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Development of an educational method to rethink and learn oncological brain

surgery in an "a la carte" connectome-based perspective

Article in Acta Neurochirurgica · May 2023

DOI: 10.1007/s00701-023-05626-2

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TECHNICAL NOTE

Development of an educational method to rethink and learn

oncological brain surgery in an “a la carte” connectome-based
perspective
Pablo A. Valdes1,2 · Sam Ng2,3 · Joshua D. Bernstock4,5 · Hugues Duffau2,3

Received: 31 March 2023 / Accepted: 3 May 2023

© The Author(s), under exclusive licence to Springer-Verlag GmbH Austria, part of Springer Nature 2023

Abstract
Background Understanding the structural connectivity of white matter tracts (WMT) and their related functions is a prereq-
uisite to implementing an “a la carte” “connectomic approach” to glioma surgery. However, accessible resources facilitating
such an approach are lacking. Here we present an educational method that is readily accessible, simple, and reproducible
that enables the visualization of WMTs on individual patient images via an atlas-based approach.
Methods Our method uses the patient’s own magnetic resonance imaging (MRI) images and consists of three main steps:
data conversion, normalization, and visualization; these are accomplished using accessible software packages and WMT
atlases. We implement our method on three common cases encountered in glioma surgery: a right supplementary motor area
tumor, a left insular tumor, and a left temporal tumor.
Results Using patient-specific perioperative MRIs with open-sourced and co-registered atlas-derived WMTs, we highlight
the critical subnetworks requiring specific surgical monitoring identified intraoperatively using direct electrostimulation
mapping with cognitive monitoring. The aim of this didactic method is to provide the neurosurgical oncology community
with an accessible and ready-to-use educational tool, enabling neurosurgeons to improve their knowledge of WMTs and to
better learn their oncologic cases, especially in glioma surgery using awake mapping.
Conclusions Taking no more than 3–5 min per patient and irrespective of their resource settings, we believe that this method
will enable junior surgeons to develop an intuition, and a robust 3-dimensional imagery of WMT by regularly applying it to
their cases both before and after surgery to develop an “a la carte” connectome-based perspective to glioma surgery.

Keywords Glioma · Brain tumor · White matter tracts · Brain mapping · Connectome · Awake surgery

Previous presentations None. Abbreviations

WMT White matter tracts
* Pablo A. Valdes MRI Magnetic resonance imaging
[email protected]
DTI Diffusion tensor imaging
1
Department of Neurosurgery, University of Texas Medical SMA Supplementary motor area
Branch, Galveston, TX 77555, USA DICOM Digital Imaging and Communications in
2
Department of Neurosurgery, Hôpital Gui de Chauliac, CHU Medicine
Montpellier, 80 Av Augustin Fliche, 34295 Montpellier, T1W T1-weighted
France FLAIR Fluid-attenuated inversion recovery
3
Team “Plasticity of Central Nervous System, Human Stem NIFTI Neuroimaging Informatics Technology
Cells and Glial Tumors”, Institute of Functional Genomics, Initiative
INSERM U1191, University of Montpellier, 141 Rue de la MNI Montreal Neurological Institute
cardonille, 34091 Montpellier, France
4
3D 3-Dimensional
Department of Neurosurgery, Harvard Medical 2D 2-Dimensional
School/Brigham and Women’s Hospital, Boston, MA 02115,
USA CST Corticospinal tract
5 NMN Negative motor network
David H. Koch Institute for Integrative Cancer Research,
Massachusetts Institute of Technology, Cambridge, MA, FAT Frontal aslant tract
USA FST Fronto-striatal tract

