Eloquent glioma resection assisted by brain connectomics: A new tool for awake neurosurgery

Background: Awake craniotomy with intraoperative mapping remains the gold standard for resection of gliomas in eloquent brain regions, enabling functional preservation while maximizing tumor removal. Recent advances in brain connectomics provide a connectivity-based approach, complementing traditional localization strategies by visualizing patient-specific structural and functional networks. We report the first Latin American case of diffuse glioma resection in the motor cortex using connectome-guided neuronavigation combined with awake functional monitoring. Case Description: A 43-year-old male presented with focal motor seizures affecting the left upper limb. Preoperative magnetic resonance imaging revealed a motor-eloquent lesion. Patient-specific connectome parcellation identified intratumoral motor parcels, guiding surgical approach planning. During awake craniotomy, intraoperative mapping confirmed motor activation sites, enabling selective resection. Surgery was halted upon detecting transient monoparesis (3/5, Daniels scale) to preserve function. Postoperative recovery was complete within 2 weeks. Pathology confirmed the World Health Organization grade 2 diffuse astrocytoma. Conclusion: This case illustrates the synergistic potential of connectome-guided neuronavigation and awake surgery in achieving a balance between oncologic and functional goals. Connectomics enhances preoperative planning by delineating individualized cortical-subcortical networks, even in anatomically distorted brains. Awake mapping provides real-time functional verification, mitigating limitations such as brain shift and resolution constraints inherent to navigation alone. While evidence is still limited to small series, this integrated approach offers a promising avenue for safe maximal resection in eloquent gliomas. Further studies are needed to validate its impact on long-term functional and oncologic outcomes.