside from the FN and the TN were revealed by DTT in patients who retained functional hearing. Penetrating fibers were also found using DTT. This technique can be useful during VS resection 9).

Yoshino et al. visualized facial or vestibulocochlear nerves in nine of 11 patients (81.8%). For the first time, DTT proved able to visualize not only the facial nerve but also the vestibulocochlear nerve in VS patients. Despite our findings, good methods for distinguishing whether a visualized nerve tract represents facial nerve, vestibulocochlear nerve, or only noise remain unavailable. Close attention should therefore be paid to the interpretation of visualized fibers 10).

George E, Heier L, Kovanlikaya I, Greenfield J. Diffusion tensor imaging of pyramidal tract reorganization after pediatric stroke. Childs Nerv Syst. 2014 Jan 14. [Epub ahead of print] PubMed PMID: 24420673.
Fudaba H, Shimomura T, Abe T, Matsuta H, Momii Y, Sugita K, Ooba H, Kamida T, Hikawa T, Fujiki M. Comparison of Multiple Parameters Obtained on 3T Pulsed Arterial Spin-Labeling, Diffusion Tensor Imaging, and MRS and the Ki-67 Labeling Index in Evaluating Glioma Grading. AJNR Am J Neuroradiol. 2014 Jul 3. [Epub ahead of print] PubMed PMID: 24994829.
Sener S, Van Hecke W, Feyen BF, Van der Steen G, Pullens P, Van de Hauwe L, Menovsky T, Parizel PM, Jorens PG, Maas AI. Diffusion Tensor Imaging: A Possible Biomarker in Severe Traumatic Brain Injury and Aneurysmal Subarachnoid Hemorrhage? Neurosurgery. 2016 Jun 27. [Epub ahead of print] PubMed PMID: 27352277.
Yuan W, Mangano FT, Air EL, Holland SK, Jones BV, Altaye M, Bierbrauer K. Anisotropic diffusion properties in infants with hydrocephalus: a diffusion tensor imaging study. AJNR Am J Neuroradiol. 2009 Oct;30(9):1792-8. doi: 10.3174/ajnr.A1663. Epub 2009 Aug 6. PubMed PMID: 19661167.
Yuan W, Harpster K, Jones BV, Shimony JS, McKinstry RC, Weckherlin N, Powell SS, Barnard H, Engsberg J, Kadis DS, Dodd J, Altaye M, Limbrick DD, Holland SK, Simpson SM, Bidwell S, Mangano FT. Changes of White Matter Diffusion Anisotropy in Response to a 6-Week iPad Application-Based Occupational Therapy Intervention in Children with Surgically Treated Hydrocephalus: A Pilot Study. Neuropediatrics. 2016 Jul 20. [Epub ahead of print] PubMed PMID: 27438376.
Siasios I, Kapsalaki EZ, Fountas KN, Fotiadou A, Dorsch A, Vakharia K, Pollina J, Dimopoulos V. The role of diffusion tensor imaging and fractional anisotropy in the evaluation of patients with idiopathic normal pressure hydrocephalus: a literature review. Neurosurg Focus. 2016 Sep;41(3):E12. doi: 10.3171/2016.6.FOCUS16192. PubMed PMID: 27581308.
Wu J.S., Zhou L.F., Tang W.J. Clinical evaluation and follow-up outcome of diffusion tensor imaging-based functional neuronavigation: a prospective, controlled study in patients with gliomas involving pyramidal tracts. Neurosurgery. 2007;61(5):935–948.
Torres CV, Manzanares R, Sola RG. Integrating Diffusion Tensor Imaging-Based Tractography into Deep Brain Stimulation Surgery: A Review of the Literature. Stereotact Funct Neurosurg. 2014 Sep 18;92(5):282-290. [Epub ahead of print] PubMed PMID: 25248076.
Wei PH, Qi ZG, Chen G, Hu P, Li MC, Liang JT, Guo HC, Ling F, Bao YH. Identification of cranial nerves near large vestibular schwannomas using superselective diffusion tensor tractography: experience with 23 cases. Acta Neurochir (Wien). 2015 May 7. [Epub ahead of print] PubMed PMID: 25948078.
Yoshino M, Kin T, Ito A, Saito T, Nakagawa D, Ino K, Kamada K, Mori H, Kunimatsu A, Nakatomi H, Oyama H, Saito N. Feasibility of diffusion tensor tractography for preoperative prediction of the location of the facial and vestibulocochlear nerves in relation to vestibular schwannoma. Acta Neurochir (Wien). 2015 Jun;157(6):939-46; discussion 946. doi: 10.1007/s00701-015-2411-y. Epub 2015 Apr 12. PubMed PMID: 25862170.
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