Intraoperative neurophysiological monitoring and survival outcomes in patients with isocitrate dehydrogenase-wildtype glioblastoma

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Abstract
Background: Intraoperative neurophysiological monitoring (IONM) facilitates safe glioma resection in eloquent regions. Its effect on survival in molecularly defined isocitrate dehydrogenase (IDH)-wildtype glioblastoma remains uncertain. We assessed the association between IONM-supported surgery and survival outcomes in this high-risk population and explored subgroups deriving the greatest benefit. Methods: We retrospectively analyzed 200 adults who underwent first-time resection for IDH-wildtype glioblastoma between 2012 and 2021. Co-primary outcomes were progression-free survival (PFS) and overall survival (OS), evaluated through Kaplan-Meier estimates and multivariable Cox models. Secondary 1:1 propensity score-matched analyses were performed based on age, preoperative KPS, MGMT methylation status, preoperative tumor volumes, and localization. Volumetric analysis included contrast-enhancing (CE) and non-CE tumor components. Subgroup analyses were stratified by tumor location. Results: In the unmatched cohort, IONM was independently associated with prolonged PFS (HR 0.60, 95% CI, 0.45-0.84) and OS (HR 0.60, 95% CI, 0.43-0.83), along with younger age, MGMT methylation, higher KPS, and smaller postoperative volumes. IONM patients had higher complete CE resection rates (64.2% vs 40.4%, P = .0005) and improved functional preservation (postoperative KPS 80 vs. 70, P = .008), despite more early deficits. In the location-matched cohort (n = 104), median PFS was 12 months with IONM vs 7 months without (P = .0007), and OS was 17 vs 11 months (P = .0018). Supramaximal resections occurred exclusively in the IONM group. The benefit was most evident in frontal, parietal, and insular tumors. Conclusions: IONM-supported surgery was associated with more extensive resection, functional preservation, and longer survival in IDH-wildtype glioblastoma. IONM was more frequently used in tumors located in frontal, parietal, and insular regions, consistent with the functional complexity of these areas.

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