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DES Direct electrical stimulation patient-specific DTI images might overcome this problem [4,
VPMC Ventral premotor cortex 9, 29], creation of individual patient WMT reconstructions for
PrG Precentral gyrus accurate and daily use in glioma surgeries faces several chal-
SLF-III Superior longitudinal fasciculus III lenges: not all patients receive a DTI acquisition; WMT recon-
AF Arcuate fasciculus structions have severe reproducibility limitations with important
IFOF Inferior fronto-occipital fasciculus rates of false positives and negatives; disagreement between
MFG Middle frontal gyrus expert teams using the same data; and pathology-specific arti-
DLPFC Dorsolateral prefrontal cortex facts negatively impact the accuracy of reconstructions (e.g.,
PPTT Pyramids and Palm Trees Test brain edema in tumors) [5, 24, 27, 38, 43, 56, 69, 70, 74, 78].
ILF Inferior longitudinal fasciculus From a global perspective, it is important to highlight that access
STG Superior temporal gyrus may be a limitation, as there are institutions including in low-
MTG Middle temporal gyrus and middle-income countries, where trainees/surgeons may have
ITG Inferior temporal gyrus no access to the appropriate software for reproducible and accu-
TR Thalamic radiations rate WMT reconstruction.
Given the importance of WMT connectivity and the chal-
lenges of visualizing the patient-specific pathology in rela-
Introduction tion to critical WMT, here we present a method that is readily
accessible, simple, and reproducible, enabling visualization of
Proper functioning of the human connectome depends on the WMT connectivity for individual patient images using an
the integrity of the brain’s cortical hubs and subcortical deep atlas-based approach. We implement our method on three of the
white matter tracts (WMT) [30]. Awake cortical [61] and most common cases in glioma surgery: a right supplementary
subcortical mapping [15] are the gold standard approach in motor area (SMA) tumor, a left insular tumor, and a left tempo-
glioma surgery [11] as they allow one to maximize extent ral tumor. We use our method on the individual patient images
of tumor resection while concurrently reducing the rates of to discuss the critical deep connectivity in relation to the tumor,
postoperative deficit(s) [21]. Such an approach has shown the expected functional responses as well as the actual responses
benefits on postoperative cognitive [42, 48, 50] and socio- found during awake surgery, and the anatomofunctional cor-
professional [49] outcomes, and overall survival [11, 16, 55]. relates on postoperative imaging. We hope that by enabling an
Intraoperative cognitive mapping requires the execution of improved understanding of the human connectome in their daily
intraoperative tasks tailored to the patient’s needs, preop- clinical practice, surgeons will be able to maximize the advan-
erative neuropsychological examination, tumor location, and tages of awake mapping surgery to achieve the oncofunctional
connectomic constraints [10, 12, 13, 15, 33, 66]. Patients balance [22].
undergo the selected tasks in a combined manner [23] (e.g.,
including movement, naming task [34], line bisection task
[31], reading task [51], picture association task [47], or men- Methods
talizing task [32, 82] and so forth) depending on the expected
relation(s) to specific cortical hubs’ WMTs [19, 66]. Data acquisition and conversion
To successfully implement such “connectomic approach” to
glioma surgery, the surgeon needs to have a firm understanding The patient’s clinical MRIs are provided in Digital Imaging and
of the underlying functional connectomics, i.e., have a work- Communications in Medicine (DICOM) format (Fig. 1a). Input
ing knowledge of the anatomy of the WMTs and functional images should include a high-resolution T1-weighted (T1W)
network(s) involved [12–15, 66]. To achieve this, studies cen- image. Additional MRI sequences can be used, such as fluid-
tered on cadaveric brain dissections to visualize cortical and sub- attenuated inversion recovery (FLAIR) images, for visualizing
cortical structures provide detailed descriptions of these WMTs; non-enhancing tumors, edema, and infiltrative tumor margins.
in doing so, their relative locations in relation to key anatomical The next step is to convert the DICOM data into a for-
landmarks (e.g., ventricles), and other WMTs and their cortical mat compatible with subsequent steps, i.e., the Neuroim-
terminations have also been defined [25, 28, 41, 44, 45]. Further, aging Informatics Technology Initiative (NIFTI) format,
diffusion tensor imaging (DTI) databanks are publicly available, which contains all the relevant spatial information for
providing information on the average patterns of structural con- visualization and image processing. We use one of two
nectivity and underlying WMTs at the population level [7, 8, open-source software packages for this conversion, MRI-
72, 79, 83]. cron (http:// www. mccau sland center.sc. edu/ mricro/ mricr
However, cadaveric dissections and population-level on/) or MRIcroGL (https://www.nitrc.org/projects/mricr
DTI studies do not allow surgeons to visualize the WMT of ogl), which enable importing of DICOM images, anonymi-
patients in relation to their pathology. While the acquisition of zation, and conversion to NIFTI. This is accomplished via

