Stereotactic Diffusion Tensor Tractography For Gamma Knife Stereotactic Radiosurgery

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1 Disclosures The authors of this study declare that they have no commercial or other interests in the presentation of this study. This study does not contain any use of offlabel devices or treatments.

2 Stereotactic Diffusion Tensor Tractography For Gamma Knife Stereotactic Radiosurgery C Gavin FRCS H I Sabin FRCS The London Gamma Knife Centre at Bart s, St Bartholomew's Hospital London. UK.

3 Objective The integration of modern neuroimaging into treatment planning has increased the therapeutic potential & safety of stereotactic radiosurgery We report our method of integrating Stereotactic Diffusion Tensor Tractography (DTI) magnetic resonance imaging into conventional treatment planning for Gamma Knife Stereotactic Radiosurgery (GK-SRS).

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5 Literature Summary GK-SRS Author Publication &Year Tract(s) Tolerance (Gy) Maruyama JNS 2009 Arcuate Fasiculus Frontal 10Gy Temporal 6Gy Maruyama JNS 2007 Optic Radiation Less than 8Gy Maruyama JNS 2005 Corticospinal Tract Tract Vol <25 Gy, Dmax 28Gy Maruyama IJROBP 2008 Pyramidal tract PT<23Gy ideally outside 20Gy isodose Int Capsule more sensitive

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10 Methods 20 patients who underwent GK-SRS comprised the study cohort. 1 test case, 5 patients with AVM, 9 patients with cerebral metastases, 1 parasagittal meningioma & 4 patients with vestibular schwannoma. Diffusion tensor images were performed at the time of standard GK Protocol MR (T1 & T2) imaging for treatment with the patient's head being secured by a leksell stereotactic frame. All studies were performed on a 1.5T Magnet (Phillips) with our standard head coil. DTI was performed with diffusion gradients in 32 directions & coregistered to the volumetric T1 study. DTI post processing by means of commercially available software (Medtronic Inc.) allowed tensor computation & the creation of DEC, ADC & FA mapped sequences. In addition the software allowed visualized critical tracts to be exported as a structural volume & integrated into gamma plan as an organ at risk during shot planning. The combined images were transferred to Gamma plan & integrated into treatment planning.

11 Initial Study Cohort N=20 Meningioma 5% Vestibular Schwannoma 20% Test Case 5% Pathology AVM 25% Metastases 45%

12 MRI Phillips 1.5 T

13 MR TI Vol & DTI Vol Mismatch

14 Co-registration Error

15 MR Exam Card

16 STEALTHViz StealthViz uses the deterministic Fiber Assignment by Continuous Tracking (FACT) algorithm developed by Mori et al at Johns Hopkins. Probabilistic algorithms take much longer to compute so are not amenable to interactive exploration of fiber tracts.

17 ROI and threshold settings in different fibre tracts. Bejoy Thomas et al. Brain 2005;128:

18 DTI GUI

19 Exporting Tracts Navigation Exam: the navigation exam used as the reference in the Coregistration step of the DTI Tensor Preparation and to build the tracts. This should be same exam that is to be used as the reference exam when registering the patient in surgery. Also Export Navigation Exam: check this box to export the navigation exam along with the 3D object data. Also Export Hybrid Navigation Exam: check this box to export an exam in which the 3D object data is overlaid as filled areas on the navigation exam. If the 3D object is too thick, adjust the 3D Object Distance in the More Options dialog of the Fiber Tracking tool card.

20 Importing to Gamma Plan CD Import Dicom Data Format 3D Object Hybrid Exam (3D Object merged with Volume) Navigation Exam Merging with Treatment Plan Object segmentation & label as organ at risk.

21 Results Stereotactic DTI was successful in all patients with generation of correct directionally coded color (DEC) images. Tract generation with the software was straightforward & reproducible particularly axial tracts such as the optic radiation & the arcuate fasciculus. Corticospinal tract visualization suffered from some artifact from the base of the stereotactic frame but this was over come by a combination of frame/mr volume adjustment & DTI seeding parameters. Co-registration of the DTI series with the T1 treatment volume at the time of imaging was essential for the generation of correct tensor data. All patients with the exception of the VS cases had treatment pathology in the vicinity of eloquent tracts and or cortex. No new neurological deficit due to radiation was recorded at the short- term follow-up.

22 Illustrative Cases Mets Optic Tract Mets Thalamus AVM Optic Radiation AVM Optic Corticospinal tract

23 Metastases: Optic Radiation Compression & Corticospinal tract displacement

24 Cortical AVM near Optic Radiation

25 Optic Radiation: Tract between 8 & 6 GY isodose contours.

26 AVM & Cortico-spinal Tract

27 CS Tract as 3D Object

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29 AVM 22Gy at the 42% isodose, achieving 95% coverage of a 14.36cc lesion

30 Trigeminal Nerve Hodaie M, Chen DQ, Quan J, Laperriere N (2012) Tractography Delineates Microstructural Changes in the Trigeminal Nerve after Focal Radiosurgery for Trigeminal Neuralgia. PLoS ONE 7(3): e doi: /journal.pone return of FA to baseline may correlate with pain recurrence

31 Technical Issues Image acquisition Distortion from Leksell Frame. Co-Registration Tract construction visualisation. Export To Gamma Plan. Integration in to planning. Dynamic Shaping

32 Progress Update: Cases to Date N=42 Acoustic Neuroma Metastases AVM Cavernoma Meningioma

33 Future Developments New MRI Friendly Leksell Stereotactic Frame. Conventional Neuro-Head Coils Higher field Less Distortion/Noise.

34 Conclusions Recent reports in the medical literature have suggested that white matter tracts (particularly the optic radiation & arcuate fasciculus) are more vulnerable to radiation during SRS than what was previously thought. Integration of Stereotactic Tractography into GK-SRS represents a promising tool for preventing GK-SRS complications by reduction in radiation doses to functional organs at risk, including critical cortical areas & subcortical white matter tracts.

35 Thank you

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