Role of diffusion tensor imaging in a patient with spontaneous intracerebral hematoma treated by stereotactic evacuation

doi:10.1016/j.surneu.2007.04.004

Surgical Neurology

Volume 70, Issue 1, July 2008, Pages 75-78

https://doi.org/10.1016/j.surneu.2007.04.004 Get rights and content

Abstract

Background

Diffusion tensor imaging is a newly developed technique used to visualize the white matter fibers in the human brain. In previous reports, DTI has been applied in patients with neoplasms, lacunar infarction, ischemic stroke, degenerative motor disease, and diffuse axonal injury, and has become a powerful tool in predicting clinical outcome. However, the implementation of DTI in patients with spontaneous ICH treated by stereotactic evaluation of hematoma has never been reported.

Case Description

The authors describe a case of a well-predicted outcome of DTI in a 37-year-old right-handed man who presented with sudden onset of vomiting and weakness of right extremities 2 hours before admission. Computed tomographic head scan revealed 1 hyperdense hematoma measuring about 3.9 × 2.2 × 2.6 cm (about 15 mL in volume) located in the left putamen, compressing the posterior limb of left internal capsule. Preoperative DTI revealed that white matter tracts were compressed by the hematomas. After the patient underwent stereotactic evacuation of hematoma, good recovery of muscle power was noted in the right extremities. Postoperative DTI revealed the restoration of white matter tracts.

Conclusion

Diffuse tensor imaging is a useful tool for the visualization of white matter tracts, especially the corticospinal tract, which regulates motor function in human beings. In patients with ICH treated by stereotactic aspiration of hematomas, clinical outcome could be more precisely predicted by preoperative DTI.

Introduction

Unlike conventional MR imaging, which provided limited information on white matter tracts, DTI, first described by Mori et al [11], is a newly developed technique used to track and visualize white matter fibers in the human brain. Because of the good correlation between DTI and clinical outcome, DTI has become a powerful method to assess the involvement of white matter tracts in patients with neoplasms, lacunar infarction, hemorrhagic stroke, ischemic stroke, degenerative motor disease, and diffuse axonal injury [1], [7], [9], [12]. However, the practical value of DTI in patients with spontaneous ICH treated by stereotactic evacuation of hematoma has been never discussed in the literature. We present the well-predicted outcome of DTI in a case of spontaneous ICH treated by stereotactic evacuation.

Section snippets

Case report

A 37-year-old right-handed man presented with sudden onset of vomiting and weakness of right extremities 2 hours before admission. At the emergency department, the patient had a blood pressure of 176/80 mm Hg, pulse rate of 90/min, respiratory rate of 20/min, and body temperature of 36.8°C. Neurologic examinations revealed slurred speech, weakness of right extremities (muscle power scored as grade 1 over 5), and presence of right plantar flexion. Laboratory examination showed no remarkable

Discussion

White matter fibers in the human brain play an important role in conducting the functional regions. The ability to identify the involvement of white matter fibers may be a useful index of severity of diseases, and would allow clinical physicians to predict the surgical outcome and long-term disability. Conventional MR imaging provides reliable integrity of the white matter fibers, with limited capacity to predict the clinical outcome [12]. As advancement in MR methodologies, white matter

Conclusion

Diffusion tensor imaging is a useful tool for visualization of white matter tracts, particularly the corticospinal tract, which mandates motor function in human beings. In patients with ICH treated by stereotactic aspiration of hematomas, the clinical outcome could be more precisely predicted by preoperative DTI.

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Cited by (19)

