Brain tumor surgery: supplemental intra-operative imaging techniques and future challenges

Abstract

Modern brain tumor surgery stands in the pillar of maximum safe resection. Tumor borders are always challenging, especially infiltration zones in malignant brain tumors. Novel technologies are designed for a better delineation and to increase the extent of resection (EOR) in brain tumor surgery, such as: cortical and sub-cortical mapping strategies with somatosensory-evoked potentials, awake stimulation mapping and cortical/sub-cortical stimulation for motor pathways, important for resection in eloquent areas; intra-operative imaging as functional and intra-operative magnetic resonance imaging, diffusion tensor imaging and intra-operative ultrasound are important for the tumor borders and to achieve the gross total resection; neurochemical navigation methods as 5-aminolevulinic and sodium fluorescein are important for the non-contrast-enhanced tumor border; future methods can be achieved with augmented reality surgery, new intra-operative chemical markers, and visualization methods. Nevertheless all these techniques seem to be promising, the real challenge in the future will be held in how to apply them and how they really affect the prognosis of the patients. Also, new concepts in tumor genetics will provide knowledge for the tumor behavior and will guide resection. Despite all limitations, the increasing importance of safe EOR shows the possible benefits of the novel technologies and surgical advances in brain tumor surgery, taking it to a new step of the neuronavigation era.