- Email: [email protected]
Role of diffusion tensor imaging in a patient with spontaneous intracerebral hematoma treated by stereotactic evacuation
Available online at www.sciencedirect.com
Surgical Neurology 70 (2008) 75 – 78 www.surgicalneurology-online.com
Imaging
Role of diffusion tensor imaging in a patient with spontaneous intracerebral hematoma treated by stereotactic evacuation Cheng-Ta Hsieh, MD a , Cheng-Yu Chen, MD b , Yung-Hsiao Chiang, MD, PhD a , Chin-Hong Chang, MD c , Cheng-Fu Chang, MD, PhD a,⁎ Departments of aNeurological Surgery and bRadiology, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan c Department of Neurosurgery, Chi Mei Medical Center, Tainan, Taiwan Received 19 March 2007; accepted 9 April 2007
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. © 2008 Elsevier Inc. All rights reserved.
Keywords:
Diffusion tensor imaging; Fiber tracking; Hematoma; Stereotactic aspiration
1. 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. 2. Case report
Abbreviations: CT, computed tomography; DTI, diffuse tensor imaging; ICH, intracerebral hemorrhage; MR, magnetic resonance. ⁎ Corresponding author. Tel.: +886 2 8792 7177; fax: +886 2 8792 7178. E-mail address: [email protected] (C.-F. Chang). 0090-3019/$ – see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.surneu.2007.04.004
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,
76
C.-T. Hsieh et al. / Surgical Neurology 70 (2008) 75–78
Fig. 2. Diffusion tensor imaging series. A: Preoperative images reveal that the left corticospinal tract was compressed by the hematomas (white arrow). B: Postoperative images demonstrate that the left corticospinal tract was intact and restored (white arrow).
Fig. 1. Computed tomographic scan of head series. A: At admission, the images reveal a hyperdense hematoma, approximately 15 mL in volume and located in the left putamen, compressing the posterior limb of left internal capsule. B: One hour before surgery, images show that hematomas increased in volume to 19 mL. C: Thirteen hours after surgery, the volume of hematomas decreased to 9.5 mL.
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 contribution. An immediate CT 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 (Fig. 1A). Spontaneous ICH was diagnosed; the patient subsequently underwent stereotactic evacuation of hematoma 7 hours after admission. Magnetic resonance imaging of the brain, performed 3.5 hours after admission, revealed that an acute intracerebral hematoma involved the left dorsal putamen, posterior limb of internal capsule, dosrolateral thalamus, corona radiate, and medial temporal lobe. A view of the left corticospinal tract
C.-T. Hsieh et al. / Surgical Neurology 70 (2008) 75–78
(obtained via DTI) showed that it was compressed by the hematoma (Fig. 2A). The volume of hematoma was about 19.4 mL in the preoperative stereotactic CT scan of the head (Fig. 1B). During the operation, the target was set in the central hematoma. The hematoma (volume, about 12 mL) was aspirated smoothly. Postoperative CT head scan, at 13 hours after surgery, revealed a residual hematoma measuring about 3.3 × 1.6 × 3.6 cm (volume, about 9.5 mL) located in the left putamen (Fig. 1C). The corticospinal tract, viewed by postoperative DTI, was intact and restored (Fig. 2B). Postoperatively, the motor functions of the affected right extremities recovered rapidly to the extent that the patient was able to overcome the force of gravity 1 day after surgery and overcome resistance 4 days from onset, especially in the right extremities. One month from onset, he was able to perform fine motor activities and could walk with a normal gait.
77
The clinical outcome of spontaneous putaminal hemorrhages has been predicted by several grading systems, according to the location and extension of hematomas in CT brain scan [3,8]. However, sensitivity and specificity remain obscure. Similar to other diseases such as ischemic stroke, neoplasms, or traumatic injuries, the involvement of white matter fibers is 1 of the factors affecting clinical function in ICH. With DTI, the relationship between the corticospinal tract and hematoma could be visualized, thereby offering a more accurate prediction of outcome for clinical physicians. In our case, DTI revealed that the corticospinal tract was compressed by the hematoma, which resulted in weakness in right extremities. After the stereotactic evaluation of the hematoma, the corticospinal tract was restored and preserved in DTI. This could explain why the affected extremities recovered rapidly and successfully. However, because of technical limitations, not all real fiber tracts can be demonstrated in DTI [1].