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Fig. 1 Method workflow. Our readily accessible method consists of SPM12 to implement a normalization algorithm to register the patient
three steps: (a) data acquisition and conversion — the surgeon col- MRIs to a MNI template; and (c) visualization — the surgeon loads
lects the DICOM formatted MRIs from their hospital system and con- the white matter tracts of interest and can interactively visualize in
verts them to NIFTI format using MRIcron/MRIcroGL; (b) normal- 2-dimensional cross-sectional view or 3-dimensional views the MRI,
ization — the surgeon uses the T1W images and FLAIR images in tumor, and white matter tracts

the < Import > function to select the DICOM data folder, arcuate fasciculus) averaged from a population. Here we use
or by a “drag and drop” approach, “dragging” the folder the HCP1065 atlas derived from the largest cohort of normal
with DICOM files and “dropping” into the MRIcron/ brains [79] (http://brain.labsolver.org/diffusion-mri-templ
MRIcroGL window (Suppl. Methods). ates/tractography) (Suppl. Table 1 with list of WMTs).
While atlases are population-averaged (derived from
1065 subjects as in the HCP1065 atlas), numerous stud-
Normalization ies have shown that they are in fact useful for drawing
conclusions across large patient cohorts [7, 37, 72, 79].
Clinical MRIs exist in “space and coordinates” specific to the Accordingly, here we describe two approaches that ena-
patient (Fig. 1b). To enable use of clinical images with an ble one to produce 2-dimensional (2D) and 3D views of
atlas-based approach, the patient’s MRI needs to be registered WMTs on patient-specific clinical MRIs (Fig. 1c). To
unto a template MRI that is commonly defined as the Mon- visualize in 2D, we open the NIFTI volume with MRI-
treal Neurological Institute (MNI) space [31, 33]. This process cron or MRIcroGL. Then, using the < Overlay > function,
is called “normalization”. All open-sourced subcortical atlas we open the WMT volume of interest, and finally, the
used hereafter are provided in the MNI space, by convention. selected tracts(s) are overlayed on the clinical MRI, with
We describe two normalization techniques, although dif- the user adjusting the colors for visualization. The user
ferent techniques are used in neuroimaging studies. We use can also segment the tumor to create a tumor volume
the open-source toolbox from SPM12 [60] (https://www. using MRIcron (Suppl. Methods 1).
fil.ion.ucl.ac.uk/spm/software/download/) implemented in To visualize in 3D, we use Surf Ice. Unlike MRIcron/
the software package MATLAB. Using a graphical user MRIcroGL, the volumes in Surf Ice exist as a “volume
interface, the user can select the high-resolution image as mesh”. As such, to visualize tracts in Surf Ice, the user
well as a second image to visualize non-enhancing tumor needs to convert the NIFTI volumes into a Surf Ice “vol-
(Suppl. Methods). Once the NIFTI images are normalized, ume mesh”. Then, they can load the segmented tumor vol-
the user can proceed to visualize their normalized clinical ume and tract(s) of interest as overlays. The corresponding
MRI with any pertinent WMT atlas. author can provide the NIFTI volumes and volume meshes
for all tracts in the HCP1065 atlas as well as an MNI152
Visualization template and whole brain meshes for 2D and 3D visualiza-
tion. Thus, the surgeon can collect their MRI DICOM data
A subcortical atlas is a 3-dimensional (3D) volume(s) from their hospital, convert to NIFTI, and visualize in 2D
that contains the volume occupied by a WMT(s) (e.g., left and/or 3D.

