• Giovanni Muscas, Antonio Pisano, Riccardo Carrai, Andrea Bianchi, Federico Capelli, Vita Maria Montemurro, Cristiana Martinelli, Enrico Fainardi, Antonello Grippo, and Alessandro Della Puppa.
• Neurosurgery Unit, Department of Neuroscience, Psychology, Pharmacology and Child Health, Careggi University Hospital and University of Florence, Florence, Italy. Electronic address: muscasgi@aou-careggi.toscana.it.
• World Neurosurg. 2023 Apr 1; 172: e565e573e565-e573.

BackgroundThe critical role of different adjuncts in improving the neurological outcome in intrinsic brain lesions affecting eloquent areas is demonstrated by their more diffuse utilization. Neurosurgeons often rely on preoperative and intraoperative diffusion tensor imaging tractography to improve the operative strategy and prognosis. We aimed to identify and validate a diffusion tensor imaging-based classification considering the relationship between the brain lesion and the corticospinal tract to predict a >50% reduction of motor evoked potentials (MEPs) during surgical excision of lesions involving the motor pathways.MethodsWe included patients consecutively enrolled at our institution between April 2020 and September 2022 with 3 patterns of increasing complexity according to the relationship between the lesion and the corticospinal tract as identified on preoperative diffusion tensor imaging. Outcome measures were >50% reduction in intraoperative MEPs and neurological outcome defined as unchanged, improved, or worsened.ResultsThe study included 83 patients. A statistically significant linear trend between higher rates of reduction of MEPs and higher classification grades was observed (P = 0.001), with sensitivity 0.60, specificity 0.88, accuracy 0.83, and area under the curve 0.75. Higher grades were associated with worse neurological outcomes (P = 0.02).ConclusionsThe classification proved reliable in anticipating reduction in intraoperative MEPs and in predicting neurological outcome. Using this classification in patients undergoing surgery for lesions involving the motor pathways could help in counseling the patient, surgical planning, enhancing teamwork of operating room personnel, and improving the patient's prognosis.Copyright © 2023 Elsevier Inc. All rights reserved.

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