Advancing Precision in Neuro-Oncology with Intraoperative Imaging and Fluorescence Guidance: A Narrative Review.

Malignant gliomas remain among the most formidable challenges in neuro-oncology, given their high morbidity and rising incidence worldwide. Surgical resection represents the cornerstone of treatment, typically followed by adjuvant radiotherapy and chemotherapy. Achieving maximal safe resection, however, requires advanced intraoperative guidance. A range of adjuncts are currently employed, including 5-aminolevulinic acid (5-ALA), intraoperative ultrasound, computed tomography (iCT), and intraoperative magnetic resonance imaging (iMRI). More recently, an emerging technique-virtual MRI (vMRI)-has been developed, fusing intraoperative CT with preoperative high-resolution MRI to provide real-time, MRI-like updates of brain anatomy. Beyond imaging, tumour removal itself induces reorganization of eloquent brain networks, underscoring the critical need for precision tools that balance oncological control with preservation of neurological function. In this narrative review, we highlight and synthesize the evolving armamentarium of intraoperative technologies shaping the future of precision neuro-oncology.