Glioma Surgery

Introduction

A glioma diagnosis — or the strong suspicion of one on a brain scan — raises urgent questions. What kind of tumour is this? How quickly does it need to be treated? Will surgery affect speech, memory, or movement? What comes after the operation?

This guide is written for adults who have been told they have a glioma, or whose imaging strongly suggests one, and who are now planning surgical treatment. It explains what glioma surgery involves, how surgeons protect brain function during the operation, what recovery typically looks like, and how surgery fits into the wider plan that usually includes pathology testing, radiation, and chemotherapy.

Gliomas vary enormously — from slow-growing tumours that may be watched for years to aggressive cancers that require prompt multimodal treatment. Because of this, the specifics of any one person’s surgery and recovery depend heavily on the tumour’s location, grade, and molecular features. The information here describes the general landscape; the precise plan will be shaped by your neurosurgeon and neuro-oncology team.

What Is Glioma Surgery?

Glioma surgery is a neurosurgical operation to remove as much of a glioma tumour as can be taken out safely, while protecting the surrounding brain tissue that controls movement, speech, vision, memory, and other functions.

Common types of glioma include:

• Astrocytoma — arises from astrocytes, a star-shaped type of glial cell. Astrocytomas range from slow-growing (low-grade) to highly aggressive.
• Oligodendroglioma — arises from oligodendrocytes, the cells that produce the insulating myelin around nerves. These tumours often have a particular molecular signature (1p/19q co-deletion) that affects treatment.
• Glioblastoma — the most aggressive form of adult glioma, classified as grade 4 under the World Health Organization (WHO) system.
• Ependymoma — arises from ependymal cells lining the fluid-filled spaces of the brain and spinal cord.

The WHO classifies gliomas by grade (1 to 4) and, since 2021, by molecular markers in the tumour tissue. Grade and molecular profile together drive treatment decisions and outlook far more than the tumour’s appearance on a scan alone — which is one of the reasons surgery (or at minimum a biopsy) is so central to care.

The Goals of Glioma Surgery

Surgery for a glioma may serve several purposes at the same time:

• Tissue diagnosis. A scan can suggest a glioma, but only examining tumour cells under a microscope — with modern molecular testing — can confirm the type, grade, and molecular profile.
• Maximal safe resection. Removing as much tumour as possible without harming healthy brain function. The more tumour removed safely, the better the typical outcome for most glioma types.
• Symptom relief. Reducing pressure on the brain, easing headaches, improving weakness, and often reducing seizures.
• Improving the effect of later treatment. Radiation and chemotherapy generally work better when less tumour is left behind.

Complete removal is not always possible — particularly when the tumour spreads through or sits within critical regions such as the speech, motor, or visual pathways. In these situations, partial removal (debulking) or biopsy alone may be the safer choice. Major neuro-oncology guidelines, including those from the National Comprehensive Cancer Network (NCCN) and the European Association of Neuro-Oncology (EANO), describe the central principle as maximal safe resection — the most tumour that can be removed without causing new neurological harm.

Why Is Glioma Surgery Performed?

Surgery is part of the standard treatment for most gliomas. The reasons a neurosurgeon may recommend an operation include:

• Imaging shows a brain mass consistent with a glioma, and tissue is needed to confirm the diagnosis and guide treatment.
• The tumour is causing symptoms such as seizures, headaches, weakness on one side of the body, vision changes, personality change, or difficulty with speech or memory.
• The tumour is large enough to raise pressure inside the skull or to push on critical brain structures.
• The tumour appears to be growing on follow-up scans, even if symptoms are mild.
• Removing the tumour is expected to improve survival, delay progression, or improve quality of life.

For some small, asymptomatic, low-grade gliomas in locations where surgery would carry high risk, careful observation with periodic imaging — sometimes called watch and wait — may be discussed as an alternative or a delay strategy. This decision is usually made by a multidisciplinary team that includes a neurosurgeon, neuro-oncologist, radiation oncologist, and neuroradiologist.