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Results likely to be encountered during surgery in 2D (Fig. 2a)

and 3D (Fig. 2b). First, the corticospinal tract (CST) was
Case number 1 — right supplementary motor area noted to be ~ 1 cm posterior to the tumor. Second, two
(SMA) low-grade glioma tracts of the “negative motor network” (NMN), the frontal
aslant tract (FAT) and the fronto-striatal tract (FST) [39],
Here we present the case of a 31-year-old right-handed were posterior medial, posterior lateral, and at the depth
female with an incidental discovery of a 59 cm 3 lesion of the tumor. As was evident upon review of the periop-
with hyperintense FLAIR signal in the right SMA/pre- erative MRI/overlayed WMTs, the anterior component of
SMA regions (Fig. 2a). We applied our method on the the FST and the medial component of the FAT were likely
patient’s preoperative images to visualize three WMTs infiltrated and/or displaced by the tumor. At this stage,
by understanding the relevant WMT anatomy, the surgeon

Fig. 2 Case #1: Right SMA/pre-SMA tumor. a Preoperative MRI a functional response (tag# on brain, with color coded legend for all
images notable for a hyperintense FLAIR mass in the right SMA/ images on the right) at the beginning (left) and end (right) of surgery.
pre-SMA region, with 2D overlays of the FAT (blue), FST (green), White arrows point to locations mapped for FAT and FST. d Postop-
and CST (red) following data acquisition, normalization, and visu- erative MRI with surgical cavity and FAT, FST, and CST overlay as
alization. b 3D views showing relation of FAT, FST, and CST and in (a). e MRI images with location of functional tags and their rela-
the tumor (gray). c Intraoperative images showing tags found to have tion to the deep connectivity

