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J Neurol Surg B Skull Base 2021; 82(05): 576-592
DOI: 10.1055/s-0040-1713775
Original Article

The Role of 3D Tractography in Skull Base Surgery: Technological Advances, Feasibility, and Early Clinical Assessment with Anterior Skull Base Meningiomas

Srikant S. Chakravarthi 
1   Department of Neurosurgery, Aurora Neuroscience Innovation Institute, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin, United States
,
Melanie B. Fukui
1   Department of Neurosurgery, Aurora Neuroscience Innovation Institute, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin, United States
,
Alejandro Monroy-Sosa 
1   Department of Neurosurgery, Aurora Neuroscience Innovation Institute, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin, United States
,
Lior Gonen
2   Department of Neurosurgery, Shaare Zedek Medical Center, Jerusalem, Israel
,
Austin Epping
1   Department of Neurosurgery, Aurora Neuroscience Innovation Institute, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin, United States
,
Jonathan E. Jennings
1   Department of Neurosurgery, Aurora Neuroscience Innovation Institute, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin, United States
,
Laila Perez de San Roman Mena
1   Department of Neurosurgery, Aurora Neuroscience Innovation Institute, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin, United States
,
Sammy Khalili
1   Department of Neurosurgery, Aurora Neuroscience Innovation Institute, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin, United States
,
Maharaj Singh
1   Department of Neurosurgery, Aurora Neuroscience Innovation Institute, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin, United States
,
Juanita M. Celix
1   Department of Neurosurgery, Aurora Neuroscience Innovation Institute, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin, United States
,
Bhavani Kura
1   Department of Neurosurgery, Aurora Neuroscience Innovation Institute, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin, United States
,
Nathaniel Kojis
1   Department of Neurosurgery, Aurora Neuroscience Innovation Institute, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin, United States
,
Richard A. Rovin
1   Department of Neurosurgery, Aurora Neuroscience Innovation Institute, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin, United States
,
Amin B. Kassam
1   Department of Neurosurgery, Aurora Neuroscience Innovation Institute, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin, United States
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Abstract

Objective The aim of this study is to determine feasibility of incorporating three-dimensional (3D) tractography into routine skull base surgery planning and analyze our early clinical experience in a subset of anterior cranial base meningiomas (ACM).

Methods Ninety-nine skull base endonasal and transcranial procedures were planned in 94 patients and retrospectively reviewed with a further analysis of the ACM subset.

Main Outcome Measures (1) Automated generation of 3D tractography; (2) co-registration 3D tractography with computed tomography (CT), CT angiography (CTA), and magnetic resonance imaging (MRI); and (3) demonstration of real-time manipulation of 3D tractography intraoperatively. ACM subset: (1) pre- and postoperative cranial nerve function, (2) qualitative assessment of white matter tract preservation, and (3) frontal lobe fluid-attenuated inversion recovery (FLAIR) signal abnormality.

Results Automated 3D tractography, with MRI, CT, and CTA overlay, was produced in all cases and was available intraoperatively. ACM subset: 8 (44%) procedures were performed via a ventral endoscopic endonasal approach (EEA) corridor and 12 (56%) via a dorsal anteromedial (DAM) transcranial corridor. Four cases (olfactory groove meningiomas) were managed with a combined, staged approach using ventral EEA and dorsal transcranial corridors. Average tumor volume reduction was 90.3 ± 15.0. Average FLAIR signal change was –30.9% ± 58.6. 11/12 (92%) patients (DAM subgroup) demonstrated preservation of, or improvement in, inferior fronto-occipital fasciculus volume. Functional cranial nerve recovery was 89% (all cases).

Conclusion It is feasible to incorporate 3D tractography into the skull base surgical armamentarium. The utility of this tool in improving outcomes will require further study.

