Malignant gliomas are characterized by their propensity to invade surrounding brain parenchyma. The median survival of patients is less than 2 years with maximal surgical resection, chemotherapy, and radiotherapy. Although there have been controversial arguments about the role of surgical resection, there is increasing evidence that a safe and radical removal of malignant glioma is associated with a better survival outcome. Surgery is still essential to obtain brain tissue for pathological analysis, and reduce mass effect. Intraoperative magnetic resonance imaging, neuronavigation, ultrasonography, and fluorescence-guided surgery are the most used tools worldwide. 5-Aminolevulinic acid surgery, combined with Stupp protocol, produces a median survival of 15 months. The objectives of perioperative positioning are to enhance optimal exposure, prevent injury related to position, and maintain normal body alignment without excess flexion, extension, or rotation. Advances in surgical techniques have contributed to enhanced recovery after tumor resection, improved postoperative functional status, and decreased length of stay in the hospital. This chapter presents the current literature related to the surgical management of high-grade gliomas.

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Background: Glioblastoma multiforme (GBM) owes an ominous prognosis: its mean overall survival is 14 months. The extent of surgical resection (ESR) highlights among factors in which an association has been found to a somewhat better prognosis. However, the association between greater ESR and prolonged overall (OS) survival is not a constant finding nor a proven cause-and-effect phenomenon. To our objective is to establish the strength of association between ESR and OS in patients with GBM through a systematic review and meta-analysis. Methods: In accordance with PRISMA-P recommendations, we conducted a systematic literature search; we included studies with adult patients who had undergone craniotomy for GBM. Our primary outcome is overall postoperative survival at 12 and 24 months. We reviewed 180 studies, excluded 158, and eliminated 8; 14 studies that suited our requirements were analyzed. Results: The initial level of evidence of all studies is low, and it may be degraded to very low according to GRADE criteria because of design issues. The definition of different levels of the extent of resection is heterogeneous and poorly defined. We found a great amount of variation in the methodology of the operation and the adjuvant treatment protocol. The combined result for relative risk (RR) for OS for 12 months analysis is 1.25 [95% confidence interval (95% CI) 1.14–1.36, P < .01], absolute risk reduction (ARR) of 15.7% (95% CI 11.9–19.4), relative risk reduction (RRR) of 0.24 (95% CI 0.18–0.31), number needed to treat (NNT) 6; for 24-month analysis RR is 1.59 (95% CI 1.11–2.26, P < .01) ARR of 11.5% (95% CI 7.7–15.1), relative risk reduction (RRR) of 0.53 (95% CI 0.33–0.76), (NNT) 9. In each term analysis, the proportion of alive patients who underwent more extensive resection is significantly higher than those who underwent subtotal resection. Conclusion: Our results sustain a weak but statistically significant association between the ESR and OS in patients with GBM obtained from observational studies with a very low level of evidence according to GRADE criteria. As a consequence, any estimate of effect is very uncertain. Current information cannot sustain a cause-and-effect relationship between these variables.

Cerebral salt wasting syndrome, occurring in some patients with subarachnoid hemorrhage, is more commonly related to certain specific anatomic locations of the ruptured aneurysm, responds to sodium replacement therapy and fluids and can be diagnosed and treated based on the clinical, hydroelectrolytic and hemodynamic course of the patient. Further studies are needed to define the underlying mechanism of this condition.

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