3. 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 tractography could be demonstrated under invariant indices such as fractional anisotropy, via DTI [9]. In an in vivo study of cerebral and cardiac diseases, DTI successfully provided the visualized, 3dimensional images of white matter tracts, especially the corticospinal tract [4]. In recent reports, the disruption of white matter fibers in patients with neoplasms, lacunar infarction, hemorrhagic stroke, ischemic stroke, degenerative motor disease, and diffuse axonal injury were successfully demonstrated by DTI [1,7,9,12]. In a technology report, Hlatky et al [6] demonstrated that new neurologic deficits after the removal of a tumor adjacent to the projection fibers could be reduced under the guidance of tractography and intraoperative neuronavigation. Therefore, DTI is a powerful tool to visualize the white matter fibers in the human brain and to predict the clinical outcome. However, the value of DTI in patients with hemorrhagic stroke after stereotactic evacuation of hematoma has never been discussed in the literature. Stereotactic evacuation of hematomas is a minimal invasive and alternative surgery to treat patients with spontaneous ICH, especially in putaminal hemorrhage [5]. Although surgical intervention in ICH remains a topic for debate [10], in selected patients, stereotactic surgery has been proved to effectively reduce the volume of hematomas from 60% to 88% and to result in better Glasgow Coma Scale recovery and functional neurologic outcomes including Barthel index, Functional Independence Measure Score, and muscle power improvement of the affected limbs [2,5].
4. 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. References [1] Akai H, Mori H, Aoki S, Masutani Y, Kawahara N, Shibahara J, Ohtomo K. Diffusion tensor tractography of gliomatosis cerebri: fiber tracking through the tumor. J Comput Assist Tomogr 2005;29:127-9. [2] Cho DY, Chen CC, Chang CS, Lee WY, Tso M. Endoscopic surgery for spontaneous basal ganglia hemorrhage: comparing endoscopic surgery, stereotactic aspiration, and craniotomy in noncomatose patients. Surg Neurol 2006;65:547-55. [3] Fujitsu K, Muramoto M, Ikeda Y, Inada Y, Kim I, Kuwabara T. Indications for surgical treatment of putaminal hemorrhage. Comparative study based on serial CT and time-course analysis. J Neurosurg 1990;73:518-25. [4] Gillard JH, Papadakis NG, Martin K, Price CJ, Warburton EA, Antoun NM, Huang CL, Carpenter TA, Pickard JD. MR diffusion tensor imaging of white matter tract disruption in stroke at 3 T. Br J Radiol 2001;74:642-7. [5] Hattori N, Katayama Y, Maya Y, Gatherer A. Impact of stereotactic hematoma evacuation on activities of daily living during the chronic period following spontaneous putaminal hemorrhage: a randomized study. J Neurosurg 2004;101:417-20. [6] Hlatky R, Jackson EF, Weinberg JS, McCutcheon IE. Intraoperative neuronavigation using diffusion tensor MR tractography for the resection of a deep tumor adjacent to the corticospinal tract. Stereotact Funct Neurosurg 2005;83:228-32. [7] Jang SH, Kwon YH, Lee MY, Ahn SH, Kim JH, Jeong DH, Choi BY, Lee DG. Corticospinal tract compression by hematoma in a patient with intracerebral hemorrhage: a diffusion tensor tractography and functional MRI study. Yonsei Med J 2006;47:135-9. [8] Kanaya H, Yukawa H, Ito Z, et al. Grading and indications for treatment of ICH of basal ganglia (cooperative study in Japan). In: Pia HW, Langmaid C, Zierski J, editors. Spontaneous intracerebral
78
C.-T. Hsieh et al. / Surgical Neurology 70 (2008) 75–78
hematomas: advances in diagnosis and therapy. Berlin: SpringerVerlag; 1980. p. 268-74. [9] Kunimatsu A, Aoki S, Masutani Y, Abe O, Mori H, Ohtomo K. Threedimensional white matter tractography by diffusion tensor imaging in ischaemic stroke involving the corticospinal tract. Neuroradiology 2003;45:532-5. [10] Lee JI, Nam do H, Kim JS, Hong SC, Shin HJ, Park K, Eoh W, Kim JH. Stereotactic aspiration of intracerebral haematoma: significance of
surgical timing and haematoma volume reduction. J Clin Neurosci 2003;10:439-43. [11] Mori S, Crain BJ, Chacko VP, van Zijl PC. Three-dimensional tracking of axonal projections in the brain by magnetic resonance imaging. Ann Neurol 1999;45:265-9. [12] Parmar H, Golay X, Lee KE, Hui F, Sitoh YY. Early experiences with diffusion tensor imaging and magnetic resonance tractography in stroke patients. Singapore Med J 2006;47:198-203.
