Aggressive resection in Metastatic spinal tumors (MST) includes three main en bloc techniques: vertebrectomy, hemivertebrectomy, and corpectomy. En bloc excision aims to remove the tumor in one piece without violation, ensuring appropriate pathological margins. Vertebrectomy (marginal or wide en bloc excision) is indicated when the tumor is centrally located with at least one uninvolved pedicle. Thoracic lesions are often managed in a single stage, whereas lumbar lesions usually require a two-stage approach to reduce neurological risk. Posterior mobilization precedes anterior tumor delivery, with careful neural decompression. Hemivertebrectomy is used for eccentrically located tumors involving part of the vertebral body, pedicle, or transverse process. It preserves uninvolved structures and may reduce morbidity compared with total vertebrectomy. Lastly, corpectomy can be performed via anterior, posterior, or combined approaches to remove tumor and reconstruct the anterior column. Indications for aggressive surgery depend on multidisciplinary evaluation, life expectancy, functional status, tumor biology, and mechanical instability. While isolated metastasis may justify radical resection, prognosis and systemic disease burden must guide decisions. Despite favorable long-term outcomes in selected patients, en bloc vertebrectomy carries high morbidity and frequent revision surgery. Careful patient selection, embolization, vascular support and experienced surgical teams are essential to optimize management.

Background: The Treatment Of Brain Arteriovenous malformations Study is a pragmatic study comprising 2 randomized trials and prospective registries of patients with brain arteriovenous malformations (AVMs). We report the results of the stereotactic radiosurgery (SRS) registry. Methods: TOBAS uses an algorithm integrating clinical judgment and randomization. When SRS was selected as the preferred curative modality and randomized allocation of SRS versus observation was judged unreasonable, patients were included in the SRS registry (with/without pre-SRS embolization). The primary outcome was modified Rankin Scale > 2 at last follow-up. Secondary outcomes included serious adverse events, AVM rupture, radiation-induced changes, and magnetic resonance angiographic results at 3 years. Analyses were intent-to-treat. Results: From June 2014 to May 2021, 1010 patients were recruited; 105 (10.4%) were offered participation in the SRS registry. After exclusions, 94 patients were analyzed; most had ruptured (n = 64/94 [68%]), small AVMs (0-3 cm) (84 [89%]), within eloquent brain (57 [61%]). Pre-SRS embolization was performed in 19 (20%); 4 were cured and 3 had endovascular complications, leaving 87/94 (93%) patients who received SRS. The median SRS dose was 22 Gy (interquartile range: 20-24). During a mean follow-up of 51 months, the primary outcome (modified Rankin Scale > 2) occurred in 7/94 (7%; 95% confidence interval [CI]: 4%-15%), with serious adverse events in 16/94 (17%; 95% CI: 11%-26%), including AVM rupture in 5/94 (5%; 95% CI: 2%-12%), and symptomatic radiation-induced changes in 6/87 (7%; 95% CI: 3%-14%). Three-year imaging follow-up, available in 79/94 (84%) confirmed AVM occlusion in 51/79 (65%; 95% CI: 54%-74%) or 54% (95% CI: 44%-64%) of all patients. Conclusions: In this prospective registry, radiosurgery with or without embolization was relatively safe, but of moderate efficacy, with 3-year AVM occlusion in 54%-65% patients.

Purpose: Aneurysmal subarachnoid haemorrhage (aSAH) is a severe form of stroke. Clearing blood from the cerebrospinal fluid by intraventricular fibrinolysis (IVF) through an external ventricular drain (EVD) has been hypothesized to improve functional outcome. The aim of this study was to evaluate the effect of IVF on functional outcome after aSAH. Methods: FIVHeMA is a multicentre phase III randomized controlled trial (RCT). Patients with aSAH requiring EVD insertion were included. Patients were randomized to receive either EVD alone or IVF. The primary outcome was good functional outcome at 6 months, defined as modified Rankin Scale (mRS) 0–3. To increase statistical power, an individual patient data meta-analysis (IPD-MA) of similar RCT was also performed. Results: The trial was terminated early because the target enrolment of 440 participants was deemed not feasible. 84 patients were randomized: 44 to EVD alone and 40 to IVF. Primary outcome was achieved in 39/44 (89%) with EVD alone and 34/40 (85%) with IVF (OR=0.7, 95% CI 0.2–2.6; p=0.63). Secondary and safety outcomes were similar across groups. Non-significant reductions were observed in delayed neurological deficit (OR=0.4, 95% CI 0.1–1.1; p=0.065) and chronic hydrocephalus (OR=0.4, 95% CI 0.1–1.0; p=0.054) in the IVF group. In the IPD-MA combining 137 patients from 4 trials, good outcome was observed in 55/71 (77%) with IVF and 50/66 (76%) with EVD alone (Peto OR=1.4, 95% CI 0.6–3.3; p=0.42).Conclusions: This prematurely terminated trial, complemented by IPD-MA, found no evidence that IVF improves functional outcome after aSAH.

