The surgical management of diffuse gliomas: Current state of neurosurgical management and future directions

Abstract

After recent updates to the World Health Organization pathological criteria for diagnosing and grading diffuse gliomas, all major North American and European neuro-oncology societies recommend a maximal safe resection as the initial management of a diffuse glioma. For neurosurgeons to achieve this goal, the surgical plan for both low- and high-grade gliomas should be to perform a supramaximal resection when feasible based on pre-operative imaging and the patient’s performance status, utilizing every intraoperative adjunct to minimize post-operative neurological deficits. While the surgical approach and technique can vary, every effort must be taken to identify and preserve functional cortical and subcortical regions. In this summary statement on the current state of the field, we describe the tools and technologies that facilitate the safe removal of diffuse gliomas and highlight intra-operative and post-operative management strategies to minimize complications for these patients. Moreover, we discuss how surgical resections can go beyond cytoreduction by facilitating biological discoveries and improving the local delivery of adjuvant chemo- and radiotherapies.

The role of postoperative blood pressure management in early postoperative hemorrhage in awake craniotomy glioma patients

“…[17,36] Our study contributes valuable insights supporting the establishment of a rigid systolic blood pressure limit of 140 mmHg during the early postoperative course. Building upon previous research by Young et al, [16,19,20] our data reinforces the notion that maintaining blood pressure within this threshold might be conducive to favorable outcomes in patients undergoing awake glioma surgery.…”

“…This requires continuous blood pressure measurement with some patients necessitating anti-hypertensive treatments transiently after craniotomy for glioma resection, which can usually only be provided by invasive blood pressure measurements in intermediate or intensive care units. ( [14][15][16] In recent years, there has been a growing interest in understanding the relationship between blood pressure management and postoperative complications in glioma patients. As previously described, comorbidities as well as fluctuations of blood pressure can significantly influence the postoperative morbidity in glioblastoma (GBM) patients.…”

“…[17,18] However, standardized blood pressure goals after a craniotomy for glioma resection are not well-defined and demonstrate the need for further studies. [16,19,20] Data on the impact of blood pressure management, other radiological and neuro-oncological parameters like residual tumor volume as potential source of bleeding, preoperative hypertension and patient age on the occurrence of postoperative complications like hemorrhage are limited.…”

Finite element analysis of a neural implant for cytostatic hypothermia and a novel heat management system

“…In addition, supra-total resection, i.e. resecting beyond the tumor bulk mass and into brain, results in improved survival [6], [7]. However, resecting healthy brain is not an ideal approach as it can result in functional deficits and morbidity [8].…”

Advances in Intraoperative Glioma Tissue Sampling and Infiltration Assessment

“…Maximizing the extent of resection is of utmost importance for survival; however, as recent studies have demonstrated, minimizing the neurological deficits is prognostically important as well [3,4]. Surgical expertise in resecting these tumors, which are sometimes nearly indistinguishable from the adjacent normal tissue, is necessary for minimizing post-operative morbidity [5]. Moreover, it is well known that intraoperative adjuncts such as stimulation mapping reduce the risk of injury to critical cortical and subcortical structures [6].…”