Maximal Safe Resection in Glioblastoma: Use of Adjuncts

Glioblastoma is a malignant primary brain neoplasm for which no cure exists due to the infiltrative nature of this tumor. Maximal safe resection is the cornerstone of treatment that was shown to prolong patient survival. To maximize the extent of resection while preserving neurological status of the patient, good understanding of tumor anatomy as well as location of eloquent cortex and subcortical pathways is required. A number of imaging and functional adjuncts can be used before and during surgery to achieve both of these goals. This chapter first describes the use of preoperative adjuncts such as functional MRI, diffusion tensor imaging, navigated transcranial magnetic stimulation, and others, to help with preoperative planning. Furthermore, it describes the principles of intraoperative techniques such as fluorescence, direct electrical stimulation, and awake craniotomy, that allow intraoperative visualization of tumor tissue as well as mapping of functional cortical and subcortical areas to safely accomplish maximal tumor resection.