Is surgical resection predict overall survival in frail patients with glioblastoma, IDH-wildtype?

PURPOSE: We assessed the impact of frailty on surgical outcomes, survival, and functional dependency in elderly patients harboring a glioblastoma, isocitrate dehydrogenase (IDH)-wildtype. METHODS: We retrospectively reviewed records of old and frail patients surgical treated at a single neurosurgical institution between January 2018 to May 2021. Inclusion criteria were: (1) neuropathological diagnosis of glioblastoma, IDH-wildtype; (2) patient≥65years at the time of surgery; (3) available data to assess the frailty index according to the 5-modified Frailty Index (5-mFI). RESULTS: A total of 47 patients were included. The 5-mFI was at 0 in 11 cases (23.4%), at 1 in 30 cases (63.8%), at 2 in two cases (4.2%), at 3 in two cases (4.2%), and at 4 in two cases (4.2%). A gross total resection was performed in 26 patients (55.3%), a subtotal resection was performed in 13 patients (27.6%), and a biopsy was performed in 8 patients (17.1%). The rate of 30-day postoperative complications was higher in the biopsy subgroup and in the 5-mFI=4 subgroup. Gross total resection and age≤70years were independent predictors of a longer overall survival. Sex, 5-mFI, postoperative complications, and preoperative Karnofsky Performance Status score did not influence overall survival and functional dependency. CONCLUSION: In patients≥65years harboring a glioblastoma, IDH-wildtype, gross total resection remains an independent predictor of longer survival and good postoperative functional recovery. The frailty, assessed by the 5-mFI score, does not influence surgery and outcomes in this dataset. Further confirmatory analyses are required.

Training and teaching of vagus nerve stimulation surgery: Worldwide survey and future perspectives.

OBJECTIVE: Vagus nerve stimulation (VNS) therapy has been used for more than two decades to treat drug resistant epilepsy and depression and most recently received FDA approval for stroke rehabilitation. Expanding indications will renew the interest in the technique and increase the number of surgeons to be trained. The aim of this study was to survey surgeons with substantial expertise on optimal teaching and training approaches. METHODS: Anonymous forms comprising 16 questions were sent by e-mail to surgeons with substantial expertise. Statistical analyses were used to compare the answers of the most experienced surgeons (>5 years) with the less experienced ones (<5 years). RESULTS: Fully-completed forms were collected from 57 experts from 20 countries. The placement of the helical coils was deemed to be the most difficult step by 36 (63.2%) experts, and the use of optical magnification during this step was deemed necessary by 39 (68.4%) experts. Vocal cord palsy should be largely avoidable with proper surgical technique according to 44 (77.2%) experts. The teaching tool considered the most useful was mentoring (38, 66.7%). The future of VNS surgery teaching was deemed to be in anatomical workshops (29, 50.9%) and surgical simulation (26, 45.6%). Overall, answers did not vary significantly according to experience. CONCLUSIONS: VNS surgery should be mastered by actively participating in dedicated practical training courses and by individual mentoring during actual surgery, which is still the best way to learn. This study highlights the need for a formal training course and possible specific accreditation.

Spinal epidural capillary hemangioma: A systematic literature review and an illustrative case.

BACKGROUND: Spinal hemangiomas are rare vascular malformations resulting from proliferation of vascular endothelial cells. The cavernous form is the most common and represents 5-12% of spinal vascular malformations, while the capillary form is rare. CASE DESCRIPTION: A 56-year-old patient with no past medical history presented with progressive spinal cord compression symptoms localizing to the T10 level with MRC grade 4 proximal paraparesis. Preoperative MRI demonstrated a well-delineated, dumbbell-shaped, epidural lesion, without bony involvement, resulting in spinal cord compression at the T7 and T8 levels. The patient underwent gross total surgical resection of the lesion. At the one month follow up, the patient's strength improved to MRC grade 5, and sensation had fully returned. The histopathological diagnosis was a capillary hemangioma. Exclusively epidural capillary hemangiomas are extremely rare with only 26 cases reported in the literature. They are mainly located at the thoracic level (T4-T6). The MRI features include a well-circumscribed mass, hyperintense on T2-weighted sequence in 92% of cases, isointense on T1-weighted sequence in 88% of cases, and homogeneous contrast enhancement in 100% of cases. No tumor recurrence has been observed after gross total surgical removal. CONCLUSIONS: When evaluating progressive spinal cord compression by a purely epidural spinal lesion, the differential diagnosis should include capillary hemangioma, in addition to schwannoma, meningioma, and lymphoma. Early and complete surgical removal is the first line treatment.

