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Neurol India. 2019 May-Jun;67(3):763-769. doi: 10.4103/0028-3886.263199.

Presurgical simulation for neuroendoscopic procedures: Virtual study of the integrity of neurological pathways using diffusion tensor imaging tractography.

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Department of Neurosurgery, Hospital Clinic, Barcelona, Spain.
Department of Neurosurgery, University of California, San Francisco, California, USA.
Department of Radiology, Hospital Clinic, Barcelona, Spain.
Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA.
Department of Neurosurgery, John Hopkins University, Baltimore, Maryland, USA.



White matter (WM) transgression is an unexplored concept in neuroendoscopy. Diffusion tensor image (DTI) tractography could be implemented as a planning and postoperative evaluation tool in functional disconnection procedures (FDPs), which are, currently, the subject of technological innovations. We intend to prove the usefulness of this planning method focused on the assessment of WM injury that is suitable for planning FDPs.


Ten cranial magnetic resonance studies (20 sides) without pathological findings were processed. Fascicles were defined by two regions of interest (ROIs) using the fiber assignment method by the continuous tracking approach. Using three-dimensional (3D) simulation and DTI tractography, we created an 8-mm virtual endoscope and an uninjured inferior fronto-occipital fasciculus (IFOF) from two ROIs. The injured tract was generated using a third ROI built from the 3D model of the intersection of the oriented trajectory of the endoscope with the fascicle. Data and images were quantitatively and qualitatively analyzed.


The average percentage of the injured fibers was 32.0% (range: 12.4%-70%). The average intersected volume was 1.1 cm3 (range: 0.3-2.3 cm3). Qualitative analysis showed the inferior medial quadrant of the inferior fronto-occipital fasciculus (IFOF) as the most frequently injured region. No hemispherical asymmetry was found (P > 0.5).


DTI tractography is a useful surgical planning tool that could be implemented in several endoscopic procedures. Together with a functional atlas, the presented technique provides a noninvasive method to assess the potential sequelae and thus to optimize the surgical route. The suggested method could be implemented to analyze pathological WM fascicles and to assess the surgical results of FDP such as hemispherotomy or amygdalohippocampectomy. More studies are needed to overcome the limitations of the tractography based information and to develop more anatomically and functionally reliable planning systems.


Diffusion tensor imaging; endoscopy; epilepsy; simulation; transgression; white matter

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