The value of white matter tractography by diffusion tensor imaging in altering a neurosurgeon’s operative plan

Abstract Objective To investigate if the implementation of white matter (WM) fiber tractography by diffusion tensor imaging in pre-surgical planning for supratentorial tumors proximal to eloquent WM tracts can alter a neurosurgeon’s operative strategy. Methods A retrospective review was conducted of patients with supratentorial brain tumors within eloquent WM tracts who underwent DTI tractography as part of their preoperative assessment. These patients were classified into three different DTI groups per the radiology reports: Group 1, intact WM tracts; Group 2, deviated and/or displaced WM bundles; Group 3, patients with an established WM injury (interrupted and/or destroyed tracts). A blinded prospective behavioral study followed, where four neurosurgeons reviewed the preoperative images at two different times (MRI 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. Results Fifteen patients (mean age of 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 the DTI group 3 in the motor category and the optic category 75% of the time. DTI did not alter the planned surgical approach. Conclusion 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.