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Developments in diffusion MRI modalities and their impact on cranial neurosurgery

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Magnetic resonance imaging (MRI) techniques based on diffusion have been in existence for just over two decades, however, their use in clinical practice has only recently caught up. Diffusion weighted imaging and diffusion tensor imaging are two modalities of MRI that have the potential to provide neurosurgeons with important diagnostic information in the preoperative and intraoperative settings. 

Background physics

Diffusion MRI relies on the translational motion property of water molecules where they move in a random thermal or Brownian motion. ADDIN EN.CITE <EndNote><Cite><RecNum>6</RecNum><DisplayText>(1, 2)</DisplayText><record><rec-number>6</rec-number><foreign-keys><key app="EN" db-id="axeaztsd39ea0uezzvz5wvdbvv5s2eeewpxw">6</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>LeBihan, D.</author><author>Mangin, J-F.</author><author>Poupon, C.</author><author>Clark, Chris A.</author><author>Pappata, S.</author><author>Molko, N.</author><author>Chabriat, H.</author></authors></contributors><titles><title>Diffusion tensor imaging: Concepts and Applications</title><secondary-title>Journal of Magnetic Resonance Imaging</secondary-title></titles><periodical><full-title>Journal of Magnetic Resonance Imaging</full-title></periodical><pages>534-546</pages><volume>13</volume><dates><year>2001</year></dates><urls></urls></record></Cite><Cite><Author>Mori</Author><Year>2006</Year><RecNum>8</RecNum><record><rec-number>8</rec-number><foreign-keys><key app="EN" db-id="axeaztsd39ea0uezzvz5wvdbvv5s2eeewpxw">8</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Mori, Susumu</author><author>Zhang, Jiangyang</author></authors></contributors><titles><title>Principles of Diffusion Tensor Imaging and Its Applications to Basic Neuroscience Research</title><secondary-title>Neuron</secondary-title></titles><periodical><full-title>Neuron</full-title></periodical><pages>527-539</pages><volume>51</volume><dates><year>2006</year></dates><isbn>08966273</isbn><urls></urls><electronic-resource-num>10.1016/j.neuron.2006.08.012</electronic-resource-num></record></Cite></EndNote>( HYPERLINK \l "_ENREF_1" \o "LeBihan, 2001 #6" 1,  HYPERLINK \l "_ENREF_2" \o "Mori, 2006 #8" 2) The diffusion on water molecules provides information on the structure and organisation of tissue. This property of water molecules is taken advantage of in diffusion weighted imaging (DWI) and is used primarily in neuroimaging to diagnose ischaemic stroke. The cytotoxic oedema that occurs post stroke restricts the diffusion of water molecules and therefore, high signal intensity is seen within the lesion (Figure 1). ADDIN EN.CITE  ADDIN EN.CITE.DATA ( HYPERLINK \l "_ENREF_1" \o "LeBihan, 2001 #6" 1,  HYPERLINK \l "_ENREF_3" \o "Stieltjes, 2001 #9" 3,  HYPERLINK \l "_ENREF_4" \o "Hagmann, 2006 #14" 4) 

In certain tissues, such as axons, the diffusion of water molecules does not occur in all directions, but is rather anisotropic and moves only in the direction of the axon. ADDIN EN.CITE  ADDIN EN.CITE.DATA ( HYPERLINK \l "_ENREF_4" \o "Hagmann, 2006 #14" 4-6) The diffusion tensor model allows measurement of diffusion along different axes fitted to a three-dimensional ellipsoid (Figure 2). 

