Although surgical intervention alone is not yet a cure for diffuse infiltrating gliomas, surgery is usually the initiating and primary therapeutic step for malignant gliomas in the principles of clinical management. In the absence of adequate prospective clinical randomized trials, the assessment of the extent of resection of diffuse gliomas in relation to the survival benefit to patients has relied heavily on retrospective clinical data analysis. Available evidence suggests that extensive surgical resection prolongs survival expectations in patients with high-grade tumors. Surgical treatment not only clarifies the histopathological and molecular pathological diagnosis, reduces tumor cell load, lowers intracranial pressure, and alleviates neurological deficits, but also creates favorable conditions for the development and implementation of adjuvant radiotherapy regimens. Therefore, the significance of surgical management for the treatment of glioma is certain. The development of imaging and microscopic neurosurgical techniques have been instrumental in the surgical management of gliomas. The application of cranial CT and MRI scanning techniques has enhanced the preoperative clinical diagnosis of gliomas and aided preoperative decision making by showing anatomical details of the tumor and with brain structures. Microscopic neurosurgical techniques, using the sulcus and gyrus as boundaries and anatomical resection along the course of the white matter fiber bundles at the tumor margins, have improved the degree of resection and safety of glioma surgery. However, gliomas often diffusely infiltrate and involve functional brain areas and deep structures. Conventional CT and MRI scans alone cannot provide us with information about the metabolism of the tumor and its impact on the functional structures of the brain, and precise spatial localization of deep intracranial lesions is difficult, which further affects the effectiveness of surgical resection of tumors involving the functional areas of the brain and the deeper parts of the brain. Since the end of the 20th century, gliomas have entered the era of image-guided and neurofunction-guided surgery. Multimodal 3D image fusion and neuronavigation, neurophysiological monitoring and arousal surgery, and intraoperative real-time imaging have been applied to the surgical resection of gliomas, which has led to the innovation of surgical strategies and the implementation of maximum safe resection of tumors. I. Multimodal image fusion with three-dimensional (3D) surgical planning and neuronavigation The development of brain imaging technology remains an important driver for the advancement of surgical treatment of malignant gliomas in the last decade. MRI-based techniques for water diffusion quantification, including apparent diffusion coefficient (apparentdiffusioncoefficient,ADC), anisotropy (fractionalanisotropy), diffusiontensorimaging,DTI), and cerebralbloodvolume( cerebralbloodvolume,CBV) and multivoxel magnetic resonance spectroscopy (MRspectrum,MRS) can help neurosurgeons to better identify preoperative targets for surgical resection. Functional MRI (functinalMRI,fMRI) helps the surgeon to pre-determine the functional impact of the tumor on important brain regions and deep structures, providing important information to achieve maximum safe resection of the tumor and minimum neurological damage. While the MRI examination is performed, the corresponding functional tasks are accomplished. With bloodoxygen level-dependent functionalMRI (BOLD-fMRI), we can determine the function of motor, sensory, language and visual cortical areas. BOLD-fMRI allows us to image these important functional areas of the brain not only with physiological individual differences, but also pathologically, where tumors can distort or destroy functional brain structures or remodel neurological functions. Fiber bundle tracer imaging relies on anisotropy to measure the directionality of water diffusion along the white matter fiber bundles and produces a three-dimensional image visualizing key fiber bundles in the white matter, such as corticospinal tracts, arcuate tracts and/or optic radiations, which can reflect the compression, displacement or destruction of the fiber bundles by the tumor, making it a reliable method to assess the involvement of white matter fiber bundles by the tumor. Three-dimensional visualization of medical images overcomes the flaws of precise spatial localization of tumors on two-dimensional images. On three-dimensional images, we can multimodally integrate the tumor image, the intracranial arterial and venous vascular system, the location of relevant brain functional areas, and the adjacency of the tumor to the nerve fiber tracts. Not only can MRI information be fused in three dimensions, but also the metabolic images suggested by PET-CT can be fused synchronously.PET-CT is able to reflect the heterogeneity of glioma metabolism well, while detecting smaller interstitial foci in low-grade gliomas, which is important for guiding surgical resection and biopsy.PET-CT is also useful for depicting the contours of the infiltrative extension of gliomas. Studies have shown that the tumor volume shown by MRI enhancement may be smaller than that shown by C-methionine PET imaging. In some cases, PET shows extension of the lesion into functional brain areas that are not matched by MRI enhancement, suggesting that the operator must reconsider the surgical strategy. The three-dimensional virtual reality environment created by the computer can help neurosurgeons to plan the surgery, visualize the tumor