Brain Tumor Surgery | Prof. Zhu Wei (Neurosurgery) | CMCS Shanghai

About Prof. Zhu Wei

Prof. Zhu Wei is a distinguished neurosurgeon at Huashan Hospital, Fudan University — one of China's foremost centres for neurosurgical oncology, skull base surgery, and cerebrovascular disease, and a national reference institution for the management of complex intracranial tumours. He focuses on microsurgical resection of intracranial tumours, skull base surgery, and cerebrovascular disease, with particular expertise in the surgical management of tumours involving eloquent cortex — the language, motor, and sensory areas of the brain where tumour resection carries the highest risk of permanent neurological deficit. Prof. Zhu is widely regarded as one of China's foremost experts in complex brain surgery, with a clinical philosophy that holds that the goal of neurosurgical oncology is the maximum safe resection — the greatest extent of tumour removal achievable without producing new or worsened neurological deficits — and that achieving this goal in eloquent cortex requires the integration of preoperative functional mapping, intraoperative neurophysiological monitoring, real-time neuronavigation, and advanced microsurgical technique into a unified, patient-specific surgical strategy. His department at Huashan Hospital has established one of Shanghai's most comprehensive programmes for eloquent cortex tumour surgery, with a dedicated team whose outcomes in functional preservation and extent of resection are recognised as among the most advanced in China.

Case Overview

A middle-aged Chinese woman presented with recurrent headaches and progressive visual deterioration. MRI of the brain revealed a large mass in the left temporal lobe — approximately 6 cm in diameter, with poorly defined margins, invasion of the language centre (Wernicke's area) and motor cortex, and significant surrounding oedema. The tumour's location in eloquent cortex, its size, and its intimate relationship with critical language and motor structures placed this case among the most technically demanding in neurosurgical oncology. Functional MRI (fMRI) and diffusion tensor imaging (DTI) were performed to precisely map the language and motor functional areas and their relationship to the tumour, providing the navigational foundation for the surgical strategy. Following multidisciplinary team (MDT) discussion involving neurosurgery, neuroradiology, anaesthesia, and the ICU, the team formulated a surgical strategy incorporating microscopic tumour resection, intraoperative neurophysiological monitoring, real-time neuronavigation, and ultrasonic aspiration. The procedure was completed in approximately 6 hours with well-controlled intraoperative blood loss. The patient was transferred to the ICU postoperatively, returned to the general ward on day 10, and was discharged in good condition on postoperative day 15 — with no major complications and progressive recovery of neurological function.

Patient Background

• Name / Nationality: Mrs. [Pseudonym] — Chinese female, middle-aged
• Chief Complaint: Recurrent headaches and progressive visual deterioration
• History of present illness: Progressive headaches with onset of visual symptoms; MRI workup revealed a large left temporal lobe mass with invasion of eloquent cortex and significant surrounding oedema. Neurological examination demonstrated early language and cognitive changes consistent with involvement of the language cortex.
• Tumour characteristics:
  • Location: Left temporal lobe — involving Wernicke's language area and adjacent motor cortex
  • Size: Approximately 6 cm in diameter
  • Margins: Poorly defined — infiltrative growth pattern
  • Surrounding oedema: Significant — contributing to mass effect and symptom burden
  • Functional involvement: Language centre (Wernicke's area) and motor cortex directly involved
• Neurological status: Early language changes; visual symptoms; headaches; no complete motor deficit at presentation
• Surgical risk: High — tumour location in eloquent cortex; risk of permanent language deficit (aphasia) and motor deficit (hemiparesis) with resection; size and poorly defined margins increase complexity of safe resection

Diagnostic Workup

Neuroimaging

• MRI brain with and without contrast: Large left temporal lobe mass, approximately 6 cm; poorly defined margins; significant surrounding oedema; mass effect on adjacent structures; contrast enhancement pattern assessed for tumour grade characterisation
• Functional MRI (fMRI): Precise mapping of language (Wernicke's area, Broca's area) and motor functional areas; spatial relationship between functional cortex and tumour margins defined; surgical safety margins established
• Diffusion tensor imaging (DTI): White matter tractography of the arcuate fasciculus and corticospinal tract; relationship between critical white matter pathways and tumour defined; risk of tract injury during resection assessed; navigational data integrated into the intraoperative neuronavigation system

