The Role of Surgery Along the Diffuse Low-Grade Glioma Timeline: Insights into Surgical Paradigms

Diffuse low-grade glioma (DLGG) present a complex challenge in neurosurgery because of their infiltrative characteristics and the potential for malignant transformation over time. Historically, DLGG management emphasized a conservative approach, balancing tumor control with preservation of neurological function. However, recent advancements in neuroimaging, intraoperative mapping techniques, and adjuvant therapies have reshaped surgical strategies, promoting more aggressive resections with improved patient survival. Longitudinal studies have elucidated the natural history of DLGGs, guiding clinicians in determining optimal timing for surgical intervention based on tumor growth kinetics and patient-specific factors. The incorporation of sophisticated imaging techniques, such diffusion tensor imaging and functional MRI, has transformed preoperative planning, allowing surgeons to more precisely define tumor boundaries and minimize damage to eloquent areas during resection. In this clinical setting, the combination of brain mapping techniques and intraoperative neurophysiological monitoring is the cornerstone to maximize tumor resection while minimizing the risk of postoperative permanent neurological deficits. This chapter examines the pivotal role of surgery in the DLGG management, with a focus on its significance across different stages of gliomagenesis. Emphasis is placed on surgical indications in incidental, symptomatic LGGs, and during disease progression, alongside an exploration of surgery’s role in controlling tumor-related epilepsy.