Optimizing glioblastoma resection: intraoperative mapping and beyond

Abstract

The management of glioblastomas starts with surgical resection if possible, along with subsequent chemotherapy and radiation therapy. Several retrospective studies have suggested that extent of resection plays a role in the prognosis of glioblastoma patients. The importance of extent of resection must be balanced with preserving patient's functional status for tumors in eloquent areas. Here we review the preoperative imaging modalities such as functional MRI and magnetoencephalography (MEG), and the intraoperative techniques such as motor and language mapping, intraoperative MRI, and intraoperative techniques such as 5-aminolevulinic acid administration, that allow maximal safe operative resection of glioblastomas.

Keywords: MRI; glioblastoma; mapping; resection; tractography.

Figure 1.. Post-gadolinium enhanced T1 MRI showing a 49 year-old man with a cerebellar vermis high-grade glioma.

(A) Sagittal and (B) axial. Shown are the neuro-navigation (green) trajectories intra-operatively, demonstrating the supracerebellar–infratentorial approach that was used for operative resection of this tumor. For color images please see www.futuremedicine.com/doi/full/10.2217/cns.14.36

Figure 2.. Example of magnetoencephalography-derived images obtained from a 44-year-old male with a left frontal lobe high grade glioma.

Magnetoencephalography revealed a focus in the left frontal lobe associated with picture naming that was posterior the lesion. These images were loaded into operating room neuronavigation, and awake intraoperative language mapping was used to corroborate the preoperative magnetoencephalography.

Figure 3.. Intraoperative screenshot, demonstrating diffusion tensor imaging tracks.

(A) Axial and (B) coronal post-gadolinium T1 enhanced MRI from a 36-year-old man with a lesion in the left amygdala. Motor (red) diffusion tensor imaging (DTI) tracks are shown at the level of the midbrain (A) and corona radiata and internal capsule (B). (C) Axial post-gadolinium enhanced and (D) coronal T2 MRI showing a 66-year-old woman with a cystic glioblastoma and enhancing mural nodule in the right posterior cingulate gyrus. Optic radiations (yellow) and corticospinal tracts (red) were generated using DTI imaging and are shown as well as neuro-navigation (green). For color images please see www.futuremedicine.com/doi/full/10.2217/cns.14.36