Using this model, the degree of diffusion anisotropy can be measured. ADDIN EN.CITE <EndNote><Cite><Author>Mori</Author><Year>2006</Year><RecNum>8</RecNum><DisplayText>(2, 4)</DisplayText><record><rec-number>8</rec-number><foreign-keys><key app="EN" db-id="axeaztsd39ea0uezzvz5wvdbvv5s2eeewpxw">8</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Mori, Susumu</author><author>Zhang, Jiangyang</author></authors></contributors><titles><title>Principles of Diffusion Tensor Imaging and Its Applications to Basic Neuroscience Research</title><secondary-title>Neuron</secondary-title></titles><periodical><full-title>Neuron</full-title></periodical><pages>527-539</pages><volume>51</volume><dates><year>2006</year></dates><isbn>08966273</isbn><urls></urls><electronic-resource-num>10.1016/j.neuron.2006.08.012</electronic-resource-num></record></Cite><Cite><Author>Hagmann</Author><Year>2006</Year><RecNum>14</RecNum><record><rec-number>14</rec-number><foreign-keys><key app="EN" db-id="axeaztsd39ea0uezzvz5wvdbvv5s2eeewpxw">14</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Hagmann, Patric</author><author>Jonasson, Lisa</author><author>Maeder, Philippe</author><author>Thiran, Jean-Philippe</author><author>Wedeen, Van J.</author><author>Meuli, Reto</author></authors></contributors><titles><title>Understanding Diffusion MR Imaging Techniques: From Scalar Diffusion-weighted Imaging to Diffusion Tensor Imaging and Beyond1</title><secondary-title>Radiographics</secondary-title></titles><periodical><full-title>Radiographics</full-title></periodical><pages>S205-S223</pages><volume>26</volume><dates><year>2006</year><pub-dates><date>October 2006</date></pub-dates></dates><urls><related-urls><url>http://radiographics.rsna.org/content/26/suppl_1/S205.abstract</url></related-urls></urls><electronic-resource-num>10.1148/rg.26si065510</electronic-resource-num></record></Cite></EndNote>( HYPERLINK \l "_ENREF_2" \o "Mori, 2006 #8" 2,  HYPERLINK \l "_ENREF_4" \o "Hagmann, 2006 #14" 4) Fractional anisotropy allows the shape of the diffusion to be measured with a scalar value between zero (isotropic) and one (anisotropic). ADDIN EN.CITE <EndNote><Cite><Author>Hagmann</Author><Year>2006</Year><RecNum>14</RecNum><DisplayText>(2, 4)</DisplayText><record><rec-number>14</rec-number><foreign-keys><key app="EN" db-id="axeaztsd39ea0uezzvz5wvdbvv5s2eeewpxw">14</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Hagmann, Patric</author><author>Jonasson, Lisa</author><author>Maeder, Philippe</author><author>Thiran, Jean-Philippe</author><author>Wedeen, Van J.</author><author>Meuli, Reto</author></authors></contributors><titles><title>Understanding Diffusion MR Imaging Techniques: From Scalar Diffusion-weighted Imaging to Diffusion Tensor Imaging and Beyond1</title><secondary-title>Radiographics</secondary-title></titles><periodical><full-title>Radiographics</full-title></periodical><pages>S205-S223</pages><volume>26</volume><dates><year>2006</year><pub-dates><date>October 2006</date></pub-dates></dates><urls><related-urls><url>http://radiographics.rsna.org/content/26/suppl_1/S205.abstract</url></related-urls></urls><electronic-resource-num>10.1148/rg.26si065510</electronic-resource-num></record></Cite><Cite><Author>Mori</Author><Year>2006</Year><RecNum>8</RecNum><record><rec-number>8</rec-number><foreign-keys><key app="EN" db-id="axeaztsd39ea0uezzvz5wvdbvv5s2eeewpxw">8</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Mori, Susumu</author><author>Zhang, Jiangyang</author></authors></contributors><titles><title>Principles of Diffusion Tensor Imaging and Its Applications to Basic Neuroscience Research</title><secondary-title>Neuron</secondary-title></titles><periodical><full-title>Neuron</full-title></periodical><pages>527-539</pages><volume>51</volume><dates><year>2006</year></dates><isbn>08966273</isbn><urls></urls><electronic-resource-num>10.1016/j.neuron.2006.08.012</electronic-resource-num></record></Cite></EndNote>( HYPERLINK \l "_ENREF_2" \o "Mori, 2006 #8" 2,  HYPERLINK \l "_ENREF_4" \o "Hagmann, 2006 #14" 4) Fractional anisotropy is the fraction of the magnitude of the diffusion that is due to anisotropic diffusion, and from this diffusion tensor imaging (DTI) can be observed. ADDIN EN.CITE  ADDIN EN.CITE.DATA ( HYPERLINK \l "_ENREF_1" \o "LeBihan, 2001 #6" 1,  HYPERLINK \l "_ENREF_2" \o "Mori, 2006 #8" 2,  HYPERLINK \l "_ENREF_4" \o "Hagmann, 2006 #14" 4) Colours (red, blue and green) are assigned to each axis and help visualise the three dimensional representation producing tractographic images (Figure 3).

Limitations of earlier MR modalities

MRI uses the signals produced by the proton nuclei to produce images that demonstrate anatomical information. ADDIN EN.CITE <EndNote><Cite><Author>Mori</Author><Year>2006</Year><RecNum>8</RecNum><DisplayText>(2)</DisplayText><record><rec-number>8</rec-number><foreign-keys><key app="EN" db-id="axeaztsd39ea0uezzvz5wvdbvv5s2eeewpxw">8</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Mori, Susumu</author><author>Zhang, Jiangyang</author></authors></contributors><titles><title>Principles of Diffusion Tensor Imaging and Its Applications to Basic Neuroscience Research</title><secondary-title>Neuron</secondary-title></titles><periodical><full-title>Neuron</full-title></periodical><pages>527-539</pages><volume>51</volume><dates><year>2006</year></dates><isbn>08966273</isbn><urls></urls><electronic-resource-num>10.1016/j.neuron.2006.08.012</electronic-resource-num></record></Cite></EndNote>( HYPERLINK \l "_ENREF_2" \o "Mori, 2006 #8" 2) One key limitation of conventional MRI is contrast. Since MRI detects the protons of water molecules and produces grayscale images, unless two anatomical regions contain water molecules that have different chemical or physical properties, they are indistinguishable. ADDIN EN.CITE <EndNote><Cite><Author>Mori</Author><Year>2006</Year><RecNum>8</RecNum><DisplayText>(2)</DisplayText><record><rec-number>8</rec-number><foreign-keys><key app="EN" db-id="axeaztsd39ea0uezzvz5wvdbvv5s2eeewpxw">8</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Mori, Susumu</author><author>Zhang, Jiangyang</author></authors></contributors><titles><title>Principles of Diffusion Tensor Imaging and Its Applications to Basic Neuroscience Research</title><secondary-title>Neuron</secondary-title></titles><periodical><full-title>Neuron</full-title></periodical><pages>527-539</pages><volume>51</volume><dates><year>2006</year></dates><isbn>08966273</isbn><urls></urls><electronic-resource-num>10.1016/j.neuron.2006.08.012</electronic-resource-num></record></Cite></EndNote>( HYPERLINK \l "_ENREF_2" \o "Mori, 2006 #8" 2) In order to differentiate different regions, T1 and T2 relaxation times and the diffusion coefficient are used.