OBJECTIVE:Pyogenic spondylodiscitis is a serious disease whose incidence is increasing. Several studies have demonstrated the efficacy of surgical management by circumferential arthrodesis at the cost of autologous bone grafting, which is not without morbidity. In this first French series, we evaluated the safety and efficacy of rh-BMP 2 in pyogenic infections of the lower thoracic and lumbar spine. METHODS:This retrospective study included 20 patients operated on between January 2010 and December 2023 for pyogenic spondylodiscitis or spondylitis of the lower thoracic or lumbar region by circumferential arthrodesis with the use of rh-BMP 2 in interbody implants. An age-matched control group of 16 patients was included for comparison. RESULTS:Radiological fusion was observed in all patients at 6 months in the rh-BMP2 group. No complications specifically attributable to rh-BMP2 were observed during follow-up. In the control group, fusion was acquired at an average of 23 months (p = 0.02*). CONCLUSIONS:In this small retrospective series, the use of rh-BMP2 was associated with a high early fusion rate. However, these findings must be interpreted with caution given methodological limitations. Further prospective studies are required.

Although radiation therapy is used less frequently in the treatment of functioning and nonfunctioning pituitary adenomas, it still plays a role to control volume and secretion. Radiation therapy remains to be considered in the therapeutic algorithm for these diseases, as mentioned in all recent national and international guidelines. Recent studies have focused on the use of stereotactic approaches, either given as a single dose or as a fractionated one. However, some patients may still benefit from conformal fractionated radiotherapy. The choice among these procedures is currently based mainly on adenoma's profile in terms of size, quality of the radiological definition, invasiveness, and aggressiveness, as well as local availability. Endocrine efficacy in functioning pituitary adenomas and tumor control in nonfunctioning pituitary adenomas seem equivalent regardless of the technique. This review will try to determine whether gender should also be considered as a predictive factor of efficacy and toxicity.

We report the case of an adult-type diffuse glioma with spinal leptomeningeal dissemination, corresponding to a new molecularly methylation class, identified as "Adult-type diffuse high-grade glioma, IDH-wildtype, subtype E," using the Heidelberg Epignostix CNS Tumor Classifier v12.8. Clinical, histo-molecular, cerebrospinal fluid analyses and neuro-radiological data were recorded. A 43-year-old man was diagnosed 5 years ago with a diffuse glioma and subsequent spinal leptomeningeal dissemination. He received radiochemotherapy based on temozolomide followed by monthly temozolomide (6 months) but relapsed 15 months later. After three additional therapeutic lines, bevacizumab was introduced, achieving a clinical and imaging response with subtotal regression of lesions. To date, glioblastoma remains under control, 5 years after diagnosis and 3 years after bevacizumab introduction. We describe an unusual prolonged response to bevacizumab in a new subtype of adult-type diffuse high-grade glioma, with spinal leptomeningeal dissemination. Despite frequent dreadful prognosis in patients treated for high-grade gliomas, there are rare long-term responder patients. This situation remains unclear, particularly in the context of spinal leptomeningeal dissemination. The identification of new subtypes could help differentiate between miscellaneous prognostic group. It would be relevant to consider these subgroups in future clinical trials.

