Challenges In Managing Supratentorial Tumors Without Neuronavigation: Institutional Experience and Alternatives

Background: Supratentorial tumors, which including gliomas, meningiomas, and metastatic lesions, account for 70% of primary malignant tumors and represent a significant clinical challenge globally. Neuronavigation (NN) optimizes outcomes but remains inaccessible in places like Peshawar, Pakistan, due to cost and infrastructure barriers. This study documents challenges and alternatives in managing tumors without neuronavigation. Methodology: A mixed-methods cross-sectional study was conducted over 8 months in three neurosurgical departments (Khyber Teaching Hospital, Hayatabad Medical Complex, and Lady Reading Hospital) in Peshawar. Quantitative data from 86 patients undergoing supratentorial tumor resection without NN were analyzed alongside qualitative interviews with 15 neurosurgeons. Variables included tumor characteristics, surgical techniques (anatomic landmarks, intraoperative ultrasound (IOUS), stereotactic frames), operative time (>4 hours defined prolonged), complications, residual tumor (>10%), and hospital stay. Quantitative data were analyzed using SPSS v26 with chi-square, t-tests, and logistic regression; surgeon experiences were analyzed using Braun and Clarke's reflexive thematic analysis. Results: Residual tumors occurred in 24.4% of cases, significantly exceeding the hypothesized >10% threshold. Long operative times (>4 hours) were seen in 74.4% of surgeries. Anatomic landmark techniques had the highest residual tumor rates (31.7%) and complications (52.4%). IOUS reduced operative times (mean: 4.6 hours) but 25% still showed residual tumors. Logistic regression identified temporal lobe location (OR: 3.2, p=0.02) and surgeon experience <10 years (OR: 2.8, p=0.04) as predictors of residual tumors. Qualitative analysis revealed spatial disorientation challenges (93% of surgeons), technical limitations of alternatives (73%), and psychological impact on practice (87%). Conclusion: Supratentorial tumor resections without neuronavigation produce suboptimal outcomes with 24.4% residual tumor rates, significantly higher than NN-assisted benchmarks. Surgeons reported substantial spatial uncertainty and professional stress, particularly in eloquent areas. These findings highlight the need for policy interventions to improve NN access and surgeon training in resource-limited settings.