Abstract
Awake surgery is difficult in glioma patients with preoperative aphasia. A 29-year-old right-handed bilingual (Spanish/English) patient experienced intractable seizures with severe language disorders due to a voluminous left fronto-temporo-insular tumor. We performed awake procedure with initial laborious language mapping, but with real-time improvement throughout the debulking, allowing preservation of the connectivity. A substantial residue was left. Postoperative cognitive rehabilitation resulted in a dramatic functional improvement, in both languages, permitting a complementary awake surgery, this time with a perfect collaboration of the patient. This multistep strategy enabled 92% of resection while enhancing quality of life with language recovery and epilepsy control.
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References
Almairac F, Herbet G, Moritz-Gasser S, de Champfleur NM, Duffau H (2015) The left inferior fronto-occipital fasciculus subserves language semantics: a multilevel lesion study. Brain Struct Funct 220(4):1983–1995
Azad TD, Duffau H (2020) Limitations of functional neuroimaging for patient selection and surgical planning in glioma surgery. Neurosurg Focus 48(2):E12
Bu LH, Zhang J, Lu JF, Wu JS (2020) Glioma surgery with awake language mapping versus generalized anesthesia: a systematic review. Neurosurg Rev. https://doi.org/10.1007/s10143-020-01418-9
Darlix A, Rigau V, Fraisse J, Gozé C, Fabbro M, Duffau H (2020) Postoperative follow-up for selected diffuse low-grade gliomas with WHO grade III/IV foci. Neurology 94(8):e830–e841
Duffau H (2013) The reliability of asleep-awake-asleep protocol for intraoperative functional mapping and cognitive monitoring in glioma surgery. Acta Neurochir (Wien) 155(10):1803–1804
Duffau H (2015) Stimulation mapping of white matter tracts to study brain functional connectivity. Nat Rev Neurol 11(5):255–265
Duffau Hu (2020) Why brain radiation therapy should take account of the individual structural and functional connectivity: toward an irradiation “à la carte.” Crit Rev Oncol Hematol 154:103073
Duffau H (2021) New philosophy, clinical pearls and methods for intraoperative cognition mapping and monitoring “à la carte” in brain tumor patients. Neurosurgery 88(5):919–930
Duffau H, Gatignol P, Mandonnet E, Capelle L, Taillandier L (2008) Intraoperative subcortical stimulation mapping of language pathways in a consecutive series of 115 patients with Grade II glioma in the left dominant hemisphere. J Neurosurg 109(3):461–471
Duffau H, Gatignol P, Mandonnet E, Peruzzi P, Tzourio-Mazoyer N, Capelle L (2005) New insights into the anatomo-functional connectivity of the semantic system: a study using cortico-subcortical electrostimulations. Brain 128:797–810
Ferracci FX, Duffau H (2018) Improving surgical outcome for gliomas with intraoperative mapping. Expert Rev Neurother 18(4):333–341
Gogos AJ, Young JS, Morshed RA, Hervey-Jumper SL, Berger MS (2020) Awake glioma surgery: technical evolution and nuances. J Neurooncol 147(3):515–524
Herbet G, Duffau H (2019) Awake craniotomy and bedside cognitive mapping in neurosurgery. In: Pearson CM, Ecklund-Johnson E, Gale SD (eds) Neurosurgical Neuropsychology. Academic Press, Chennai, pp 113–138
Herbet G, Duffau H (2020) Revisiting the functional anatomy of the human brain: toward a meta-networking theory of cerebral functions. Physiol Rev 100(3):1181–1228
Herbet G, Maheu M, Costi E, Lafargue G, Duffau H (2016) Mapping neuroplastic potential in brain-damaged patients. Brain 139:829–844
Ius T, Angelini E, Thiebaut de Schotten M, Mandonnet E, Duffau H (2011) Evidence for potentials and limitations of brain plasticity using an atlas of functional resectability of WHO grade II gliomas: towards a “minimal common brain.” Neuroimage 56:992–1000
Khan OH, Herbet G, Moritz-Gasser S, Duffau H (2014) The role of left inferior fronto-occipital fascicle in verbal perseveration: a brain electrostimulation mapping study. Brain Topogr 27(3):403–411
Metz-Lutz MN, Kremin H, Deloche G (1991) Standardisation d’un test de dénomination orale: contrôle des effets de l’âge, du sexe et du niveau de scolarité chez les sujets adultes normaux. Rev Neuropsychol 1:73–95