Diffusion Weighted Imaging

DWI provides MRI with diffusion coefficient contrast. As such, it has provided very important information especially in new areas of infarct. It also has a role in brain tumour diagnosis. DWI is able to distinguish between cerebral abscess and necrotic or cystic neoplasms. ADDIN EN.CITE <EndNote><Cite><Author>Cruzjr</Author><Year>2006</Year><RecNum>3</RecNum><DisplayText>(7)</DisplayText><record><rec-number>3</rec-number><foreign-keys><key app="EN" db-id="axeaztsd39ea0uezzvz5wvdbvv5s2eeewpxw">3</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Cruzjr, L.</author></authors></contributors><titles><title>Diffusion Tensor Magnetic Resonance Imaging of Brain Tumors</title><secondary-title>Magnetic Resonance Imaging Clinics of North America</secondary-title></titles><periodical><full-title>Magnetic Resonance Imaging Clinics of North America</full-title></periodical><pages>183-202</pages><volume>14</volume><dates><year>2006</year></dates><isbn>10649689</isbn><urls></urls><electronic-resource-num>10.1016/j.mric.2006.06.003</electronic-resource-num></record></Cite></EndNote>( HYPERLINK \l "_ENREF_7" \o "Cruzjr, 2006 #3" 7) On DWI, abscess have a high signal due to restricted diffusion created by the pus within the cavity, while cystic necrotic tumours typically have a low signal. ADDIN EN.CITE <EndNote><Cite><Author>Chang</Author><Year>2002</Year><RecNum>12</RecNum><DisplayText>(8)</DisplayText><record><rec-number>12</rec-number><foreign-keys><key app="EN" db-id="axeaztsd39ea0uezzvz5wvdbvv5s2eeewpxw">12</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Chang, S.C.,</author><author>Lai, P.H., </author><author>Chen, W.L., </author><author>Weng, H.H., </author><author>Ho, J.T.,</author><author>Wang, J.S.  </author></authors></contributors><titles><title> Diffusion-weighted MRI features of brain abscess and cystic or necrotic brain tumors: comparison with conventional MRI.</title><secondary-title>Clinical Imaging</secondary-title></titles><periodical><full-title>Clinical Imaging</full-title></periodical><pages>227-236</pages><volume>26</volume><dates><year>2002</year></dates><urls></urls></record></Cite></EndNote>( HYPERLINK \l "_ENREF_8" \o "Chang, 2002 #12" 8) One other area where DWI has been shown to provide benefit is in discriminating between tumour, infiltration, peritumoural oedema and normal parenchyma. ADDIN EN.CITE <EndNote><Cite><Author>Cruzjr</Author><Year>2006</Year><RecNum>3</RecNum><DisplayText>(7)</DisplayText><record><rec-number>3</rec-number><foreign-keys><key app="EN" db-id="axeaztsd39ea0uezzvz5wvdbvv5s2eeewpxw">3</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Cruzjr, L.</author></authors></contributors><titles><title>Diffusion Tensor Magnetic Resonance Imaging of Brain Tumors</title><secondary-title>Magnetic Resonance Imaging Clinics of North America</secondary-title></titles><periodical><full-title>Magnetic Resonance Imaging Clinics of North America</full-title></periodical><pages>183-202</pages><volume>14</volume><dates><year>2006</year></dates><isbn>10649689</isbn><urls></urls><electronic-resource-num>10.1016/j.mric.2006.06.003</electronic-resource-num></record></Cite></EndNote>( HYPERLINK \l "_ENREF_7" \o "Cruzjr, 2006 #3" 7) In 2001 the first use of DWI in tumour resection was described by Coenen and colleagues. ADDIN EN.CITE <EndNote><Cite><Author>Coenen</Author><Year>2001</Year><RecNum>2</RecNum><DisplayText>(9)</DisplayText><record><rec-number>2</rec-number><foreign-keys><key app="EN" db-id="vx2pps05jexw0peves6pz0avz0xezw20s290" timestamp="1400376995">2</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Coenen, V. A.</author><author>Krings, T.</author><author>Mayfrank, L.</author><author>Polin, R.S.</author><author>Reinges, M.H.T.</author><author>Thron, A.</author><author>Gilsback, J.M.</author></authors></contributors><titles><title>Three-dimensional Visualization of the Pyramidal Tract in a Neuronavigation System during Brain Tumor Surgery: First Experiences and Technical Note</title><secondary-title>Neurosurgery</secondary-title></titles><periodical><full-title>Neurosurgery</full-title><abbr-1>Neurosurgery</abbr-1></periodical><pages>8</pages><volume>49</volume><number>1</number><section>86</section><dates><year>2001</year></dates><urls></urls></record></Cite></EndNote>( HYPERLINK \l "_ENREF_9" \o "Coenen, 2001 #2" 9) They used it preoperatively to map the pyramidal tract with success in three out of four patients with glioma and meningioma in eloquent areas. ADDIN EN.CITE <EndNote><Cite><Author>Coenen</Author><Year>2001</Year><RecNum>2</RecNum><DisplayText>(9)</DisplayText><record><rec-number>2</rec-number><foreign-keys><key app="EN" db-id="vx2pps05jexw0peves6pz0avz0xezw20s290" timestamp="1400376995">2</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Coenen, V. A.</author><author>Krings, T.</author><author>Mayfrank, L.</author><author>Polin, R.S.</author><author>Reinges, M.H.T.</author><author>Thron, A.</author><author>Gilsback, J.M.</author></authors></contributors><titles><title>Three-dimensional Visualization of the Pyramidal Tract in a Neuronavigation System during Brain Tumor Surgery: First Experiences and Technical Note</title><secondary-title>Neurosurgery</secondary-title></titles><periodical><full-title>Neurosurgery</full-title><abbr-1>Neurosurgery</abbr-1></periodical><pages>8</pages><volume>49</volume><number>1</number><section>86</section><dates><year>2001</year></dates><urls></urls></record></Cite></EndNote>( HYPERLINK \l "_ENREF_9" \o "Coenen, 2001 #2" 9) It is in this sphere that diffusion tensor imaging, has proven to be more beneficial.

