Post-recurrence management of malignant glial brain tumors: therapeutic strategies, evidence and limitations, palliative care, terminal sedation, and end-of-life considerations.

Recurrent malignant gliomas, particularly glioblastoma, remain among the most challenging entities in neuro-oncology, with nearly universal relapse and limited survival despite aggressive multimodal upfront treatment. Management at recurrence is heterogeneous and lacks a universally accepted standard of care, reflecting modest efficacy of available therapies and marked biological divergence between primary and recurrent tumors. This review provides a comprehensive and critical synthesis of current evidence supporting active salvage strategies, including repeat surgery, reirradiation, systemic therapies, and tumor-treating fields, highlighting indications, outcomes, and limitations. Special emphasis is placed on patient selection, extent of resection, modern radiotherapy techniques, and the role of molecularly refined approaches, which benefit only small, well-defined subgroups. Given the limited survival gains achievable with oncologic treatments, the review further addresses the central role of early integrated palliative care in recurrent malignant glioma, encompassing symptom control, home-based support, advance care planning, and end-of-life decision-making. Particular attention is paid to palliative (terminal) sedation and the ethical-legal framework surrounding euthanasia and medical aid in dying, with specific reference to the Spanish context. Overall, this article aims to contextualize therapeutic decision-making within an integrated, patient-centered model that balances potential oncologic benefit with quality of life, functional preservation, and respect for patient values.