The Value of White Matter Tractography by Diffusion Tensor Imaging in Altering a Neurosurgeon's Operative Plan

To investigate if the implementation of white matter (WM) fiber tractography by diffusion tensor imaging in presurgical planning for supratentorial tumors proximal to eloquent WM tracts can alter a neurosurgeon's operative strategy. A retrospective review was conducted of patients with supratentorial brain tumors within eloquent WM tracts who underwent diffusion tensor imaging (DTI) tractography as part of their preoperative assessment. These patients were classified into 3 different DTI groups per the radiology reports: group 1, intact WM tracts; group 2, deviated and/or displaced WM bundles; and group 3, patients with an established WM injury (interrupted and/or destroyed tracts). A blinded prospective behavioral study followed, in which 4 neurosurgeons reviewed the preoperative images at 2 different times (magnetic resonance imaging without DTI, followed by a review of the DTI). They provided estimations about the DTI group of each individual eloquent WM category in every patient, and their planned surgical approach. Fifteen patients (mean age, 58.3 years) were included in the study. The neurosurgeons provided a correct DTI group estimation in 53%, 60%, and 57% of the cases that involved motor/sensory pathway tracts, optic tracts, and language tracts, respectively. The neurosurgeons underestimated DTI group 3 in the motor category and in the optic category 75% of the time. DTI did not alter the planned surgical approach. DTI WM tractography helped neurosurgeons to correctly identify patients with interrupted motor and optic pathway tracts so they could be more aggressive with the extent of tumor resection, despite its inability to alter the operative approach.