Advantages and application of Diffusion Tensor Imaging in Neurosurgery

DTI provides two extra levels of contrast, and with that, more information. Diffusion anisotropy and fibre orientation allow DTI to provide anatomical information about white matter tracts within the brain. ADDIN EN.CITE  ADDIN EN.CITE.DATA ( HYPERLINK \l "_ENREF_2" \o "Mori, 2006 #8" 2-4) In neurosurgery, DTI has the potential to be used preoperatively to distinguish between brain tumours and brain abscesses  ADDIN EN.CITE <EndNote><Cite><Author>Toh</Author><Year>2011</Year><RecNum>17</RecNum><DisplayText>(10)</DisplayText><record><rec-number>17</rec-number><foreign-keys><key app="EN" db-id="axeaztsd39ea0uezzvz5wvdbvv5s2eeewpxw">17</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Toh, C.H.</author><author>Wei, K.-C.</author><author>Ng, S.-H.</author><author>Wan, Y.-L.</author><author>Lin, C.-P.</author><author>Castillo, M.</author></authors></contributors><titles><title>Differentiation of Brain Abscesses from Necrotic Glioblastomas and Cystic Metastatic Brain Tumors with Diffusion Tensor Imaging</title><secondary-title>American Journal of Neuroradiology</secondary-title></titles><periodical><full-title>American Journal of Neuroradiology</full-title></periodical><pages>1646-1651</pages><volume>32</volume><dates><year>2011</year><pub-dates><date>October 1, 2011</date></pub-dates></dates><urls><related-urls><url>http://www.ajnr.org/content/32/9/1646.abstract</url></related-urls></urls><electronic-resource-num>10.3174/ajnr.A2581</electronic-resource-num></record></Cite></EndNote>( HYPERLINK \l "_ENREF_10" \o "Toh, 2011 #17" 10), distinguishing different types of tumours based on peritumoural oedema  ADDIN EN.CITE  ADDIN EN.CITE.DATA ( HYPERLINK \l "_ENREF_11" \o "Toh, 2007 #18" 11-13), and perhaps most interestingly in surgical planning for tumour resection. ADDIN EN.CITE <EndNote><Cite><Author>Nimsky</Author><Year>2005</Year><RecNum>16</RecNum><DisplayText>(14)</DisplayText><record><rec-number>16</rec-number><foreign-keys><key app="EN" db-id="axeaztsd39ea0uezzvz5wvdbvv5s2eeewpxw">16</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Nimsky, Christopher</author><author>Ganslandt, Oliver</author><author>Hastreiter, Peter</author><author>Wang, Ruopeng</author><author>Benner, Thomas</author><author>Sorensen, A Gregory</author><author>Fahlbusch, Rudolf</author></authors></contributors><titles><title>Preoperative and Intraoperative Diffusion Tensor Imaging-based Fiber Tracking in Glioma Surgery</title><secondary-title>Neurosurgery</secondary-title></titles><periodical><full-title>Neurosurgery</full-title></periodical><pages>130-138 10.1227/01.NEU.0000144842.18771.30</pages><volume>56</volume><keywords><keyword>Diffusion tensor imaging</keyword><keyword>Fiber tracking</keyword><keyword>Functional imaging</keyword><keyword>Glioma surgery</keyword><keyword>Intraoperative high-field magnetic resonance imaging</keyword><keyword>Tractography</keyword><keyword>White matter tracts</keyword><keyword>00006123-200501000-00022</keyword></keywords><dates><year>2005</year></dates><isbn>0148-396X</isbn><urls><related-urls><url>http://journals.lww.com/neurosurgery/Fulltext/2005/01000/Preoperative_and_Intraoperative_Diffusion_Tensor.22.aspx</url></related-urls></urls></record></Cite></EndNote>( HYPERLINK \l "_ENREF_14" \o "Nimsky, 2005 #16" 14) 