Surgical Neurology 70 (2008) 75 – 78 www.surgicalneurology-online.com
Imaging
Role of diffusion tensor imaging in a patient with spontaneous intracerebral hematoma treated by stereotactic evacuation Cheng-Ta Hsieh, MD a , Cheng-Yu Chen, MD b , Yung-Hsiao Chiang, MD, PhD a , Chin-Hong Chang, MD c , Cheng-Fu Chang, MD, PhD a,⁎ Departments of aNeurological Surgery and bRadiology, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan c Department of Neurosurgery, Chi Mei Medical Center, Tainan, Taiwan Received 19 March 2007; accepted 9 April 2007
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. © 2008 Elsevier Inc. All rights reserved.
Keywords:
Diffusion tensor imaging; Fiber tracking; Hematoma; Stereotactic aspiration
1. 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. 2. Case report
Abbreviations: CT, computed tomography; DTI, diffuse tensor imaging; ICH, intracerebral hemorrhage; MR, magnetic resonance. ⁎ Corresponding author. Tel.: +886 2 8792 7177; fax: +886 2 8792 7178. E-mail address: [email protected] (C.-F. Chang). 0090-3019/$ – see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.surneu.2007.04.004
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,
76
C.-T. Hsieh et al. / Surgical Neurology 70 (2008) 75–78
Fig. 2. Diffusion tensor imaging series. A: Preoperative images reveal that the left corticospinal tract was compressed by the hematomas (white arrow). B: Postoperative images demonstrate that the left corticospinal tract was intact and restored (white arrow).
Fig. 1. Computed tomographic scan of head series. A: At admission, the images reveal a hyperdense hematoma, approximately 15 mL in volume and located in the left putamen, compressing the posterior limb of left internal capsule. B: One hour before surgery, images show that hematomas increased in volume to 19 mL. C: Thirteen hours after surgery, the volume of hematomas decreased to 9.5 mL.
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 contribution. An immediate CT 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 (Fig. 1A). Spontaneous ICH was diagnosed; the patient subsequently underwent stereotactic evacuation of hematoma 7 hours after admission. Magnetic resonance imaging of the brain, performed 3.5 hours after admission, revealed that an acute intracerebral hematoma involved the left dorsal putamen, posterior limb of internal capsule, dosrolateral thalamus, corona radiate, and medial temporal lobe. A view of the left corticospinal tract
C.-T. Hsieh et al. / Surgical Neurology 70 (2008) 75–78
(obtained via DTI) showed that it was compressed by the hematoma (Fig. 2A). The volume of hematoma was about 19.4 mL in the preoperative stereotactic CT scan of the head (Fig. 1B). During the operation, the target was set in the central hematoma. The hematoma (volume, about 12 mL) was aspirated smoothly. Postoperative CT head scan, at 13 hours after surgery, revealed a residual hematoma measuring about 3.3 × 1.6 × 3.6 cm (volume, about 9.5 mL) located in the left putamen (Fig. 1C). The corticospinal tract, viewed by postoperative DTI, was intact and restored (Fig. 2B). Postoperatively, the motor functions of the affected right extremities recovered rapidly to the extent that the patient was able to overcome the force of gravity 1 day after surgery and overcome resistance 4 days from onset, especially in the right extremities. One month from onset, he was able to perform fine motor activities and could walk with a normal gait.
77
The clinical outcome of spontaneous putaminal hemorrhages has been predicted by several grading systems, according to the location and extension of hematomas in CT brain scan [3,8]. However, sensitivity and specificity remain obscure. Similar to other diseases such as ischemic stroke, neoplasms, or traumatic injuries, the involvement of white matter fibers is 1 of the factors affecting clinical function in ICH. With DTI, the relationship between the corticospinal tract and hematoma could be visualized, thereby offering a more accurate prediction of outcome for clinical physicians. In our case, DTI revealed that the corticospinal tract was compressed by the hematoma, which resulted in weakness in right extremities. After the stereotactic evaluation of the hematoma, the corticospinal tract was restored and preserved in DTI. This could explain why the affected extremities recovered rapidly and successfully. However, because of technical limitations, not all real fiber tracts can be demonstrated in DTI [1].