PURPOSE:The 2022 WHO classification states no histological grading exists to assess pituitary adenoma (PA) aggressiveness. The European Society of Endocrinology refers to the term "unusually rapid growth rate" when defining an aggressive PA. This study aimed to evaluate three-dimensional volume growth rate (3DVGR) in multiple PAs and correlate it with tumor progression and histopathology. METHODS:Patients with growing or proliferative PAs who underwent surgery were retrospectively selected. Gadolinium-enhanced 3D T1-weighted MRI was required. RESULTS:A total of 76 3DVGR measurements were performed on 50 nonproliferative and 25 proliferative PAs, with median 3DVGRs of 21.2%/year and 60.2%/year, respectively (P < .0001). ROC analysis (AUC 0.992, P < .001) defined three 3DVGR groups: <50%/year, ≥50%, and <80%/year, ≥80%/year with a median PFS of 99.0, 39.0, and 7.0 months, respectively. In tumors with 3DVGR <50%/year, proliferative status had no significant progression-free survival impact (P = .381). In contrast, proliferative tumors with 3DVGR ≥50%/year had worse outcomes than those with 3DVGR <50%/year (P < .001). In multivariate analysis, only 3DVGR ≥50%/year predicted early progression (P < .001), unlike proliferative status. Combining 3DVGR ≥80%/year or 50% ≤3DVGR < 80%/year with Ki67 ≥ 8% identified 12 PAs with a median PFS of 8.5 months vs 64 months in others. CONCLUSION:PA proliferation may be categorized as: <10%/year: non and/or slowly progressive, 10-49%/year: slowly progressive, 50-79%/year: progressive, ≥80%/year: highly progressive. 3DVGR appears to be a valuable tool to evaluate PA proliferation alongside histology.

OBJECTIVE:The risk-benefit balance of pituitary stalk (PS) preservation during craniopharyngioma (CP) surgery remains insufficiently investigated. Although preservation requires meticulous microsurgical dissection, frequent invasion of the PS by the CP also raises the question of the feasibility of preservation. Herein, the authors assessed the impact of preserving the PS in a large consecutive series of adult patients who underwent endoscopic endonasal surgery for CP. METHODS:The authors performed a retrospective single-center study of adult, surgery-naive patients with supradiaphragmatic CP treated via the extended transsphenoidal transtubercular approach between 2002 and 2023. The following variables were analyzed: PS status (fully preserved, partially preserved, and sacrificed or not identified), extent of CP resection (gross-total, near-total, or partial resection), CP size, postoperative endocrine outcomes, recurrence, and use of adjuvant radiotherapy. RESULTS:Eighty-three patients were included in the study. The PS was fully preserved in 18% of patients, partially preserved in 17%, and sacrificed or not identified in 65%. PS preservation, either partially or fully, was associated with significantly lower rates of anterior pituitary deficiencies (p < 0.001), vasopressin deficiency (p = 0.001), and significantly lower postoperative weight gain (p = 0.033). When the maximal tumor diameter exceeded 24 mm, the risk of PS sacrifice increased threefold (p = 0.027). CONCLUSIONS:Partial or complete preservation of the PS during surgery for CP is associated with improved postoperative endocrine outcomes without compromising the tumor resection or increasing the risk of recurrence. When anatomically feasible, PS preservation should be considered as a key surgical objective in the management of CP.

OBJECTIVE Many patients recruited in the Treatment of Brain Arteriovenous Malformations Study (TOBAS) are managed conservatively. The aim of this study was to monitor what happened to those patients. METHODS TOBAS comprises two randomized controlled trials and multiple prospective registries. All patients with brain arteriovenous malformations (AVMs) can participate. This report concerns patients selected for conservative management. The primary trial outcome measure is related death or dependency (modified Rankin Scale [mRS] score > 2) at 10 years. Secondary outcomes include intracranial hemorrhages, nonhemorrhagic neurological events, and serious adverse events (SAEs). For this report, outcome results are presented using patient-years, Kaplan-Meier survival curves, and Cox log-rank tests. There was no blinding. RESULTS From June 2014 to May 2021, 1010 patients were recruited, of whom 498 (49%) were proposed the prospective observation registry. After exclusions, 434 (87%) patients remained for analysis. The majority of patients had unruptured AVMs (378/434 [87%]), of which 195 (52%) were low grade (Spetzler-Martin grade I or II). During a mean follow-up period of 3.2 years (total 1368 patient-years), the primary outcome occurred in 23 of 434 (5%) patients, corresponding to an incidence of 1.7 (95% CI 1.1-2.5) per 100 patient-years. For unruptured AVMs the incidence was 1.1 (95% CI 0.7-1.9) per 100 patient-years, and for low-grade unruptured AVMs it was 0.6 (95% CI 0.2-1.7) per 100 patient-years. Poor outcomes were more frequent in patients with a history of rupture (HR 5.6 [95% CI 2.4-13.0], p < 0.001), infratentorial AVMs (HR 2.9 [95% CI 1.1-7.3], p = 0.027), and age >= 55 years (HR 3.2 [95% CI 1.4-7.6], p = 0.007). Major intracranial hemorrhage occurred in 35 of 434 (8%) patients (incidence of 2.6 [95% CI 1.9-3.6] per 100 patient-years; 2.0 [95% CI 1.3-2.9] per 100 patient-years for unruptured AVMs and 1.3 [95% CI 0.6-2.6] per 100 patient-years for low-grade unruptured AVMs). Major AVM hemorrhages were more frequent in ruptured (HR 4.4 [95% CI 2.1-8.9], p < 0.001), large (HR 2.6 [95% CI 1.1-6.6], p = 0.039), and high-grade (HR 2.5 [95% CI 1.2-5.3], p = 0.013) AVMs and those with deep venous drainage (HR 2.1 [95% CI 1.1-4.2], p = 0.032). SAEs occurred in 48 of 434 (11%) patients (incidence of 3.6 [95% CI 2.7-4.8] per 100 patient-years). For unruptured AVMs the incidence was 2.8 (95% CI 2.0-4.0) per 100 patient-years, and for low-grade unruptured AVMs it was 1.8 (95% CI 1.0-3.2) per 100 patient-years. CONCLUSIONS Nearly half of TOBAS participants were observed. Rates of untoward neurological events were within expected boundaries.

