Awake craniotomy for malignant glioma resection

There is mounting evidence that gross total resection (GTR) of the MRI contrast-enhancing portions of malignant gliomas (WHO grades III and IV) improves survival. Any survival benefits gained from the aggressive resection of high-grade gliomas suspected of lying near or involving eloquent cortex, however, may be outweighed by the risk of causing permanent neurological deficits. As a result, tumors near eloquent cortex may be subtotally resected under general anesthesia or referred for conservative management. By applying techniques developed for epilepsy surgery, several authors have demonstrated that awake cortical and subcortical mapping techniques can be used to guide aggressive resections in patients with various histopathological diagnoses while minimizing the rate of postoperative deficits. Though there has been some evidence that this aggressive approach may involve greater risks in the subset of patients with malignant gliomas while at the same time leading to less extensive resections, we have found that a GTR can be achieved in the majority of these patients while maintaining an acceptably low risk of permanent neurological deficits.