Safe surgery for glioblastoma: Recent advances and modern challenges

Abstract

One of the major challenges during glioblastoma surgery is balancing between maximizing extent of resection and preventing neurological deficits. Several surgical techniques and adjuncts have been developed to help identify eloquent areas both preoperatively (fMRI, nTMS, MEG, DTI) and intraoperatively (imaging (ultrasound, iMRI), electrostimulation (mapping), cerebral perfusion measurements (fUS)), and visualization (5-ALA, fluoresceine)). In this review, we give an update of the state-of-the-art management of both primary and recurrent glioblastomas. We will review the latest surgical advances, challenges, and approaches that define the onco-neurosurgical practice in a contemporary setting and give an overview of the current prospective scientific efforts.

Keywords: glioblastoma; imaging; intraoperative mapping; preoperative mapping; review.

Figure 1.

Intraoperative ultrasound. A: Intraoperative image of a glioma in the right parietal lobe. B: Intraoperative image of the cavity after tumor resection. C: Pre-resection B-mode image of the tumor and surrounding tissue. D: Post-resection B-mode ultrasound image of the resection cavity.

Figure 2.

Electrocortical stimulation with intraoperative ultrasound. A: Intraoperative ultrasound before starting tumor removal. B: Electrocortical stimulation mapping using awake craniotomy to determine eloquent brain areas. C: Tumor resection based on mapping procedure, aided by the neuro-linguist. D: Intraoperative ultrasound after tumor resection to identify potential residual tumor.