Who Is a Candidate?

Most adults with a newly identified glioma are considered for some form of surgery, but the kind and extent of surgery vary widely. Factors that the surgical team weighs include:

• Tumour location. Tumours in eloquent brain areas — regions that control speech, movement, vision, or memory — require especially careful planning and may favour awake surgery or limited resection.
• Tumour size and how it spreads. Some gliomas have well-defined edges; others infiltrate normal brain tissue, making complete removal impossible.
• Suspected grade and type. Imaging features, age, and clinical picture give clues to whether the tumour is low- or high-grade, which influences how aggressively to operate and how quickly.
• Overall health and fitness for surgery. Age alone is not a barrier, but heart, lung, and other medical conditions affect anaesthesia risk.
• Neurological status. Existing deficits, the presence of seizures, and overall functional ability shape the goals of surgery.
• Patient preferences. What matters most to the person undergoing surgery — for example, preserving the ability to speak a particular language, return to a specific job, or care for children — is part of the planning conversation.

For patients who are not candidates for open surgery — because of deep or diffuse tumour location, poor general health, or personal choice — a stereotactic biopsy alone may be performed to obtain tissue. This is a smaller operation that gives diagnostic information without attempting tumour removal, allowing radiation and chemotherapy to be tailored to the precise tumour type.

Alternatives and Adjacent Treatments

Glioma surgery rarely stands alone. It is usually one part of a sequence that may include radiation, chemotherapy, and newer targeted therapies. Alternatives to maximal resection — or treatments that follow it — include:

Stereotactic Biopsy Alone

When the tumour cannot be safely removed, a small needle biopsy guided by computer navigation can confirm the diagnosis. Treatment then proceeds with radiation, chemotherapy, or both, without an open resection.

Observation (Watch and Wait)

For selected small, low-grade, asymptomatic gliomas, careful monitoring with serial MRI scans may be appropriate. This approach delays surgery and its risks until evidence of growth or symptoms appears. The decision is individualised and not suitable for high-grade or symptomatic tumours.

Radiation Therapy

Radiation uses focused beams of energy to damage tumour cells. It is given after surgery for most high-grade gliomas and for many low-grade gliomas, particularly when tumour remains or recurrence risk is high. Modern techniques such as intensity-modulated radiation therapy (IMRT) and proton therapy aim to spare healthy brain.

Chemotherapy

Temozolomide is the most widely used chemotherapy for glioblastoma and certain other gliomas, typically given alongside and after radiation. Other regimens, such as PCV (procarbazine, lomustine, vincristine), are used for some oligodendrogliomas and astrocytomas based on molecular features.

Tumour Treating Fields (TTFields)

In some countries, a wearable device delivering low-intensity alternating electric fields to the scalp is used for newly diagnosed and recurrent glioblastoma. Availability varies.

Targeted and Investigational Therapies

Targeted drugs — including IDH inhibitors for gliomas with IDH mutations — and clinical trials of immunotherapy and other novel agents are reshaping treatment for some glioma types. Eligibility is determined by molecular testing of tumour tissue, which is one reason surgery or biopsy is so important early on.

For most patients with a newly diagnosed glioma, the decision is not surgery versus no surgery but rather what kind and how much surgery, followed by the right combination of further treatments. The plan is set by a neuro-oncology multidisciplinary team.

Surgical Approaches

The surgical approach is chosen based on the tumour’s location, the surrounding brain functions, and the goals of the operation. The main options include:

Craniotomy with Microsurgical Resection

This is the most common approach. Craniotomy means temporarily removing a section of the skull (a bone flap) to reach the brain. Using a high-powered operating microscope and microsurgical instruments, the surgeon carefully separates tumour from healthy tissue. At the end of the operation, the bone flap is replaced and fixed in place with small plates and screws, and the scalp is closed in layers.

