Care pathway

1. At the time of diagnosis

   The first consultation with Prof. Mandonnet makes it possible to get acquainted and to explain the disease and its treatment options: surgery, chemotherapy (Temodal or PCV), radiotherapy, targeted therapy (Vorasidenib, Ivosidenib). Surgery is most often proposed as first-line treatment because of its proven benefit. The principle of a functionally maximal resection is explained in detail, as well as how an awake procedure is carried out.

   Transient disorders may appear in the immediate postoperative period, but recover remarkably thanks to brain plasticity and cognitive rehabilitation (PRM department of Prof. Beaudreuil). The vast majority of patients return to work after 3 to 6 months of rehabilitation (article). However, significant fatigue may persist for a few months, which may require a return on a part-time therapeutic schedule (article).

2. Preparation for awake surgery

   A comprehensive assessment is carried out before the procedure:

   • Language and cognitive assessment with a speech therapist from the team (Isabelle Poisson, Marion Barberis, Cécile Prevost, Sophie Bouteloup). Essential for identifying subtle vulnerabilities indicating that the brain has reached the limits of its compensatory capacity.
   • Specialized functional and anatomical imaging — to confirm language-function lateralization and select appropriate intraoperative monitoring tests.
   • Electroencephalogram (EEG) — to optimize adjustment of anti-seizure medications.
   • Preoperative consultations with the anesthesiologist and nurse anesthetist, to prepare for the hypno-sedation technique used at Lariboisière.

3. During surgery

   Awake surgery is one of the most reliable methods for maximizing resection while preserving function. The procedure lasts approximately 5 to 6 hours, including 2 hours awake during which the patient performs various tasks under the guidance of the speech therapist. The entire operating-room team supports and encourages the patient throughout the procedure.

4. After surgery

   The pathology results (Prof. Biassette’s department) are available within 5 to 10 days. Depending on the tumor type and grade, additional treatment may be proposed: radiotherapy, chemotherapy, or targeted therapy. In high-grade tumors (glioblastomas), chemoradiotherapy is almost systematic. Enrollment in promising clinical trials is offered whenever possible.

5. Further treatment

   In the vast majority of cases, a period of clinical and radiological surveillance is instituted. Adjuvant treatment is proposed only in the event of progression or signs of aggressiveness, after discussion at the multidisciplinary tumor board (neuro-oncologist, radiation oncologist, radiologist, pathologist, molecular biologist, neurosurgeon). Options include:

   • Chemotherapy with the PCV regimen (procarbazine – CCNU – vincristine)
   • Radiotherapy
   • Targeted anti-IDH mutation therapy (Vorasidenib, Ivosidenib)
   • Repeat surgery

Search

• Digital tools for cognitive assessment — LABCOM Cog-Toolkit Joint laboratory between Frontlab at the Brain Institute and the company Humans Matter. The Cog-Surg platform, dedicated to awake surgery, is currently under development.
• Prediction of post-surgical cognitive functions Prof. Mandonnet’s work on understanding brain plasticity: cognitive flexibility (publication) and creativity (publication). Other functions are under study: motivation, social cognition, working memory.
• Mechanisms of plasticity using MRI and PET Collaborative project with Orsay Hospital aiming to describe the neural bases of postoperative brain reorganization, with the hope of developing new methods to optimize recovery.