Functional Assessment

• Neuropsychological assessment: Language function, memory, and cognitive status evaluated at baseline; deficits documented and used to guide intraoperative monitoring strategy
• Visual field assessment: Visual field defects characterised; relationship to tumour location assessed

Multidisciplinary Team (MDT) Assessment

• MDT discussion: Neurosurgery, neuroradiology, anaesthesia, and ICU; comprehensive assessment of tumour resectability, functional risk, and perioperative management strategy; decision to proceed with microsurgical resection under intraoperative neurophysiological monitoring and neuronavigation confirmed; individualised surgical and perioperative plan formulated

Prof. Zhu's pre-operative assessment: The left temporal lobe is the most functionally demanding location for a tumour of this size. Wernicke's area — the cortical centre for language comprehension — is directly involved, and the corticospinal tract is at risk from the tumour's posterior extension. The fMRI and DTI give us the precise spatial relationship between the tumour and the functional structures we must protect — they are the navigational foundation of the surgical strategy. The goal is maximum safe resection: we will remove as much tumour as the functional boundaries allow, using the intraoperative monitoring to tell us in real time when we are approaching the limits of safe resection. The monitoring is not a passive safety net — it is an active guide that allows us to push the resection further than would be safe without it, because it gives us immediate feedback on the functional consequences of each surgical step. The combination of preoperative functional mapping, intraoperative monitoring, and real-time neuronavigation is what makes maximum safe resection achievable in eloquent cortex.

Treatment Strategy: Microsurgical Resection with Intraoperative Neurophysiological Monitoring and Real-Time Neuronavigation

The diagnosis was Large Left Temporal Lobe Intracranial Tumour with Eloquent Cortex Involvement in a middle-aged patient with progressive neurological symptoms and high surgical complexity.

The treatment principle was: maximum safe microsurgical resection of the left temporal lobe tumour — guided by real-time neuronavigation and intraoperative neurophysiological monitoring to define and respect the functional boundaries of safe resection, with ultrasonic aspiration to facilitate tumour removal while minimising traction on surrounding eloquent cortex and white matter tracts.

Procedure — Microsurgical Tumour Resection with Multimodal Intraoperative Guidance:

• Tumour localisation and neuronavigation: Preoperative fMRI and DTI data integrated into the intraoperative neuronavigation system; real-time navigation used throughout the procedure to define tumour margins, track the relationship between the surgical field and the functional cortex, and guide the extent of resection; navigation accuracy confirmed at the start of the procedure
• Microsurgical resection: Craniotomy performed with the patient positioned to optimise access to the left temporal lobe; operating microscope used throughout for magnified visualisation of tumour-brain interface; meticulous microsurgical dissection of tumour from surrounding brain parenchyma, vessels, and cortical structures; tumour debulking using ultrasonic aspiration (CUSA) — allowing efficient tumour removal with minimal mechanical traction on surrounding eloquent tissue
• Intraoperative neurophysiological monitoring: Continuous monitoring of motor evoked potentials (MEPs) and somatosensory evoked potentials (SSEPs) throughout the procedure; direct cortical stimulation used to map the motor cortex and define the safe resection boundary; language monitoring performed as required by the tumour's proximity to Wernicke's area; real-time feedback from the monitoring team used to guide surgical decisions at each step of the resection
• Functional preservation: Resection halted at the functional boundaries defined by the monitoring — preserving the language and motor cortex and the critical white matter tracts identified on preoperative DTI; no sacrifice of functional tissue accepted
• Total operative time: Approximately 6 hours; intraoperative blood loss well controlled

Treatment Course and Outcomes

Intraoperative

• Microsurgical tumour resection completed successfully under Prof. Zhu Wei's guidance; maximum safe resection achieved within the functional boundaries defined by intraoperative monitoring; no significant intraoperative neurophysiological changes indicating functional injury; intraoperative blood loss well controlled; no major intraoperative complications

Postoperative ICU Course (Days 1–10)

