Just like how a treasure map reveals hidden pathways to a chest of gold, diffusion tensor imaging (DTI) is a cutting-edge technique that uncovers the intricate network of white matter alterations in Parkinson’s disease (PD). PD is not just limited to motor symptoms; it also encompasses various non-motor symptoms that dominate the disease’s progression. To understand the underlying structural changes in the brain, scientists have turned to DTI, which allows them to detect early axonal abnormalities caused by PD. By analyzing DTI data from the past five years, researchers have unraveled how this imaging technique can identify different stages and subtypes of PD, as well as atypical parkinsonism. Furthermore, DTI tractography has proven to be invaluable in guiding interventional treatments like deep brain stimulation. The evidence gathered from multisite DTI studies suggests that this method, along with advanced analytical tools, can track the dynamic processes of PD and distinguish between the affected structural networks in PD and other parkinsonism syndromes. With continued research and optimization, DTI holds great promise for tailoring personalized treatments for PD patients based on their unique clinical conditions and risk profiles.

Parkinson’s disease (PD) is the second most common age-related neurodegenerative disease with cardinal motor symptoms. In addition to motor symptoms, PD is a heterogeneous disease accompanied by many non-motor symptoms that dominate the clinical manifestations in different stages or subtypes of PD, such as cognitive impairments. The heterogeneity of PD suggests widespread brain structural changes, and axonal involvement appears to be critical to the pathophysiology of PD. As α-synuclein pathology has been suggested to cause axonal changes followed by neuronal degeneration, diffusion tensor imaging (DTI) as an in vivo imaging technique emerges to characterize early detectable white matter changes due to PD. Here, we reviewed the past 5-year literature to show how DTI has helped identify axonal abnormalities at different PD stages or in different PD subtypes and atypical parkinsonism. We also showed the recent clinical utilities of DTI tractography in interventional treatments such as deep brain stimulation (DBS). Mounting evidence supported by multisite DTI data suggests that DTI along with the advanced analytic methods, can delineate dynamic pathophysiological processes from the early to late PD stages and differentiate distinct structural networks affected in PD and other parkinsonism syndromes. It indicates that DTI, along with recent advanced analytic methods, can assist future interventional studies in optimizing treatments for PD patients with different clinical conditions and risk profiles.

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