We can be quite accurate in localing gliomas where they are situated in brain with frameless neuronavigation or frame based approach. fMRI is useful but is not accurate to localise speech. The peroperative localisation has therfore become imporatantand is really helpful. The normal position of motor strip and speech area can be marked on scalp but because of shift by tumour these landmarks also change.

The best way to deal with this is doing surgery in awake patient. I have done 40 plus awake craniotomies and never had a patient where it was abondoned although my colleague had to convert one patient from awake to general anaesthesia half way through.

No patient if talked to in detail about awake procedure has refused to to undergo surgery. The surgeon has to be little fast and engage patient in some conversation and reassure him/her from time to time. I am quite fast in doing craniotomy with my trephine and can finish glioma surgery in about 2 hours. I am showing pictures of an 18 years old girl whom I operated few days back with my technique of awake craniotomy.