target to be removed, and select the most suitable resection method. In glioma resection, although the surgeon can judge the extent of tumor resection by the vascular distribution, color and texture of the tumor, the demarcation between the tumor and edematous white matter is not clear. Multimodal 3D neuronavigation technology in glioma resection improves the surgeon’s ability to approach and resect lesions, especially subcortical lesions. The minimally invasive concept of brain tumor surgery is better realized with 3D image guidance because the surgeon can obtain interactive dynamic information feedback during the operation. However, since the neuronavigation system is based on preoperative imaging data MRI, the interactive information feedback does not respond to real-time intraoperative images. Brain drift due to dural opening, loss of cerebrospinal fluid, and resection of the lesion reduces the reliability of this technique. II.REAL-TIME IMAGING IN ONCOLOGY Intraoperatively Stereotactic imaging, fMRI, and DTI have elucidated important functional and anatomical information through image fusion. This information, along with real-time intraoperative tumor visualization if combined, will be a powerful way to provide surgeons with real-time intraoperative guidance. Intraoperative MRI (iMRI) has shown significant advantages in this regard. Currently, more than 100 medical centers around the world are equipped with this latest technology. With the ability to perform intraoperative MRI scans on patients, doctors can analyze the extent of tumor resection and potential neurological effects based on the scan results, and determine whether further resection is necessary. iMRI overcomes the pitfalls of using preoperative images for neuronavigation that are susceptible to cerebral drift, and provides more objective imaging evidence for determining the extent of tumor resection during the operation. iMRI also allows for the early detection of intraoperative complications such as hemorrhage, ventricular obstruction, and brain blockage. It also allows early detection of intraoperative complications, such as hemorrhage, ventricular obstruction and cerebral ischemia, and timely management. In microsurgery for glioma, intraoperative ultrasound integrated with neuronavigation system can provide better localization and presentation of the tumor, adjacent ventricles, and peripheral blood vessels of the tumor, displaying real-time images of the brain tumor and guiding surgical resection. Comparing intraoperative ultrasound with iMRI, it also has the advantages of low equipment cost, dexterity and convenience, short examination time, and less chance of contamination. The use of fluoroscopy in the surgical resection of malignant gliomas also improves the rate of total resection of malignant gliomas under the naked eye. This technique requires the patient to take 5-aminolevulinic acid (5-ALA), a non-fluorescent precursor drug, orally. In brain tissue, 5-ALA is metabolized to the fluorescent protoporphyrin IX (PpIX) via the heme synthesis pathway. Due to the disruption of the brain barrier in gliomas, tumor neovascularization and overexpression of membrane transport proteins by tumor cells, which can contribute to the uptake of more 5-ALA by tumor tissues, and changes in the expression of enzymes involved in heme synthesis in tumor cells, these factors promote the accumulation of PpIX in high-grade gliomas; the expression of PpIX is very low in normal brain tissues. With the aid of a blue-light surgical microscope emitting a wavelength of 400 nm, the brain tissue can be seen to be blue and the tumor to be red, increasing the contrast between the tumor and the brain tissue for intraoperative tumor identification and resection. Phase III clinical studies have reported longer progression-free survival in patients who had tumors removed using fluorescence guidance. In order to assess the effectiveness of the degree of surgical resection using fluorescence guidance, efforts are needed to conduct randomized, controlled, multicenter clinical trial studies. Intraoperative neurophysiological detection and arousal surgery Neurophysiological monitoring technology is the gold standard for intraoperative cerebral functional area localization technology. Comprehensive wake-up surgery, intraoperative sensorimotor evoked potential monitoring, intraoperative cortical electrical stimulation and subcortical electrical stimulation and other electrophysiological techniques are used to label brainmapping during surgery, and to realize the precise positioning and real-time protection of functional cortical and subcortical functional pathways during glioma resection. Arousal surgery is an important match for real-time monitoring of higher-level neurological functions during brain tumor resection, mainly for determining the location of brain language areas, but also for locating motor and sensory areas. In cases where the tumor is in extremely close proximity to functional brain areas, the manner and extent of tumor resection is extremely critical in preserving vital neurological function. In wake surgery, the anesthesiologist needs to ensure the patient’s stability and comfort while he or she is awake, but also allows the patient to communicate adequately and complete the localization of brain function. For example, during tumor resection, the neurosurgeon and neurophysiological monitor, while performing direct cortical electrical stimulation, talk to the patient, and in the process record the cortical stimulation points corresponding to the point at which the patient