Diffusion Tensor Tractography for Decompressive Operation Decisions in Patients With Intracerebral Hemorrhage

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A 34-year-old, right-handed male patient was diagnosed with an intracerebral hemorrhage (ICH) in the left corona radiata and basal ganglia (Fig. 1A). Diffusion tensor image data were acquired three times (second, sixth, and tenth day after onset) using a sensitivity-encoding head coil at 1.5 T. Initially, the patient showed severe weakness of the right limb (Motricity Index: 28 [full score: 100]; Manual Muscle Test for the right finger flexor: 2 [full score: 5]1). On the second day of diffusion tensor tractography (DTT), the left corticospinal tract (CST) was severely compressed to the posterior side, although its integrity was preserved (Fig. 1B). At 6 days after onset, the patient's right hemiparesis was aggravated (Motricity Index: 15; Manual Muscle Test for the right finger flexor: 0, except for the second finger: 2-).
However, his brain computed tomography and T2-weighted images showed only a mild increment of perihematomal edema without increased intracerebral hematoma. In contrast, DTT on the same day revealed more posteriorly compressed and narrowed left CST compared with the previous DTT. Therefore, craniotomy and extraventricular drainage for the intracerebral hematoma were performed through the left prefrontal area on the sixth day. The day after the operation, his right hemiparesis markedly improved (Motricity Index: 42; Manual Muscle Test for the right finger flexor: 2). Restoration of the posteriorly compressed left CST was observed on the tenth day of DTT.
The neurosurgeons initially decided against decompressive surgery because the patient could move his affected fingers partially, meaning that the integrity of the left CST might be spared. In fact, the integrity of the left CST was preserved on the second day of DTT, although severely compressed. At 6 days after onset, his right hemiparesis progressed with aggravated findings of the left CST on DTT, although brain computed tomography and conventional magnetic resonance imaging did not show rebleeding of ICH. Based on these findings, the neurosurgeons performed decompressive surgery for the left ICH at the sixth day. On the day after the surgery, his right hemiparesis was markedly improved. We think this motor recovery was mainly attributed to the decompressed left CST. However, the following limitations of DTT should be considered: diffusion tensor image data can be affected by stroke lesion in the acute stage and the regions of fiber complexity and fiber crossing in the subcortical white matter, resulting in false results.2 Our findings suggest that DTT for the CST might be useful in deciding for decompressive operation in patients with ICH in critical areas regarding motor function.

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