Is awake brain surgery in high-grade glioma patients and a severe aphasia feasible? A case study.
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1
Department of Neurosurgery, Erasmus Medical Center, Erasmus University Rotterdam, Netherlands
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2
Department of Anesthesiology, Erasmus Medical Center, Erasmus University Rotterdam, Netherlands
Introduction. Awake brain surgery with intraoperative direct electrical stimulation (DES) is the gold standard treatment for low-grade gliomas (LGG) in eloquent areas aiming at maximal tumor resection with language preservation (De Witt Hamer, Robles, Zwinderman, Duffau, & Berger, 2012; Duffau, 2018). High-grade gliomas (HGG, WHO grade III, IV) are typically treated with classical surgery (non-awake). A recent meta-analysis revealed that awake surgery in HGG enhanced better surgical outcomes (e.g. overall survival, gross total resection) (Gerritsen, Arends, Klimek, Dirven, & Vincent, 2019). However, as language deficits in HGG are generally more severe than in LGG (Noll, Sullaway, Ziu, Weinberg, & Wefel, 2015), DES becomes a challenge: the distinction between pre-existent aphasia and DES induced paraphasias is less clear. Preoperative severe aphasia is even a contraindication for awake brain surgery (Dziedzic & Bernstein, 2014).
Aim. To demonstrate neurolinguistic procedure in awake surgery in a HGG patient with severe aphasia.
Methods. We present “G2” (right-handed male, 70 years old) with a large (50 x 41 mm) glioblastoma multiforme (GBM, WHO grade IV) in the left temporal lobe (Wernicke’s area), elected for awake surgery. Extensive neurolinguistic examination was performed pre- and 3 months postoperatively.
Results. Preoperatively, G2 presented with an aphasia with Wernicke characteristics (TT score 5.5/36) with impairments in object naming, repetition and the auditory input route. Errors in speech production except reading aloud consisted of phonological paraphasias, neologisms, stereotypes and perseverations. Semantic judgment (odd-picture/word-out), reading aloud (words, short sentences) and sentence completion with one word (DuLIP, De Witte et al., 2015) were intact. Intraoperatively, test-instructions and stimuli were visually presented on a tablet. Correct items from object naming (DuLIP) were selected for DES: no reproducible language errors (1 semantic paraphasia, 1 neologism) were elicited with repeated DES, indicating the absence of critical cortical language areas. During resection, semantics, reading aloud and sentence completion remained stable. Tumor resection was discontinued when new neologisms and perseverations occurred during object naming (subcortical level). Extent of resection: gross total. Postoperatively (3 months), G2 remained stable in semantic tasks, improved in object naming and the Token Test and deteriorated in repetition (due to the defective auditory input route; for test scores, see Table 1).
Discussion. For the first time we demonstrated that awake surgery with DES was possible in a patient with severe aphasia. Extensive preoperative neurolinguistic investigation of different input and output routes (auditory, visual) is necessary to make adequate selection of language tests/items. By doing so, the linguist can focus on the intact linguistic modality/level which facilitates reliable interpretation of further language deterioration (nature and severity of paraphasias) during surgery. We made use of the intact visual input route to present test instructions and to monitor language during awake brain surgery. Findings in this case suggest that awake surgery in GBM is safe and feasible. High expertise of a multidisciplinary awake team is mandatory, including a specialized clinical linguist. A case-series will follow and a RCT is currently ongoing to assess the added value of awake surgery in GBM (SAFE Trial NL7589).
References
De Witt Hamer, P. C., Robles, S. G., Zwinderman, A. H., Duffau, H., & Berger, M. S. (2012). Impact of intraoperative stimulation brain mapping on glioma surgery outcome: a meta-analysis. J Clin Oncol, 30(20), 2559-2565. doi:10.1200/jco.2011.38.4818
De Witte, E., Satoer, D., Robert, E., Colle, H., Verheyen, S., Visch-Brink, E., & Marien, P. (2015). The Dutch Linguistic Intraoperative Protocol: a valid linguistic approach to awake brain surgery. Brain Lang, 140, 35-48.
Duffau, H. (2018). Is non-awake surgery for supratentorial adult low-grade glioma treatment still feasible? Neurosurg Rev, 41(1), 133-139. doi:10.1007/s10143-017-0918-9
Dziedzic, T., & Bernstein, M. (2014). Awake craniotomy for brain tumor: indications, technique and benefits. Expert Rev Neurother, 14(12), 1405-1415.
Gerritsen, J. K. W., Arends, L., Klimek, M., Dirven, C. M. F., & Vincent, A. J. E. (2019). Impact of intraoperative stimulation mapping on high-grade glioma surgery outcome: a meta-analysis. Acta Neurochir (Wien), 161(1), 99-107.
Keywords:
awake brain surgery,
Language mapping,
Severe aphasia,
glioblastoma multiform (GBM),
case study
Conference:
Academy of Aphasia 57th Annual Meeting, Macau, Macao, SAR China, 27 Oct - 29 Oct, 2019.
Presentation Type:
Poster presentation
Topic:
Not eligible for student award
Citation:
Satoer
D,
Schouten
J,
Eralp
I,
Vincent
A and
Visch-brink
E
(2019). Is awake brain surgery in high-grade glioma patients and a severe aphasia feasible? A case study..
Front. Hum. Neurosci.
Conference Abstract:
Academy of Aphasia 57th Annual Meeting.
doi: 10.3389/conf.fnhum.2019.01.00046
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Received:
05 May 2019;
Published Online:
09 Oct 2019.
*
Correspondence:
Dr. Djaina Satoer, Department of Neurosurgery, Erasmus Medical Center, Erasmus University Rotterdam, Rotterdam, Netherlands, d.satoer@erasmusmc.nl