**3.2 Clinical and imaging recording**

Patient response during awake mapping is an important component in the data analysis also after surgery. Published data show different levels of analysis of response depending on the aim of mapping. Specifically, response registrations depend upon the presence of a either professional figure in the operating room for providing a written record of the findings or the use of audiotape or/and videotape recordings to be evaluated by a blinded or multiple postoperative examiners (Corina et al, 2005; Duffau et al., 2006; Haglund 1994; Sanai et al., 2008).

Audio-videotaping the mapping procedures is particularly useful for checking mouth and face muscles in order to classify language disorders and to detect eye movements which, mostly in frontal sites, could interfere with reading (Malow et al., 1996; Milea et al., 2002; Peraud et al., 2004; Roux et al., 2003b; Van Buren & Fedio, 1978). Documentation with pictures or audio-videotape of the brain was systematically obtained during stimulation to match sites with response site by site.

#### **3.3 Positioning**

Positioning is a compromise between patient and surgeon comfort. Ideally, positioning attains a head position that should fulfill requisites besides those of the surgeon: patient muscle relaxation; airways accessibility for the anesthesiologist; and the possibility of talking and interacting with the staff including watching the personal computer. For these reasons, the patient is positioned while awake. A rigid headrest with pins is perfectly tolerated by the patient after the administration of a local anesthetic.

#### **3.4 Craniotomy**

Language-mapping techniques were historically developed in the context of epilepsy surgery, in which large craniotomies exposed the brain well beyond the region of surgical interest to localize multiple cortical regions containing stimulation-induced language and motor function (i.e., "positive" sites) prior to resection. Recently, with increasing reliance on mapping, craniotomies have gradually been reduced to the size necessary to approach the lesion, thereby allowing for minimal cortical exposure overlying the tumor, less extensive intraoperative mapping, and a more time-efficient neurosurgical procedure (Sanai et al., 2008).

#### **3.5 Surgical instruments**

302 Advances in the Biology, Imaging and Therapies for Glioblastoma

Blood loss: Gupta observed that blood loss is less in AS than in GA (266 ml vs. 365 ml;

 Postoperative local complications: Taylor found a 2.5% wound-complication and postoperative hematoma rate, similar to that described in a large study conducted on 1427 elective supratentorial craniotomies (Taylor et al., 1995; Taylor & Bernstein, 1999). Mean postoperative hospital stay and intensive care unit (ICU) stay: these are not significant results (Gupta et al., 2007). An awake craniotomy carries low morbidity and mortality rates and minimizes the need for ICU admission and the total hospital stay. Patient age: most authors agree that patients must be older than 11 years (Berger et al.,

Patient response during awake mapping is an important component in the data analysis also after surgery. Published data show different levels of analysis of response depending on the aim of mapping. Specifically, response registrations depend upon the presence of a either professional figure in the operating room for providing a written record of the findings or the use of audiotape or/and videotape recordings to be evaluated by a blinded or multiple postoperative examiners (Corina et al, 2005; Duffau et al., 2006; Haglund 1994;

Audio-videotaping the mapping procedures is particularly useful for checking mouth and face muscles in order to classify language disorders and to detect eye movements which, mostly in frontal sites, could interfere with reading (Malow et al., 1996; Milea et al., 2002; Peraud et al., 2004; Roux et al., 2003b; Van Buren & Fedio, 1978). Documentation with pictures or audio-videotape of the brain was systematically obtained during stimulation to

Positioning is a compromise between patient and surgeon comfort. Ideally, positioning attains a head position that should fulfill requisites besides those of the surgeon: patient muscle relaxation; airways accessibility for the anesthesiologist; and the possibility of talking and interacting with the staff including watching the personal computer. For these reasons, the patient is positioned while awake. A rigid headrest with pins is perfectly

Language-mapping techniques were historically developed in the context of epilepsy surgery, in which large craniotomies exposed the brain well beyond the region of surgical interest to localize multiple cortical regions containing stimulation-induced language and motor function (i.e., "positive" sites) prior to resection. Recently, with increasing reliance on mapping, craniotomies have gradually been reduced to the size necessary to approach the lesion, thereby allowing for minimal cortical exposure overlying the tumor, less extensive

tolerated by the patient after the administration of a local anesthetic.

Sarang, & Dinsmore, 2003).

p<0.05) (Gupta et al., 2007).

**3.2 Clinical and imaging recording** 

match sites with response site by site.

1989).

Sanai et al., 2008).

**3.3 Positioning** 

**3.4 Craniotomy** 

of patients, whereas other studies have reported rates as high as 16% (Bello et al., 2007; Petrovich Brennan et al., 2007; Serletis et al., 2007; Taylor & Bernstein, 1999). Some authors advocated the use of propofol to reduce intraoperative seizures (Berkenstadt et al., 2001; Danks et al., 1998; Gignac et al., 1993; Herrick et al., 1997; Huncke et al., 1998;

> Essential devices for accurate surgical techniques are the intraoperative microscope and the ultrasonic aspirator. The neuronavigator has a multipurpose application: define the cortical boundaries of lesions, especially in LGGs; establish the site of corticectomy and the trajectory to subcortical lesions; provide image-assisted surgery for both fMRI (motor task) and DTI; and establish the distance to anatomical landmarks. These advantages are limited to the first part of the operation prior to brain shift. In this regard, intraoperative MRI is a promising tool for improving accuracy in subcortical mapping of fascicles and functions.
