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Updated: Aug 7, 2026
Role of Diffusion MRI Tractography in Endoscopic Endonasal Skull Base Surgery
Published on: July 5, 2021
An Integrated Paradigm for Brainstem Cavernoma Surgery : Combining Defined Surgical Timing with Diffusion Tensor
Liang He1, Zongyu Xiao1, Ke Xu1
1Department of Neurosurgery, The Fourth Affiliated Hospital of Soochow University, Suzhou, China.
Objective:
To evaluate a surgical strategy for hemorrhagic brainstem cavernous malformations by assessing 1) the impact of surgical timing (hemorrhage-to-surgery interval), and 2) the utility of preoperative diffusion tensor imaging (DTI) tractography for corticospinal tract (CST) preservation.
Methods:
In a retrospective cohort of 41 consecutive patients, the hemorrhage-to-surgery interval was stratified into acute (<3 weeks), subacute (3-8 weeks), and delayed (>8 weeks). Preoperative DTI tractography for CST mapping was utilized in 24 patients (DTI group) and not in 17 (non-DTI group); assignment was determined by magnetic resonance imaging scanner availability rather than clinical selection. The primary outcome was unfavorable functional status (modified Rankin scale score >2) at final follow-up.
Results:
The median hemorrhage-to-surgery interval was 53.0 days. Delayed surgery independently predicted unfavorable outcome at discharge (adjusted odds ratio, 9.03; 95% confidence interval, 1.10-73.94; p=0.04). Preoperative DTI was associated with a significantly lower rate of postoperative motor deterioration at discharge (12.5% vs. 47.1%; p=0.04). Subgroup analysis showed that the protective effect of DTI was significant only in the delayed surgery group (p=0.04), whereas among patients operated within 8 weeks, motor deterioration rates were low regardless of DTI use (16.7% vs. 16.7%; p=1.00). Persistent postoperative motor deficit was the strongest determinant of long-term disability (44.4% vs. 3.1%; p=0.006).
Conclusion:
A hemorrhage-to-surgery interval exceeding 8 weeks independently predicts poorer early functional recovery. Preoperative DTI tractography reduces postoperative motor deficits-the key driver of long-term disability-with its benefit most pronounced in the delayed surgery setting. We propose a risk-stratified, dual-emphasis strategy : timely intervention within 8 weeks when feasible, complemented by DTI tractography, which is particularly valuable in mitigating the increased risks of delayed surgery. This framework offers a practical, evidence-informed approach for optimizing functional outcomes.
