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Application of High-Definition Fiber Tractography in the Management of Supratentorial Cavernous Malformations: A Combined Qualitative and Quantitative Approach

Abhinav, Kumar MD*; Pathak, Sudhir MS; Richardson, R. Mark MD, PhD*; Engh, Johnathan MD*; Gardner, Paul MD*; Yeh, Fang-Cheng MD§; Friedlander, Robert M. MD*; Fernandez-Miranda, Juan C. MD*

doi: 10.1227/NEU.0000000000000336
Research-Human-Clinical Studies

BACKGROUND: High-definition fiber tractography (HDFT), an advanced white matter (WM) imaging technique, was evaluated in the management of supratentorial cavernous malformations.

OBJECTIVE: To investigate the relationship of cavernous malformations to the relevant perilesional WM tracts with HDFT and to characterize associated changes first qualitatively and then quantitatively with our novel imaging measure, quantitative anisotropy (QA).

METHODS: Imaging analysis was carried out by researchers blinded to the clinical details. Contralateral WM tracts were used for comparison. Mean QA values were obtained for whole WM tracts. Qualitatively affected superior longitudinal fasciculus/arcuate fibers and corticospinal tracts were further analyzed with the use of mean QA values for the perilesional segments.

RESULTS: Of 10 patients, HDFT assisted with the decision-making process and the offer of surgical resection in 2 patients, lesion approach and removal in 7 patients, and conservative management in 1 patient. Of 17 analyzed WM tracts, HDFT demonstrated partial disruption in 2 tracts, complete disruption in 2 tracts, a combination of displacement and partial disruption in 1 tract, displacement only in 7 tracts, and no change in 5 tracts. Qualitative changes correlated with clinical symptoms. Mean QA values for the whole WM tracts were similar, with the exception of 1 case demonstrating complete disruption of 2 WM tracts. QA-based perilesional segment analysis was consistent with qualitative data in 5 assessed WM tracts.

CONCLUSION: HDFT illustrated the precise spatial relationship of cavernous malformations to multiple WM tracts in a 3-dimensional fashion, optimizing surgical planning, and demonstrated associated disruption and/or displacement, with both occurring perilesionally. These changes were supported by our quantitative marker, which needs further validation.

ABBREVIATIONS: AF, arcuate fasciculus

CM, cavernous malformation

CMU, Carnegie Mellon University

CST, corticospinal tract

DSI, diffusion spectrum imaging

DTI, diffusion tensor imaging

FA, fractional anisotropy

HDFT, high-definition fiber tractography

QA, quantitative anisotropy

SLF, superior longitudinal fasciculus

TPC, thalamopostcentral

UF, uncinate fasciculus

WM, white matter

*Department of Neurological Surgery, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania;

Learning and Research Development Center, Department of Psychology, University of Pittsburgh, Pittsburgh, Pennsylvania;

§Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania

Correspondence: Juan C. Fernandez-Miranda, MD, Department of Neurological Surgery, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, 200 Lothrop St, PUH B-400, Pittsburgh, PA 15213. E-mail:

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Received November 01, 2013

Accepted February 07, 2014

Copyright © by the Congress of Neurological Surgeons