Jean Talairach (1911-2007). An untold story of the pioneer of stereotactic and functional neurosurgery.

CONTEXT: The Department of neurosurgery of the Sainte-Anne Hospital hosted Jean Talairach who created and developed stereotactic neurosurgery in France. Despite numerous neurosurgical and neuroscientific achievements, little is known about the life of Jean Talairach. METHODS: Systematic screening of Sainte-Anne Hospital Museum, Henry Ey Library, and Bibliothèque Inter-Universitaire de Santé funds, and medical databases using the term "Jean Talairach". RESULTS: Jean Talairach started his medical career at the Sainte-Anne Hospital in 1942 as a psychiatrist and became a neurosurgeon due to his interest in stereotactic neurosurgery. During World War II, Jean Talairach joined the French Resistance in Paris, then the French First Army. Jean Talairach created an original and specific stereotactic methodology with appropriate stereotactic frame and tools and performed one of the first human stereotactic surgeries in 1948. He described the reference lines passing by the anterior and posterior commissures in 1952 and developed a tridimensional co-planar stereotactic atlas of the human brain. With the collaboration of Jean Bancaud, he created stereo-electroencephalography to investigate patients suffering from drug-resistant epilepsy. The "Sainte-Anne school" trained French and foreign stereotactic and functional neurosurgeons ensuring the spread of Jean Talairach's innovative ideas. Jean Talairach retired in 1980. CONCLUSION: Jean Talairach's achievements encapsulate the evolution of neurosurgery in France during the 20th century. He developed an original stereotactic methodology including a tridimensional stereotactic atlas of the human brain and a stereotactic frame. He created stereo-electroencephalography, which remains the gold-standard to investigate patients suffering from drug-resistant epilepsy.

[Medulloblastomas: review]. / Les médulloblastomes: revue générale.

INTRODUCTION: The term of "medulloblastoma" refers to cerebellar tumors belonging to the family of primitive neuro-ectodermic tumors (PNET). Medulloblastomas represent 40% of cerebellar tumors, 15 to 20% of brain tumors and the first cause of malignant brain tumors in childhood. Seventy to 80% of cases are diagnosed in children versus 20 to 30% in adults. UPDATED KNOWLEDGE: Diagnosis is based on clinical and radiological exams, and proved on pathological analysis in association with molecular biology. Treatment comprises surgery, craniospinal radiotherapy except for children under five years of age and chemotherapy according to age and high-risk criteria. Medulloblastoma is a rare case of a central nervous system tumor which is radio- and chemo-sensitive. Treatment goals are, on one hand, to improve the survival rates and, on the other hand, to avoid late neurocognitive, neuroendocrine and orthopedic side effects related to radiation therapy, notably in children. The prognosis is relatively good, with a five year survival rate over 75% after complete resection of a localized tumor although sequelae may still compromise outcome. PERSPECTIVES AND CONCLUSION: Management of patients with medulloblastoma implies a multidisciplinary approach combining the contributions of neurosurgery, neuroradiology, pediatric oncology, neuro-oncology and radiotherapy teams.

Management of patients suffering from hemorrhagic intracranial metastases: Propositions to help the neurosurgeon in emergency situations based on a literature review.