• Patient transferred to the ICU immediately postoperatively for intensive monitoring; individualised recovery protocol implemented — vital sign monitoring, cerebral oedema management, infection prevention, nutritional support, and early neurological rehabilitation; neurological function monitored closely with progressive improvement
• No major postoperative complications — no haemorrhage, no new motor deficit, no seizures requiring intervention, no wound infection

General Ward and Discharge (Days 10–15)

• Patient transferred to the general ward on postoperative day 10; neurological rehabilitation continued; language and motor function progressively recovering; diet and mobility restored
• Comprehensive assessment on postoperative day 15 confirmed good overall condition; discharge criteria met; patient discharged in good condition on day 15 with ongoing outpatient rehabilitation plan

Prof. Zhu's clinical reflection: The outcome of this case — maximum safe resection of a 6 cm eloquent cortex tumour, preserved language and motor function, no major complications, and discharge on day 15 — is the result of the integration of preoperative functional mapping, intraoperative monitoring, and real-time neuronavigation into a unified surgical strategy. The fMRI and DTI defined the boundaries before we entered the operating room; the monitoring enforced those boundaries in real time during the resection; and the neuronavigation kept us oriented within the tumour's three-dimensional anatomy throughout the procedure. Each of these technologies contributes something that the others cannot provide alone — together, they allow us to achieve a level of precision in eloquent cortex surgery that was not possible a generation ago. The patient's progressive neurological recovery in the postoperative period reflects the functional preservation that this precision makes possible: the language and motor cortex were protected, and the brain's capacity for recovery from the oedema and mass effect of the tumour is now able to express itself without the additional burden of surgical injury to functional tissue.

Expert Commentary — Prof. Zhu Wei

1. Functional Mapping and Intraoperative Neurophysiological Monitoring: The Technical Foundation of Maximum Safe Resection in Eloquent Cortex

The surgical management of intracranial tumours involving eloquent cortex — the language, motor, and sensory areas of the brain whose injury produces permanent, functionally devastating deficits — requires a level of precision that conventional neurosurgical technique alone cannot provide. The fundamental challenge is spatial: the tumour and the functional cortex occupy the same anatomical territory, and the surgeon must navigate the boundary between them with a precision measured in millimetres. Preoperative functional MRI (fMRI) and diffusion tensor imaging (DTI) provide the spatial framework for this navigation: fMRI maps the cortical activation patterns associated with language and motor tasks, defining the location of the functional areas relative to the tumour; DTI maps the white matter tracts — the arcuate fasciculus for language, the corticospinal tract for motor function — that connect the functional cortex to the rest of the brain and whose injury produces deficits as severe as direct cortical damage. These preoperative maps are integrated into the intraoperative neuronavigation system, providing the surgeon with a real-time three-dimensional reference for the relationship between the surgical field and the functional structures that must be preserved. Intraoperative neurophysiological monitoring — continuous MEP and SSEP recording, direct cortical stimulation for motor mapping, and language monitoring where indicated — provides the real-time functional feedback that the navigation system cannot: it tells the surgeon not just where the functional cortex is, but whether the surgical manoeuvres being performed are affecting its function. The combination of preoperative mapping and intraoperative monitoring transforms the surgical approach to eloquent cortex tumours from a navigation by anatomical landmarks to a navigation by functional boundaries — allowing the surgeon to push the resection to the true limits of functional safety rather than the conservative margins that anatomical uncertainty alone would impose.

2. Ultrasonic Aspiration in Eloquent Cortex Tumour Surgery: Mechanism, Advantages, and the Rationale for Minimising Mechanical Traction

Ultrasonic aspiration — the use of a cavitating ultrasonic probe (CUSA, Cavitron Ultrasonic Surgical Aspirator) to fragment and aspirate tumour tissue — is a critical enabling technology for microsurgical resection of tumours in eloquent cortex, because it allows efficient tumour debulking with minimal mechanical traction on the surrounding brain parenchyma. The fundamental advantage of ultrasonic aspiration over conventional mechanical tumour removal in eloquent cortex is the elimination of traction: conventional techniques — bipolar coagulation and suction, tumour forceps, and piecemeal resection — require the application of mechanical force to the tumour and its interface with the surrounding brain, producing traction on the adjacent cortex and white matter that can injure functional tissue even when the resection remains within the anatomical tumour margins. Ultrasonic aspiration fragments the tumour in situ through cavitation — the formation and collapse of microscopic bubbles at the probe tip — and aspirates the fragmented tissue without the application of mechanical traction to the surrounding brain. This allows the surgeon to debulk the tumour from within, progressively collapsing it toward the resection margins without pulling on the adjacent eloquent cortex. In combination with the real-time feedback of intraoperative neurophysiological monitoring, ultrasonic aspiration allows the surgeon to approach the functional boundaries of safe resection with a precision and safety that conventional mechanical techniques cannot match.

