Diffusion Tractography in Deep Brain Stimulation Surgery: A Review

Deep brain stimulation (DBS) is believed to exert its therapeutic effects through modulation of brain circuitry, yet conventional preoperative planning does not allow direct targeting or visualization of white matter pathways. Diffusion MRI tractography (DT) is virtually the only non-invasive method of visualizing structural connectivity in the brain, leading many to suggest its use to guide DBS targeting. DT-guided DBS not only has the potential to allow direct white matter targeting for established applications [e.g., Parkinson’s disease (PD), essential tremor (ET), dystonia], but may also aid in the discovery of new therapeutic targets for a variety of other neurologic and psychiatric diseases. Despite these exciting opportunities, DT lacks standardization and rigorous anatomic validation, raising significant concern for the use of such data in stereotactic brain surgery. This review covers the technical details, proposed methods, and initial clinical data for the use of DT in DBS surgery. Rather than focusing on specific disease applications, this review focuses on methods that can be applied to virtually any DBS target.