INTRODUCTION: Brain metastases are the most common intracranial neoplasm in adult patients, and one of the fearsome complications proves to be intratumoral hemorrhage. The neurosurgical management of patients harboring a bleeding brain metastasis is not fully established and there is still today an ongoing debate on the optimal management of these patients. The aim of this article is to provide the neurosurgeons with practical tools to assist in their decision-making process in the management of BMs. METHODS: We conducted a literature review of the relevant Pubmed, Cochrane, and Google scholar-indexed articles published between 2000 and 2019. The following key words were entered in the Pubmed search engine: [metastasis], [metastases], [brain metastases], [brain metastasis], [hemorrhage], [hematoma], [blood clot], [intracerebral hemorrhage], [intracranial hemorrhage]. The review was performed in accordance with the PRISMA recommendations. RESULTS: Based on PubMed, Cochrane, and Google scholar, 459 articles were retained, 392 were then removed because of their non-adequacy with the topic and, 9 articles were removed because they were not written in English language. So, 58 articles were analyzed. Radiological evaluation is crucial, but few traps exist. The frequency of overall brain tumor-related with intracranial hematoma is 7.2%, with a higher frequency for secondary tumors. The local recurrence rate after resection of a hemorrhagic metastasis seems to be better probably because of an easier "en bloc" resection thanks to the hematoma. An atypical presentation is reported in up to 4% in patients with chronic or acute subdural hematoma. Patients with subarachnoid hemorrhage and epidural hematoma are rare. A clear-cut correlation between the incidence of bleeding event in brain mets and prior stereotactic radiosurgery was not established. CONCLUSION: The current literature pertaining to the neurosurgical management of acute bleeding in brain metastasis is scant and the level of evidence remains low (experts 'opinions; class C). Herein we suggest a flowchart to assist in dealing with those difficult patients.

Anatomical and functional MR imaging to define tumoral boundaries and characterize lesions in neuro-oncology.

Neuroimaging and especially MRI has emerged as a necessary imaging modality to detect, measure, characterize and monitor brain tumours. Advanced MRI sequences such as perfusion MRI, diffusion MRI and spectroscopy as well as new post-processing techniques such as automatic segmentation of tumours and radiomics play a crucial role in characterization and follow up of brain tumours. The purpose of this review is to provide an overview on anatomical and functional MRI use for brain tumours boundaries determination and tumour characterization in the specific context of radiotherapy. The usefulness of anatomical and functional MRI on particular challenges posed by radiotherapy such as pseudo progression and pseudo esponse and new treatment strategies such as dose painting is also described.

Symptomatic progestin-associated atypical grade II meningioma. A first case report.

BACKGROUND: Long-term use of high-dose progestin is known to promote the development of meningioma. Atypical meningioma in a patient under progestin has not previously been reported. CASE REPORT: A 53-year-old right-handed woman presented with focal onset seizures, without impaired consciousness. Medical history featured endometriosis, treated successively by cyproterone acetate 25mg/day for 2 months then 50mg/day for 101 months, and chlormadinone acetate 5mg/day for 68 months then 10mg/day for 83 months. Brain MRI revealed multiple extra-axial lesions suggestive of left central meningioma associated with anterior skull base meningiomatosis. Surgical resection of the left central meningioma was achieved and progestin was withdrawn. Neuropathology diagnosed grade II atypical meningioma. Close clinical and imaging monitoring was implemented without adjuvant oncological treatment. At 25 months, imaging follow-up showed no recurrence of the left central meningioma and a significant regression of all other lesions, except for the right frontal lesion. CONCLUSIONS: Neurosurgeons should be aware of the possible aggressiveness of meningioma in patients under progestin, and particularly those treated by different types of progestin over a long period of time without interruption. This may require systematic close monitoring, to adapt neurosurgical management.

Acute intracranial hypertension management in metastatic brain tumor: A French national survey.

BACKGROUND: Brain metastases occur in 15-30% of cancer patients and their frequency has increased over time. They can cause intracranial hypertension, even in the absence of hydrocephalus. Emergency surgical management of brain metastasis-related intracranial hypertension is not guided by specific recommendations. OBJECTIVE: We aimed to make a French national survey of emergency management of intracranial hypertension without hydrocephalus in the context of cerebral metastasis. METHODS: A national online survey of French neurosurgeons from 16 centers was conducted, consisting of three clinical files, with multiple-choice questions on diagnostic and therapeutic management in different emergency situations. RESULTS: In young patients without any previously known primary cancer, acute intracranial hypertension due to a seemingly metastatic single brain tumor indicated emergency surgery for all those interviewed; 61% aimed at complete resection; brain MRI was mandatory for 74%. When a primary cancer was known, 74% of respondents were more likely to propose surgery if an oncologist confirmed the possibility of adjuvant treatment; 27% were more likely to operate on an emergency basis when resection was scheduled after multi-disciplinary discussion, prior to acute degradation. CONCLUSION: Currently, there is no consensus on the emergency management of intracranial hypertension in metastatic brain tumor patients. In case of previously known primary cancer, a discussion with the oncology team seems necessary, even in emergency. Decision criteria emerge from our literature review, but require analysis in further studies.