Moritz-Gasser S, Duffau H (2009) Cognitive processes and neural basis of language switching: proposal of a new model. NeuroReport 20(18):1577–1580
Pujol S, Wells W, Pierpaoli C et al (2015) The DTI challenge: toward standardized evaluation of diffusion tensor imaging tractography for neurosurgery: the DTI challenge on tractography for neurosurgery. J Neuroimaging 25(6):875–882
Sellier A, Moritz-Gasser S, Lemaitre A-L, Herbet G, Duffau H (2020) Presence of a translator in the operating theater for awake mapping in foreign patients with low-grade glioma: a surgical experience based on 18 different native languages. J Neurosurg 1–9. https://doi.org/10.3171/2020.6.JNS201071
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The first draft of the manuscript was written by Elisa Louppe and Hugues Duffau. All authors commented on the previous versions of the manuscript. All authors have read and approved the final manuscript.
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The patient gave his written informed consent to participate in the study and to the retrospective extraction of anonymized clinical and neuroanatomical data from his medical records.
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In the present case report, the authors describe a two-stage awake surgery procedure, guided by direct electrical stimulation (DES) in a young severely aphasic patient with a bulky left fronto-temporo-insular glioma which had a significant mass effect but seemed not to invade the white matter. This surgical strategy for optimizing the treatment of aphasic patients has rarely been discussed in the literature. During the first operation, an arduous DES-mapping was done, and the left anterior temporal lobe was removed. When the debulking advanced, a real-time partial improvement was seen in the language functions. This real-time improvement made it possible to additionally make a resection of the orbito-frontal part of the glioma, a part of the inferior frontal gyrus and the antero-superior part of the insula. Finally, also a resection of the mesio-temporal structures was done under general anesthesia. The mentioned improvement gave rise to the estimation that a potential for language recovery was available. This assumption of a potential lead to the decision to perform a second operation under better conditions, in order to achieve further improvement of language and removal of as much as possible of remaining posterior and deep parts of the tumor, with preservation of the connectivity. The second operation was performed after three months rehabilitation with language training and continued chemotherapy. During this second awake surgery, the surgical team could cooperate with the patient in an effective way, due to the improvement in language after the first operation. That made it possible to use the DES-mapping in an optimal manner and remove most of the residual parts of the inferior frontal gyrus as well as the middle and posterior parts of the insula in a safe way, reaching a level of 92% of resection (EOR), while sparing the inferior fronto-occipital fasciculus, i.e., the main part of the ventral stream, which has a crucial significance for the concept formation and categorization by naming. Furthermore, after the second operation, the language functions recovered rapidly, the epilepsy control was improved and the patient was able to resume his work 3 months post-surgery.
This case report is of interest since it demonstrates that the two-stage awake surgery method could offer the possibility of making an accurate assessment of the language recovery potential in glioma patients with preoperative aphasia secondary from compression of subcortical structures, thereby facilitating the choice between a radical surgical strategy or a plan aiming to preserve tracts essential for subcortical connectivity.
Åsa Bergendal
Stockholm, Sweden
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Louppe, E., Moritz-Gasser, S. & Duffau, H. Language recovery through a two-stage awake surgery in an aphasic patient with a voluminous left fronto-temporo-insular glioma: case report. Acta Neurochir 163, 3115–3119 (2021). https://doi.org/10.1007/s00701-021-04932-x
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DOI: https://doi.org/10.1007/s00701-021-04932-x