Brain Hodotopy: From Esoteric Concept to Practical Surgical Applications

BACKGROUND The traditional neurosurgical approach to cerebral lesions is based on the classic view of a rigid brain organization in fixed "eloquent" areas. However, this method is brought into discussion by the conceptual and methodological advances in neurosciences that provide a more dynamic representation of the anatomo-functional distribution of the human central nervous system (CNS). OBJECTIVE AND METHODS We review the relevant literature concerning the main features of the modern CNS representation and their implications in neurosurgical practice. RESULTS The CNS is an integrated, wide, plastic network made up of cortical functional epicenters, "topic organization," connected by both short-local and large-scale white matter fibers, ie, "hodological organization." According to this model, called hodotopic, brain function results from parallel streams of information dynamically modulated within an interactive, multimodal, and widely distributed circuit. The application of this framework, which can be studied by combining preoperative, intraoperative, and postoperative mapping techniques, enables the neurosurgeon exploration of the individual anatomo-functional architecture, including neurocognitive and emotional aspects. Thus, it is possible to adapt the surgical approach specifically to each patient and to each lesion according to the individual organization. Several experiences demonstrate the possibility of removing regions traditionally considered inoperable without inducing permanent deficits and the potential use of these areas as a safe passage to deeper territories. CONCLUSION We advocate the more systematic integration of a hodotopical view of the CNS to improve the surgical indications and planning for brain lesions, with the goal of optimizing both the extent of resection and functional outcome.