The Role of magnetic resonance spectroscopy in neurosurgical decision making: A structured review article

Background: Magnetic resonance spectroscopy (MRS) provides a non-invasive "molecular window" into tissue biochemistry by quantifying key cellular metabolites within the central nervous system. While conventional magnetic resonance imaging (MRI) provides excellent anatomic detail, it often falls short in differentiating tumor margins, distinguishing neoplastic processes from non-neoplastic mimics, grading gliomas preoperatively, and identifying recurrent disease from treatment-induced effects like radiation necrosis.Objective: This review synthesizes established clinical evidence and meta-analytical findings on the utility of proton MRS (1H-MRS) and multi-voxel magnetic resonance spectroscopic imaging (MRSI) in neurosurgical planning, intraoperative navigation, and postoperative decision making.Methods: Clinical trials, cohort studies, and meta-analyses published up to June 2026 were identified across major biomedical databases, including PubMed, EMBASE, and the Cochrane Library. Studies were evaluated based on their clinical impact, diagnostic accuracy, and utility in changing surgical strategy.Results: MRS significantly enhances diagnostic accuracy when added to conventional MRI protocols. Key biochemical markers—primarily N-acetyl aspartate (NAA), Choline (Cho), Creatine (Cr), Lactate (Lac), Lipid (Lip), and 2-hydroxyglutarate (2HG)—serve as metabolic indicators of cellular density, neuronal integrity, and anaerobic metabolism. Reported literature indicates pooled sensitivity and specificity for differentiating high-grade from low-grade gliomas using Cho/NAA and Cho/Cr ratios ranging from 70% to 80%. Furthermore, MRSI-defined metabolic abnormalities extend an average of 24% beyond T2-weighted hyperintense margins in infiltrative gliomas, directly impacting surgical resection margins and target selection for stereotactic biopsies.Conclusion: Integrated multi-parametric MRI and high-field MRS protocol suites provide essential metabolic data that fundamentally reshape neurosurgical approaches, optimize maximal safe resections, and minimize diagnostic uncertainty. However, lack of technical standardization across scanner vendors remains a primary hurdle to universal clinical integration.