Contemporary surgical strategies for resection of intracranial gliomas

Diffuse gliomas are the most common primary brain tumors in adults. Maximal safe resection represents the recommended initial management step for affected patients, and accumulating evidence emphasizes the favorable effects of more extensive resection on survival. The oncological role of surgery seems to be most pronounced in tumors with an aggressive natural history, and the concept of supramaximal resection is currently emerging, particularly in IDH-wildtype glioblastoma and IDH-mutant astrocytoma. Interactive effects between more extensive resection and other clinical prognostic markers on outcome have recently been described, and a more profound understanding of these interactions can help in identifying patients most likely to benefit from aggressive surgery. Advanced pre-operative imaging, intraoperative diagnostics of the molecular tumor properties, fluorescence-guided approaches, and real-time feedback on the tumor cell content at the margins of the resection cavity allow neurosurgeons to tailor the extent of resection according to the presumed biological tumor boundaries. Advances in functional mapping techniques have been established to push the resection boundaries while avoiding jeopardizing outcome by preserving neurological functioning. In the current review, we discuss the evidence for resection across different glioma subtypes. We then outline contemporary resection strategies to achieve maximal resection, elaborate on technical adjuncts to minimize the risk of clinical deterioration even when resecting tumors located in eloquent brain areas, and finally elaborate on emerging intraoperative diagnostics, which may affect surgical strategies. As such, this review aims to provide neurosurgeons with the information needed to navigate judicious surgical decision-making in an era of precision neurosurgical care.