[Management of tumoral epilepsy in meningioma surgery: Review of the literature and survey of French national practices]. / Gestion de l'épilepsie tumorale dans la chirurgie des méningiomes : revue de la littérature et enquête sur les pratiques nationales.

Prophylaxis or treatment of tumor-associated seizures is adaily concern in neurosurgical practice but is often guided by the surgeon's habits rather than evidence from clinical trials, which is lacking. The present study reviews the literature on the incidence, clinical aspects and treatment of epilepsy and epileptic seizures in patients undergoing surgery for meningioma. Based on the published data, we then performed a French nationwide survey of neurosurgeons' practices regarding perioperative management of meningioma-related epilepsy and epileptic seizures.

Optimization of high-grade glioma resection using 5-ALA fluorescence-guided surgery: A literature review and practical recommendations from the neuro-oncology club of the French society of neurosurgery.

BACKGROUND: When feasible, the surgical resection is the standard first step of the management of high-grade gliomas. 5-ALA fluorescence-guided-surgery (5-ALA-FGS) was developed to ease the intra-operative delineation of tumor borders in order to maximize the extent of resection. METHODS: A Medline electronic database search was conducted. English language studies from January 1998 until July 2018 were included, following the PRISMA guidelines. RESULTS: 5-ALA can be considered as a specific tool for the detection of tumor remnant but has a weaker sensibility (level 2). 5-ALA-FGS is associated with a significant increase in the rate of gross total resection reaching more than 90% in some series (level 1). Consistently, 5-ALAFGS improves progression-free survival (level 1). However, the gain in overall survival is more debated. The use of 5-ALA-FGS in eloquent areas is feasible but requires simultaneous intraoperative electrophysiologic functional brain monitoring to precisely locate and preserve eloquent areas (level 2). 5-ALA is usable during the first resection of a glioma but also at recurrence (level 2). From a practical standpoint, 5-ALA is orally administered 3 hours before the induction of anesthesia, the recommended dose being 20 mg/kg. Intra-operatively, the procedure is performed as usually with a central debulking and a peripheral dissection during which the surgeon switches from white to blue light. Provided that some precautions are observed, the technique does not expose the patient to particular complications. CONCLUSION: Although 5-ALA-FGS contributes to improve gliomas management, there are still some limitations. Future methods will be developed to improve the sensibility of 5-ALA-FGS.

[Changes in spontaneous epileptic activity after selective intrahippocampal transection in a model of chronic mesial temporal lobe epilepsy]. / Modifications de l'activité épileptique spontanée par déconnexion sélective intrahippocampique dans un modèle chronique d'épilepsie mésiotemporale.

Drug-resistant mesial temporal lobe epilepsy with hippocampal sclerosis is associated with anatomical, ultrastructural and functional changes that facilitate generation and spread of epileptic seizures. Intrahippocampal circuits are modified in their transversal lamellar and longitudinal translamellar organization. Neuronal death and the neuroplasticity of surviving cells contribute to major phenomena: an increased hyperexcitability of the hippocampal formation and an increased synchronization of its principal cells. Selective disruption of the epileptic networks that are involved in mesial temporal lobe epilepsy may have a therapeutic effect. We present here the preliminary results of a selective intrahippocampal transection in a chronic model of mesial temporal lobe epilepsy after focal injection of kainic acid in adult mice. A complete transection of the hippocampal formation (including dentate gyrus and hippocampus proper, sparing the fimbria) results in a blockade of ictal activities spread from the generator, a reduction in their frequency and an increase in their duration. In contrast, after a transection sparing the dentate gyrus and hilus, no modification was noted. In this model of mesial temporal lobe epilepsy, longitudinally projecting axonal circuits of the dentate gyrus and hilus appear to be implicated in generation, propagation and interruption of ictal activities within hippocampal formation.

[Corticectomy: technical considerations]. / Cortectomies: aspects techniques.

The surgical treatment of epilepsy requires careful preparation and presents a certain number of technical specificities. The neurosurgeon must master not only the technical aspects but also the therapeutic and functional trade-off in order to modulate the procedure according to morphological and electrophysiological intraoperative data. A large number of technical variants have been developed to correspond to epileptological or functional anatomical considerations. Until this point, the choice of a particular technique does not seem to have a significant impact on the therapeutic effectiveness of surgery, and differences in results can be related to the presurgical evaluation and surgical indications. On the other hand, technical development promises to play an important role in limiting the long-term neurocognitive consequences of surgery.