Modern craniotomy for glioma is supported by several technologies:

• Neuronavigation — a GPS-like system that uses pre-operative MRI to guide the surgeon through the anatomy.
• Intraoperative MRI — in some centres, a scan is performed during the operation to confirm how much tumour has been removed before closing.
• Fluorescence-guided surgery — the patient drinks a substance called 5-aminolevulinic acid (5-ALA) before surgery, which makes high-grade glioma tissue glow pink under a special light, helping the surgeon distinguish tumour from normal brain.
• Ultrasound — provides real-time imaging during the operation.

Awake Craniotomy

For tumours near brain regions that control speech, movement, or other key functions, the operation may be performed with the patient awake for part of the procedure. The scalp and skull are numbed with local anaesthetic, and sedation is adjusted so the patient can talk, count, name objects, or move a hand on command while the surgeon works.

This is called intraoperative brain mapping. By stimulating small areas of the brain with a tiny electrical probe and observing what happens — for example, whether the patient’s speech changes — the surgeon can identify the borders of safe resection in real time. Awake craniotomy is widely used in experienced neuro-oncology centres for gliomas in or near eloquent areas, because it has been shown to support more extensive tumour removal while reducing the risk of permanent neurological deficits.

The procedure is not painful: the brain itself has no pain receptors, and the scalp and skull are well anaesthetised. Patients are carefully prepared and supported by the anaesthesia team throughout.

Minimally Invasive and Endoscopic-Assisted Approaches

For some deep-seated tumours or tumours within the brain’s fluid-filled ventricles, smaller openings combined with endoscopes (narrow telescopes with cameras) or tubular retractors allow access with less disruption of overlying tissue. These approaches are used selectively when anatomy is favourable.

Stereotactic Biopsy

When the goal is diagnosis only, or when open resection is not possible, a small hole is drilled in the skull and a fine needle is passed under image guidance to take small samples of tumour tissue. The procedure is shorter and recovery is faster than open craniotomy, but it does not remove tumour.

Laser Interstitial Thermal Therapy (LITT)

In selected cases, a thin laser probe is placed into the tumour through a small skull opening and used to heat and destroy tumour tissue under MRI guidance. LITT is offered at some specialised centres for deep or recurrent gliomas.

The choice among these approaches is made by the surgical team based on imaging, mapping, and the patient’s overall situation.

Preparing for Glioma Surgery

The weeks before glioma surgery are usually spent on detailed planning. Specific tests and steps vary, but typical preparation includes:

Imaging and Functional Studies

• MRI of the brain with contrast, often including special sequences that show the tumour’s structure and surrounding swelling.
• Functional MRI (fMRI) — identifies which parts of the brain are active during specific tasks (such as speaking, moving a hand, or seeing), so the surgeon knows where critical functions live in relation to the tumour.
• Diffusion tensor imaging (DTI) or tractography — maps the major nerve-fibre pathways of the brain.
• CT scan — sometimes used to assess bone anatomy or to plan the craniotomy.

Medical and Anaesthetic Assessment

• Blood tests, ECG, and chest X-ray as needed.
• Review by the anaesthesia team to identify any medical conditions that may affect surgery.
• Adjustment of medications — for example, blood thinners are usually paused, and steroids such as dexamethasone may be started to reduce brain swelling.
• Anti-seizure medication may be started or adjusted, especially if seizures have occurred.

Neuropsychological Testing

For tumours near memory, language, or executive-function regions, baseline cognitive testing is often performed. This helps the team plan surgery and gives a starting point against which to measure recovery.

Counselling and Consent

The neurosurgeon explains the goals of surgery, the realistic extent of resection, and the specific risks for this tumour in this location. For awake craniotomy, the patient meets the team in advance and rehearses the kinds of tasks they will be asked to do during the operation. Written informed consent is taken after questions have been answered.