BACKGROUND:Intracranial pseudoaneurysms are rare and account for less than 2% of all intracranial aneurysms. They most frequently occur after head injury, but they also can be caused by iatrogenic arterial injury during neurosurgical or ENT procedures. No clear guidelines are established concerning the treatment and surveillance of such aneurysms. METHODS:In this article, we present 2 cases of iatrogenic pseudoaneurysms treated conservatively and we propose a review of literature of the management and outcome of intracranial iatrogenic pseudoaneurysms. CASE REPORT AND RESULTS:The first case is one during a transcranial approach and the second one during a transsphenoidal approach, that were both conservatively treated with a close follow-up and a spontaneous healing of the aneurysm. CONCLUSION:Endovascular treatment or surgical clipping are 2 valid therapeutic options in iatrogenic pseudoaneurysms, which should be preferred when feasible with a reasonable risk. In contrast, in case of a small pseudoaneurysm, important risk and complex procedures, conservative treatment with a close follow-up appears to be a valuable alternative.

Treatment-refractory meningioma is a widely used term but lacks standardized criteria, impairing research comparability and treatment evaluation. The aim of this study was to assess the heterogeneity of patient populations labeled as treatment-refractory and to explore recommendations for better consistency. We systematically reviewed 69 studies published before 2024 and analyzed individual participant data from 15 cohorts (n = 211) that included treatment-refractory patients who underwent experimental therapy with somatostatin receptor (SSTR)-targeted therapies. A reference cohort (n = 102) with newly diagnosed WHO-3 meningiomas was used descriptively for comparison. Progression and death were the primary endpoints. Hazard rate ratios were estimated via Poisson regression, and inter-study heterogeneity was quantified using I² statistics. Definitions of treatment-refractory varied substantially across previous studies. WHO-1 patients showed high statistical inter-study variability, particularly for the long-acting SSTR-analogues group when assessing progression (I² = 81.7

Craniopharyngiomas are rare hypothalamic-pituitary tumors found in young children, adolescents and adults, and their multidisciplinary management required, calls for consistent practices for practicioners, patients and families. The French Endocrine Society and French Society for Pediatric Endocrinology & Diabetes enlisted and coordinated adult and paediatric endocrinologists, neurosurgeons, pathologists, radiotherapists as well as psychologists, dieticians and a patient association, to draft a reference document on this severe disease. The management of craniopharyngiomas remains complex due to their aggressive nature, invasive behavior, and propensity for recurrence, requiring a sequential and measured therapeutic approach and follow-up in expert centers. Although patient survival rates are high, the consequences of both the tumor and its treatment can lead to serious comorbidities and impaired quality of life, particularly in those patients with lesional hypothalamic syndrome. Recent advances have allowed the two described tumor types - papillary and adamantinomatous - to be associated with distinct molecular signatures, specific pathophysiological mechanisms and ipso facto, distinct therapeutic approaches, including innovative medications for hyperphagia, that will continue to evolve. This consensus statement covers all stages in the management of patients with craniopharyngioma, from diagnosis to therapeutic strategies including the long-term follow-up.

