1811. Diffusion Tensor Imaging in Neuronavigation to Guide a Trans-Sulcal Approach to Glioma in Awake Craniotomy

Authors: Thomas Gianaris, MD; Gina Monaco, MD, PhD; Jonathan Weyhenmeyer, MD; Mitesh Shah, MD (Indianapolis, IN)

Introduction:

Preservation of eloquent brain and associated white matter tracts is the cornerstone of deep glioma surgery, and numerous techniques have been applied previously to minimize risk to these structures.  By combining existing technologies including awake craniotomy and diffusion tensor imaging (DTI) with new modalities including minimally-invasive trans-sulcal approaches, we may be able to anticipate structures at risk and alter operative course accordingly via redirection of the trans-sulcal obturator.


Methods:

An 80 year old man with a large right-sided deep glioblastoma underwent awake craniotomy with intraoperative speech and motor testing.  Preoperative MRI with diffusion tensor imaging of his white matter tracts was used as a template for intraoperative neuronavigation.  A small craniotomy was made and the BrainPath obturator (a minimally invasive rigid tunneler) was inserted into a sulcus and slowly passed into the tumor based on real-time evaluation of these DTI tracts and motor and speech testing feedback from the patient.  Once the tumor was accessed, it was then resected through this hollow tube as much as possible without causing undue neurological morbidity.

Results:
Glioma was resected to the fullest extent possible until the patient began to experience signs of neurological deficit on language and functional testing, at which point further resection was halted.


Conclusion:

By identifying white matter tracts with diffusion tensor imaging via real-time neuronavigation, a trans-sulcal approach tube can be more effectively targeted to avoid or, if need be, divide these tracts appropriately, preserving eloquent tissue function.  The use of an awake craniotomy allows confirmation of these tracts in real-time as well, heightening accuracy.