Practical Preparation

• Hair is usually only shaved in a narrow strip along the planned incision — whole-head shaving is rarely needed in modern practice.
• Fasting for several hours before surgery, as instructed.
• Arranging help at home for the first weeks of recovery.
• If seizures have occurred, the patient should not drive until cleared by a doctor.

What Happens During Glioma Surgery

The exact steps depend on the approach, but a typical craniotomy for glioma includes the following stages:

1. Anaesthesia. The patient is taken to the operating theatre and either put fully to sleep (general anaesthesia) or sedated with the plan to wake them up for mapping (awake craniotomy). Monitoring lines are placed.
2. Positioning and head fixation. The head is held steady in a special clamp so that imaging and navigation remain accurate throughout.
3. Registration of navigation. The neuronavigation system is calibrated to match the patient’s anatomy with the pre-operative MRI.
4. Incision and craniotomy. The scalp is opened, and a bone flap is carefully cut and lifted to expose the dura, the tough covering of the brain.
5. Opening the dura. The dura is opened to reveal the brain surface.
6. Tumour localisation and (if planned) mapping. The tumour is located using navigation and ultrasound. In awake surgery, the patient is gradually woken up, and the surgeon uses a small electrical stimulator to map speech and movement areas.
7. Tumour resection. Using microscopic instruments — including suction, fine cautery, and an ultrasonic aspirator that breaks up tumour while sparing blood vessels — the surgeon removes tumour piece by piece, working to the edge that is safe.
8. Confirming the extent of resection. Depending on the centre, intraoperative MRI, ultrasound, or fluorescence guidance may be used to check how much tumour remains.
9. Closure. The dura is sewn closed, the bone flap is replaced and secured, and the scalp is closed in layers. A small drain may be left for a day or two.

Recovery from glioma surgery unfolds over weeks to months and depends on the tumour’s location, the extent of resection, and whether further treatment follows.

The First Few Days in Hospital

• Most patients spend the first 24 to 48 hours in an intensive care or high-dependency unit for close neurological monitoring.
• A scan (usually MRI) is performed within 24 to 72 hours to assess how much tumour was removed.
• Headache, fatigue, and a swollen scalp around the incision are common and managed with pain medication.
• Steroids are typically used to reduce brain swelling and tapered over the following weeks.
• Anti-seizure medication is often continued for at least several weeks.
• Early mobilisation — sitting up, then walking with help — usually begins within a day or two.
• Total hospital stay typically ranges from about 4 to 10 days, depending on progress and complexity.

The First Few Weeks at Home

• Fatigue is often the dominant symptom and can last for weeks. Rest is important.
• The incision is kept clean and dry; staples or sutures are removed at the wound check, typically 10 to 14 days after surgery.
• Heavy lifting, straining, and contact activities are avoided.
• Driving is not permitted until cleared by the medical team, particularly when seizures have occurred or anti-seizure medication has been started.
• The final pathology report, including molecular testing, usually becomes available within one to three weeks and shapes the next stage of treatment.

Rehabilitation

Depending on the tumour’s location and any neurological changes after surgery, rehabilitation may include:

• Physiotherapy for weakness, balance, or coordination.
• Speech and language therapy for difficulty with speech, understanding language, or swallowing.
• Occupational therapy for help with daily activities, memory strategies, and return to work.
• Neuropsychology for memory, attention, and emotional adjustment.

Many post-operative deficits improve significantly over weeks to months, although some may persist. Early rehabilitation tends to support better recovery.

Returning to Normal Activities

Light walking and gentle activity can usually resume within the first two weeks. Return to work depends on the job, the extent of recovery, and whether further treatment is starting. Some people return to office-based work within 4 to 8 weeks; others — particularly those undergoing radiation and chemotherapy — may need longer or may modify their workload.

Risks and Complications

Glioma surgery is a major operation, and even with modern techniques, real risks remain. Understanding them helps with informed consent and recovery planning.