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can plan intraoperative tasks and possible intraoperative superior, and medial aspect of the tumor at the level of the
findings during surgery. For example, stimulation of the posterior limb of the internal capsule. Second, we identi-
FST at the posterior medial aspect of the tumor resec- fied two tracts of the “dorsal system”: the superior longi-
tion location would cause a NMN functional response tudinal fasciculus-III (SLF-III) at the lateral and superior
including movement arrest and possible difficulty with aspect of the tumor and the arcuate fasciculus (AF) imme-
bimanual coordination [57]. diately adjacent and medial to the SLF-III on the periphery
The patient underwent a right-sided awake craniotomy, of the superior circular sulcus along the superior aspect
and direct electrostimulation (DES) was used to identify of the tumor. Finally, the inferior fronto-occipital fascicu-
the ventral premotor cortex ([VPMC]; response: anarthria; lus (IFOF) was identified at the anterior boundary of the
tag #1) at the lateral aspect of the precentral gyrus (PrG) tumor; coursing along the temporal stem at the medial
(Fig. 2c). The frontal and Rolandic cortex were mapped aspect of the tumor; and lateral to the putamen towards
to identify the primary motor area (response: involun- the occipital lobe at the posterior and medial aspect of
tary movements, face and upper limb; tags #2 and #3, the tumor. By learning the deep connectivity, the surgeon
respectively). can plan their surgical approach, prepare cognitive tasks,
The tumor was resected up to the FAT and FST, which and understand expected functional findings. For example,
were the functional boundaries identified by DES. The while operating at the superior and lateral aspect of the
patient experienced left upper limb movement arrest tumor, we could expect articulatory disorders due to the
and articulatory disorders with interruption in naming SLF-III, whereas at the superior aspect of the tumor, along
and counting (tag #47) at the posterior lateral depth; the superior circular sulcus, we could expect language dis-
left upper limb movement arrest as well as inhibition of orders such as anomia and phonological paraphasias due
bimanual coordination when asked to perform simultane- to the AF located medial to the SLF-III [18].
ous tasks with both upper limbs (tag #48) at the posterior The patient underwent an awake left-sided craniotomy
medial depth; movement arrest of the left lower limb and for tumor resection, and DES identified the negative motor
inhibition of bimanual coordination (tag #49) at the pos- areas (response: cessation of fluency and right upper limb
terior medial surface; and arrest of the upper and lower movement; tags #1–2) and the VPMC (response: articula-
limbs on the left with intact right-sided movements and tory arrest; tag #3) (Fig. 3c). The posterolateral MFG with
intact language (tag #50) at the most posterior medial the dorsolateral prefrontal cortex (DLPFC) demonstrated
aspect. disorders on the Pyramids and Palm Trees Test ([PPTT]; tag
Postoperative MRI images (Fig. 2d) show the surgical #4). A frontal transopercular approach was used to expose
cavity in relation to the FAT, FST, and CST. In relation the insular surface, disconnect the insula, and resect the
to the surgical cavity: the FAT courses along the lateral tumor [18, 20, 62].
and posterior aspect; the FST is observed at the medial Preoperative images predicted four tracts that were iden-
and posterior aspect, with anterior terminations included tified intraoperatively as the functional boundaries of the
within the resection however with preservation of its pos- lesion. In line with this, the patient experienced right upper
terior terminations; and the CST is located ~ 1 cm pos- limb involuntary movements during DES (no tag although
terior, explaining why no involuntary movements were positive identification intraoperatively) at the posterior supe-
elicited by DES. Thus, postoperative images correlate rior depth (CST); articulatory disorders and anomia (no tag)
the intraoperative functional responses to their respec- at the posterior lateral depth (SLF-III and AF); and semantic
tive WMT and location relative to the resection cavity paraphasias as well as repeated hesitations during the PPTT
(Fig. 2e), following the expected subcortical somatotopy (tags #49–50) at the level of the inferior insular sulcus, tem-
of the NMN [58], and allowing the patient to have no sei- poral stem, and lateral aspect of the frontal horn (IFOF).
zures and no deficits at 3-month follow-up with a return Postoperative images (Fig. 3d) show the surgical cavity
to normal activities. in relation to these four WMTs. The CST is shown with
decreased displacement from mass effect. The SLF-III and
Case number 2 — left insular low-grade glioma AF are shown at the superior aspect of the tumor from lat-
eral to medial, respectively. The IFOF bordered the cavity
Next, we present the case of a 26-year-old right-handed at the inferior frontal region, temporal stem, and towards the
male with seizures who was found to have a 43 cm 3 sagittal striatum. Therefore, critical WMTs of the dorsal and
lesion with hyperintense FLAIR signal in the left insula ventral systems and their expected 3D anatomofunctional
(Fig. 3a). As was done with the case above, we used the relationships were identified and preserved intraoperatively
patient’s preoperative images to visualize four WMT (Fig. 3e), allowing the patient to have no seizures and no
likely to be encountered during surgery in 2D (Fig. 3a) deficits including normal language evaluation at 3-month
and 3D (Fig. 3b). The CST was noted to be at the posterior, follow-up.

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Fig. 3 Case #2: Left insular tumor. a Preoperative MRI images nota- coded on the right) at the beginning (left) and end (right) of surgery.
ble for a hyperintense FLAIR lesion in the left insula. The SLF-III Given the limited surgical corridor, no tags are visualized for SLF-III,
(yellow), AF (green), IFOF (blue), and CST (red) are overlayed fol- AF, and CST. d Postoperative MRI with surgical cavity and SLF-III,
lowing data acquisition, normalization, and visualization with atlas- AF, IFOF, and CST overlay as in (a) notable for a significant decrease
based tracts. b 3-Dimensional views showing relation of SLF-III, AF, in mass effect. e 3-Dimensional views with and without tumor vol-
IFOF, and CST and the tumor (gray). c Intraoperative images show- ume and SLF-III, AF, IFOF, and CST overlay correlating location of
ing tags found to have a functional response (tag# on brain, and color intraoperative functional responses and deep connectivity

