Supratentorial function-eloquent brain tumour surgeries challenge the balance between maximal tumour resection and preservation of neurological function. This study aims to evaluate the efficacy of preoperative and intraoperative mapping techniques on resection outcomes and post-operative deficits. This systematic review and meta-analysis examined literature up to March 2023, sourced from PubMed, Embase, and Medline. Criteria for inclusion were studies on patients undergoing surgery for supratentorial brain tumours, comparing preoperative mapping only (POM), intraoperative neuromonitoring and mapping (IONM), and combined techniques (POM&IONM), excluding non-randomized controlled trials. Data extraction focused on rates of gross total resection (GTR) and focal neurological deficits (FNDs). The main outcomes, assessed through a random-effects model and Cochran's Q-test for subgroup analysis. The study protocol is published on PROSPERO CRD42024512306. 19 studies involving 992 patients were included. Systematic review with meta-analysis revealed a non-significantly higher average GTR rates for POM&IONM (49.13%) and POM (50.79%) compared to IONM alone (41.23%). Highest rates of GTR were achieved with tractography-guided resection in POM group (66.59% versus fMRI–20.00%, p = 0.0004), multimodal stimulation in IONM group (54.16% versus low frequency stimulation (LFS)–13.29%, p < 0.0001) and in POM&IONM group (65.88% versus LFS–37.77%, p = 0.0036). Within the same tumour histology–metastasis, high grade and low grade glioma–there are no differences in the GTR rates achieved in the different groups (p > 0.05). In language-eloquent tumours and in awake craniotomy techniques regardless of tumour functional eloquence, POM&IONM group had higher GTR when compared to IONM groups (language eloquent tumours–POM&IONM 43.31% versus IONM–15.09%, p = 0.022; awake craniotomy technique–POM&IONM–41.22% versus IONM–12.08%, p = 0.0006). Permanent FNDs were higher in the IONM group (IONM-73.0%; POM-29.6%; POM&IONM-33.7% of immediate postoperative deficits, p = 0.0010). A combined POM&IONM approach is responsible for higher rates of GTR in patients with language eloquent tumours and in both awake and asleep craniotomy techniques regardless of the tumour functional eloquence. The tumour histology is not relevant for differences in GTR rates among different mapping and monitoring strategies. Permanent postoperative FNDs are more likely with standalone utilization of IONM. Not applicable.

Background: Acute subdural hematoma (aSDH) is a major cause of admission at Neurosurgical Emergency Department. Nevertheless, concerns regarding surgical indication in patients with multiple comorbidities, poor neurological status, antithrombotic therapy, and older age still persist. Therefore, a correct recognition of predictive outcome factors at hospital discharge is crucial to an appropriate neurosurgical treatment. Methods: Eighty-nine medical records of consecutive patients with age ≥18 years old who were submitted to aSDH evacuation between January 2008 and May 2012 were reviewed. Demographic characteristics, neurological status on admission, anticoagulant or antiplatelet therapy, and outcome on discharge were collected. Patients with insufficient data concerning these variables were excluded from the study. Results: Sixty-nine patients were included; 52% were male; 74% were older than 65 years; 41% were under oral antithrombotic therapy (OAT); at admission, 54% presented with Glasgow coma scale (GCS) ≤8; 23% were submitted to a craniectomy instead of a craniotomy; 26% of the patients died, 32% were dependent, and 42% were independent on discharge. Crude analysis revealed craniectomy, A/A pupils, GCS ≤8 at admission statistically significant related with the worst outcome (P < 0.05). In the adjusted evaluation only A/A pupils (P = 0.04) was associated to poor outcome (spontaneous etiology P = 0.052). Considering daily living independency at hospital discharge, either male gender (P = 0.044) and A/A pupils (P = 0.030) were related to the worst outcome. No effect of age in outcome was observed. Conclusions: Male gender and A/A pupils are associated with lower probability of achieving independency living at hospital discharge. A/A pupils, low GCS at admission, spontaneous etiology, and craniectomy were associated with the worst outcome. Age and OAT were not predictive factors in this series. Caution should be taken when considering these factors in the surgical decision.

MGMT promoter methylation is related to the increased sensitivity of tumour tissue to chemotherapy with temozolomide (TMZ) and thus to improved patient survival. However, it is unclear how the extent of MGMT promoter methylation affects outcomes. In our study, a single-centre retrospective study, we explore the impact of MGMT promoter methylation in patients with glioblastoma who were operated upon with 5-ALA. Demographic, clinical and histology data, and survival rates were assessed. A total of 69 patients formed the study group (mean age 53.75 ± 15.51 years old). Positive 5-ALA fluorescence was noted in 79.41%. A higher percentage of MGMT promoter methylation was related to lower preoperative tumour volume (p = 0.003), a lower likelihood of 5-ALA positive fluorescence (p = 0.041) and a larger extent of resection EoR (p = 0.041). A higher MGMT promoter methylation rate was also related to improved progression-free survival (PFS) and overall survival (OS) (p = 0.008 and p = 0.006, respectively), even when adjusted for the extent of resection (p = 0.034 and p = 0.042, respectively). A higher number of adjuvant chemotherapy cycles was also related to longer PFS and OS (p = 0.049 and p = 0.030, respectively). Therefore, this study suggests MGMT promoter methylation should be considered as a continuous variable. It is a prognostic factor that goes beyond sensitivity to chemotherapy treatment, as a higher percentage of methylation is related not only to increased EoR and increased PFS and OS, but also to lower tumour volume at presentation and a lower likelihood of 5-ALA fluorescence intraoperatively.

Fluorescence-guided surgery (FGS) was pioneered for glioma and is now established as the standard of care. Gliomas are infiltrative tumours with diffuse margins. FGS provides improved intra-operative identification of tumour margins based on tumour-specific emission visible to the operating surgeon, resulting in increased rates of gross total resection. Multiple fluorescence agents may be used including 5-ALA, fluorescein sodium, and indocyanine green (ICG). This review details the indication, required equipment, mechanism of action, evidence base, limitations, and regulatory issues for each fluorophore as utilised in current clinical practice. FGS for glioma is limited by a reliance on subjective interpretation of visible fluorescence, which is often not present in low-grade glioma (LGG) or at the infiltrative tumour margin. Consequently, there has been a drive to develop enhanced, objective FGS techniques utilising both quantitative fluorescence (QF) imaging systems and novel fluorophores. This review provides an overview of emerging QF imaging systems for FGS. The pipeline for novel fluorophore development is also summarised.