Preserving function through the sulcus: A technical note on the awake trans-sulcal approach for resection of primary motor cortex glioblastomas

Ryan Gensler; Melanie Alfonzo Horowitz; Mostafa Abdulrahim; Sofia Melamed; Rayhan Asad; A Karim Ahmed; Youssef Georges Comair; Jordina Rincon-Torroella; Chetan Bettegowda

doi:10.1016/j.clineuro.2025.108912

Preserving function through the sulcus: A technical note on the awake trans-sulcal approach for resection of primary motor cortex glioblastomas

Clin Neurol Neurosurg. 2025 Jul:254:108912. doi: 10.1016/j.clineuro.2025.108912. Epub 2025 Apr 18.

Authors

Ryan Gensler¹, Melanie Alfonzo Horowitz², Mostafa Abdulrahim², Sofia Melamed³, Rayhan Asad⁴, A Karim Ahmed⁴, Youssef Georges Comair⁵, Jordina Rincon-Torroella⁵, Chetan Bettegowda⁶

Affiliations

¹ Johns Hopkins University School of Medicine, Baltimore, MD, United States. Electronic address: rtg41@georgetown.edu.
² Johns Hopkins University School of Medicine, Baltimore, MD, United States.
³ Johns Hopkins University, Baltimore, MD, United States.
⁴ University of Maryland, College Park, MD, United States.
⁵ Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, MD, United States.
⁶ Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, MD, United States. Electronic address: cbetteg1@jhmi.edu.

PMID: 40328141
DOI: 10.1016/j.clineuro.2025.108912

Abstract

Background: Tumors located in the primary motor cortex or associated motor areas present significant surgical challenges due to their proximity to critical motor pathways. Traditional transcortical approaches often risk motor deficits due to extensive cortical disruption. The trans-sulcal approach leverages natural sulcal corridors to minimize cortical damage, potentially improving outcomes. This study evaluates the efficacy and safety of the trans-sulcal approach in awake resection of glioblastomas (GBM) located within the motor cortex.

Methods: Five patients with motor cortex or motor-associated glioblastomas (GBMs) who underwent awake craniotomy with trans-sulcal tumor resection between 2023 and 2024 were provided by two neurosurgeons at a single institution as representative examples to illustrate the technical approach. Surgical planning incorporated preoperative imaging, intraoperative functional mapping, and neuronavigation guidance. Postoperative outcomes, including extent of resection, and neurological function were assessed through imaging and clinical evaluations at variable time frames including some at 1-2 weeks and some additionally at 3 months postoperatively.

Results: One patient achieved gross total resection, two had near-total resections, and two underwent biopsy. No patients experienced permanent novel motor deficits. Transient deficits were observed but did not result in long-term impairment. Functional outcomes were stable or improved early postoperatively, with later declines attributed to tumor progression rather than surgical effects. No major surgical complications were reported.

Conclusions: The trans-sulcal approach demonstrates significant potential for safe and effective resection of motor cortex GBMs. By minimizing cortical disruption and utilizing advanced imaging and intraoperative mapping, this technique facilitates tumor resection while preserving motor function. These findings support its role as a method for addressing tumors in eloquent brain regions, though further comparative studies are warranted.

Keywords: Cortical mapping; Functional preservation; Minimally Invasive; Motor cortex tumors; Outcomes; Trans-sulcal approach.

MeSH terms

Adult
Aged
Brain Neoplasms* / diagnostic imaging
Brain Neoplasms* / surgery
Craniotomy* / methods
Female
Glioblastoma* / diagnostic imaging
Glioblastoma* / surgery
Humans
Male
Middle Aged
Motor Cortex* / diagnostic imaging
Motor Cortex* / surgery
Neuronavigation / methods
Neurosurgical Procedures* / methods
Treatment Outcome
Wakefulness / physiology