Current applications of diffusion tensor tractography analysis of corticospinal tracts for prognostication of motor outcomes or optimization of neurosurgical intervention in hypertensive intracranial hemorrhage
2022, Brain Hemorrhages
Citation Excerpt :
Of note, a majority of the articles was published by two labs (Jang and Koyama). There were 16 studies classified as case reports (Table 1), 22 observational studies with larger sample sizes (Table 2), and four studies investigating surgical versus conservative management (Table 3).15–56 Information regarding imaging parameters and DTT software can be found in Table 4.
Intracranial hemorrhage (ICH) causes often devastating brain injury. Predicting long-term motor prognosis and identifying neurosurgical candidates in cases of ICH has been an imprecise practice. Diffusion tensor tractography (DTT) is an imaging modality that may aid in this challenge. This literature review aimed to investigate DTT applications in patients with spontaneous ICH for either motor function prognosis or surgical intervention.
A PubMed and Ovid literature review was performed to select and evaluate studies utilizing DTT for motor prognostication or analysis/optimization of surgical outcomes in patients with spontaneous hypertensive ICH. Studies investigating ICH due to suspected vascular anomalies were excluded.
Forty-two studies met criteria. Six studies addressed surgical application. Surgery was not associated with increased mortality but was associated with decreased hematoma volume and CST compression and improved motor outcomes. Prognostic studies demonstrated that DTT correlates with motor function at multiple timepoints.
DTT is a relatively new imaging technique that may help predict prognosis of patients’ motor function after spontaneous ICH. Additionally, it could possibly serve as an adjunct for determining which patients would benefit from surgical decompression or even help guide surgical approach to hematomas that displace the CST.
Minimally Invasive Surgery for Evacuating the Intracerebral Hematoma in Early Stages Decreased Secondary Damages to the Internal Capsule in Dog Model of ICH Observed by Diffusion Tensor Imaging
2017, Journal of Stroke and Cerebrovascular Diseases
Diffusion tensor imaging was used to observe the effects of performing early minimally invasive surgery (MIS) on internal capsule in dog model of intracerebral hemorrhage (ICH).
Twenty-five male dogs were selected to prepare an ICH model, and then they were randomly distributed into a model control (MC) group (5 dogs) or an MIS group (20 dogs). In the MIS group, the intracerebral hematoma was evacuated by stereotactic minimally invasive procedures over 6 hours (5 dogs), 12 hours (5 dogs), 18 hours (5 dogs), or 24 hours (5 dogs) after successful induction of ICH. The same procedure was performed in the MC group but without evacuating the hematoma. All the animals were sacrificed within 2 weeks after the hematoma was surgically evacuated. The neurologic deficit score and diffusion tensor imaging (DTI) were observed before and after the MIS. The perihematomal blood-brain barrier (BBB) permeability and the brain water content (BWC) were measured 2 weeks after the hematoma was surgically evacuated.
The DTI demonstrated that integrity of the internal capsule restored largely after surgery and the fractional anisotropy (FA) values of the internal capsule on the hematoma side increased significantly as compared with those in the MC group or those before surgery in the same group. The postoperative ratios of FA values of each MIS subgroup increased compared with the MC group and those before surgery in the same subgroup before operation. The neurologic deficit score, the perihematomal BBB permeability, and the BWC of each MIS subgroup decreased significantly compared with those of the MC group. The 6-12–hour group displayed a more favorable result.
Performing the MIS in the early stage (6-12 hours) after ICH could decrease the secondary damages to the internal capsule so as to promote the recovery of motor function. The optimal time window for MIS should be within 6-12 hours after onset of ICH.
Diffusion tensor imaging in hemorrhagic stroke
2015, Experimental Neurology
Citation Excerpt :
There are at least two other studies that have looked at the role of DTI in detecting recovery of the white matter fibers following ICH and treatment with hematoma evacuation (Hsieh et al., 2008a; Wu et al., 2011). Heish et al. in a case report demonstrate recovery of white matter fibers in CST damaged by putaminal hematoma correlating with improved motor function post-evacuation of hematoma by minimally invasive techniques (Hsieh et al., 2008b). Similarly Wu et al. (ref 2 in Guofeng article) demonstrate similar significant correlation in 27 patients treated with minimally invasive methods to evacuate the hematoma, between improved FA and fiber density in CST and motor function outcome (Wu et al., 2011).
Diffusion tensor imaging (DTI) has evolved considerably over the last decade to now be knocking on the doors of wider clinical applications. There have been several efforts over the last decade to seek valuable and reliable application of DTI in different neurological disorders. The role of DTI in predicting outcomes in patients with brain tumors has been extensively studied and has become a fairly established clinical tool in this scenario. More recently DTI has been applied in mild traumatic brain injury to predict clinical outcomes based on DTI of the white matter tracts. The resolution of white matter fiber tractography based on DTI has improved over the years with increased magnet strength and better tractography post-processing. The role of DTI in hemorrhagic stroke has been studied preliminarily in the scientific literature. There is some evidence that DTI may be efficacious in predicting outcomes of motor function in animal models of intracranial hemorrhage. Only a handful of studies of DTI have been performed in subarachnoid hemorrhage or intraventricular hemorrhage scenarios. In this manuscript we will review the evolution of DTI, the existing evidence for its role in hemorrhagic stroke and discuss possible application of this non-invasive evaluation technique of human cerebral white matter tracts in the future.