DTI allows visualization of the white matter tracts within the brain, including their relationship to an adjacent tumour. ADDIN EN.CITE <EndNote><Cite><Author>Cruzjr</Author><Year>2006</Year><RecNum>3</RecNum><DisplayText>(7)</DisplayText><record><rec-number>3</rec-number><foreign-keys><key app="EN" db-id="axeaztsd39ea0uezzvz5wvdbvv5s2eeewpxw">3</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Cruzjr, L.</author></authors></contributors><titles><title>Diffusion Tensor Magnetic Resonance Imaging of Brain Tumors</title><secondary-title>Magnetic Resonance Imaging Clinics of North America</secondary-title></titles><periodical><full-title>Magnetic Resonance Imaging Clinics of North America</full-title></periodical><pages>183-202</pages><volume>14</volume><dates><year>2006</year></dates><isbn>10649689</isbn><urls></urls><electronic-resource-num>10.1016/j.mric.2006.06.003</electronic-resource-num></record></Cite></EndNote>( HYPERLINK \l "_ENREF_7" \o "Cruzjr, 2006 #3" 7) The degree of involvement of a tumour with white matter can be determined by the degree of anisotropy. If the white matter tracts are displaced normal anisotropy is maintained relative to the contralateral tract, however their location or orientation is abnormal. An invaded white matter tract has a slightly reduced anisotropy without displacement. An infiltrated white matter tract has more reduction in its anisotropy, while a disrupted tract has even further reduction in its anisotropy and is also unidentifiable on tractography. Oedematous white matter has normal anisotropy but abnormal T2 weighted signal intensity. ADDIN EN.CITE  ADDIN EN.CITE.DATA ( HYPERLINK \l "_ENREF_2" \o "Mori, 2006 #8" 2,  HYPERLINK \l "_ENREF_7" \o "Cruzjr, 2006 #3" 7,  HYPERLINK \l "_ENREF_15" \o "Yen, 2009 #11" 15) Based on the effect on related white matter structures, inferences can be made of the type of tumour involved. Low grade gliomas have been described to displace rather than destruct white matter tracts while, tract disruption is most commonly seen in higher grade tumours. ADDIN EN.CITE <EndNote><Cite><Author>Cruzjr</Author><Year>2006</Year><RecNum>3</RecNum><DisplayText>(7)</DisplayText><record><rec-number>3</rec-number><foreign-keys><key app="EN" db-id="axeaztsd39ea0uezzvz5wvdbvv5s2eeewpxw">3</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Cruzjr, L.</author></authors></contributors><titles><title>Diffusion Tensor Magnetic Resonance Imaging of Brain Tumors</title><secondary-title>Magnetic Resonance Imaging Clinics of North America</secondary-title></titles><periodical><full-title>Magnetic Resonance Imaging Clinics of North America</full-title></periodical><pages>183-202</pages><volume>14</volume><dates><year>2006</year></dates><isbn>10649689</isbn><urls></urls><electronic-resource-num>10.1016/j.mric.2006.06.003</electronic-resource-num></record></Cite></EndNote>( HYPERLINK \l "_ENREF_7" \o "Cruzjr, 2006 #3" 7) Using diffusion tensor metrics, others have been able to distinguish between cerebral abscesses and high grade gliomas, as well as distinguishing cerebral metastases from other primary cerebral neoplasms using tensor metrics within peritumoural oedema. ADDIN EN.CITE  ADDIN EN.CITE.DATA ( HYPERLINK \l "_ENREF_10" \o "Toh, 2011 #17" 10,  HYPERLINK \l "_ENREF_11" \o "Toh, 2007 #18" 11,  HYPERLINK \l "_ENREF_13" \o "Lu, 2004 #20" 13) DTI has the potential to provide an enormous improvement to the diagnostic tools available to neurosurgeons. 

