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Review
. 2021 Jan 11;10(2):236.
doi: 10.3390/jcm10020236.

The Neurosurgeon's Armamentarium for Gliomas: An Update on Intraoperative Technologies to Improve Extent of Resection

Alexander J Schupper  1 , Raymund L Yong  1 , Constantinos G Hadjipanayis  1
Affiliations
Review

The Neurosurgeon's Armamentarium for Gliomas: An Update on Intraoperative Technologies to Improve Extent of Resection

Alexander J Schupper et al. J Clin Med. .

Abstract

Maximal safe resection is the standard of care in the neurosurgical treatment of high-grade gliomas. To aid surgeons in the operating room, adjuvant techniques and technologies centered around improving intraoperative visualization of tumor tissue have been developed. In this review, we will discuss the most advanced technologies, specifically fluorescence-guided surgery, intraoperative imaging, neuromonitoring modalities, and microscopic imaging techniques. The goal of these technologies is to improve detection of tumor tissue beyond what conventional microsurgery has permitted. We describe the various advances, the current state of the literature that have tested the utility of the different adjuvants in clinical practice, and future directions for improving intraoperative technologies.

Keywords: 5-ALA; extent of resection; fluorescein; fluorescence-guided surgery; glioblastoma; glioma surgery; iMRI; intraoperative imaging; neuromonitoring; ultrasound.

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Conflict of interest statement

C.G.H. is a consultant for NX Development Corporation (NXDC) and Synaptive Medical. NXDC, a privately held company, markets Gleolan (5-ALA, aminolevulinic acid hydrochloride). Gleolan is an optical imaging agent approved for the visualization of malignant tissue during glioma surgery. Hadjipanayis is a consultant for NXDC and receives royalty payments for the sale of Gleolan. Hadjipanayis receives financial compensation as a consultant and lecturer for Synaptive (manufacturer of the 3D Synaptive MODUS V device). He has also received speaker fees by Carl Zeiss and Leica.

Figures

Figure 1
Figure 1
Fluorescence emission wavelengths of the most commonly used fluorophores used in glioma surgery. 5-ALA, 5-aminolevulinic acid; ICG, indocyanine green; FM, Frequency Modulation; AM, Amplitude Modulation. (Permission from Hadjianapyis CG, Stummer W. Fluorescence Guided Neurosurgery. New York: Thieme Medical Publishers; 2018) [5].
Figure 2
Figure 2
Fluorescence-guided surgery using 5-ALA for resection of a high-grade glioma. (A) shows the resection cavity under white light and (B) shows the red and pink fluorescence under blue light based upon tumor cell density, with the surrounding normal brain appearing blue without signs of fluorescence. 5-ALA, 5-aminolevulinic acid. (Permission from Hadjipanayis CG et al. Fluorescence Guided Brain Tumor Surgery. Youmans & Winn Neurological Surgery 8th Edition. Chapter 157B. New York: Elsevier; 2021) [21].
Figure 3
Figure 3
Fluorescence-guided surgery using fluorescein sodium for resection of a high-grade glioma. (A) shows the resection cavity under white light and (B) shows the green-yellow fluorescence under fluorescence. Fluorescein is not tumor-specific, as seen by the extravasated fluorophore within normal brain tissue and edematous brain. (Permission from Hadjianapyis CG et al. Fluorescence Guided Brain Tumor Surgery. Youmans & Winn Neurological Surgery 8th Edition. Chapter 157B. New York: Elsevier; 2021) [21].
Figure 4
Figure 4
Operating room schematic outlining the various surgical adjuncts used in malignant glioma surgery, including fluorescence-guided surgery, visualization with the surgical microscope and exoscope, Raman spectroscopy with handheld probe devices, intraoperative ultrasound, intraoperative MRI and neuromonitoring.
See this image and copyright information in PMC

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