![]() Such a balance is often referred to as the patient “onco-functional balance.” However, while it is well known that not all cortical tissue is functionally eloquent and the brain is generally resistant to a degree of surgical reduction, glioma patients continue to present post-operatively with poor cognitive functioning limiting social interactions and integration back into the workforce ( 3– 5). While also considering numerous factors such as patient prognosis, tumor topography relative to “eloquent” or “non-eloquent” cerebrum has generally guided the aggressiveness of surgical cytoreduction in hopes of minimizing the risk of inducing new neurologic deficits ( 2). Modern glioma surgery has advanced based on the understanding that maximal tumor resection improves overall survival ( 1). In this manuscript, we review four concepts with detailed examples which will help us better understand post-operative cognitive outcomes and provide a guide for how to utilize connectomics to reduce cognitive morbidity following cerebral surgery. However, connectome-based neurosurgery and related applications for neurorehabilitation are relatively nascent and require further work moving forward to optimize our ability to add highly valuable connectomic data to our surgical armamentarium. ![]() ![]() Fortunately, recent large-scale movements in the neuroscience community, such as the Human Connectome Project (HCP), have provided updated neural data detailing the many intricate macroscopic connections between cortical regions which integrate and process the information underlying complex human behavior within a brain “connectome.” Connectomic data can provide us better maps on how to understand convoluted cortical and subcortical relationships between tumor and human cerebrum such that neurosurgeons can begin to make more informed decisions during surgery to maximize the onco-functional balance. Furthermore, reduction of the brain into isolated cortical regions without consideration of the complex, interacting brain networks which these regions function within to subserve higher-order cognition inherently prevents our successful navigation of true eloquent and non-eloquent cerebrum. Such observations are likely related to the difficulty in interpreting the highly-dimensional information these technologies present to us regarding cognition in addition to our classically poor understanding of the functional and structural neuroanatomy underlying complex higher-order cognitive functions. Furthermore, advancements in multimodal imaging technologies have improved our ability to extend the rate of resection while minimizing the risk of inducing new neurologic deficits, together referred to as the “onco-functional balance.” However, despite the common utilization of invasive techniques such as cortical mapping to identify eloquent tissue responsible for language and motor functions, glioma patients continue to present post-operatively with poor cognitive morbidity in higher-order functions. Traditionally, neurosurgeons have considered that lesions in “non-eloquent” cerebrum can be more aggressively surgically managed compared to lesions in “eloquent” regions with more known functional relevance. The surgical management of brain tumors is based on the principle that the extent of resection improves patient outcomes. 3Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Sydney, NSW, Australia.2Department of Neurosurgery, Rush University Medical Center, Chicago, IL, United States.1Robert Wood Johnson School of Medicine, Rutgers University, New Brunswick, NJ, United States. ![]() Dadario 1, Bledi Brahimaj 2, Jacky Yeung 3 and Michael E.
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