Case number 3 — left anterior temporal low-grade longitudinal fasciculus (ILF) at the lateral and basal aspect
glioma of the anterior temporal lobe. The IFOF was shown along
the medial aspect of the tumor along the temporal stem and
Next, we present the case of a 26-year-old right-handed along the superior lateral aspect of the temporal horn. The
female with partial seizures and language difficulties with AF had terminations at the superior, middle, and inferior
a 20 cm3 hyperintense FLAIR lesion located primarily in temporal gyri (STG, MTG, and ITG, respectively) at the
the left anterior temporal region with partial extension posterior boundary of the tumor. The somatosensory path-
into the insula (Fig. 4a). Our method visualized four main ways (thalamic radiations [TR]) and CST were noted at the
WMTs likely to be encountered in surgery in 2D (Fig. 4a) posterior, superior, and medial depth of the tumor at the
and 3D (Fig. 4b). Tumor was noted to infiltrate the inferior level of the posterior limb of the internal capsule.

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Fig. 4 Case #3: Left anterior temporal-insular tumor. a Preoperative (gray). c Intraoperative images showing tags found to have a func-
MRI images notable for a hyperintense FLAIR mass in the left ante- tional response (tag# on brain, and color coded on the bottom right)
rior temporal lobe with infiltration of the insula, with 2D overlays of at the beginning (left) and end (right) of surgery. d Postoperative MRI
the ILF (magenta), IFOF (blue), AF (green), TR (yellow), and CST with surgical cavity and the ILF, IFOF, AF, TR, and CST overlay as
(cyan) following data acquisition, normalization, and visualization. b in (a)
3D views showing relation of ILF, IFOF, AF, TR, CST, and the tumor

The patient underwent an awake left-sided craniotomy, in the deep part of the temporal resection (IFOF) [26];
and DES identified the VPMC (response: articulatory right upper limb dysesthesias in the posterior aspect of
arrest; tags #1–2) (Fig. 4c). As in cases #1 and #2, pre- the insula near the internal capsule (tag #47) (TR adjacent
operative MRI images revealed tracts that were in fact to the CST); jargonaphasia at the posterior border of the
identified intraoperatively at the functional boundaries of resection (tag #48) (temporal terminations of the AF as it
the resection (Fig. 4c). The patient experienced semantic crosses the IFOF); and missing words (tag #49) at the most
paraphasias during DES (tag #50) at the temporal stem posterior and basal aspect of the resection ~ 3.0 to 3.5 cm

