Acta Neurochirurgica

, Volume 160, Issue 5, pp 1043–1050 | Cite as

Glioma surgery with intraoperative mapping—balancing the onco-functional choice

  • Jannick Brennum
  • Christina M. Engelmann
  • Johanne Asperud Thomsen
  • Jane Skjøth-Rasmussen
Original Article - Brain Tumors



Balancing survival versus risk of inducing functional deficits is a challenge when resecting gliomas in or near eloquent areas. Our objectives were to assess deficits prior to and at 6 and 12 months after awake craniotomies with cortical and subcortical mapping in patients with suspected grade 2 gliomas in eloquent areas. We analyzed whether pre- and intraoperative factors were linked to an increased risk of postoperative deficits.


Retrospective study of 92 consecutive patients operated between January 2010 and June 2014. All deficits reported by any healthcare professional and KPS-score preoperatively, immediately postoperatively (day 1–10), at 6 months and 12 months, were analyzed.


A decrease in neurological and or cognitive function was common in the first days after surgery, with a significant improvement at 6 months after surgery and further improvement at 12 months. Immediately after surgery, 33% of the patients had severe deficits compared to 2% prior to surgery; this improved to 9% at 6 months and 3% at 12 months. However, at 12 months, 18% of the patients had new or worsened minor or moderate deficits and only 10% had no deficits compared to 39% prior to surgery. There were only minor changes in KPS. None of the recorded pre/intraoperative factors were found significantly to influence the risk of moderate/severe late postoperative deficits.


A significant amount of the patients in this study experienced new or worsened neurological and or cognitive deficits during follow-up. We found a higher frequency of deficits than normally reported. This is due to the inclusion of mild deficits, the use of patient-reported data, and our focus on cognitive deficits. Our study indicates that the impact of awake craniotomy with mapping on patient outcome is larger than expected. This in no way negates the use of the technique.


Glioma Neurosurgery Brain mapping Awake craniotomy 



Thank you to the following people who have helped in gathering and analyzing the data presented in this article: Almdal K, Grøndal O, Johannsen M, and Azam A.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

For this type of study, formal consent is not required.