General Surgical Risks

• Bleeding inside or around the brain.
• Infection of the wound, bone flap, or, less commonly, the brain itself (meningitis).
• Blood clots in the legs or lungs, particularly after a long operation and reduced mobility.
• Reaction to anaesthesia.

Neurological Risks

• New or worsened neurological deficits — for example, weakness on one side, speech difficulty, vision changes, or memory problems. These may be temporary or, less often, permanent.
• Seizures, including new seizures in patients who had not had them before.
• Brain swelling around the surgical area, usually managed with steroids.
• Cerebrospinal fluid leak — leakage of the fluid that surrounds the brain, sometimes requiring further treatment.
• Hydrocephalus — build-up of fluid in the brain, occasionally requiring a drain or shunt.

Tumour-Specific Risks

• Incomplete removal. Particularly when tumour involves critical areas, some tumour is left behind by design to protect function.
• Tumour recurrence. Most gliomas, especially higher-grade ones, can recur or progress over time, even after extensive surgery and additional treatment.

Risk levels vary widely by tumour type and location. The neurosurgeon will explain the specific risks for the individual case during the consent discussion. Across the field, advanced imaging, intraoperative mapping, and high-volume neuro-oncology teams are associated with lower complication rates.

Life After Glioma Surgery

Life after glioma surgery is shaped by three things at once: physical and cognitive recovery, the next steps of cancer treatment, and the emotional impact of a brain tumour diagnosis.

Further Treatment Based on Pathology

Once the tumour’s grade and molecular profile are confirmed, the multidisciplinary team recommends a tailored plan. For example:

• Glioblastoma is typically treated with radiation combined with temozolomide chemotherapy, followed by further temozolomide cycles, as described in NCCN and EANO guidelines.
• Anaplastic (grade 3) gliomas are usually treated with radiation plus chemotherapy, with the specific regimen depending on molecular features.
• Low-grade (grade 2) gliomas may be observed after maximal resection in some cases, or treated with radiation and chemotherapy based on risk factors.

Follow-Up Imaging

Regular MRI scans — typically every few months at first, then less frequently — are used to monitor for recurrence or progression. The timing is set by the neuro-oncology team.

Seizure Management

If seizures occurred before surgery, anti-seizure medication is usually continued and adjusted over time. Driving restrictions follow local rules and the advice of the treating doctor. Some patients are able to come off medication after a period of seizure freedom; others continue long-term.

Cognitive and Emotional Recovery

Fatigue, memory difficulties, slower thinking, mood changes, and anxiety are common after brain surgery and during further treatment. Neuropsychology, counselling, and patient support groups can help. Family members are often deeply affected too and benefit from support.

Return to Work, Driving, and Daily Life

Many people return to meaningful work and daily activities after glioma surgery. The pace varies. Open conversation with employers, gradual return-to-work plans, and adjustments such as flexible hours or reduced screen time can ease the transition.

Glioma Surgery in Children

Gliomas behave differently in children than in adults, and surgery is shaped by these differences. Most paediatric gliomas are low-grade, and many occur in the cerebellum (the part of the brain at the back of the skull involved in balance and coordination) or along the brainstem and optic pathways. The molecular features of childhood gliomas also differ from adult tumours, and treatment decisions take these into account.

Key differences in paediatric glioma surgery include:

• Higher rates of complete resection. Many childhood low-grade gliomas, such as pilocytic astrocytomas of the cerebellum, can be completely removed, and complete resection is often associated with long-term tumour control.
• Greater concern for long-term effects of radiation. Radiation to the developing brain can affect growth, hormones, and cognition. Paediatric teams aim to avoid or delay radiation when possible, particularly in young children, by maximising surgical removal and using chemotherapy or targeted therapy.
• Specialist paediatric care. Children with gliomas are typically managed by paediatric neurosurgeons, paediatric neuro-oncologists, and paediatric anaesthetists in centres equipped for children. Family-centred care, play therapy, and schooling support are part of the package.
• Targeted therapies in selected tumours. Certain paediatric gliomas with BRAF or other specific molecular changes can be treated with targeted drugs, sometimes in place of or alongside radiation.

