NTMS based tractography and segmental diffusion analysis in patients with brainstem gliomas: Risk stratification and clinical potential

Introduction: Surgery on the brainstem level is associated with a high -risk of postoperative morbidity. Recently, we have introduced the combination of navigated transcranial magnetic stimulation (nTMS) and diffusion tensor imaging (DTI) tractography to define functionally relevant motor fibers tracts on the brainstem level to support operative planning and risk stratification in brainstem cavernomas. Research question: Evaluate this method and assess it's clinical impact for the surgery of brainstem gliomas. Material and methods: Patients with brainstem gliomas were examined preoperatively with motor nTMS and DTI tractography. A fractional anisotropy (FA) value of 75% of the individual FA threshold (FAT) was used to track descending corticospinal (CST) and -bulbar tracts (CBT). The distance between the tumor and the somatotopic tracts (hand, leg, face) was measured and diffusion parameters were correlated to the patients' outcome. Results: 12 patients were enrolled in this study, of which 6 underwent surgical resection, 5 received a stereotactic biopsy and 1 patient received conservative treatment. In all patients nTMS mapping and somatotopic tractography were performed successfully. Low FA values correlated with clinical symptoms revealing tract alteration by the tumor (p = 0.049). A tumor -tract distance (TTD) above 2 mm was the critical limit to achieve a safe complete tumor resection. Discussion and conclusion: nTMS based DTI tractography combined with local diffusion analysis is a valuable tool for preoperative visualization and functional assessment of relevant motor fiber tracts, improving planning of safe entry corridors and perioperative risk stratification in brainstem gliomas tumors. This technique allows for customized treatment strategy to maximize patients' safety.