  1. 1.
    Aaronson NK, Taphoorn MJ, Heimans JJ, Postma TJ, Gundy CM, Beute GN, Slotman BJ, Klein M (2011) Compromised health-related quality of life in patients with low-grade glioma. J Clin Oncol 29(33):4430–4443CrossRefPubMedGoogle Scholar
  2. 2.
    Aghi MK, Nahed BV, Sloan AE, Ryken TC, Kalkanis SN, Olson JJ (2015) The role of surgery in the management of patients with diffuse low grade glioma: a systematic review and evidence-based clinical practice guideline. J Neuro-Oncol 125(3):503–530CrossRefGoogle Scholar
  3. 3.
    Bello L, Gallucci M, Fava M, Carrabba G, Giussani C, Acerbi F, Baratta P, Songa V, Conte V, Branca V, Stocchetti N, Papagno C, Gaini SM (2007) Intraoperative subcortical language tract mapping guides surgical removal of gliomas involving speech areas. Neurosurgery 60(1):67–80 discussion 80CrossRefPubMedGoogle Scholar
  4. 4.
    Brennum J, Maier CM, Almdal K, Engelmann CM, Gjerris M (2015) Primo non nocere or maximum survival in grade 2 gliomas? A medical ethical question. Acta Neurochir 157(2):155–164CrossRefPubMedGoogle Scholar
  5. 5.
    Chang EF, Potts MB, Keles GE, Lamborn KR, Chang SM, Barbaro NM, Berger MS (2008) Seizure characteristics and control following resection in 332 patients with low-grade gliomas. J Neurosurg 108(2):227–235CrossRefPubMedGoogle Scholar
  6. 6.
    De Witt Hamer PC, Gil Robles S, Zwinderman AH, Duffau H, Berger MS (2012) Impact of intraoperative stimulation brain mapping on glioma surgery outcome: a meta-analysis. J Clin Oncol 30:2559–2565CrossRefPubMedGoogle Scholar
  7. 7.
    Drewes C, Sagberg LM, Jakola AS, Gulati S, Solheim O (2015) Morbidity after intracranial tumor surgery: sensitivity and specificity of retrospective review of medical records compared with patient-reported outcomes at 30 days. J Neurosurg 123(4):972–977CrossRefPubMedGoogle Scholar
  8. 8.
    Duffau H (2014) Towards an “active” cognitive assessment in patients with diffuse low-grade glioma. World Neurosurg 82(1–2):e129–e131CrossRefPubMedGoogle Scholar
  9. 9.
    Duffau H (2017) Mapping the connectome in awake surgery for gliomas: an update. J Neurosurg Sci 61(6):612–630PubMedGoogle Scholar
  10. 10.
    Duffau H, Mandonnet E (2013) The “onco-functional balance” in surgery for diffuse low-grade glioma: integrating the extent of resection with quality of life. Acta Neurochir 155(6):951–957CrossRefPubMedGoogle Scholar
  11. 11.
    Duffau H, Taillandier L (2015) New concepts in the management of diffuse low-grade glioma: proposal of a multistage and individualized therapeutic approach. Neuro-Oncology 17(3):332–342PubMedGoogle Scholar
  12. 12.
    Fountain DM, Allen D, Joannides AJ, Nandi D, Santarius T, Chari A (2016) Reporting of patient-reported health-related quality of life in adults with diffuse low-grade glioma: a systematic review. Neuro-Oncology 18(11):1475–1486PubMedPubMedCentralGoogle Scholar
  13. 13.
    Gustafsson M, Edvardsson T, Ahlström G (2006) The relationship between function, quality of life and coping in patients with low-grade gliomas. Support Care Cancer 14(12):1205–1212CrossRefPubMedGoogle Scholar
  14. 14.
    Hervey-Jumper SL, Berger MS (2016) Maximizing safe resection of low- and high-grade glioma. J Neuro-Oncol 130(2):269–282CrossRefGoogle Scholar
  15. 15.
    Ius T, Isola M, Budai R, Pauletto G, Tomasino B, Fadiga L, Skrap M (2012) Low-grade glioma surgery in eloquent areas: volumetric analysis of extent of resection and its impact on overall survival. A single-institution experience in 190 patients. J Neurosurg 117(6):1039–1052CrossRefPubMedGoogle Scholar
  16. 16.
    Jakola AS, Myrmel KS, Kloster R, Torp SH, Lindal S, Unsgard G, Solheim O (2012) Comparison of a strategy favoring early surgical resection vs a strategy favoring watchful waiting in low-grade gliomas. JAMA 308(18):1881–1888CrossRefPubMedGoogle Scholar
  17. 17.
    Jakola AS, Skjulsvik AJ, Myrmel KS, Sjåvik K, Unsgård G, Torp SH, Aaberg K, Berg T, Dai HY, Johnsen K, Kloster R, Solheim O (2017) Surgical resection versus watchful waiting in low-grade gliomas. Ann Oncol 28(8):1942–1948CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Jakola AS, Unsgard G, Myrmel KS, Kloster R, Torp SH, Lindal S, Solheim O (2012) Low grade gliomas in eloquent locations - implications for surgical strategy, survival and long term quality of life. PLoS One 7(12):e51450. CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Klein M, Duffau H, De Witt Hamer PC (2012) Cognition and resective surgery for diffuse infiltrative glioma: an overview. J Neuro-Oncol 108(2):309–318CrossRefGoogle Scholar
  20. 20.
    Li Z, Wang Y, Yu J, Shi Z, Guo Y, Chen L, Mao Y (2017) Low-grade glioma segmentation based on CNN with fully connected CRF. J Healthc Eng 2017:9283480PubMedPubMedCentralGoogle Scholar
  21. 21.
    Pessina F, Navarria P, Cozzi L, Ascolese AM, Simonelli M, Santoro A, Tomatis S, Riva M, Fava E, Scorsetti M, Bello L (2016) Value of surgical resection in patients with newly diagnosed grade III glioma treated in a multimodal approach: surgery, chemotherapy and radiotherapy. Ann Surg Oncol 23(9):3040–3046CrossRefPubMedGoogle Scholar
  22. 22.
    Pignatti F, van den Bent M, Curran D, Debruyne C, Sylvester R, Therasse P, Afra D, Cornu P, Bolla M, Vecht C, Karim AB, European OFRATOCBTCG, European OFRATOCRCG (2002) Prognostic factors for survival in adult patients with cerebral low-grade glioma. J Clin Oncol 20(8):2076–2084CrossRefPubMedGoogle Scholar
  23. 23.
    Racine CA, Li J, Molinaro AM, Butowski N, Berger MS (2015) Neurocognitive function in newly diagnosed low-grade glioma patients undergoing surgical resection with awake mapping techniques. Neurosurgery 77(3):371–379CrossRefPubMedGoogle Scholar
  24. 24.
    Southwell DG, Birk HS, Han SJ, Li J, Sall JW, Berger MS (2017) Resection of gliomas deemed inoperable by neurosurgeons based on preoperative imaging studies. J Neurosurg 10:1–9. CrossRefGoogle Scholar
  25. 25.
    Southwell DG, Hervey-Jumper SL, Perry DW, Berger MS (2016) Intraoperative mapping during repeat awake craniotomy reveals the functional plasticity of adult cortex. J Neurosurg 124(5):1460–1469CrossRefPubMedGoogle Scholar
  26. 26.
    Talacchi A, d’Avella D, Denaro L, Santini B, Meneghelli P, Savazzi S, Gerosa M (2012) Cognitive outcome as part and parcel of clinical outcome in brain tumor surgery. J Neuro-Oncol 108(2):327–332CrossRefGoogle Scholar
  27. 27.
    van den Bent MJ, Wefel JS, Schiff D, Taphoorn MJ, Jaeckle K, Junck L, Armstrong T, Choucair A, Waldman AD, Gorlia T, Chamberlain M, Baumert BG, Vogelbaum MA, Macdonald DR, Reardon DA, Wen PY, Chang SM, Jacobs AH (2011) Response assessment in neuro-oncology (a report of the RANO group): assessment of outcome in trials of diffuse low-grade gliomas. Lancet Oncol 12(6):583–593CrossRefPubMedGoogle Scholar
  28. 28.
    Zadeh G, Khan OH, Vogelbaum M, Schiff D (2015) Much debated controversies of diffuse low-grade gliomas. Neuro-Oncology 17(3):323–326CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer-Verlag GmbH Austria, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Neurosurgery, RigshospitaletUniversity of CopenhagenCopenhagenDenmark

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