Résumé
The classical concept underlying neuro-oncologic surgery is to excise a tumor mass that is displacing the brain with the goal of increasing survival. Recent progress in connectomics has led to a better understanding of neural processes as well as a paradigmatic shift in glioma surgery based on strong interactions between neuro-oncology and cognitive neuroscience. First, a glioma is not a focal mass invaginated within the parenchyma but a diffuse tumoral disease invading the brain. This principle resulted in a new surgical philosophy—that is, to maximally remove the infiltrated tissue while also preserving eloquent cerebral networks. Second, this approach requires a clear definition of which structures are critical to preserving quality of life versus those that can be compensated by neuroplastic mechanisms. Because limitations of functional reshaping are mainly represented by the subcortical connectivity, mapping the connectome by using cortical and subcortical electrical stimulation during surgery is a priority. Neurosurgeons must switch from image-guided surgery to functional mapping-guided resection (i.e., from technologic guidance within the operating theater to a philosophy based on exploration of the dynamics of delocalized neural circuits throughout resection). In fact, awake mapping with real-time monitoring and mapping of sensorimotor, visuospatial, language, executive, and emotional functions has made it possible to optimize the oncofunctional balance. Third, surgery should not be seen in isolation but rather integrated in the course of global multistage therapeutic management, especially in the case of low-grade gliomas, opening the door to repeat resections due to the potential of remapping over subsequent years. “Cognitive neuro-oncologic surgery” that aims to improve both quality of life and survival must become “connectomal neurosurgery.”