SURG-64. Do More Intraoperative Paradigms Improve Outcomes? A Propensity-Weighted Study Using NeuroMapper in Awake Glioma Surgery

Abstract BACKGROUND NeuroMapper, a tablet-based mapping tool allows testing of diverse cognitive-linguistic functions, though the effect of number of paradigms used on patient outcomes remains unclear. This study explores relationships between intraoperative mapping complexity and outcomes, including return-to-work (RTW), in patients with language-eloquent low- (LGG) and high-grade gliomas (HGG). METHODS Patients with LGG and HGG who underwent awake craniotomy with NeuroMapper-guided direct electrical stimulation (DES) language mapping between 2018–2024 were included. Outcomes included RTW, progression-free survival (PFS), and overall survival (OS); surgical duration was also examined. Covariate-balancing propensity scores (CBPS) addressed confounding by tumor grade (post-weight SMDs<0.10). Weighted logistic regression modeled RTW; CBPS-weighted Cox models assessed PFS and OS. Linear regression analyzed intraoperative variables and surgical time. RESULTS A total of 65 LGG and 124 HGG patients were included. Mapping complexity ranged from 1–6 tasks (median = 4), with the most frequently used tasks across cases including object (98%), verb (80%), and auditory (61%) naming. Motor tasks were used in 66%. Independent predictors of RTW included preoperative KPS ≥ 80 (OR 1.82, p=0.007), absence of recurrent disease (OR 0.30, p<0.001), use of 5–6 paradigms most often interrogating noun and verb naming and auditory and reading comprehension[KN1] (OR 1.54, p=0.047), positive mapping (OR 2.41, p=0.017), and subtotal resection (OR 3.14, p=0.012). IDH mutation was associated with improved PFS (HR 0.15, p<0.001), and subtotal resection with worse PFS (HR 3.00, p < 0.001). Positive mapping predicted longer OS (HR 0.57, p=0.04[KN2]), with speech tasks showing the highest DES hit rates. Surgical duration was unaffected by mapping variables including number of paradigms used but was longer in patients with obesity (β=0.28, p=0.038). CONCLUSION Testing more diverse paradigms and achieving positive NeuroMapper-guided mapping were associated with improved RTW and longer OS. Functional recovery remained key, and mapping complexity did not prolong surgery.