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Table of Contents    
COMMENTARY
Year : 2019  |  Volume : 67  |  Issue : 3  |  Page : 770-771

Presurgical simulation for neuroendoscopic procedures to virtually study the integrity of neurological pathways using diffusion tensor imaging tractography


Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, Mumbai, India

Date of Web Publication23-Jul-2019

Correspondence Address:
Dr. Chandrashekhar Deopujari
Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, Mumbai
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.263200

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How to cite this article:
Deopujari C, Shaikh S. Presurgical simulation for neuroendoscopic procedures to virtually study the integrity of neurological pathways using diffusion tensor imaging tractography. Neurol India 2019;67:770-1

How to cite this URL:
Deopujari C, Shaikh S. Presurgical simulation for neuroendoscopic procedures to virtually study the integrity of neurological pathways using diffusion tensor imaging tractography. Neurol India [serial online] 2019 [cited 2019 Aug 24];67:770-1. Available from: http://www.neurologyindia.com/text.asp?2019/67/3/770/263200




Diffusion tensor imaging (DTI) indirectly contributes to a better understanding of the brain anatomy, especially related to the anatomy of white fibres and tracts, by interpreting the diffusion characteristics of water molecules within the fibres. This is now a well-established modality of anatomical evaluation in the field of neuro-radiology and provides a distinct advantage over the traditional assessment using magnetic resonance imaging (MRI).[1] DTI not only enables us to study the white matter structural integrity in ageing patients, psychiatric conditions, closed head injury, alcoholism and developmental disorders,[2] but also helps us in identifying the invasive/infiltrative nature of the tumour. It helps us in planning of the surgical entry point and trajectory; assessing the possibility of complete tumor removal; and, in anticipating neurological deficits. DTI can also evaluate the success of disconnective surgeries for epilepsy, such as a hemispherotomy [Figure 1].
Figure 1: Recurrence of seizure 8 years after the initial surgery for hemispherotomy in a child with drop attacks. Further surgery for disconnection in the genu and anterior commissure was performed

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Micro-surgical procedures for intraventricular lesions are commonly associated with complications attributable mainly to the type of approach taken by the neurosurgeon to access the ventricular system.[3] This is one of the reasons for the spurt in the use of endoscope for intraventricular procedures in the last decade or so. The same group of authors in 2017 have described the relative prevention of white matter transgression while accessing the ventricles through the frontal transcortical approach by making use of DTI simulation.[4] In an earlier clinical study, diffusion tensor tractography (DTT) studies have shown that the middle frontal gyrus approach for intraventricular lesions disrupts more amount of neural fibers as compared to the superior frontal gyrus approach.[5]

Today, endoscopy also plays a role in procedures for epilepsy surgery, such as a hemispherotomy, amygdalohippocampectomy, disconnection procedures for hypothalamic hamartoma, or corpus callostomy.[6] Pre-surgical simulation in such instances can provide immense benefit in reducing the postoperative morbidity of the patient. DTI also contributes in reducing the subcortical damage of fibers during minimally invasive ventricular approaches, such as those described utilizing tubular retractors.[7]

The entry point and the trajectory taken to reach various parts of the ventricular system have not been clearly elucidated in Dr. Garcia's accompanying paper addressing the various endoscopic intraventricular procedures. This may be considered in future studies as an important factor while evaluating the damage caused by a particular surgical approach.[8]

Some of the problems mentioned that may be encountered while gaining entry into the temporal horn can be overcome by the use of newer flexible endoscopes, which have been recently introduced. They provide better or equivalent vision and can result in reduction of subcortical damage during the transcortical entry of the endoscope.

Simulation plays a great role today in educating neurosurgeons, as well as in surgical planning, and further work in this area using DTI will be extremely useful to reduce the learning curve for the young neurosurgeons. This will eventually benefit neurosurgeons in reducing the morbidity for the patients with brain tumors, as well as with epilepsy and other disorders.



 
  References Top

1.
Parekh MB, Gurjarpadhye AA, Manoukian MA, Dubnika A, Rajadas J, Inayathullah M. Recent developments in diffusion tensor imaging of brain. Radiol Open J 2015;1:1–12.  Back to cited text no. 1
    
2.
Chanraud S, Zahr N, Sullivan EV, Pfefferbaum A. MR diffusion tensor imaging: A window into white matter integrity of the working brain. Neuropsychol Rev 2010;20:209–25.  Back to cited text no. 2
    
3.
Milligan BD, Meyer FB. Morbidity of transcallosal and transcortical approaches to lesions in and around the lateral and third ventricles: A single-institution experience. Neurosurgery 2010;67:1483-96.  Back to cited text no. 3
    
4.
García S, Rincon-Torroella J, Benet A, Oleaga L, González Sánchez JJ. Assessment of white matter transgression during neuroendoscopic procedures using diffusion tensor image fiber tracking. World Neurosurg 2017;99:232-40.  Back to cited text no. 4
    
5.
Szmuda T, Słoniewski P, Szmuda M, Waszak PM, Starzyńska A. Quantification of white matter fibre pathways disruption in frontal transcortical approach to the lateral ventricle or the interventricular foramen in diffusion tensor tractography. Folia Morphol (Warsz) 2014;73:129-38.  Back to cited text no. 5
    
6.
Chandra SP, Tripathi M. Endoscopic epilepsy surgery: Emergence of a new procedure. Neurol India 2015;63:571-82.  Back to cited text no. 6
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7.
Eliyas JK, Glynn R, Kulwin CG, Rovin R, Young R, Alzate J, et al. Minimally invasive transsulcal resection of intraventricular and periventricular lesions through a tubular retractor system: Multicentric experience and results. World Neurosurg 2016;90:556-64.  Back to cited text no. 7
    
8.
García-García S, Kakaizada S, Oleaga L, Benet A, Rincon-Toroella J, González-Sánchez JJ. Presurgical simulation for neuroendoscopic procedures: Virtual study of the integrity of neurological pathways using diffusion tensor imaging tractography. Neurol India 2019;67:763-9.  Back to cited text no. 8
    


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