3. The Clinical Significance of Maximum Safe Resection in Eloquent Cortex Glioma: Oncological Benefit, Functional Outcome, and the Evidence Base for Aggressive Surgical Strategy

The oncological rationale for maximum safe resection in eloquent cortex glioma — the pursuit of the greatest extent of tumour removal achievable without producing new neurological deficits — rests on a substantial and growing body of evidence demonstrating that extent of resection is an independent predictor of survival in both low-grade and high-grade glioma. The biological basis for this relationship is the reduction of tumour cell burden: each log reduction in the number of viable tumour cells achieved by surgical resection reduces the substrate available for tumour recurrence and progression, and extends the interval before the residual tumour reaches a clinically significant volume. In eloquent cortex glioma, the historical tension between oncological benefit and functional preservation — the assumption that aggressive resection in eloquent cortex necessarily produces unacceptable neurological deficits — has been substantially resolved by the development of the multimodal intraoperative guidance techniques described in this report. The evidence from centres with extensive experience in eloquent cortex surgery — including Huashan Hospital — demonstrates that maximum safe resection guided by intraoperative monitoring and neuronavigation achieves greater extent of resection than conservative surgery, with equivalent or superior functional outcomes, because the monitoring allows the surgeon to approach the true functional boundaries of safe resection rather than the conservative anatomical margins that unguided surgery imposes. The clinical significance of this case extends beyond the individual patient: it demonstrates that with the appropriate technical infrastructure, multidisciplinary organisation, and surgical expertise, maximum safe resection of eloquent cortex tumours is achievable with functional preservation — and that the outcomes achievable at a centre of excellence like Huashan Hospital, Fudan University, represent the current standard of what is possible in complex neurosurgical oncology.

How CMCS Shanghai Coordinated This Case

CMCS Shanghai supported the patient and family throughout the diagnostic, surgical, and recovery pathway at Huashan Hospital, Fudan University, including: priority consultation coordination with Prof. Zhu Wei's neurosurgery team, with bilingual review of all prior MRI, fMRI, DTI, and clinical records; bilingual interpretation throughout the MDT discussion, surgical planning consultation, and all postoperative review appointments; bilingual explanation of the surgical strategy — the rationale for microsurgical resection with intraoperative monitoring and neuronavigation, the functional mapping approach, the expected operative duration, and the postoperative recovery and rehabilitation pathway; coordination of preoperative fMRI, DTI, neuropsychological assessment, and anaesthetic evaluation with bilingual results communication and clinical summary; bilingual surgical consent process — ensuring the patient and family had a complete understanding of the procedure, the functional preservation strategy, the monitoring approach, and the postoperative rehabilitation plan; postoperative ICU and ward coordination including bilingual communication of recovery milestones, neurological function trends, and discharge planning; and long-term oncological follow-up coordination including MRI surveillance scheduling, neuropathology result communication, and bilingual coordination of adjuvant treatment planning.

For international patients with complex intracranial tumours — including those involving eloquent cortex, skull base structures, or cerebrovascular anatomy requiring the highest level of neurosurgical expertise — Prof. Zhu Wei's team at Huashan Hospital, Fudan University, offers access to one of China's most advanced neurosurgical oncology programmes. CMCS ensures that expertise is accessible: in the patient's language, with every step of the diagnostic, surgical, rehabilitation, and surveillance pathway coordinated and communicated clearly, from the first specialist consultation through long-term oncological follow-up.

This case report is de-identified and published for educational purposes. All clinical details have been anonymized in accordance with patient privacy standards. CMCS Shanghai is a medical concierge service and does not provide direct medical care.