[Animal models to develop surgery of focal epilepsies?]. / Des modèles animaux pour développer la chirurgie des épilepsies focales ?

A model is a simplified preparation that reproduces only the most critical features of a disease. To be considered as a validated animal model, such an experimental preparation must fulfill three criteria: isomorphism or similarities of the symptoms; predictivity or identical pharmacological reactivity; homology or etiological similarity. In epilepsy, the use of animal models helps our understanding of physiological and pathological networks involved in the genesis, maintenance, and propagation of seizures. The animal models of epilepsy are also useful in designing and testing new surgical therapeutical strategies, in particular using deconnection or neuromodulation in drug-resistant focal epilepsies. Here we describe three animal models of focal epilepsy, adapted to addressing experimental surgery issues. Kindling consists in the regular liminar stimulation of a given brain structure in the rodent to develop a focal discharge that is secondarily generalized. The local application of epileptogenic agents such as cobalt, iron, or penicillin leads to focal discharges that do not generalize in the rodent or the primate. It is a model of focal neocortical epilepsy without secondary generalization. The focal application of kainate, an excitotoxic glutamate agonist, in the dorsal hippocampus of the adult mouse results, after a latent period, in spontaneous and recurrent focal discharges, behavioral interictal troubles, drug resistance, and histological anomalies reminiscent of hippocampal sclerosis. This constitutes a model of mesial-temporal epilepsy. Better knowledge, in these models, of the neural networks generating, propagating, and/or controlling the seizures should make it possible to design innovative surgical approaches for the treatment of drug-resistant epilepsies.

[Epileptiform activities generated in vitro by human temporal lobe tissue]. / Activités épileptiques produites in vitro par le tissu temporal humain.

Drug-resistant partial epilepsies, including temporal lobe epilepsies with hippocampal sclerosis and cortical dysplasias, offer the opportunity to study human epileptic activity in vitro since the preferred therapy often consists of the surgical removal of the epileptogenic zone. Slices of this tissue retain functional neuronal networks and may generate epileptic activity. The properties of cells in this tissue do not seem to be significantly changed, but excitatory synaptic characteristics are enhanced and GABAergic inhibition is preserved. Typically, epileptic activity is not generated spontaneously by the neocortex, whether dysplastic or not, but can be induced by convulsants. The initiation of ictal discharges in neocortex depends on both GABAergic signaling and increased extracellular potassium. In contrast, a spontaneous interictal-like activity is generated by tissues from patients with temporal lobe epilepsies associated with hippocampal sclerosis. This activity is initiated not in the hippocampus but in the subiculum, an output region that projects to the entorhinal cortex. Interictal events seem to be triggered by GABAergic cells, which paradoxically excite approximately 20% of subicular pyramidal cells, while simultaneously inhibiting the majority. Interictal discharges are therefore sustained by both GABAergic and glutamatergic signaling. The atypical depolarizing effects of GABA depend on a pathological elevation in the basal levels of chloride in some subicular cells, similar to those of developmentally immature cells. This defect is caused by the perturbation of the expression of the cotransporters regulating the intracellular chloride concentration, the importer NKCC1, and the extruder KCC2. Blockade of excessive NKCC1 by the diuretic bumetanide restores intracellular chloride and thus hyperpolarizing GABAergic actions, suppressing interictal activity.

[Surgical resections in functional areas: report of 89 cases]. / Résections en région fonctionnelle: étude d'une série de 89 cas.

