Contribution of cortical and subcortical electrostimulation in brain glioma surgery: methodological and functional considerations.

The aim of brain glioma surgery is to maximize the quality of resection, while minimizing the risk of sequelae. Due to the frequent location of gliomas in "eloquent areas" and because of major interindividual anatomofunctional variability, the cortical functional organization, effective connectivity and potential for plasticity must be studied for each patient individually. Consequently, in addition to preoperative functional neuroimaging, intraoperative electrostimulation (IES) can be used, under general anesthesia for motor mapping or on awake patient for language and cognitive mapping. This is an easy, accurate, reliable, and safe technique of detection of both cortical and subcortical functionally essential structures. Thus, IES enables: (i) to study the individual cortical functional organization before any resection; (ii) to understand the pathophysiology of areas involved by gliomas; (iii) to map the subcortical structures along the resection, allowing a study of the anatomofunctional connectivity; (iv) to analyze the mechanisms of on-line short-term plasticity, using repeated IES; (v) to tailor the resection according to individual cortico-subcortical functional boundaries, enabling to optimize the benefit:risk ratio of surgery. Moreover, IES can be combined with perioperative functional neuroimaging, before and after surgery, to validate these noninvasive techniques and to better understand the short-term and long-term plasticity mechanisms based on functional cortical reshaping and connectivity changes. Such individual knowledge allows planning multiple-stages surgery. In conclusion, IES enables to increase the impact of surgery on the natural history of gliomas, to preserve the quality of life, and to better understand the dynamic functional anatomy of the brain.