Keywords

skull base surgery - neuronavigation - tractography - computed tomography - computed tomography angiography - magnetic resonance imaging - diffusion tensor imaging


Publication History

Received: 04 February 2020

Accepted: 25 April 2020

Article published online:
14 August 2020

© 2020. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Bello L, Gambini A, Castellano A. et al. Motor and language DTI fiber tracking combined with intraoperative subcortical mapping for surgical removal of gliomas. Neuroimage 2008; 39 (01) 369-382
    CrossrefPubMedGoogle Scholar
  • 2 Wu JS, Zhou LF, Tang WJ. et al. Clinical evaluation and follow-up outcome of diffusion tensor imaging-based functional neuronavigation: a prospective, controlled study in patients with gliomas involving pyramidal tracts. Neurosurgery 2007; 61 (05) 935-948 , discussion 948–949
    CrossrefPubMedGoogle Scholar
  • 3 Abdullah KG, Lubelski D, Nucifora PG, Brem S. Use of diffusion tensor imaging in glioma resection. Neurosurg Focus 2013; 34 (04) E1 . Doi: 10.3171/2013.1.FOCUS12412
    CrossrefPubMedGoogle Scholar
  • 4 Nimsky C. Intraoperative acquisition of fMRI and DTI. Neurosurg Clin N Am 2011; 22 (02) 269-277 , ix
    CrossrefPubMedGoogle Scholar
  • 5 Witwer BP, Moftakhar R, Hasan KM. et al. Diffusion-tensor imaging of white matter tracts in patients with cerebral neoplasm. J Neurosurg 2002; 97 (03) 568-575
    CrossrefPubMedGoogle Scholar
  • 6 Romano A, D'Andrea G, Minniti G. et al. Pre-surgical planning and MR-tractography utility in brain tumour resection. Eur Radiol 2009; 19 (12) 2798-2808
    CrossrefPubMedGoogle Scholar
  • 7 Clark CA, Barrick TR, Murphy MM, Bell BA. White matter fiber tracking in patients with space-occupying lesions of the brain: a new technique for neurosurgical planning?. Neuroimage 2003; 20 (03) 1601-1608
    CrossrefPubMedGoogle Scholar
  • 8 Prevedello DM, Ditzel Filho LF, Fernandez-Miranda JC. et al. Magnetic resonance imaging fluid-attenuated inversion recovery sequence signal reduction after endoscopic endonasal transcribiform total resection of olfactory groove meningiomas. Surg Neurol Int 2015; 6: 158 . Doi: 10.4103/2152-7806.166846
    CrossrefPubMedGoogle Scholar
  • 9 Synaptive Medical. BrightMatterTM Plan. 2015.www.synaptivemedical.com/products/plan/
    Google Scholar
  • 10 Chakravarthi S, Monroy-Sosa A, Gonen L. et al. Reanalyzing the “far medial” (transcondylar-transtubercular) approach based on three anatomical vectors: the ventral posterolateral corridor. J Neurosurg Sci 2018; 62 (03) 347-355
    CrossrefPubMedGoogle Scholar
  • 11 Kassam AB, Prevedello DM, Carrau RL. et al. The front door to Meckel's cave: an anteromedial corridor via expanded endoscopic endonasal approach- technical considerations and clinical series. Neurosurgery 2009;64(3, Suppl)ons71–ons82, discussion ons82–ons83. Doi: 10.1227/01.NEU.0000335162.36862.54
    Google Scholar
  • 12 Kassam A, Snyderman CH, Mintz A, Gardner P, Carrau RL. Expanded endonasal approach: the rostrocaudal axis. Part I. Crista galli to the sella turcica. Neurosurg Focus 2005; 19 (01) E3
    PubMedGoogle Scholar
  • 13 Kassam A, Snyderman CH, Mintz A, Gardner P, Carrau RL. Expanded endonasal approach: the rostrocaudal axis. Part II. Posterior clinoids to the foramen magnum. Neurosurg Focus 2005; 19 (01) E4
    CrossrefPubMedGoogle Scholar
  • 14 Gardner PA, Kassam AB, Thomas A. et al. Endoscopic endonasal resection of anterior cranial base meningiomas. Neurosurgery 2008; 63 (01) 36-52 , discussion 52–54
    CrossrefPubMedGoogle Scholar
  • 15 Rangel-Castilla L, Russin JJ, Spetzler RF. Surgical management of skull base tumors. Rep Pract Oncol Radiother 2016; 21 (04) 325-335
    CrossrefPubMedGoogle Scholar
  • 16 Komotar RJ, Starke RM, Raper DM, Anand VK, Schwartz TH. Endoscopic endonasal versus open transcranial resection of anterior midline skull base meningiomas. World Neurosurg 2012; 77 (5-6): 713-724
    CrossrefPubMedGoogle Scholar
  • 17 Schroeder HW. Indications and limitations of the endoscopic endonasal approach for anterior cranial base meningiomas. World Neurosurg 2014; 82 (6, Suppl): S81-S85
    CrossrefPubMedGoogle Scholar
  • 18 Yaşargil MG. A legacy of microneurosurgery: memoirs, lessons, and axioms. [Miscellaneous Article] Neurosurgery 1999; 45 (05) 1025-1092
    CrossrefPubMedGoogle Scholar
  • 19 Yasargil MG. Surgical concerns. In: Microneurosurgery. 3B. New York: Thieme; 1988: 25-53
    Google Scholar
  • 20 de Almeida JR, Carvalho F, Vaz Guimaraes Filho F. et al. Comparison of endoscopic endonasal and bifrontal craniotomy approaches for olfactory groove meningiomas: a matched pair analysis of outcomes and frontal lobe changes on MRI. J Clin Neurosci 2015; 22 (11) 1733-1741
    CrossrefPubMedGoogle Scholar
  • 21 Bowers CA, Altay T, Couldwell WT. Surgical decision-making strategies in tuberculum sellae meningioma resection. Neurosurg Focus 2011; 30 (05) E1 . Doi: 10.3171/2011.2.FOCUS1115
    Google Scholar
  • 22 de Divitiis E, Esposito F, Cappabianca P, Cavallo LM, de Divitiis O. Tuberculum sellae meningiomas: high route or low route? A series of 51 consecutive cases. Neurosurgery 2008; 62 (03) 556-563 , discussion 556–563
    CrossrefPubMedGoogle Scholar
  • 23 Kitano M, Taneda M, Nakao Y. Postoperative improvement in visual function in patients with tuberculum sellae meningiomas: results of the extended transsphenoidal and transcranial approaches. J Neurosurg 2007; 107 (02) 337-346
    CrossrefPubMedGoogle Scholar
  • 24 Fatemi N, Dusick JR, de Paiva Neto MA, Malkasian D, Kelly DF. Endonasal versus supraorbital keyhole removal of craniopharyngiomas and tuberculum sellae meningiomas. Neurosurgery 2009;64(05, Suppl 2):269–284, discussion 284–286
    Google Scholar
  • 25 Ottenhausen M, Rumalla K, Alalade AF. et al. Decision-making algorithm for minimally invasive approaches to anterior skull base meningiomas. Neurosurg Focus 2018; 44 (04) E7 . Doi: 10.3171/2018.1.FOCUS17734
    CrossrefPubMedGoogle Scholar
  • 26 Bi WL, Abedalthagafi M, Horowitz P. et al. Genomic landscape of intracranial meningiomas. J Neurosurg 2016; 125 (03) 525-535
    CrossrefPubMedGoogle Scholar
  • 27 Aguiar PH, Tahara A, Almeida AN. et al. Olfactory groove meningiomas: approaches and complications. J Clin Neurosci 2009; 16 (09) 1168-1173
