Pterion Prep CraniPro VUMC Case Prep
2026-06-27

Case Prep: Glioma Resection (Supratentorial)

Case / Approach Snapshot

One-Liner

[Age]yo [M/F] with a [size] cm [left/right] [frontal/temporal/parietal/insular] [WHO grade II/III/IV] glioma presenting with [seizures/focal deficit/headaches/cognitive changes] planned for [awake/asleep] craniotomy for maximal safe resection.

Figures, Imaging & Video

🎥 Operative videos & resources

🧭 Operative approach: Pterional craniotomy — detailed corridor setup, step-by-step technique & figures

Glioblastoma — preoperative MRI with DTI tractography (A–D) and postoperative MRI showing gross total resection (E–F)

Preoperative MRI + DTI and postoperative gross-total-resection MRI. Source: Maragkos et al., Front Neurol 2021;12:644804, Fig 1. CC BY 4.0.

Intraoperative 5-ALA (PpIX) fluorescence — pink tumor bulk (asterisk) and infiltrative margin (white arrows) under violet light

Intraoperative 5-ALA fluorescence guiding resection of tumor bulk and infiltrative margin. Source: Maragkos et al., Front Neurol 2021;12:644804, Fig 2. CC BY 4.0.

High-Yield Literature

Curated Image Set

Open-access figures are embedded from PubMed Central articles and kept unique to this guide.

Glioma Resection — Figure 2 Figure 2. Counts of IL-9+ CD4+ T cells in glioma tissue(A–F) the photomicrographs show the IL-9+ (in red) CD4+ (in brown) T cells in glioma tissue from glioma-bearing mice. Panel F is negative… Source: Induction of specific T helper-9 cells to inhibit glioma cell growth — Oncotarget 2017; CC BY.

Glioma Resection — Figure 3 Figure 3. SEB regulates IL-9 gene expression in CD4+ T cellsCD4+ CD25− T cells were cultured SEB (at gradient doses as denoted) for 6 days. Cytosolic and nuclear extracts were prepared from the… Source: Induction of specific T helper-9 cells to inhibit glioma cell growth — Oncotarget 2017; CC BY.

Glioma Resection — Figure 4 Figure 4. SEB induces Th9 cellsCD4+ CD25− T cells and DCs (T cell:DC = 5:1) were cultured in the presence of SEB (100 ng/ml) and IL-2 (10 ng/ml; used as a T cell activator) for 6 days. The medium… Source: Induction of specific T helper-9 cells to inhibit glioma cell growth — Oncotarget 2017; CC BY.

Glioma Resection — Figure 5 Figure 5. SEB and glioma cell extracts induce glioma-specific Th9 cellsTh9 cells were generated from naïve CD4+ CD25− T cells with the presence of glioma extracts (5 μg/ml) and DCs in the presence… Source: Induction of specific T helper-9 cells to inhibit glioma cell growth — Oncotarget 2017; CC BY.

Glioma Resection — Figure 6 Figure 6. Glioma-specific Th9 cells induce glioma cell apoptosisTh9 cells were generated in the same procedures of Figure 4D. The cells (contain both Th9 cells and DCs; or #, naïve CD4+ T cells)… Source: Induction of specific T helper-9 cells to inhibit glioma cell growth — Oncotarget 2017; CC BY.

Glioma Resection — Figure 7 Figure 7. Administration with SEB enforces the effect of immunotherapy of Ag on experimental gliomaThe bars indicate the tumor size (mean ± SD) recorded from glioma-bearing mice. The treatment is… Source: Induction of specific T helper-9 cells to inhibit glioma cell growth — Oncotarget 2017; CC BY.

Glioma Resection — FIGURE 1 FIGURE 1. Glioma tissues are susceptible to SARS‐CoV‐2. (A) Immunofluorescent staining detecting the presence of the SARS‐CoV‐2 spike protein and ACE2 in glioblastoma tissue obtained from a… Source: Evidences of neurological injury caused by COVID‐19 from glioma tissues and glioma organoids — CNS Neuroscience & Therapeutics 2024; CC BY.

Glioma Resection — FIGURE 3 FIGURE 3. The global comparison of the differences of the neuronal cells or non‐neuronal cells in normal brain tissues, glioma tissues, and glioma‐COVID tissues. (A, B) UMAP representation of the… Source: Evidences of neurological injury caused by COVID‐19 from glioma tissues and glioma organoids — CNS Neuroscience & Therapeutics 2024; CC BY.