3. 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 tractography could be demonstrated under invariant indices such as fractional anisotropy, via DTI [9]. In an in vivo study of cerebral and cardiac diseases, DTI successfully provided the visualized, 3dimensional images of white matter tracts, especially the corticospinal tract [4]. In recent reports, the disruption of white matter fibers in patients with neoplasms, lacunar infarction, hemorrhagic stroke, ischemic stroke, degenerative motor disease, and diffuse axonal injury were successfully demonstrated by DTI [1,7,9,12]. In a technology report, Hlatky et al [6] demonstrated that new neurologic deficits after the removal of a tumor adjacent to the projection fibers could be reduced under the guidance of tractography and intraoperative neuronavigation. Therefore, DTI is a powerful tool to visualize the white matter fibers in the human brain and to predict the clinical outcome. However, the value of DTI in patients with hemorrhagic stroke after stereotactic evacuation of hematoma has never been discussed in the literature. Stereotactic evacuation of hematomas is a minimal invasive and alternative surgery to treat patients with spontaneous ICH, especially in putaminal hemorrhage [5]. Although surgical intervention in ICH remains a topic for debate [10], in selected patients, stereotactic surgery has been proved to effectively reduce the volume of hematomas from 60% to 88% and to result in better Glasgow Coma Scale recovery and functional neurologic outcomes including Barthel index, Functional Independence Measure Score, and muscle power improvement of the affected limbs [2,5].
4. 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. References [1] Akai H, Mori H, Aoki S, Masutani Y, Kawahara N, Shibahara J, Ohtomo K. Diffusion tensor tractography of gliomatosis cerebri: fiber tracking through the tumor. J Comput Assist Tomogr 2005;29:127-9. [2] Cho DY, Chen CC, Chang CS, Lee WY, Tso M. Endoscopic surgery for spontaneous basal ganglia hemorrhage: comparing endoscopic surgery, stereotactic aspiration, and craniotomy in noncomatose patients. Surg Neurol 2006;65:547-55. [3] Fujitsu K, Muramoto M, Ikeda Y, Inada Y, Kim I, Kuwabara T. Indications for surgical treatment of putaminal hemorrhage. Comparative study based on serial CT and time-course analysis. J Neurosurg 1990;73:518-25. [4] Gillard JH, Papadakis NG, Martin K, Price CJ, Warburton EA, Antoun NM, Huang CL, Carpenter TA, Pickard JD. MR diffusion tensor imaging of white matter tract disruption in stroke at 3 T. Br J Radiol 2001;74:642-7. [5] Hattori N, Katayama Y, Maya Y, Gatherer A. Impact of stereotactic hematoma evacuation on activities of daily living during the chronic period following spontaneous putaminal hemorrhage: a randomized study. J Neurosurg 2004;101:417-20. [6] Hlatky R, Jackson EF, Weinberg JS, McCutcheon IE. Intraoperative neuronavigation using diffusion tensor MR tractography for the resection of a deep tumor adjacent to the corticospinal tract. Stereotact Funct Neurosurg 2005;83:228-32. [7] Jang SH, Kwon YH, Lee MY, Ahn SH, Kim JH, Jeong DH, Choi BY, Lee DG. Corticospinal tract compression by hematoma in a patient with intracerebral hemorrhage: a diffusion tensor tractography and functional MRI study. Yonsei Med J 2006;47:135-9. [8] Kanaya H, Yukawa H, Ito Z, et al. Grading and indications for treatment of ICH of basal ganglia (cooperative study in Japan). In: Pia HW, Langmaid C, Zierski J, editors. Spontaneous intracerebral
78
C.-T. Hsieh et al. / Surgical Neurology 70 (2008) 75–78
hematomas: advances in diagnosis and therapy. Berlin: SpringerVerlag; 1980. p. 268-74. [9] Kunimatsu A, Aoki S, Masutani Y, Abe O, Mori H, Ohtomo K. Threedimensional white matter tractography by diffusion tensor imaging in ischaemic stroke involving the corticospinal tract. Neuroradiology 2003;45:532-5. [10] Lee JI, Nam do H, Kim JS, Hong SC, Shin HJ, Park K, Eoh W, Kim JH. Stereotactic aspiration of intracerebral haematoma: significance of
surgical timing and haematoma volume reduction. J Clin Neurosci 2003;10:439-43. [11] Mori S, Crain BJ, Chacko VP, van Zijl PC. Three-dimensional tracking of axonal projections in the brain by magnetic resonance imaging. Ann Neurol 1999;45:265-9. [12] Parmar H, Golay X, Lee KE, Hui F, Sitoh YY. Early experiences with diffusion tensor imaging and magnetic resonance tractography in stroke patients. Singapore Med J 2006;47:198-203.