“Biopsy-only” glioblastoma (BO-GB) is an understudied entity associated with a poor outcome for whom quality of life preservation is essential. Our objective was to define and determine the time of autonomy duration in BO-GB and its potential predictive factors. Patients diagnosed with IDH wild-type BO-GB and enrolled in a prospective regional cohort from 2014 to 2017 were analyzed for their clinical features, functional status, histo-molecular profile, neuroimaging findings, and treatment details. 137 patients were included in the present analysis. Median age at inclusion was 66 years old and median KPS was 70. Median time of autonomy duration was 7.7 months (CI95

Purpose: Bilateral inferior petrosal sinus sampling (BIPSS) with corticotropin-releasing hormone (CRH) was the gold standard for distinguishing Cushing disease (CD) from ectopic ACTH secretion (EAS). CRH, however, is no longer available.Objective: To assess the reliability of BIPSS with desmopressin to differentiate CD from EAS.Methods: A retrospective study included patients who underwent BIPSS with desmopressin for ACTH-dependent hypercortisolism, with the whole diagnostic procedure in a single center.Results: Fifty-eight patients with confirmed etiological diagnosis were included: 51 CD, 7 EAS. Forty-three CD patients (84.3%) had post-stimulation ratio ≥2 before stimulation and 6 of the other 8 (75%) had a ratio ≥3. All EAS patients were correctly diagnosed before and after stimulation. Sensitivity was 84.3% before stimulation and 92.2% combining pre- and post-stimulation results; specificity reached 100%. A ROC curve established optimal thresholds at 1.4 before stimulation and 1.7 after.Conclusion: Desmopressin is a good substitute for CRH, correcting diagnosis compared to baseline BIPSS in 12% of cases.

Contexte Le cathétérisme des sinus pétreux (KTSP) avec stimulation par CRH était considéré comme le « gold standard » pour différencier maladie de Cushing (MC) et sécrétion ectopique d’ACTH (EAS). Le CRH n’est désormais plus disponible. Objectif Déterminer la fiabilité du KTSP avec stimulation par la desmopressine pour distinguer MC et EAS. Méthodes Inclusion rétrospective des patients ayant subi un KTSP à la desmopressine pour hypercortisolisme ACTH-dépendant entre 1995 et 2023 et ayant un diagnostic étiologique de certitude. Résultats Sur les 73 patients ayant eu un KTSP à la desmopressine, 59 ont été inclus représentant 52 MC et 7 EAS. En utilisant les seuils habituels (ratio central/périphérique ≥ 2 avant stimulation et ≥ 3 après), tous les patients avec EAS ont été correctement diagnostiqués. Parmi les 52 patients avec MC, 43 (82,7 %) présentaient un ratio ≥ 2 avant stimulation. Concernant les 9 patients restants, 7 (77,8 %) présentaient un ratio maximal post-simulation ≥ 3. Au total, la sensibilité était de 82,7 % avant stimulation et 77,8 % après, tandis que la spécificité atteignait 100 %. Une courbe ROC a établi des seuils optimaux à 1,4 avant stimulation et 1,7 après, permettant une sensibilité de 88,5 % et 96,2 % avant et après stimulation, respectivement, alors que la spécificité restait inchangée à 100 %. Aucune complication du geste n’a été observée. Conclusion Le KTSP est un examen fiable. La stimulation par desmopressine corrige le diagnostic basal dans 11,8 % des cas. Cette procédure diagnostique peut donc remplacer le KTSP avec stimulation par CRH.

Several retrospective studies and meta-analyses of Peptide Radionuclide Radiation Therapy in meningiomas suggest six-month progression-free survival improvement for WHO grade 1 and 2 meningiomas. In the present study, we aimed to evaluate the impact of such treatment on three-dimensional volume growth rate (3DVGR) in nonanaplastic meningiomas. The authors performed a retrospective study including eight patients treated with Lutathera®. Millimetric 3D T1-weighted with gadolinium enhancement magnetic resonance imaging sequences were requested for volume measurement. Then, tumor growth rate was classified following a previously described 3DVGR classification (Graillon et al.). Patients harbored seven WHO grade 2 meningiomas and one aggressive WHO grade 1. All patients, except one, underwent four treatment cycles. 3DVGR significantly decreased at 3, 6, and 12 months after treatment initiation analyzing each lesion separately. Mean and median 3DVGR from all patients were respectively at 29.5