Sahin Hanalioglu ¹ Siyar BAHADIR, MD ¹ Ahmet Ozak ¹ Kivanc Yangi ¹ Giancarlo Mignucci-Jiménez ¹ Alberto Fuentes ¹ Ethan Mathew ¹ Dakota Graham ¹ Muhammed Altug ¹ Egemen Gok ¹ Gregory Turner ¹ Michael T. Lawton ¹ Mark Preul ^2*

• ¹ Barrow Neurological Institute (BNI), Phoenix, Arizona, United States
• ² Division of Neurological Surgery, Barrow Neurological Institute (BNI), Phoenix, Arizona, United States

Introduction: Brain cross-sectional images, tractography, and segmentation are valuable resources for neuroanatomical education and research but are also crucial for neurosurgical planning that may improve outcomes in cerebellar and brainstem interventions. While ultrahigh-resolution 7-Tesla (7T) magnetic resonance imaging (MRI) and diffusion tensor imaging (DTI) reveal such structural brain details in living or fresh unpreserved brain tissue, imaging standard formalin-preserved cadaveric brain specimens often used for neurosurgical anatomic studies has proven difficult. This study sought to develop a practical protocol to provide anatomic information and tractography results of an ex vivo human brainstemcerebellum specimen. Materials and Methods: A protocol was developed for specimen preparation and 7T MRI with image postprocessing on a combined brainstem-cerebellum specimen obtained from an 85-year-old male cadaver with a postmortem interval of 1 week that was stored in formalin for 6 months. Anatomic image series were acquired for detailed views and diffusion tractography to map neural pathways and segment major anatomic structures within the brainstem and cerebellum. Results: Complex white matter tracts were visualized with high-precision segmentation of crucial brainstem structures, delineating the brainstem-cerebellum and mesencephalic-dentate connectivity, including the Guillain-Mollaret triangle. Tractography and fractional anisotropy mapping revealed the complexities of white matter fiber pathways, including the superior, middle, and inferior cerebellar peduncles and visible decussating fibers. 3D reconstruction and quantitative and qualitative analyses verified the anatomical precision of the imaging relative to a standard brain space. Discussion: This novel imaging protocol successfully captured the intricate 3D architecture of the brainstem-cerebellum network. The protocol, unique in several respects (including tissue preservation and rehydration times, choice of solutions, preferred sequences, voxel sizes, and diffusion directions) aimed to balance high resolution and practical scan times. This approach provided detailed neuroanatomical imaging while avoiding impractically long scan times. The extended postmortem and fixation intervals did not compromise the diffusion imaging quality. Moreover, the combination of time efficiency and ultrahigh-resolution imaging results makes this protocol a strong candidate for optimal use in detailed neuroanatomical studies, particularly in presurgical trajectory planning.