J Neurosurg Sci
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Traumatic brain injury (TBI) is a significant contributing factor to injury-related deaths worldwide. Despite the medical and fiscal importance of this subject, guidelines for the surgical management of closed and penetrating TBI are largely based on Level III evidence. Furthermore, the results of a large, costly trial designed to further elucidate the role of decompressive craniectomy, an important surgical intervention in patients with severe TBI and medically-refractory intracranial hypertension, have limited applicability. ⋯ There will continue to be unresolved controversies regarding decisions pertaining to defining an "optimal" surgical candidate, specific timing, techniques, and post-operative management of TBI patients who undergo surgery. New guidelines for the surgical management of TBI are forthcoming. Regardless, for neurosurgeons involved in the care of individuals with TBI, understanding the pathophysiologic and neurophysiologic consequences of surgical interventions, and gaining an understanding of the extant literature is imperative.
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Awake surgery is not a new technique: this is a new philosophy. Indeed, in surgery for diffuse gliomas performed in awake patients, the goal is not anymore to remove a "tumor mass" according to oncological boundaries (which in essence do not exist in infiltrating neoplasms), but to resect a part of the brain invaded by a chronic tumoral disease, according to functional limits both at cortical and subcortical levels. Therefore, intraoperative electrical mapping is accepted as the gold standard in order to gain information about the functionality of the underlying tissue when performing neuro-oncological surgery. ⋯ Beyond clinical implications, awake surgery represents a unique opportunity to study neural networks underpinning sensorimotor, visuospatial, language, executive and even behavioral functions in humans. This led to propose new models of connectomics, breaking with the localizationist view of brain processing, and opening the window to the concept of neuroplasticity. In summary, awake mapping enables to make a link between surgical neurooncology and cognitive neurosciences, to improve both survival and quality of life of glioma patients.