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from the temporal pole (posterior functional component to contralateral akinesia of the hemibody and/or mutism
of the ILF) [34] (Fig. 4c). (i.e., SMA syndrome). SMA syndrome, although revers-
Postoperative images (Fig. 4d) show the ILF partially ible, is regularly followed by permanent deficit in bimanual
included within the surgical cavity, with its posterior por- coordination and fine motor skills even with intact motor
tion at the posterior and basal aspect of the surgical cavity mapping of the CST [39, 40]. In Case #1, we visualized
consistent with intraoperative difficulties with lexical access. these WMTs with DES confirmation of the NMN soma-
The AF terminations are seen at and in proximity to the totopy. Recent advances demonstrate the importance of the
IFOF at the posterior aspect of the surgical cavity. Thus, our FAT and FST of the NMN [6, 59], such that preservation
method confirmed the intraoperative DES findings, enabling of NMN deep connectivity has been shown to decrease the
a maximally safe resection and the patient showing no defi- risk of SMA syndrome and permanent deficit in bimanual
cits and partial improvement in neuropsychological scores coordination and fine motor skills [57, 59]. Thus, by under-
at 3-month follow-up. standing the WMTs of the NMN in relation to the CST in
SMA and Rolandic tumors, the surgeon can perform an “a
la carte” surgery that would be particularly relevant in, for
Discussion example, a concert pianist wishing to preserve bimanual and
fine motor skills.
Understanding the structural connectivity of WMTs and Case #2 presented a patient with a left insular tumor; such
their related functions is critical in glioma surgery. Here lesions require the surgeon to understand and visualize the
we present a method that is readily accessible, simple, and complex anatomofunctional relationships of the dorsal (AF,
reproducible that enables the visualization of WMTs in the SLF-III), ventral (IFOF, ILF, UF), motor (CST), NMN (FAT,
context of a patient’s unique pathology to help neurosur- FST), and somatosensory (TR) networks. Our method can help
geons learn the connectomic constraints in glioma surgery, neurosurgeons visualize key relationships such as the proximity
and ultimately facilitate maximal safe surgical resections. between the AF and SLF at the posterior, superior, and lateral
This method has several advantages for use on glioma aspects of the resection, which explains how anomia, phono-
cases. First, it is readily accessible irrespective of the sur- logic, and/or articulatory disorders can occur [26, 30, 44, 67,
geon’s resource setting (e.g., not requiring preoperative DTI 68, 75]; visualize the displacement and infiltration of the IFOF
or expensive clinical software for WMT reconstruction and in the depths of the resection, which is imperative to avoid sig-
visualization). Second, it is simple and requires only three nificant semantic language disorders [2, 30, 64]; and localize
steps: data acquisition, normalization, and visualization. the motor and somatosensory pathways in an effort to ensure
Third, it is reproducible, enabling surgeons at all levels to no transgression into the posterior limb of the internal capsule.
apply this method for learning, teaching, and/or planning. Thus, we visualized all five major pathways in relation to this
Fourth, it is fast, allowing surgeons to produce 2D or 3D patient’s anatomy, which would be impossible with ex vivo dis-
visualization(s) in 3–5 min. sections, and prohibitively challenging in everyday use with DTI
A “connectomic approach” to glioma surgery requires reconstructions.
the surgeon to have a mental imagery of the underlying deep Finally, Case #3 presented a left temporal glioma with
connectivity for each patient. Only then can the surgeon extension into the insula. While teaching within the neu-
make preoperative plans that will positively impact post- rosurgical community would posit that anterior temporal
operative functional outcomes. In line with this, our group lobe resections ranging from 3 to 6 cm posterior from the
applies an “a la carte” approach to brain tumor patients, temporal pole in dominant or non-dominant hemispheres are
which takes into consideration the patient-specific wishes, typically safe [1, 71, 76], our method shows the terminations
sociocultural and emotional needs, and functional require- of the AF in the STG, MTG, and ITG as well as the posterior
ments for a return to work and to continue to live a normal portion of the ILF ~ 2.5 to 3.5 cm from the temporal pole and
life [12, 13, 19, 22, 66]. However, to implement this “a la just posterior to the tumor. Intraoperatively, this was con-
carte” approach, the surgeon requires foundational knowl- firmed when we observed language disorders during DES
edge about how the deep connectivity and its functional of the AF and the ILF [26, 34–36]. Had surgery proceeded
brain networks are related to the patient’s pathology [12, anatomically, without understanding the WMTs and intraop-
13, 63, 65, 66]. erative DES, the patient would have suffered significant lan-
Here we show how our method can help surgeons develop guage disorders of lexical access including possible anomic
the mental imagery of the deep connectivity with patient- aphasia as well as phonological disorders [26, 34–36].
specific MRIs harboring gliomas. Here we made use of three In all three cases, our method allowed us to critically evalu-
representative cases to demonstrate the utility of our method. ate an “a la carte” connectomic approach [18, 30] to glioma
First, we discussed a case of a patient with a right SMA/ cases, and by performing cognitive assessments during awake
pre-SMA tumor. Of note, resection of these tumors can lead surgery, enable patients to preserve function and return to a

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Ethics approval All procedures performed in studies involving human gliomas: functional brain mapping, connectionism and plastic-
participants were in accordance with the ethical standards of the ity–a review. J Neurooncol 79:77–115. https://doi.org/10.1007/
Montpellier University Medical Center and with the 1964 Helsinki s11060-005-9109-6
Declaration and its later amendments or comparable ethical standards. 14. Duffau H (2014) The huge plastic potential of adult brain and the
All patients provided informed consent to participate under a study role of connectomics: new insights provided by serial mappings
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guided surgery study for NX Development Corp. JDB has an equity 265. https://doi.org/10.1038/nrneurol.2015.51
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