Diffusion Tensor Imaging corticospinal tractography for evaluation of motor pathways radiation exposure in Gamma Knife radiosurgery treatments

Objective. The aim of this research was to demonstrate the technical feasibility and the clinical usefulness of Diffusion Tensor Imaging (DTI) tractography integration in the Gamma Knife (GK) treatment planning for arterio-venous malformations (AVMs) in order to calculate the dose delivery involving the corticospinal tract (CST). We purposed to collect data for the assessment of the CST radiation tolerance and for the development of risk models concerning treatment-related motor deficits. Material and Methods. DTI study was performed using a 3 Tesla Magnetic Resonance (MR) unit with parallel imaging technique in 34 patients harbouring cerebral AVMs in proximity of the CST undergoing GK radiosurgery. After the data processing, three-dimensional tracking of the bilateral motor pathway was carried out. An in-house software for multimodal registration was developed. The reconstructed fiber tracts were matched on T1 volumetric data set, both obtained at 3 Tesla. Then the resulting images were registered with the 1 Tesla MR study performed under stereotactic conditions for the integration in the treatment planning. In 14 patients the evaluation of CST radiation exposure was retrospectively performed after the radiosurgical procedure; in the remaining patients the integration of CST tractography was prospectively applied during the realization of the treatment planning. Results. The fibers of CST were highlighted in both non-hemorrhagic and hemorrhagic AVMs. The amount of reconstructed fibers on the affected side was significantly lower in patients with a preoperative motor deficit. Post-radiosurgical motor complications were strongly correlated to the volume of the CST receiving ≥ 12 Gy (P = 0.010). The integral dose of the CST was significantly related to the development of motor deficits as well (P = 0.048). Dose-response models were elaborated to estimate the probability of developing motor complications using logistic regression analyses. The location of the AVM in the basal ganglia and the displacement of the CST from its anatomical course were correlated with higher volumes of the CST receiving ≥ 12 Gy. The rate of motor complications resulted lower in the prospective group than in the retrospective (5.0% vs 14.2%, respectively). Conclusions. The integration of tractography based on 3 Tesla DTI in the GK treatment planning for AVMs in proximity of the CST is feasible and reliable and can be compatible within a routine clinical setting. The volume of the CST receiving ≥ 12 Gy and the integral dose of the CST are predictors of developing motor deficits. The visualization of the CST allows to optimize the radiosurgical planning, realizing patient-tailored treatments with a reduction of the morbidity.