Review of Intraoperative Adjuncts for Maximal Safe Resection of Gliomas and Its Impact on Outcomes

Abstract

Maximal safe resection is the mainstay of treatment in the neurosurgical management of gliomas, and preserving functional integrity is linked to favorable outcomes. How these modalities differ in their effectiveness on the extent of resection (EOR), survival, and complications remains unknown. A systematic literature search was performed with the following inclusion criteria: published between 2005 and 2022, involving brain glioma surgery, and including one or a combination of intraoperative modalities: intraoperative magnetic resonance imaging (iMRI), awake/general anesthesia craniotomy mapping (AC/GA), fluorescence-guided imaging, or combined modalities. Of 525 articles, 464 were excluded and 61 articles were included, involving 5221 glioma patients, 7(11.4%) articles used iMRI, 21(36.8%) used cortical mapping, 15(24.5%) used 5-aminolevulinic acid (5-ALA) or fluorescein sodium, and 18(29.5%) used combined modalities. The heterogeneity in reporting the amount of surgical resection prevented further analysis. Progression-free survival/overall survival (PFS/OS) were reported in 18/61(29.5%) articles, while complications and permanent disability were reported in 38/61(62.2%) articles. The reviewed studies demonstrate that intraoperative adjuncts such as iMRI, AC/GA mapping, fluorescence-guided imaging, and a combination of these modalities improve EOR. However, PFS/OS were underreported. Combining multiple intraoperative modalities seems to have the highest effect compared to each adjunct alone.

From Text to Insight: A Natural Language Processing-Based Analysis of Topics and Trends in Neurosurgery

“…19,20 As central nervous system (CNS) tumors pose significant risks because of the sensitivity of surrounding neurological structures, this topic covers multifaceted efforts to balance maximal safe resection and neurological preservation. [21][22][23] The nuances of tumor location, grade, molecular markers, and patient factors require continual research to guide evidence-based treatment. 24 "Vascular Malformations" represents the broad range of vascular anomalies within the cranium and spine.…”

Posterior fossa tumor resection in children: a case report and the role of intraoperative neurophysiologic monitoring

“…Over the course of the last few decades, many different surgical tools have been added to the surgeons' armamentarium, such as the microscope, neuronavigation, ultrasound imaging, ultrasonic aspiration, fluorescenceguided surgery (FGS), and intraoperative neurophysiologic monitoring (IONM) [7,9,12,13]. These technologies and techniques, when combined, help the neurosurgeon with the complex task of resecting a posterior fossa lesion at its entirety, whenever achievable, and with the maximum safety possible [3,6,7].…”

“…Even though surgery plays a central role in the management of these lesions, it carries a high risk of permanent disability and poor quality of life [3,4,5]. Various surgical tools, such as the microscope, ultrasound aspirator, neuronavigation, fluorescence guidance, and intraoperative neurophysiological monitoring (IONM) assist the neurosurgeon with the task of achieving the safest maximum resection on these particular cases [7]. The aim of this case report is to bring awareness to the complexities of performing surgery in the posterior fossa of children and the potential of increasing surgical efficiency and safety by using adjunct surgical tools such as IONM.…”

Intraoperative Fluorophores: An Update on 5-Aminolevulinic Acid and Sodium Fluorescein in Resection of Tumors of the Central Nervous System and Metastatic Lesions—A Systematic Review and Meta-Analysis

“…The molecule is then effluxed by the ABCG2 pump into the blood, where it is excreted in the bile. The protoporphyrin accumulation is dependent on its efflux, biosynthesis, and protoporphyrin conversion to heme [5][6][7][8].…”

“…In general, Gleolan is given 2 to 4 h prior to anesthesia, since peak fluorescence occurs at six hours, aligning with the operative timing of dural incision [5][6][7][8]. Prolonged exposure to light can confer a photobleaching effect, minimizing the effectiveness of 5ala.…”