develops a speech impediment. Intraoperative neurological monitoring has been shown to be helpful in both preserving neurological integrity and increasing tumor resection. Neurophysiological monitoring and intraoperative arousal have been carried out in all major neurosurgical centers in China, and the experience and specifications of some of these units are presented in this journal. Fourth, local treatment based on surgery Local treatment of gliomas requires not only new techniques, but also needs to be accomplished under surgical intervention. The neurosurgeon not only has to complete the tumor resection, but also has to execute additional local treatment plans. Brachytherapy can be performed not only by stereotactic methods alone, but also in combination with microsurgery. For tumors in critical functional areas, surgical resection combined with interstitial radiation therapy has proven to be an effective method of tumor control, with prolonged progression-free and overall survival of the patient and preservation of neurological integrity. Implantation of a low-energy radiation source such as I-125 can trigger both high-dose necrosis within the tumor and maximize the preservation of surrounding non-tumor tissue. Brachytherapy has good radiobiological properties, does not interfere with subsequent external radiation therapy, remains effective during tumor recurrence/progression, and has no increased risk of radiation therapy complications. The local implantation of a biodegradable extended-release film encapsulating the chemotherapeutic agent allows for sustained, long-distance drug concentrations at the tumor site. Carmustine extended-release implantable diaphragms (Gliadel), implanted on the surface of the surgical remnant after tumor resection, allow for the slow release of localized carmustine over a three-week period, and have been used as an adjuvant to surgery in new or recurrent high-grade gliomas. Although carmustine extended-release implantable diaphragm can continuously maintain a high drug concentration in the interstitium achieved locally in the tumor, the drug penetration effect is limited because it relies only on passive diffusion, limiting the therapeutic efficacy. A growing body of data suggests that carmustine extended-release implantable diaphragms, in combination with other combination therapies, can slightly prolong the survival of glioblastoma patients. Convectionenhanced delivery (CED) techniques can increase the depth of penetration of localized therapeutic agents. A neurosurgeon inserts a catheter into the brain parenchyma, establishes an external pressure gradient with a syringe pump, and continuously injects the drug to provide wide distribution of the therapeutic agent into the surrounding brain tissue. Initial clinical trials have shown that intracranial CED therapy is a safe and viable treatment option for relapsed GBM. The ideal drug delivery vehicle should incorporate both Gliadel and CED technologies and be both durable with high drug concentration and good tissue distribution. Nanotechnology is also expected to significantly advance the local surgical treatment of malignant gliomas in the next 10 years. Nanoparticles can not only bind multiple therapeutic drugs, but can also be modified with brain tumor-specific antibodies, which can exert their therapeutic effects by being transported to tumor tissues through systemic or local routes of administration. Imaging of nanoparticles by means of MRI, for example, will provide detailed information on the delivery of therapeutic agents and treatment follow-up. Although the role of craniotomy in the treatment of gliomas remains unchallenged, for patients with gliomas that cannot be surgically resected, performing puncture biopsies to obtain histologic and molecular pathologic evidence is useful in guiding adjuvant therapeutic regimens and prognostic decisions. Immediately for those tumors that can be surgically resected, a puncture biopsy prior to surgery can also help to personalize their treatment. In addition to framed stereotactic biopsy, frameless neuronavigation-guided puncture biopsy can also be used to safely and successfully biopsy intracranial lesions up to 0.5 cm in size. As an important technique in neurosurgery, neuroendoscopy can also be used for resection of deep intracerebral, paraventricular and midline tumors as well as biopsy. The application of neuroendoscopy to resect tumors also enables third ventriculostomy to treat hydrocephalus caused by the tumor, thus avoiding the need for a ventriculoperitoneal shunt. Despite the significant advances in surgical treatment of gliomas, neurosurgeons must individualize their surgical strategy by analyzing the patient’s age, physical and neurological condition, location and size of the tumor, extent of cerebral involvement, surgical and non-surgical risk factors, and tumor biology and prognosis as suggested by histopathological and molecular pathological markers of the tumor. Despite the additional benefit of extended tumor resection, we still cannot underestimate the risk of surgical disability. Any serious surgical-related disability may delay the initiation of postoperative adjuvant radiotherapy and chemotherapy and still be an additional harm to the patient, worsening the prognosis. We must emphasize that no technology can replace the neurosurgeon’s precise knowledge of the brain’s anatomy; no technology can replace the surgeon’s grasp of therapeutic principles; and no technology can replace the surgeon’s ability to make individualized, comprehensive decisions about patient treatment.