    CrossrefPubMedGoogle Scholar
  • 28 Bi WL, Dunn IF. Current and emerging principles in surgery for meningioma. Linchuang Zhongliuxue Zazhi 2017; 6 (Suppl. 01) S7 . Doi: 10.21037/cco.2017.06.10
    PubMedGoogle Scholar
  • 29 Bassiouni H, Asgari S, Stolke D. Olfactory groove meningiomas: functional outcome in a series treated microsurgically. Acta Neurochir (Wien) 2007; 149 (02) 109-121 , discussion 121
    CrossrefPubMedGoogle Scholar
  • 30 Ciurea AV, Iencean SM, Rizea RE, Brehar FM. Olfactory groove meningiomas: a retrospective study on 59 surgical cases. Neurosurg Rev 2012; 35 (02) 195-202 , discussion 202
    CrossrefPubMedGoogle Scholar
  • 31 de Almeida JR, Carvalho F, Vaz Guimaraes Filho F. et al. Comparison of endoscopic endonasal and bifrontal craniotomy approaches for olfactory groove meningiomas: a matched pair analysis of outcomes and frontal lobe changes on MRI. J Clin Neurosci 2015; 22 (11) 1733-1741
    CrossrefPubMedGoogle Scholar
  • 32 Abbassy M, Woodard TD, Sindwani R, Recinos PF. An overview of anterior skull base meningiomas and the endoscopic endonasal approach. Otolaryngol Clin North Am 2016; 49 (01) 141-152
    CrossrefPubMedGoogle Scholar
  • 33 Di Maio S, Ramanathan D, Garcia-Lopez R. et al. Evolution and future of skull base surgery: the paradigm of skull base meningiomas. World Neurosurg 2012; 78 (3-4): 260-275
    CrossrefPubMedGoogle Scholar
  • 34 Brastianos PK, Horowitz PM, Santagata S. et al. Genomic sequencing of meningiomas identifies oncogenic SMO and AKT1 mutations. Nat Genet 2013; 45 (03) 285-289
    CrossrefPubMedGoogle Scholar
  • 35 Gunel M. , Yale-Bonn-Cologne Brain Tumor Genetics Study Group. 218 Meningioma Driver Mutations Determine Their Anatomical Site of Origin. Neurosurgery 2016; 63 (Suppl. 01) 185 . Doi: 10.1227/01.neu.0000489787.29664.ec
    CrossrefPubMedGoogle Scholar
  • 36 Byvalsev VA, Stepanov IA, Belykh EG, Yarullina AI. [Molecular biology of brain meningiomas]. Patol Fiziol Eksp Ter 2017; 61 (02) 82-91
    PubMedGoogle Scholar
  • 37 Gonen L, Chakravarthi SS, Monroy-Sosa A. et al. Initial experience with a robotically operated video optical telescopic-microscope in cranial neurosurgery: feasibility, safety, and clinical applications. Neurosurg Focus 2017; 42 (05) E9 . Doi: 10.3171/2017.3.FOCUS1712
    CrossrefPubMedGoogle Scholar
  • 38 Snyderman CH, Pant H, Carrau RL, Prevedello D, Gardner P, Kassam AB. What are the limits of endoscopic sinus surgery?: the expanded endonasal approach to the skull base. Keio J Med 2009; 58 (03) 152-160
    CrossrefPubMedGoogle Scholar
  • 39 Prevedello DM, Thomas A, Gardner P, Snyderman CH, Carrau RL, Kassam AB. Endoscopic endonasal resection of a synchronous pituitary adenoma and a tuberculum sellae meningioma: technical case report. Neurosurgery 2007;60(04, Suppl 2):E401, discussion E401. Doi: 10.1227/01.NEU.0000255359.94571.91
    Google Scholar
  • 40 Ditzel Filho LFS, Prevedello DM, Jamshidi AO. et al. Endoscopic endonasal approach for removal of tuberculum sellae meningiomas. Neurosurg Clin N Am 2015; 26 (03) 349-361
    CrossrefPubMedGoogle Scholar