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Koga SF, Hodges WB, Adamyan H, Hayes T, Fecci PE, Tsvankin V, Pradilla G, Hoang KB, Lee IY, Sankey EW, Codd PJ, Huie D, Zacharia BE, Verma R, Baboyan VG. Preoperative validation of edema-corrected tractography in neurosurgical practice: translating surgeon insights into novel software implementation. Front Neurol 2024; 14:1322815. [PMID: 38259649 PMCID: PMC10801029 DOI: 10.3389/fneur.2023.1322815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 12/19/2023] [Indexed: 01/24/2024] Open
Abstract
Background Peritumoral edema alters diffusion anisotropy, resulting in false negatives in tractography reconstructions negatively impacting surgical decision-making. With supratotal resections tied to survival benefit in glioma patients, advanced diffusion modeling is critical to visualize fibers within the peritumoral zone to prevent eloquent fiber transection thereafter. A preoperative assessment paradigm is therefore warranted to systematically evaluate multi-subject tractograms along clinically meaningful parameters. We propose a novel noninvasive surgically-focused survey to evaluate the benefits of a tractography algorithm for preoperative planning, subsequently applied to Synaptive Medical's free-water correction algorithm developed for clinically feasible single-shell DTI data. Methods Ten neurosurgeons participated in the study and were presented with patient datasets containing histological lesions of varying degrees of edema. They were asked to compare standard (uncorrected) tractography reconstructions overlaid onto anatomical images with enhanced (corrected) reconstructions. The raters assessed the datasets in terms of overall data quality, tract alteration patterns, and the impact of the correction on lesion definition, brain-tumor interface, and optimal surgical pathway. Inter-rater reliability coefficients were calculated, and statistical comparisons were made. Results Standard tractography was perceived as problematic in areas proximal to the lesion, presenting with significant tract reduction that challenged assessment of the brain-tumor interface and of tract infiltration. With correction applied, significant reduction in false negatives were reported along with additional insight into tract infiltration. Significant positive correlations were shown between favorable responses to the correction algorithm and the lesion-to-edema ratio, such that the correction offered further clarification in increasingly edematous and malignant lesions. Lastly, the correction was perceived to introduce false tracts in CSF spaces and - to a lesser degree - the grey-white matter interface, highlighting the need for noise mitigation. As a result, the algorithm was modified by free-water-parameterizing the tractography dataset and introducing a novel adaptive thresholding tool for customizable correction guided by the surgeon's discretion. Conclusion Here we translate surgeon insights into a clinically deployable software implementation capable of recovering peritumoral tracts in edematous zones while mitigating artifacts through the introduction of a novel and adaptive case-specific correction tool. Together, these advances maximize tractography's clinical potential to personalize surgical decisions when faced with complex pathologies.
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Affiliation(s)
- Sebastian F. Koga
- Franciscan Missionaries of Our Lady Health System, Baton Rouge, LA, United States
| | | | | | - Tim Hayes
- Synaptive Medical Inc., Toronto, ON, Canada
| | - Peter E. Fecci
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, United States
| | - Vadim Tsvankin
- Colorado Brain and Spine Institute, Englewood, CO, United States
| | - Gustavo Pradilla
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, United States
| | - Kimberly B. Hoang
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, United States
| | - Ian Y. Lee
- Department of Neurosurgery, Henry Ford Health System, Detroit, MI, United States
| | - Eric W. Sankey
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, United States
| | - Patrick J. Codd
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, United States
| | - David Huie
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, United States
| | - Brad E. Zacharia
- Department of Neurosurgery, Penn State Hershey Medical Center, Hershey, PA, United States
| | - Ragini Verma
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, United States
- Cohen Veterans Bioscience, New York, NY, United States
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