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High-grade gliomas are the most prevalent neurooncological desease in adults, their incidence increases with age, peaking in the seventh decade. This paper aims to address how to select patients for surgical resection by identifying pre-surgical predictors of 12-month mortality in newly diagnosed HGG patients aged ≥ 75 years. A prognostic score will be proposed to guide surgical decisions based on expected survival. Retrospective observational single-center cohort study was carried out at the "Città della Salute e della Scienza-Molinette" University Hospital in Turin, Italy. All consecutive patients aged ≥ 75 years newly diagnosed with HGG were included, regardless of whether they underwent surgical resection. Clinical, radiological, histological and molecular data were collected.Variables potentially available at the time of diagnosis were considered to develop a multivariable logistic regression predictive model, with 12-months overall survival as the dependent variable. 102 patients aged 75 years or older received a new diagnosis of high-grade glioma, of whom 68 underwent surgical resection. Patients undergoing surgery were slightly younger (76.9 vs 79.0 years, p = 0.007) and had better performance status (median KPS 80 vs 70). Most tumors undergoing surgery were localized in cortical or subcortical non-motor areas (p < 0.001) and less frequently deep-seated (p = 0.023) or multifocal (p < 0.001). A predictive model, the DAK-75 score, was developed: the AUROC of the final model was 0.822 (95% CI 0.741-0.902). The score includes clinical presentation, tumor location, and KPS, ranging from 0 to 20, categorizing risk scores into low-risk and high-risk groups (< or > 8). Higher scores corresponded to fewer surgical patients and higher one-year mortality rates (92.2% vs 47.1%, p < 0.001). DAK-75 score may represent a valuable tool in the decision-making process for neurosurgical intervention in elderly patients diagnosed with HGG. Further studies are needed to externally and prospectively validate the scoring system., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Simple Summary: This retrospective study investigates the validity of lateral ventricle opening during high-grade glioma (HGG) surgery, contributing to the literature by addressing its relationship with postoperative complications in a large cohort of newly diagnosed patients with HGG. The approach of dividing patients into groups with and without lateral ventricle opening enhances the study's internal validity, allowing for a direct comparison between the two conditions. The analysis of complications, including subependymal dissemination and multifocal progression, contributes to understanding associated side effects. Furthermore, the conclusion that lateral ventricle opening does not significantly increase the risks of dissemination, hydrocephalus or cerebrospinal fluid leakage suggests practical implications for surgery. Given the importance of maximizing resection for prognosis in patients with HGG and the potential risks associated with ventricle opening, this study aimed to assess the actual increase in post-surgical complications related to lateral ventricle opening and its influence on OS and PFS. A retrospective study was conducted on newly diagnosed HGG, dividing the patients into two groups according to whether the lateral ventricle was opened (69 patients) or not opened (311 patients). PFS, OS, subependymal dissemination, distant parenchymal recurrences, the development of hydrocephalus and CSF leak were considered outcome measures. A cohort of 380 patients (154 females (40.5%) and 226 males (59.5%)) was involved in the study (median age 61 years). The PFS averaged 10.9 months (±13.3 SD), and OS averaged 16.6 months (± 16.3 SD). Among complications, subependymal dissemination was registered in 15 cases (3.9%), multifocal and multicentric progression in 56 cases (14.7%), leptomeningeal dissemination in 12 (3.2%) and hydrocephalus in 8 (2.1%). These occurrences could not be clearly justified by ventricular opening. The act of opening the lateral ventricles itself does not carry an elevated risk of dissemination, hydrocephalus or cerebrospinal fluid (CSF) leak. Therefore, if necessary, it should be pursued to achieve radical removal of the disease. [ABSTRACT FROM AUTHOR]

Simple Summary: Several advantages of molecular imaging, namely, positron emission tomography (PET), have been already described in different settings of glioma management. Particularly, the use of amino acidic radiotracers for PET imaging has gained favor for their added value in diagnosis, grading, guidance, and response to treatment and in order to rule out recurrences. Despite the meaning of the biologically active volume of the tumor, a PET-integrated resection of adult-type diffuse high-grade gliomas is not routinely performed, but it can represent a further perspective for neurosurgeons. A systematic review of the literature has been performed to investigate this topic with a precise focus on the neurosurgeon's point of view presented, examining the reasons of its limited use in surgical practice and possible applications. Amino acid PET imaging has been used for a few years in the clinical and surgical management of gliomas with satisfactory results in diagnosis and grading for surgical and radiotherapy planning and to differentiate recurrences. Biological tumor volume (BTV) provides more meaningful information than standard MR imaging alone and often exceeds the boundary of the contrast-enhanced nodule seen in MRI. Since a gross total resection reflects the resection of the contrast-enhanced nodule and the majority of recurrences are at a tumor's margins, an integration of PET imaging during resection could increase PFS and OS. A systematic review of the literature searching for "PET" [All fields] AND "glioma" [All fields] AND "resection" [All fields] was performed in order to investigate the diffusion of integration of PET imaging in surgical practice. Integration in a neuronavigation system and intraoperative use of PET imaging in the primary diagnosis of adult high-grade gliomas were among the criteria for article selection. Only one study has satisfied the inclusion criteria, and a few more (13) have declared to use multimodal imaging techniques with the integration of PET imaging to intentionally perform a biopsy of the PET uptake area. Despite few pieces of evidence, targeting a biologically active area in addition to other tools, which can help intraoperatively the neurosurgeon to increase the amount of resected tumor, has the potential to provide incremental and complementary information in the management of brain gliomas. Since supramaximal resection based on the extent of MRI FLAIR hyperintensity resulted in an advantage in terms of PFS and OS, PET-based biological tumor volume, avoiding new neurological deficits, deserves further investigation. [ABSTRACT FROM AUTHOR]

Background: Gliomas are among the most challenging pathologies for neurosurgeons due to their infiltrative and recurrent nature in functionally relevant regions. Current knowledge confirms that gross total resection highly influence survival in patient with glioma. However, surgery performed in eloquent brain area, could seriously compromise the quality of life in patient with reduced life expectancy even more if it concerns the language function. Methods: 18 right-handed patients with perisylvian gliomas on the left hemisphere were prospectively analyzed over a period of 12 months. Standardized preoperative Diffusion-Tensor-Imaging based tractography of the five main language Tracts (Arcuate Fasciculus, Frontal Aslant Tract, Inferior Fronto-Occipital Fasciculus, Inferior Longitudinal Fasciculus, Uncinate Fasciculus) was navigated during the surgical procedure. Using a validated method, correlations were made between the pre-operative fascicles and their possible infiltration and surgical damage. The language status was assessed using the Aachen Aphasia Test. Results: In all nine patients who developed a permanent disorder there was pre-operative involvement of at least one fascicle and resection of at least one of these. In this way, areas of high risk of permanent language damage have emerged as a result of surgical injury: the temporoparietal junction, the middle portion of the FAT and the temporal stem. Conclusions: Navigated tractography has proven to be a user-friendly tool that can assess perioperative risk, guide surgical resection, and help the neurosurgeon to find that balance between tumor resection and function preservation. [ABSTRACT FROM AUTHOR]