Abstract
Safe and total glioma removal without loss of neurological function is still a challenge. Basic surgical strategies need to be based on a deep and precise knowledge of brain anatomy. Routine preoperative evaluations include contrast-enhanced MRI, 3D-CT angiography, and PET (FDG and methionine) followed by creation of fusion images using a neuronavigation system. Diffuse tensor image-based pyramidal tract tractography is useful in surgeries for tumor removal near the tract. Intraoperatively, in combination with neuronavigation, transcortical SEP is used to detect the central sulcus, and MEPs are monitored by stimulation on the precentral gyrus. In addition, direct bipolar stimulation in the white matter near the pyramidal tract is more reliable than transcortical derived MEPs. In this article, we illustrate two representative glioma cases : a glioma adjacent to the primary motor area and a glioma in the hippocampus. Intraoperative MRI is a powerful tool to update real-time anatomy and detect residual tumors especially when the navigation based on preoperative images becomes less useful due to brain shift.