Minimally invasive procedures reduced the damages to motor function in patients with thalamic hematoma: Observed by motor evoked potential and diffusion tensor imaging
2013, Journal of Stroke and Cerebrovascular Diseases
Citation Excerpt :
Although DTI has been widely used to evaluate changes in the CST of patients with cerebral infarction or brain injury, it has also been used to predict motor function outcome in a few patients with ICH.9-11,13,18,20 However, few studies have used DTI in patients with spontaneous ICH that was treated by a minimally invasive procedure for evacuation of the hematoma.2,16 In the present study, we used DTI to observe the changes of motor function after performing a minimally invasive procedure for evacuating a thalamic hematoma.
The purpose of this study was to observe changes in motor function using diffusion tensor imaging (DTI) and motor-evoked potential (MEP) in patients with thalamic hematoma treated by minimally invasive procedures.
Forty-three patients with thalamic hematoma were randomized to either a minimally invasive group (MI group) or a medical treatment group (MT group). The patients in the MI group underwent whole-brain DTI and MEP measurements both before and 2 weeks after the thalamic hematoma was evacuated by minimally invasive procedures. The fractional anisotropy (FA) values of the corticospinal tract (CST) in the internal capsule and MEP ipsilateral to the hematoma side and the contralateral side were determined and then compared with the MT group.
DTI showed that fibers in the internal capsule ipsilateral to the hematoma decreased either in number or were interrupted because of hematoma-induced damages, and in both groups, the CST FA values on admission were significantly lower (0.428 ± 0.032 and 0.415 ± 0.048 for the MI and MT groups, respectively) than the control values. Two weeks after the hematoma was evacuated, the number of fibers and the FA values of the CST in the internal capsule had both increased significantly relative to the values on admission. MEP was recorded simultaneously in all patients who were treated with minimally invasive procedures, and the latency of MEP decreased compared with the MT group. As FA values of the CST in internal capsule increased and MEP appeared with its latency decreased, the modified National Institutes of Health Stroke Scale score decreased after the surgery.
Minimally invasive procedures for thalamic hematoma evacuation could effectively reduce the degree of injury to the function as observed by a combination of DTI and MEP measurements.
Prediction of motor outcome in ischemic stroke involving the pyramidal tract using diffusion tensor imaging
2012, Egyptian Journal of Radiology and Nuclear Medicine
Citation Excerpt :
However, for long-term recovery, relative preservation of the integrity and anisotropy of the white matter tracts (CST particularly) plays an important role and indicates a better clinical outcome (5,6). In previous studies (3,10–12), the neuromotor outcome was found to correlate with conventional neuroimaging findings such as the size, the volume, and the extent of the infarction. Conventional imaging, however, does not give data about the microstructural organization of the white matter fiber tracts, which can be obtained from DTT.
Early evaluation of the pyramidal tract is a prerequisite in patients with ischemic stroke in order to decide the optimal treatment or to assess appropriate rehabilitation. The aim of this study was to predict motor outcome using quantitative and qualitative diffusion tensor parameters and their correlations with severity of stroke as defined by the National Institutes of Health Stroke Scale (NIHSS).
Twenty-one patients presenting with ischemic stroke were studied with DTI. All patients had diffusion measurements such as FA values of the affected and unaffected regions and the FA ratio between them. Color FA maps of the pyramidal tract were constructed and the degree of infarctions was classified into groups according to the involvements of the pyramidal tracts. The motor performance of the upper and lower extremities was assessed using the NIHSS on the day of patients’ admission and discharge. The motor outcomes were correlated with the FA values of the pyramidal tract.
The FA values of the affected pyramidal tracts were significantly lower as compared with the unaffected side (p-value <0.01). The reduction in the FA values of the affected side was significantly correlated (r = 0.41 and p-value <0.001) with the degree of pyramidal tract involvements that were significantly correlated with the motor outcome on patients’ discharge day.
Quantitative (FA values) and qualitative (the diffusion tensor tractography) diffusion parameters have potential to predict motor outcome in patients with ischemic stroke.
Minimally-invasive bedside catheter haematoma aspiration followed by local thrombolysis in spontaneous supratentorial intracerebral haemorrhage: a retrospective single-center study
2023, Frontiers in Neurology

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ImagingRole of diffusion tensor imaging in a patient with spontaneous intracerebral hematoma treated by stereotactic evacuation

Abstract

Background

Case Description

Conclusion

Introduction

Section snippets

Case report

Discussion

Conclusion

Surg Neurol

J Clin Neurosci

Diffusion tensor tractography of gliomatosis cerebri: fiber tracking through the tumor

J Comput Assist Tomogr

Indications for surgical treatment of putaminal hemorrhage. Comparative study based on serial CT and time-course analysis

J Neurosurg

MR diffusion tensor imaging of white matter tract disruption in stroke at 3 T

Br J Radiol

Impact of stereotactic hematoma evacuation on activities of daily living during the chronic period following spontaneous putaminal hemorrhage: a randomized study

J Neurosurg

Imaging
Role of diffusion tensor imaging in a patient with spontaneous intracerebral hematoma treated by stereotactic evacuation