The primary aim of tumour surgery is for maximal resection while preserving normal parenchyma. DTI allows identification of normal parenchyma and when combined with functional MRI allows preoperative identification of eloquent areas near a tumour. ADDIN EN.CITE <EndNote><Cite><Author>Cruzjr</Author><Year>2006</Year><RecNum>3</RecNum><DisplayText>(7)</DisplayText><record><rec-number>3</rec-number><foreign-keys><key app="EN" db-id="axeaztsd39ea0uezzvz5wvdbvv5s2eeewpxw">3</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Cruzjr, L.</author></authors></contributors><titles><title>Diffusion Tensor Magnetic Resonance Imaging of Brain Tumors</title><secondary-title>Magnetic Resonance Imaging Clinics of North America</secondary-title></titles><periodical><full-title>Magnetic Resonance Imaging Clinics of North America</full-title></periodical><pages>183-202</pages><volume>14</volume><dates><year>2006</year></dates><isbn>10649689</isbn><urls></urls><electronic-resource-num>10.1016/j.mric.2006.06.003</electronic-resource-num></record></Cite></EndNote>( HYPERLINK \l "_ENREF_7" \o "Cruzjr, 2006 #3" 7) Identifying these areas preoperatively can allow the neurosurgeon to plan a surgical approach that avoids these areas helping to reduce postoperative morbidity. ADDIN EN.CITE <EndNote><Cite><Author>Mori</Author><Year>2006</Year><RecNum>8</RecNum><DisplayText>(2)</DisplayText><record><rec-number>8</rec-number><foreign-keys><key app="EN" db-id="axeaztsd39ea0uezzvz5wvdbvv5s2eeewpxw">8</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Mori, Susumu</author><author>Zhang, Jiangyang</author></authors></contributors><titles><title>Principles of Diffusion Tensor Imaging and Its Applications to Basic Neuroscience Research</title><secondary-title>Neuron</secondary-title></titles><periodical><full-title>Neuron</full-title></periodical><pages>527-539</pages><volume>51</volume><dates><year>2006</year></dates><isbn>08966273</isbn><urls></urls><electronic-resource-num>10.1016/j.neuron.2006.08.012</electronic-resource-num></record></Cite></EndNote>( HYPERLINK \l "_ENREF_2" \o "Mori, 2006 #8" 2) 

Perhaps the most exciting use of DTI is in the burgeoning field of intraoperative MRI. In their study of subcortical motor tracts, Berman and colleagues used intraoperative MRI with DTI and a neuronavigation system to identify the course of these motor pathways in relation to tumours. ADDIN EN.CITE <EndNote><Cite><Author>Berman</Author><Year>2004</Year><RecNum>15</RecNum><DisplayText>(16)</DisplayText><record><rec-number>15</rec-number><foreign-keys><key app="EN" db-id="axeaztsd39ea0uezzvz5wvdbvv5s2eeewpxw">15</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Berman, Jeffrey I.</author><author>Berger, Mitchel S.</author><author>Mukherjee, Pratik</author><author>Henry, Roland G.</author></authors></contributors><titles><title>Diffusion-tensor imaging�guided tracking of fibers of the pyramidal tract combined with intraoperative cortical stimulation mapping in patients with gliomas</title><secondary-title>Journal of Neurosurgery</secondary-title></titles><periodical><full-title>Journal of Neurosurgery</full-title></periodical><pages>66-72</pages><volume>101</volume><dates><year>2004</year></dates><accession-num>15255253</accession-num><urls><related-urls><url>http://thejns.org/doi/abs/10.3171/jns.2004.101.1.0066</url></related-urls></urls><electronic-resource-num>doi:10.3171/jns.2004.101.1.0066</electronic-resource-num></record></Cite></EndNote>( HYPERLINK \l "_ENREF_16" \o "Berman, 2004 #15" 16) They found that using intraoperative DTI was able to identify subcortical tracts consistent with the known anatomy of these fibres, and recognise their displacement by tumour. Nimsky and colleagues used preoperative and intraoperative DTI to examine shift of white matter tracts during tumour resection. ADDIN EN.CITE <EndNote><Cite><Author>Nimsky</Author><Year>2005</Year><RecNum>16</RecNum><DisplayText>(14)</DisplayText><record><rec-number>16</rec-number><foreign-keys><key app="EN" db-id="axeaztsd39ea0uezzvz5wvdbvv5s2eeewpxw">16</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Nimsky, Christopher</author><author>Ganslandt, Oliver</author><author>Hastreiter, Peter</author><author>Wang, Ruopeng</author><author>Benner, Thomas</author><author>Sorensen, A Gregory</author><author>Fahlbusch, Rudolf</author></authors></contributors><titles><title>Preoperative and Intraoperative Diffusion Tensor Imaging-based Fiber Tracking in Glioma Surgery</title><secondary-title>Neurosurgery</secondary-title></titles><periodical><full-title>Neurosurgery</full-title></periodical><pages>130-138 10.1227/01.NEU.0000144842.18771.30</pages><volume>56</volume><keywords><keyword>Diffusion tensor imaging</keyword><keyword>Fiber tracking</keyword><keyword>Functional imaging</keyword><keyword>Glioma surgery</keyword><keyword>Intraoperative high-field magnetic resonance imaging</keyword><keyword>Tractography</keyword><keyword>White matter tracts</keyword><keyword>00006123-200501000-00022</keyword></keywords><dates><year>2005</year></dates><isbn>0148-396X</isbn><urls><related-urls><url>http://journals.lww.com/neurosurgery/Fulltext/2005/01000/Preoperative_and_Intraoperative_Diffusion_Tensor.22.aspx</url></related-urls></urls></record></Cite></EndNote>( HYPERLINK \l "_ENREF_14" \o "Nimsky, 2005 #16" 14) Identifying the repositioning of these white matter tracts may prevent excessive resection of normal parenchyma, reducing postoperative morbidity. At this stage, only single-centre studies have been performed, however, the data thus far is promising, that DTI when used as a preoperative and intraoperative tool can improve surgical outcome, reducing postoperative neurological morbidity. ADDIN EN.CITE  ADDIN EN.CITE.DATA ( HYPERLINK \l "_ENREF_7" \o "Cruzjr, 2006 #3" 7,  HYPERLINK \l "_ENREF_14" \o "Nimsky, 2005 #16" 14,  HYPERLINK \l "_ENREF_16" \o "Berman, 2004 #15" 16)  

