Section of Neurosurgery, Department of Neurosciences, Biomedicine and Movement Sciences, University Hospital, University of Verona, Verona, Italy.
Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, University College London, London, UK.
Adv Tech Stand Neurosurg. 2022;45:35-96. doi: 10.1007/978-3-030-99166-1_2.
In the surgery of gliomas, recent years have witnessed unprecedented theoretical and technical development, which extensively increased indication to surgery. On one hand, it has been solidly demonstrated the impact of gross total resection on life expectancy. On the other hand, the paradigm shift from classical cortical localization of brain function towards connectomics caused by the resurgence of awake surgery and the advent of tractography has permitted safer surgeries focused on subcortical white matter tracts preservation and allowed for surgical resections within regions, such as Broca's area or the primary motor cortex, which were previously deemed inoperable. Furthermore, new asleep electrophysiological techniques have been developed whenever awake surgery is not an option, such as operating in situations of poor compliance (including paediatric patients) or pre-existing neurological deficits. One such strategy is the use of intraoperative neurophysiological monitoring (IONM), enabling the identification and preservation of functionally defined, but anatomically ambiguous, cortico-subcortical structures through mapping and monitoring techniques. These advances tie in with novel challenges, specifically risk prediction and the impact of neuroplasticity, the indication for tumour resection beyond visible borders, or supratotal resection, and most of all, a reappraisal of the importance of the right hemisphere from early psychosurgery to mapping and preservation of social behaviour, executive control, and decision making.Here we review current advances and future perspectives in a functional approach to glioma surgery.
在脑胶质瘤的手术治疗中，近年来见证了前所未有的理论和技术发展，这广泛地增加了手术的适应证。一方面，已经充分证明了最大限度肿瘤切除术对预期寿命的影响。另一方面，由于唤醒手术的复兴和轨迹技术的出现，从经典的大脑皮质功能定位到连接组学的范式转变，使得手术可以更安全地集中在保留皮质下白质束上，并允许在以前被认为无法手术的区域进行手术切除，如布洛卡区或初级运动皮层。此外，当无法进行唤醒手术时，已经开发了新的睡眠期电生理技术，例如在顺应性差的情况下进行手术（包括儿科患者）或存在先前神经功能缺陷的情况下。其中一种策略是使用术中神经生理监测（IONM），通过绘图和监测技术，识别和保留功能定义但解剖上不明确的皮质下结构。这些进展与新的挑战相关联，特别是风险预测和神经可塑性的影响，肿瘤切除的适应证超出可见边界或超全切除，以及最重要的是，从早期精神外科到映射和保留社会行为、执行控制和决策的右半球的重要性的重新评估。在这里，我们回顾了胶质瘤手术的功能方法的当前进展和未来展望。
