The Concept of «Peritumoral Zone¼ in Diffuse Low-Grade Gliomas: Oncological and Functional Implications for a Connectome-Guided Therapeutic Attitude.

Diffuse low-grade gliomas (DLGGs) are heterogeneous and poorly circumscribed neoplasms with isolated tumor cells that extend beyond the margins of the lesion depicted on MRI. Efforts to demarcate the glioma core from the surrounding healthy brain led us to define an intermediate region, the so-called peritumoral zone (PTZ). Although most studies about PTZ have been conducted on high-grade gliomas, the purpose here is to review the cellular, metabolic, and radiological characteristics of PTZ in the specific context of DLGG. A better delineation of PTZ, in which glioma cells and neural tissue strongly interact, may open new therapeutic avenues to optimize both functional and oncological results. First, a connectome-based "supratotal" surgical resection (i.e., with the removal of PTZ in addition to the tumor core) resulted in prolonged survival by limiting the risk of malignant transformation, while improving the quality of life, thanks to a better control of seizures. Second, the timing and order of (neo)adjuvant medical treatments can be modulated according to the pattern of peritumoral infiltration. Third, the development of new drugs specifically targeting the PTZ could be considered from an oncological (such as immunotherapy) and epileptological perspective. Further multimodal investigations of PTZ are needed to maximize long-term outcomes in DLGG patients.

Craniectomía descompresiva en el infarto maligno de arteria cerebral media: percepción familiar, resultados y factores pronósticos / Decompressive craniectomy in malignant middle cerebral artery infarction: family perception, outcome and prognostic factors

OBJETIVO: El pronóstico en los infartos malignos de un hemisferio siembra dudas entre los neurocirujanos a la hora de indicar una hemicraniectomía descompresiva. ¿Qué resultados a corto y medio plazo se obtienen? ¿Están las familias satisfechas con la cirugía una vez el enfermo se encuentra en su domicilio? En el presente trabajo analizamos nuestra experiencia en esta materia en los últimos 13 años. MATERIAL Y MÉTODOS: Incluimos en nuestra revisión a 21 pacientes intervenidos entre 2004 y 2017 siguiendo la vía clínica de nuestro centro para el ictus. Se entrevistó a los familiares vía telefónica. Se midió el resultado funcional al alta, 3 meses, un año y actual con la escala modificada de Rankin (mRS). RESULTADOS: La edad demostró estar directamente relacionada con la mRS (r = 0,56; p = 0,035) y en el 37,5% se obtuvo un buen resultado (mRS ≤ 3). El 78,9% de los familiares entrevistados repetirían la decisión quirúrgica tomada. CONCLUSIONES: Aportamos un grupo de 21 pacientes intervenidos mediante craniectomía descompresiva por infarto maligno donde los mejores resultados funcionales se han dado entre los < 60 años. Las graves secuelas neurológicas en pacientes con infarto maligno intervenidos mediante hemicraniectomía descompresiva fueron toleradas y aceptadas por la mayoría de familias a favor de su supervivencia. No debemos dejar que esta satisfacción familiar camufle el pronóstico, teniendo que contextualizarla dentro de la situación real ambulatoria de los pacientes

OBJECTIVE: The prognosis of one hemisphere malignant infarction creates doubt among neurosurgeons about decompressive hemicraniectomy indication. What results are achieved in the short to medium term? Are families satisfied with the surgery once the patient is at home? In the present study, we analyze our experience in this matter during the last thirteen years. MATERIAL AND METHODS: In our review, twenty-one patients were included from 2004 to 2017, according to the protocol for the management of ischaemic stroke that is implemented in our institution. The relatives were interviewed by telephone. The functional outcome at discharge, 3 months, 1 year, and at present was measured using the modified Rankin scale (mRS). RESULTS: Patient age was shown to be directly related to the mRS (r = 0.56; p = 0.035) and 37.5% achieved a good outcome (mRS ≤ 3); 78.9% of the interviewed relatives would repeat the surgical decision. CONCLUSIONS: We present a 21 patients group where the best outcome was achieved in patients ≤ 60 years old. The severe neurological sequelae in patients with malignant infarction subjected to decompressive hemicraniectomy are tolerated and accepted by most families to the benefit of survival. We must not let this family satisfaction hide the prognosis, having to contextualize it within the real ambulatory situation of the patients

Decompressive craniectomy in malignant middle cerebral artery infarction: family perception, outcome and prognostic factors. / Craniectomía descompresiva en el infarto maligno de arteria cerebral media: percepción familiar, resultados y factores pronósticos.

OBJECTIVE: The prognosis of one hemisphere malignant infarction creates doubt among neurosurgeons about decompressive hemicraniectomy indication. What results are achieved in the short to medium term? Are families satisfied with the surgery once the patient is at home? In the present study, we analyze our experience in this matter during the last thirteen years. MATERIAL AND METHODS: In our review, twenty-one patients were included from 2004 to 2017, according to the protocol for the management of ischaemic stroke that is implemented in our institution. The relatives were interviewed by telephone. The functional outcome at discharge, 3 months, 1 year, and at present was measured using the modified Rankin scale (mRS). RESULTS: Patient age was shown to be directly related to the mRS (r=0.56; p=0.035) and 37.5% achieved a good outcome (mRS≤3); 78.9% of the interviewed relatives would repeat the surgical decision. CONCLUSIONS: We present a 21 patients group where the best outcome was achieved in patients ≤60 years old. The severe neurological sequelae in patients with malignant infarction subjected to decompressive hemicraniectomy are tolerated and accepted by most families to the benefit of survival. We must not let this family satisfaction hide the prognosis, having to contextualize it within the real ambulatory situation of the patients.