Connectome-guided resection of deep-seated brain tumors using tubular retractors: matched cohort outcomes and exploratory quantitative tractometry.

OBJECTIVE: Deep-seated supratentorial tumors require surgical corridors that risk injury to eloquent white matter pathways. Tubular retractors may mitigate retraction-related injury, and patient-specific connectome mapping may further inform trajectory selection. We evaluated the feasibility of integrating connectome-based planning with tubular retractor surgery and explored associated clinical and tract asymmetry outcomes in a matched cohort. METHODS: We performed a single-center retrospective review of adult patients undergoing connectome-guided resection of deep-seated supratentorial tumors using tubular retractors and compared outcomes to manually matched controls undergoing resection with standard retraction techniques. Functional outcomes included Karnofsky Performance Status (KPS) and new postoperative neurologic deficits. In patients with available quantitative tractometry, pre- and postoperative fractional anisotropy (FA) derived values and associated asymmetry indices were assessed for six major white matter tracts. RESULTS: Twenty-three patients met inclusion criteria (tubular: n = 7 tubular; controls: n = 16). Median preoperative KPS was 90 in both groups. One tubular retractor patient developed a new postoperative neurologic deficit at first follow-up, compared with 11 controls (p = 0.027). Gross total resection rates were not significantly different (tubular: 57.1% vs. controls: 37.5%; p = 0.650). Quantitative tractometry was available in 5 patients. In this exploratory subset, controls with left-sided lesions demonstrated postoperative shifts in tract asymmetry toward relative right hemispheric dominance, most prominently in association pathways including the arcuate fasciculus and superior longitudinal fasciculus. Tubular retractor cases with left-sided lesions showed smaller postoperative changes in tract asymmetry. CONCLUSIONS: Integrating patient-specific connectome mapping into tubular retractor workflows is feasible in routine practice. In this small retrospective cohort, tubular retractor cases were associated with fewer new postoperative neurologic deficits, with exploratory tractometry suggesting smaller postoperative shifts in tract asymmetry among left-sided lesions. Larger prospective studies incorporating standardized neurocognitive outcomes and systematic perioperative imaging are needed to validate clinical benefit and clarify the relationship between tract asymmetry metrics and functional recovery.