Outlook for paediatric low-grade gliomas is often considerably better than for adult high-grade gliomas, although long-term follow-up is needed to monitor for late effects and possible regrowth.

Frequently Asked Questions

Is glioma surgery a cure?

Sometimes, particularly for low-grade gliomas in favourable locations where complete removal is possible. For most adult high-grade gliomas, surgery is not a cure on its own but is an essential part of treatment that, combined with radiation and chemotherapy, can extend life and improve symptoms.

Will I need radiation or chemotherapy after surgery?

Often, yes. The need is determined by the tumour’s grade and molecular profile on the final pathology report. Some low-grade gliomas may be followed with imaging only after complete removal; most higher-grade gliomas are treated with radiation, chemotherapy, or both.

Will surgery affect my speech or movement?

There is always some risk of new neurological symptoms, especially when the tumour is near speech, motor, or other critical areas. Functional MRI, awake surgery with brain mapping, and other techniques are used to reduce this risk. Many new deficits after surgery improve substantially over weeks to months with rehabilitation.

Is awake brain surgery painful?

The brain itself has no pain receptors. The scalp and skull are numbed with local anaesthetic, and the patient is sedated for the painful parts of the operation. During the awake phase, most patients describe the experience as strange rather than painful, and the anaesthesia team supports them throughout.

How soon will the pathology results be available?

An initial impression may be available within a few days, but the full report — including molecular testing such as IDH mutation status and 1p/19q co-deletion — usually takes one to three weeks. This information is essential for tailoring further treatment.

Can a glioma come back after surgery?

Yes. Most gliomas, particularly higher-grade ones, can recur even after extensive surgery and additional treatment. Regular follow-up imaging is used to detect recurrence early. Treatment for recurrence may include further surgery, additional radiation, different chemotherapy, targeted therapy, or clinical trial participation.

How long is the hospital stay?

Most patients stay in hospital for around 4 to 10 days after a craniotomy, with the first 1 to 2 days typically in an intensive care or high-dependency unit. Stay length depends on tumour complexity and how recovery progresses.

When can I drive again?

Driving restrictions depend on local rules and on whether seizures have occurred. A doctor’s clearance is needed before resuming driving. People taking anti-seizure medication may be required to be seizure-free for a defined period before driving.

Will my hair grow back?

Modern practice usually shaves only a narrow strip along the planned incision. Hair grows back, although the scar line will remain. Many people find that a hat or hairstyle change easily covers the area.

What should I look for in a centre and surgical team?

For glioma surgery, experienced neuro-oncology centres typically offer a multidisciplinary team (neurosurgery, neuro-oncology, radiation oncology, neuropathology, neuroradiology), access to functional imaging and intraoperative mapping, the option of awake craniotomy where appropriate, and structured rehabilitation. Asking about the team’s experience with the specific tumour type and location, expected goals of surgery, and the rehabilitation pathway is reasonable and welcomed.

Conclusion

Glioma surgery is a cornerstone of modern brain tumour care. Beyond removing as much tumour as can be safely taken out, it provides the tissue needed to identify exactly what kind of glioma is present and how best to treat it. Advances in functional imaging, neuronavigation, fluorescence guidance, and awake brain mapping have made it possible to operate more thoroughly on tumours that were once considered too risky to approach — while better protecting speech, movement, memory, and personality.

Surgery is rarely the whole story. For most gliomas, the operation is followed by carefully planned radiation, chemotherapy, targeted therapy, or observation based on the tumour’s grade and molecular features. Recovery is a process that involves physical healing, rehabilitation, further cancer treatment, and emotional adjustment for both patients and families. With an experienced multidisciplinary team and clear, ongoing conversations about goals and expectations, many people with gliomas are able to return to meaningful activities and live with the condition over time.