Gliomas are the most common primary brain tumor, yet remain a challenge to effectively treat. Mounting evidence suggests that survival improves with greater tumor removal, yet being able do a complete removal can be difficult due to the tumor's infiltrating nature. 5-aminolevulinic acid (5-ALA) is a natural compound that, when patients take it by mouth 3 hours before surgery, is selectively taken up by glioma cells and causes a red/pink fluorescence (glow) under a blue light that allows tumor margins to be seen during the course of surgery. While this compound is used as a standard-of-care agent in Europe, it remains under testing by the Food and Drug Administration (FDA). A recent clinical trial in Germany, however, has demonstrated a significant improvement in the rate of complete resection for certain brain tumors (65% vs. 34%). The Barrow 5-ALA Intraoperative Confocal (BALANCE) Trial will measure the effect of 5-ALA on the amount of glioma tumor removal. To improve the usefulness of 5-ALA, a new special microscope fitted with a blue light, will be used to magnify microscopic fluorescence at the tumor margins. The investigators' hypothesis is that 5-ALA fluorescence with the use of the special microscope during surgery will greatly lower the amount of tumor left behind.
Inclusion Criteria: * Presumed newly-diagnosed supratentorial glioma (previous biopsy-only/no adjuvant therapy are eligible for randomization) * Age \> 18 years * Normal bone marrow function (WBC \> 3000, Platelets \> 100,000) Exclusion Criteria: * Infratentorial tumors * Pregnancy * Hypersensitivity to 5-aminolevulinic acid hydrochloride or porphyrins * History of photosensitivity, porphyria, or exfoliative dermatitis * Hepatic dysfunction in the last 12 months (defined by AST, ALT, ALP, bilirubin \> 2.5 x normal) * Serum creatinine \> 180 µmol/L * Estimated Glomerular Filtration Rate (eGFR) \< 60 ml/min/1.73m2 * Inability to undergo MRI scan with contrast