BACKGROUND AND PURPOSE: This multi-institutional study investigates how preoperative fMRI and DTI influence surgical decision-making and clinical outcomes in patients undergoing brain tumor resection. MATERIALS AND METHODS: Seventy patients from 4 academic centers underwent preoperative task-based fMRI and DTI: Thomas Jefferson University (TJU), n  = 51; University Hospital Basel, n =12; University of Pennsylvania (UPenn), n  = 4; and Johns Hopkins University (JHU), n =3. Six neurosurgeons completed structured pre- and postimaging surveys evaluating changes in surgical approach, craniotomy planning, extent of resection, operative duration, and diagnostic confidence. RESULTS: Integration of fMRI and DTI into surgical planning resulted in a noteworthy shift from awake to asleep craniotomies, especially at TJU ( P = .01), with “asleep” craniotomy increasing to 51% overall (χ2: P < .0001). fMRI led to a “much more aggressive” surgical plan in 39% of cases globally, most prominently at TJU (74%) and UPenn (50%), whereas JHU reported a decrease in aggressiveness in 33.3% of cases. DTI had a similar but slightly reduced impact, with “much more aggressive” being the top response (34%). fMRI was rated as more clinically valuable than DTI in 53.4% of cases overall, with TJU having the highest rate (72%). Postoperatively, a larger extent of resection was reported in 61% of cases, with shorter-than-expected surgical durations in 51%. Overall, combined fMRI/DTI had a significant “strong positive” influence on surgery in 72% and clinical care in 68% of cases, with significant interinstitutional differences ( P < .001). CONCLUSIONS: Preoperative fMRI and DTI significantly reshape neurosurgical planning by optimizing resection strategies. Most notably, preoperative mapping facilitated a significant shift from awake to asleep craniotomies, contributing to shorter-than-expected surgical durations without compromising the extent of resection. ECS : electrocortical stimulation JHU : Johns Hopkins University TJU : Thomas Jefferson University UPenn : University of Pennsylvania

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