Surgical resections for intractable epilepsy are generally associated with a high risk of permanent neurological deficit and a poor rate of seizure control. We present a series of 89 patients operated on from 1992 through 2007 for drug-resistant partial epilepsy, in whom surgery was performed in a functional area of the brain: the central (sensorimotor and supplementary motor areas) region in 48 cases, posterior regions (parietal and occipital) in 27, the insula in eight, and the language areas in six. Epilepsy was cryptogenic in 12 patients, and lesion-related in 77: malformation of cortical development in 43, tumor in 17, perinatal cicatrix in 13, vascular lesion in three, and another prenatal lesion in one. Seventy patients underwent stereoelectroencephalographic (SEEG) exploration. The surgical procedure was resective (lesionectomy or SEEG-guided corticectomy) in 83 patients and multiple stereotactic thermocoagulations in six. Ten patients were reoperated because of early seizure recurrence. A postoperative complication was observed in 12 patients. Postoperative deficits were observed in 54 patients (61%) and resolved completely in 29. In 25, a permanent deficit persisted, minor in 19 and moderate to severe in six, which did not correlate with localization or etiology. With a one-year follow-up in 74 patients (mean, 3.6 years), 53 (72%) were in Engel's class I, including 38 (51%) in class IA. Seizure outcome was significantly associated with etiology: 93% of Taylor-type focal cortical dysplasia, whereas only 40% of cryptogenic epilepsies were in class I (p<0.05). This suggests that resective or disconnective surgery for intractable partial epilepsy in functional areas of the brain may be followed by excellent results on seizures and a moderate risk of permanent neurological sequelae.

The Impact of Compressed Femtosecond Laser Pulse Durations on Neuronal Tissue Used for Two-Photon Excitation Through an Endoscope.

Accurate intraoperative tumour margin assessment is a major challenge in neurooncology, where sparse tumours beyond the bulk tumour are left undetected under conventional resection. Non-linear optical imaging can diagnose tissue at the sub-micron level and provide functional label-free histopathology in vivo. For this reason, a non-linear endomicroscope is being developed to characterize brain tissue intraoperatively based on multiple endogenous optical contrasts such as spectrally- and temporally-resolved fluorescence. To produce highly sensitive optical signatures that are specific to a given tissue type, short femtosecond pulsed lasers are required for efficient two-photon excitation. Yet, the potential of causing bio-damage has not been studied on neuronal tissue. Therefore, as a prerequisite to clinically testing the non-linear endomicroscope in vivo, the effect of short laser pulse durations (40-340 fs) on ex vivo brain tissue was investigated by monitoring the intensity, the spectral, and the lifetime properties of endogenous fluorophores under 800 and 890 nm two-photon excitation using a bi-modal non-linear endoscope. These properties were also validated by imaging samples on a benchtop multiphoton microscope. Our results show that under a constant mean laser power, excitation pulses as short as 40 fs do not negatively alter the biochemical/ biophysical properties of tissue even for prolonged irradiation.

Reirradiation with concurrent bevacizumab for recurrent high-grade gliomas in adult patients.

PURPOSE: To analyse feasibility, prognostic factors and patterns of recurrence after concurrent reirradiation and bevacizumab for recurrent high-grade gliomas. PATIENTS AND METHODS: Between 2009 and 2015, 35 patients (median 57-year-old; 21 men, 14 women) with WHO grade III (n=11) or grade IV (n=24) gliomas were included in this retrospective and consecutive single-centre study. All patients received bevacizumab (median number of treatments: 12) concomitant with reirradiation (median dose: 45Gy, median number of fractions: 18) for recurrence with median 22 months (range: 5.6-123.7 months) from first irradiation (median dose: 60Gy). RESULTS: The median follow-up was 9.2 months from reirradiation. The median overall survival from reirradiation was 10.5 months (95% confidence interval [95% CI]: 4.9-16.1) and the progression-free survival from reirradiation was 6.7 months (95% CI: 2.9-10.5). The median overall survival from initial diagnosis was 44.6 months (95% CI: 32-57.1). No grade 3 toxicity or above was reported. Prognostic factors significantly correlated with better overall survival in univariate analysis were: age at least 55 (P=0.024), initial surgery (P=0.003), and 2Gy equivalent dose (EQD2) at least 50Gy at reirradiation (P=0.046). Twenty-two patients bevacizumab-naïve at time of reirradiation had a significantly increased overall survival from reirradiation compared to patients treated with reirradiation after bevacizumab failure (17.7 vs. 5.4 months, P<0.001) as well as overall survival from initial diagnosis (58.9 vs. 33.5 months, P=0.006). This outcome was similar in patients with initial glioblastomas (P=0.018) or anaplastic gliomas (P=0.021). There was no correlation between overall survival and gross tumour volume or planning target volume, frontal localization, or number of salvage therapies before reirradiation (P>0.05). CONCLUSIONS: Concomitant reirradiation with bevacizumab in high-grade recurrent gliomas shows encouraging results in terms of survival and toxicities. Our data suggest that reirradiation should be favoured at initiation of bevacizumab, with EQD2 at least 50Gy.