Limitations of Diffusion Tensor Imaging

The major limitations of DTI are technical issues related to resolution and other artifacts. At current resolution, only a single axon direction is visible within each imaging voxel. Therefore, identifying areas of fibre crossing is not currently possible. ADDIN EN.CITE <EndNote><Cite><Author>Nimsky</Author><Year>2005</Year><RecNum>16</RecNum><DisplayText>(14)</DisplayText><record><rec-number>16</rec-number><foreign-keys><key app="EN" db-id="axeaztsd39ea0uezzvz5wvdbvv5s2eeewpxw">16</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Nimsky, Christopher</author><author>Ganslandt, Oliver</author><author>Hastreiter, Peter</author><author>Wang, Ruopeng</author><author>Benner, Thomas</author><author>Sorensen, A Gregory</author><author>Fahlbusch, Rudolf</author></authors></contributors><titles><title>Preoperative and Intraoperative Diffusion Tensor Imaging-based Fiber Tracking in Glioma Surgery</title><secondary-title>Neurosurgery</secondary-title></titles><periodical><full-title>Neurosurgery</full-title></periodical><pages>130-138 10.1227/01.NEU.0000144842.18771.30</pages><volume>56</volume><keywords><keyword>Diffusion tensor imaging</keyword><keyword>Fiber tracking</keyword><keyword>Functional imaging</keyword><keyword>Glioma surgery</keyword><keyword>Intraoperative high-field magnetic resonance imaging</keyword><keyword>Tractography</keyword><keyword>White matter tracts</keyword><keyword>00006123-200501000-00022</keyword></keywords><dates><year>2005</year></dates><isbn>0148-396X</isbn><urls><related-urls><url>http://journals.lww.com/neurosurgery/Fulltext/2005/01000/Preoperative_and_Intraoperative_Diffusion_Tensor.22.aspx</url></related-urls></urls></record></Cite></EndNote>( HYPERLINK \l "_ENREF_14" \o "Nimsky, 2005 #16" 14) Anatomic distortion of the images can also occur due to the air-brain interface. ADDIN EN.CITE <EndNote><Cite><Author>Nimsky</Author><Year>2005</Year><RecNum>16</RecNum><DisplayText>(14)</DisplayText><record><rec-number>16</rec-number><foreign-keys><key app="EN" db-id="axeaztsd39ea0uezzvz5wvdbvv5s2eeewpxw">16</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Nimsky, Christopher</author><author>Ganslandt, Oliver</author><author>Hastreiter, Peter</author><author>Wang, Ruopeng</author><author>Benner, Thomas</author><author>Sorensen, A Gregory</author><author>Fahlbusch, Rudolf</author></authors></contributors><titles><title>Preoperative and Intraoperative Diffusion Tensor Imaging-based Fiber Tracking in Glioma Surgery</title><secondary-title>Neurosurgery</secondary-title></titles><periodical><full-title>Neurosurgery</full-title></periodical><pages>130-138 10.1227/01.NEU.0000144842.18771.30</pages><volume>56</volume><keywords><keyword>Diffusion tensor imaging</keyword><keyword>Fiber tracking</keyword><keyword>Functional imaging</keyword><keyword>Glioma surgery</keyword><keyword>Intraoperative high-field magnetic resonance imaging</keyword><keyword>Tractography</keyword><keyword>White matter tracts</keyword><keyword>00006123-200501000-00022</keyword></keywords><dates><year>2005</year></dates><isbn>0148-396X</isbn><urls><related-urls><url>http://journals.lww.com/neurosurgery/Fulltext/2005/01000/Preoperative_and_Intraoperative_Diffusion_Tensor.22.aspx</url></related-urls></urls></record></Cite></EndNote>( HYPERLINK \l "_ENREF_14" \o "Nimsky, 2005 #16" 14) DTI identifies diffusion anisotropy when there is a microscopic source of diffusion anisotropy and there is a macroscopic homogeneity of the structures within a voxel. ADDIN EN.CITE <EndNote><Cite><Author>Mori</Author><Year>2006</Year><RecNum>8</RecNum><DisplayText>(2)</DisplayText><record><rec-number>8</rec-number><foreign-keys><key app="EN" db-id="axeaztsd39ea0uezzvz5wvdbvv5s2eeewpxw">8</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Mori, Susumu</author><author>Zhang, Jiangyang</author></authors></contributors><titles><title>Principles of Diffusion Tensor Imaging and Its Applications to Basic Neuroscience Research</title><secondary-title>Neuron</secondary-title></titles><periodical><full-title>Neuron</full-title></periodical><pages>527-539</pages><volume>51</volume><dates><year>2006</year></dates><isbn>08966273</isbn><urls></urls><electronic-resource-num>10.1016/j.neuron.2006.08.012</electronic-resource-num></record></Cite></EndNote>( HYPERLINK \l "_ENREF_2" \o "Mori, 2006 #8" 2) Therefore, if changes in diffusion anisotropy are found, it is not possible to conclude that the source of the abnormality is within the cellular microscopic component (myelin), or if there is a macroscopic reorganisation of axons. ADDIN EN.CITE <EndNote><Cite><Author>Mori</Author><Year>2006</Year><RecNum>8</RecNum><DisplayText>(2)</DisplayText><record><rec-number>8</rec-number><foreign-keys><key app="EN" db-id="axeaztsd39ea0uezzvz5wvdbvv5s2eeewpxw">8</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Mori, Susumu</author><author>Zhang, Jiangyang</author></authors></contributors><titles><title>Principles of Diffusion Tensor Imaging and Its Applications to Basic Neuroscience Research</title><secondary-title>Neuron</secondary-title></titles><periodical><full-title>Neuron</full-title></periodical><pages>527-539</pages><volume>51</volume><dates><year>2006</year></dates><isbn>08966273</isbn><urls></urls><electronic-resource-num>10.1016/j.neuron.2006.08.012</electronic-resource-num></record></Cite></EndNote>( HYPERLINK \l "_ENREF_2" \o "Mori, 2006 #8" 2) The effect of these technical issues on the neurosurgeon relates to the accuracy of the imaging. Distortion of images and other artifacts, can impact on surgical resection if the observed fibres do not correlate with the imaging. Using intraoperative MRI has its own set of technical limitations including longer operating times, logistical issues involving scanner placement and transporting the patient from the theatre to the scanner. In order to overcome these technical issues, evolution of the technology and development of newer methodologies is occurring. ADDIN EN.CITE <EndNote><Cite><Author>Nimsky</Author><Year>2005</Year><RecNum>16</RecNum><DisplayText>(14)</DisplayText><record><rec-number>16</rec-number><foreign-keys><key app="EN" db-id="axeaztsd39ea0uezzvz5wvdbvv5s2eeewpxw">16</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Nimsky, Christopher</author><author>Ganslandt, Oliver</author><author>Hastreiter, Peter</author><author>Wang, Ruopeng</author><author>Benner, Thomas</author><author>Sorensen, A Gregory</author><author>Fahlbusch, Rudolf</author></authors></contributors><titles><title>Preoperative and Intraoperative Diffusion Tensor Imaging-based Fiber Tracking in Glioma Surgery</title><secondary-title>Neurosurgery</secondary-title></titles><periodical><full-title>Neurosurgery</full-title></periodical><pages>130-138 10.1227/01.NEU.0000144842.18771.30</pages><volume>56</volume><keywords><keyword>Diffusion tensor imaging</keyword><keyword>Fiber tracking</keyword><keyword>Functional imaging</keyword><keyword>Glioma surgery</keyword><keyword>Intraoperative high-field magnetic resonance imaging</keyword><keyword>Tractography</keyword><keyword>White matter tracts</keyword><keyword>00006123-200501000-00022</keyword></keywords><dates><year>2005</year></dates><isbn>0148-396X</isbn><urls><related-urls><url>http://journals.lww.com/neurosurgery/Fulltext/2005/01000/Preoperative_and_Intraoperative_Diffusion_Tensor.22.aspx</url></related-urls></urls></record></Cite></EndNote>( HYPERLINK \l "_ENREF_14" \o "Nimsky, 2005 #16" 14) 

Conclusions

MRI is an imaging modality that is used everyday in modern neurosurgery. The advent of diffusion based imaging, both DWI and DTI, has provided improvements in diagnostic imaging. Using DTI, one can differentiate between different tumour types based on peritumour oedema indices. However, the most exciting use of DTI is in the intraoperative setting, where combination of intraoperative DTI and functional MRI allows eloquent areas of the brain in close proximity to tumours, to be salvaged. While still in its infancy, the use of DTI in cranial neurosurgery has the potential to significantly improve neurosurgical morbidity.References

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3.	Stieltjes B, Kaufmann WE, van Zijl PCM, Fredericksen K, Pearlson GD, Solaiyappan M, et al. Diffusion Tensor Imaging and Axonal Tracking in the Human Brainstem. NeuroImage. 2001;14:723-35.
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