History of Present Illness

Past Medical History

Imaging Review

MRI Brain (T1, T1+Gad, T2, FLAIR, DWI, ADC, SWI, perfusion)

fMRI (Functional MRI)

DTI Tractography

Labs

Neurological Examination

Mental Status

Motor

Sensory

Visual Fields

Baseline Documentation

Surgical Planning

Case Logistics, OR Needs & Orders

Diagnosis & Indication

Awake vs Asleep Decision

Position

Incision

Approach

Key Surgical Steps

  1. Craniotomy — navigation-confirmed over tumor with surrounding normal cortex exposed
  2. Dural opening — curvilinear, reflect toward tumor
  3. Cortical mapping (if awake):
    • Map motor cortex (direct cortical stimulation, 1-4 mA bipolar probe)
    • Map language sites (counting, naming, reading — watch for speech arrest, paraphasias)
    • Mark positive sites with sterile tags
  4. Identify tumor on cortical surface — color change, consistency, navigation confirmation
  5. Corticotomy — enter through non-eloquent cortex, through a sulcus when possible (transsulcal approach)
  6. Subcortical resection:
    • Use CUSA and bipolar for tumor removal
    • Stay in the tumor — identify tumor-brain interface by color, consistency, and navigation
    • 5-ALA fluorescence: Tumor glows pink/red under blue-violet light (for high-grade gliomas)
    • Ultrasound to confirm tumor boundaries and depth
  7. Subcortical mapping (if awake):
    • Stimulate white matter tracts during resection
    • Motor response = near corticospinal tract (STOP)
    • Speech error = near arcuate fasciculus or IFOF (STOP)
    • Mapping defines the functional boundary of resection
  8. Progressive circumferential resection — work around the tumor, deepening progressively
  9. Assess extent of resection:
    • Navigation (note brain shift limitation)
    • Intraoperative ultrasound
    • 5-ALA fluorescence (any residual fluorescence?)
    • Intraoperative MRI (if available) — gold standard for EOR assessment
  10. Final hemostasis — bipolar, Surgicel, Gelfoam
  11. Send specimens: Multiple samples from different tumor regions; mark enhancing rim vs core vs margin

Critical Anatomy & Structures at Risk

  1. Corticospinal tract — mapped by MEPs and subcortical stimulation; DTI shows displacement
  2. Language networks — Broca area, Wernicke area, arcuate fasciculus, IFOF, SLF
  3. Supplementary motor area (SMA) — medial frontal; resection causes transient contralateral akinesia that typically recovers
  4. Pericallosal arteries — medial tumors; branches supply motor cortex
  5. Middle cerebral artery branches — lateral/insular tumors
  6. Lenticulostriate arteries — deep/insular tumors; supply internal capsule
  7. Optic radiations — temporal/parietal/occipital tumors (Meyer’s loop in temporal lobe)
  8. Basal ganglia / internal capsule — deep margin of many tumors

Equipment & Instrumentation

Monitoring

Anesthesia Considerations

Potential Complications & Contingencies

  1. New neurological deficit — if monitoring changes, stop resection at that boundary; SMA syndrome is typically transient
  2. Intraoperative seizure (awake) — cold saline irrigation on cortex, propofol 20-50 mg IV; consider converting to asleep
  3. Hemorrhage — meticulous bipolar hemostasis; consider that GBM neovasculature is fragile
  4. Brain swelling — mannitol, hyperventilation, ensure venous drainage, additional CSF drainage
  5. Incomplete resection — document planned residual if near eloquent structures; adjuvant therapy
  6. 5-ALA false positive — reactive gliosis and radiation changes can fluoresce; correlate with navigation

Operative Note Template

Preoperative Diagnosis: [Left/Right] [location] glioma (suspected WHO Grade ___)

Postoperative Diagnosis: Same (pending final pathology and molecular profiling)

Procedure: [Left/Right] [location] craniotomy for [awake/asleep] maximal safe resection of glioma [with cortical/subcortical mapping] [with 5-ALA fluorescence guidance] [with intraoperative MRI]

[Include details specific to glioma surgery: 5-ALA findings, mapping results, functional boundaries identified, extent of resection assessment method, specimen labeling]

Postoperative Plan

Chief-Level Case Review

Use these as the senior-level mental model for Glioma Resection (Supratentorial):

Common Pimp Questions

Use these to pressure-test preparation for Glioma Resection (Supratentorial):

  1. What is the surgical goal: gross-total, maximal safe, decompression, diagnosis, or cytoreduction?
  2. What eloquent cortex, tract, cranial nerve, vessel, or sinus defines the stopping point?
  3. What adjunct changes the case: navigation, mapping, 5-ALA, ultrasound, endoscope, ICG, or neuromonitoring?
  4. What is the edema, steroid, seizure, DVT, and postop imaging plan?
  5. What complication would you check for first in PACU based on this lesion location?

Attending Preference Variables

Items that commonly vary by surgeon or institution: