Dr. Abel Ferrés Pijoan
Neurosurgeon · Spine, neuro-oncology and skull base
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Tumour surgery
Gliomas: surgical treatment
Gliomas are the most common malignant primary tumour of the central nervous system in adults. The surgical approach aims for maximal safe resection whilst preserving neurological function, combined with radiotherapy and chemotherapy according to histological grade.
What is it?
Gliomas: surgical treatment
Gliomas are tumours that arise from the glial cells of the brain (astrocytes, oligodendrocytes, ependymocytes). They account for approximately 30% of primary brain tumours and 80% of malignant brain tumours. Treatment combines maximal safe resection surgery, radiotherapy and chemotherapy, and its success depends on the histological grade (WHO I-IV) and the extent of resection achieved.
30%
of primary brain tumours are gliomas
>95%
resection target in non-eloquent areas
2-3h
typical duration of surgery
Symptoms
When to consult a neurosurgeon?
Symptoms depend on tumour location and growth rate. The most common are:
- Persistent headache, especially in the morning or with Valsalva manoeuvres
- New-onset epileptic seizures in an adult (more than 50% of gliomas present this way)
- Focal neurological deficit: loss of strength, speech or vision
- Progressive cognitive changes or personality changes
- Nausea or vomiting on an empty stomach associated with raised intracranial pressure
Urgent attention: Go to A&E if you develop a sudden severe headache, loss of consciousness or a generalised seizure.
Treatments
What techniques do we use?
Maximal safe resection
The fundamental oncological principle. Each additional 1% of resection is associated with better survival. We use neuronavigation with preoperative tractography.
Awake craniotomy
Real-time cortical and subcortical mapping for gliomas in eloquent areas (speech, movement). Avoids permanent deficits by modifying the technique according to intraoperative responses.
Neurophysiological monitoring
Continuous motor and somatosensory evoked potentials. Detects any change within fractions of a second to guide surgical adjustments.
5-ALA (tumour fluorescence)
5-aminolevulinic acid marks tumour tissue in fluorescent red under blue-light microscopy. Increases the rate of radical resection in glioblastomas.
Intraoperative MRI
Immediate confirmation of the extent of resection before closure. Allows further resection if residual tumour is visible.
Postoperative multidisciplinary committee
Neuro-oncology, medical oncology and radiotherapy teams decide on adjuvant treatment after definitive histopathology.
Our protocol
How we approach each case
Every patient with a suspected glioma undergoes preoperative multimodal 3 Tesla MRI (spectroscopy, perfusion, tractography). When the tumour contacts eloquent areas, awake surgery is considered after prior neuropsychological assessment. Intraoperative biopsy guides the aggressiveness assessment and allows the surgical strategy to be adjusted. After surgery, the case is presented to the neuro-oncology committee within 7 days to decide on standard adjuvant treatment (radiotherapy plus temozolomide following the Stupp protocol for glioblastomas).
Perioperative protocol
How we organise each case
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1 · Preoperative work-up
Multimodal brain MRI (functional, DTI, spectroscopy), methionine-PET where indicated, neuropsychological assessment and genetic counselling if suspected. Review by the neuro-oncology committee.
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2 · Surgery
Surgery with neuronavigation, 5-ALA fluorescence for high-grade gliomas, cortical mapping and awake craniotomy when the lesion affects eloquent areas (language, motor). Intraoperative MRI where available.
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3 · Immediate postoperative period
ICU for 24 hours, postoperative MRI within 72 hours to measure the extent of resection. Chemoradiotherapy following the Stupp protocol begins 3-4 weeks later for high-grade gliomas.
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4 · Discharge and follow-up
Typical hospital stay of 4-7 days. Personalised neurocognitive rehabilitation and multidisciplinary committee follow-up every 3 months.
Team
Neurosurgeons who treat this condition
Dr. Pedro Roldán Ramos
Neurosurgeon · Spine, functional and brain
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Dr. Jorge Torales
Neurosurgeon · Skull base and spinal endoscopy
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Dr. Jhon A. Hoyos Castro
Neurosurgeon · Spine, peripheral nerve and skull base
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Dra. María Elena Filadoro
Neurosurgeon · Functional, epilepsy and spine
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Dra. M. Noelia Sosa Echeverría
Neurosurgeon · Functional and stereotaxy
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Dra. Giulia Guizzardi
Neurosurgeon · Minimally invasive and skull base
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Results
Prognosis and recovery
Prognosis depends on histological grade: low-grade gliomas (WHO II) have median survival of 7-10 years, whilst glioblastoma (WHO IV) has a median of 14-18 months with standard treatment. Resection of 98% or more is associated with a significant improvement in overall and progression-free survival. Typical postoperative recovery allows discharge in 4-6 days.
Regarding functional recovery, approximately 70% of patients recover or improve their neurological level during the first 4-8 weeks after surgery. Beyond that period, spontaneous improvement is very limited: only around 50% experience further improvement without active treatment. This is why early surgical indication and intraoperative mapping are decisive: in oncological neurosurgery, waiting is not a therapeutic option.
Frequently asked questions
Answers to your questions
What is a glioma and what is its prognosis?
A glioma is a tumour of the central nervous system that arises from glial cells. It is classified into four grades (WHO I-IV). Prognosis ranges from prolonged survival in low-grade tumours (grades I-II, median 7-10 years) to glioblastoma (grade IV, median 14-18 months with standard treatment).
Are all gliomas malignant?
No. Grade I gliomas are considered benign (e.g. pilocytic astrocytoma, common in children, curable with complete resection). Grades II-III are of intermediate malignancy and grade IV (glioblastoma) is highly malignant. Biopsy determines the exact grade.
What is an awake craniotomy and what is it used for?
It is a technique in which the patient remains conscious during part of the procedure to identify critical brain areas (speech, movement) through cortical stimulation. It is used when the tumour is close to eloquent areas and allows more tissue to be resected whilst preserving function.
How long does glioma surgery take?
Between 3 and 6 hours depending on size, location and technique (awake versus asleep). Awake surgery typically takes longer because it includes phases of cortical stimulation. A CT scan is performed immediately after surgery and the patient is admitted to ICU for the first 24 hours.
What treatment is needed after surgery?
After surgery, histopathology confirms the grade and biomarkers (IDH, MGMT, 1p/19q). Grade II-III gliomas usually require radiotherapy plus or minus chemotherapy. Glioblastoma follows the Stupp protocol (radiotherapy plus concomitant and adjuvant temozolomide). The final decision is made by the multidisciplinary committee.
Can I return to work after surgery?
Most patients return to work between 4 and 8 weeks after surgery, depending on their type of work. Neuropsychological assessments are recommended at 4-6 weeks. Residual epileptic seizures often require antiepileptic medication for at least 6-12 months postoperatively.
Is there treatment if the glioma recurs?
Yes. Recurrence can be treated with re-surgery, re-irradiation, second-line chemotherapy (lomustine, bevacizumab) or enrolment in clinical trials. Each case is reassessed by the multidisciplinary committee. Re-surgery in selected patients has demonstrated a survival benefit.
References
What the clinical guidelines say
"Maximal safe resection remains the most important modifiable prognostic factor in high-grade gliomas. Techniques such as awake surgery and 5-ALA have significantly increased rates of radical resection."
"In low-grade gliomas, the extent of resection is associated with improvement in overall and progression-free survival."
Bibliography
Scientific references consulted
Studies and clinical guidelines underpinning our approach to this condition.
- Weller M. et al. EANO guidelines on the diagnosis and treatment of diffuse gliomas of adulthood. Nat Rev Clin Oncol. 2021. View publication
- Stupp R. et al. Radiotherapy plus concomitant and adjuvant temozolomide for glioblastoma. N Engl J Med. 2005. View publication
- Stummer W. et al. Fluorescence-guided surgery with 5-aminolevulinic acid for resection of malignant glioma. Lancet Oncol. 2006. View publication
- Louis DN. et al. The 2021 WHO Classification of Tumors of the Central Nervous System. Neuro-Oncology. 2021. View publication
- Sanai N. et al. An extent of resection threshold for newly diagnosed glioblastomas. J Neurosurg. 2011. View publication
- NCCN Clinical Practice Guidelines in Oncology Central Nervous System Cancers. NCCN. 2024. View publication
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Patient reviews
What our patients say
High-grade glioma
"I arrived with a glioma I had been told was inoperable. Here they reviewed it at the tumour board and offered me a plan. The surgery was a success. Four years on, I am well."
Cervical disc herniation
"For years I had a cervical disc herniation, operated on by another team with no improvement. Minimally invasive surgery gave me back my mobility and took the pain away."
International patient
"I travelled from outside Spain. The team reviewed my case before I came and gave me a clear plan. Caring people and impeccable technique."
Request information
Second opinion on your glioma diagnosis
Send us your MRI scan and histopathology report if available. We review your case at our neuro-oncology committee and respond within 24-48 hours.