Background: Elastic image fusion (EIF) using an intraoperative CT (iCT) scan may enhance neuronavigation accuracy and compensate for brain shift. Objective: To evaluate the safety and reliability of the EIF algorithm (Virtual iMRI Cranial 4.5, Brainlab AG, Munich Germany, for the identification of residual tumour in glioblastoma surgery. Moreover, the impact of brain shift on software reliability is assessed. Methods: This ambispective study included 80 patients with a diagnosis of glioblastoma. Pre-operative MRI was elastically fused with an intraoperative CT scan (BodyTom; Samsung-Neurologica, Danvers, MA, USA) acquired at the end of the resection. Diagnostic specificity and the sensitivity of each tool was determined. The impact of brain shift on residual tumour was statistically analysed. An analysis of accuracy was performed through Target Registration Error (TRE) measurement after rigid image fusion (RIF) and EIF. A qualitative evaluation of each Virtual MRI image (VMRI) was performed. Results: VMRI identified residual tumour in 26/80 patients (32.5%), confirmed by post-operative MRI (true positive). Of these, 5 cases were left intentionally due to DES-positive responses, 8 cases underwent near maximal or subtotal resection, and 13 cases were not detected by iCT. However, in the other 27/80 cases (33.8%), VMRI reported residual tumour that was present neither on iCT nor on post-operative MRI (false positive). i-CT showed a sensitivity of 56% and specificity of 100%; VMRI demonstrated a sensitivity of 100% and specificity of 50%. Spearman correlation analysis showed a moderate correlation between pre-operative volume and VMRI tumour residual. Moreover, tumour involving insula or infiltrating more than one lobe displayed higher median values (p = 0.023) of virtual residual tumour. A statistically significant reduction towards lower TRE values after EIF was observed for test structures. Conclusions: Virtual iMRI was proven to be a feasible option to detect residual tumour. Its integration within a multimodal imaging protocol may provide neurosurgeons with intraoperatively updated imaging.

Background: Although several studies investigated the efficacy of long-term adjuvant temozolomide (TMZ) therapy in glioblastomas (GBs), no univocal data are currently available, and this topic remains controversial. The present study on our ongoing experience aims to assess whether the extended STUPP protocol confers prognostic benefits with acceptable safety. Methods: From 2004 to 2018, 81 patients with a new diagnosis of GB according to the World Health Organization (WHO) 2021 classification, treated with gross total resection (GTR) or subtotal resection (STR), were enrolled. Patients were divided into Group A (long-term TMZ; N = 40) and Group B (standard STUPP protocol; N = 41). Results: In the extended STUPP group, compared with the standard STUPP group, progression-free survival (PFS) and overall survival (OS) were significantly improved (PFS: 27.8 vs. 7.5 months, p = 0.00001; OS: 35.9 vs. 11.3 months, p = 0.0001). To mitigate a potential survival bias, we focused on those in Group B who completed the recommended six cycles. Patients in Group A demonstrated a prolonged OS compared to Group B (27 vs. 10 months, p < 0.001). Similar findings were observed in a focused analysis of patients who had achieved a minimum survival of 12 months (27 vs. 15 months, p < 0.001) or 18 months (34 vs. 24 months, p = 0.044). Conclusions: Our analysis demonstrates a PFS and OS advantage with extended STUPP and suggests that young patients without corpus callosum invasion, with methylguanine-DNA methyltransferase (MGMT) promoter methylation, and treated with GTR are the best candidates. No significant safety difference emerged between extended and standard TMZ treatment.

Purpose: Porous Titanium Microspheres (PTM)-based Sphereplasty has been recently proposed as a novel vertebral augmentation technique for thoracolumbar Vertebral Compression Fractures (VCFs), potentially promoting bony fusion and reducing long-term complications. This study aims to evaluate the clinical efficacy and safety of PTM-based Sphereplasty for the treatment of post-traumatic thoracolumbar VCFs and compared the results with data from the literature on standard PMMA-based kyphoplasty. Methods: Fifty-two patients (32 females), treated with PTMs Sphereplasty for 57 post-traumatic AO Spine A1 and A3 thoracolumbar VCFs, were prospectively enrolled. Data on demographics, fracture types, surgical details, pain scores (NRS) and disability (ODI) were analyzed. Imaging included x-ray, MRI and CT. Vertebral Body Height (VBH), Wedge Angle (WA) and Kyphosis Angle (KA) were measured. Results: Median age was 62.7 years and median follow-up was 334.0 days. Median NRS scores decreased from 8.0 to 4.0 ( p < 0.001) and ODI improved from 66.35% to 28.45% ( p < 0.001). Radiological evaluation demonstrated median KA values of 6.9° preoperatively, 5.5° postoperatively and 7.71° at final follow-up ( p = 0.026). WA decreased from 8.4° to 5.0° and 5.1°, respectively ( p < 0.001). Anterior and middle VBH improved significantly, from 19.52 to 21.65 mm ( p = 0.003) and from 17.49 to 21.20 mm ( p < 0.001), whereas there was no clinically relevant change in cranial and caudal VBHs. Conclusion: Sphereplasty is a safe and effective treatment for post-traumatic thoracolumbar VCFs, providing primary stability, pain relief and functional improvement. PTMs may represent a promising alternative to PMMA kyphoplasty, promoting bony fusion and reducing long-term complications.