Mapping of cortical speech zones and arcuate tract in patients with gliomas of temporal lobe of left hemisphere (analysis of a series of 27 observations)

Introduction. Craniotomy in conscious patients is a possible tool for optimizing of tumor resection degree (Extent of Resection) while maintaining the quality of life. Traditionally, the main focus during these operations is on the cortical speech areas. At the same time, there is a shortage of studies on mapping of long associative tracts during the removal of gliomas of dominant speech hemisphere.

Aim. To analyze the data of intraoperative mapping and the postoperative state of speech function in patients with temporal lobe gliomas of left hemisphere (including those involving arcuate bundle) operated by the use of method of craniotomy in consciousness.

Materials and methods. Gliomas of temporal lobe of left hemisphere were removed in 27 patients aged 14 to 67 years (median age 43 years). In 10 patients, the tumor was localized in middle parts of temporal lobe (at the level of middle and upper temporal gyri), in 9 patients – in posterior parts of temporal lobe and exited into the supramarginal zone, in 8 it spread partially from temporal lobe to insular area. Gliomas of high degree of malignancy were detected in 21 patients, 6 had tumors of low degree of malignancy. Surgical intervention was performed with intraoperative “awakening”. All patients underwent cortical electrophysiological stimulation in order to control localization of cortical speech zones, subcortical stimulation was performed in 21 cases to identify terminals of arcuate bundle. Speech disorders before and after surgery (on day 4–6) were evaluated by neuropsychologist using the method proposed by A. R. Luria, an automated test with the naming of pictures was additionally used intraoperatively. The average current strength of direct electrical stimulation was 3 (1.9–6.5) mA. In 12 cases, magnetic resonance (MR) tractography with construction of arcuate tract was performed before and after the surgery.

Results. Cortical temporal speech zones during intraoperative electrical stimulation were detected in 20 (74 %) of 27 patients. In 10 patients, the arcuate tract was mapped in form of appearance of mixed speech disorders in the depth of surgical wound. In 23 (85.2 %) of 27 patients in early postoperative period, an increase in speech disorders was noted of which 13 people had disorders of temporal type only and 10 people (surgery on deep posterior parts of temporal lobe) had a combination of temporal and frontal types of speech disorders (conduction aphasia). Postoperative MR‑tractography (performed in 12 patients) revealed direct intraoperative tract lesion in 5 cases and ischemia of the tract area passage in 2 cases. These 7 patients had combined speech disorders after surgery. Gross sensory aphasia after surgery was manifested in 4 patients, in 2 of them ischemia was revealed according to postoperative magnetic resonance imaging, and 2 more had hemorrhagic impregnation in the removed tumor bed.

Conclusion. When removing tumors of temporal lobe in “awakening” conditions it is necessary to map speech zones not only in the cortical, but also in the subcortical area with terminals of arcuate bundle. Mapping of speech zones in these different localizations makes it possible to identify fundamentally different speech disorders.

1. Larjavaara S., Mäntylä R., Salminen T. et al. Incidence of gliomas by anatomic location. Neuro Oncol 2007;9(3):319–25. DOI: 10.1215/15228517-2007-016

2. Penfield W., Welch K. Instability of response to stimulation of the sensorimotor cortex of man. J Phisiol 1949;109(3–4):358–65. DOI: 10.1113/jphysiol.1949.sp004399

3. Lubnin A.Yu., Salalykin V.I., Zeitlin A.M. et al. Anesthesiological support for the removal of bulky formations from functionally important areas of the cerebral hemispheres – craniotomy in consciousness. Anesteziologiya i reanimatologiya = Anesteziol Reanimatol 2000;4:4–11. (In Russ.).

4. Kulikov A.S., Kobyakov G.L., Gavrilov A.G., Lubnin A.Y. Awake craniotomy: analysis of complicated cases. Zhurnal Voprosy Neirokhirurgii im. N.N. Burdenko = Burdenkoʼs Journal of Neurosurgery 2015;79(6):15–21. (In Russ.). DOI: 10.17116/neiro201579615-21

5. Kobyakov G.L., Lubnin A.Y., Kulikov A.S. et al. Awake craniotomy. Zhurnal Voprosy Neirokhirurgii im. N.N. Burdenko = Burdenkoʼs Journal of Neurosurgery 2016;80(1):107–16. (In Russ.). DOI: 10.17116/neiro2016801107-116

6. Zuev A.A., Korotchenko E.N., Ivanova D.S. et al. Surgical treatment of eloquent brain area tumors using neurophysiological mapping of the speech and motor areas and conduction tracts. Zhurnal Voprosy Neirokhirurgii im. N.N. Burdenko = Burdenkoʼs Journal of Neurosurgery 2017;81(1):39–50. (In Russ.). DOI: 10.17116/neiro201780739-50

7. Potapov A.A., Goryainov S.A., Zhukov V.Y. et al. The longassociative pathway of the white matter: modern view from the perspective of neuroscience. Zhurnal Voprosy Neirokhirurgii im. N.N. Burdenko = Burdenkoʼs Journal of Neurosurgery 2014;78(5):66–77. (In Russ.). PMID: 25517000

8. Goryainov S.A., Kondrashov A.V., Gol’dberg M.F. et al. Long association tracts of the human white matter: an analysis of 18 hemisphere dissections and in vivo HARDI-CSD tractography. Zhurnal Voprosy Neirokhirurgii im. N.N. Burdenko = Burdenkoʼs Journal of Neurosurgery 2017;81(1):13–25. (In Russ.). DOI: 10.17116/neiro201780713-25

9. Bykanov A.E., Pitskhelauri D.I., Batalov A.I. et al. Surgical anatomy of the peri-insular association tracts. P. I. The superior longitudinal fascicle system. Zhurnal Voprosy Neirokhirurgii im. N.N. Burdenko = Burdenkoʼs Journal of Neurosurgery 2017;81(1):26–38. (In Russ.). DOI: 10.17116/neiro201780726-38

10. Zhukov V.Y., Goryaynov S.A., Buklina S.B. et al. Intraoperative mapping of long association fibers in surgery of gliomas of the speech-dominant frontal lobe. Zhurnal Voprosy Neirokhirurgii im. N.N. Burdenko = Burdenkoʼs Journal of Neurosurgery 2018;82(5):5–21. (In Russ.). DOI: 10.17116/neiro2018820515

11. Buklina S.B., Zhukov V.Y., Goryainov S.A. et al. Conduction aphasia in patients with glioma in the left hemisphere. Zhurnal Voprosy Neirokhirurgii im. N.N. Burdenko = Burdenkoʼs Journal of Neurosurgery 2021;4:29–39. (In Russ.). DOI: 10.17116/neiro20218504129.

12. Luria A.R. Disorders of higher cortical functions in focal lesions of the brain. Moscow: Publishing House of Moscow State University, 1962. (In Russ.).

13. Dragoy O., Chrabaszcz A., Tolkacheva V. Russian intraoperative naming test: a standardized tool to map noun and verb production during awake neurosurgeries. Russ J Cogn Sci 2016;3(4):4–25. DOI: 10.47010/16.4.1

14. Sanai N., Mirzadeh Z., Berger M.S. Functional outcome after language mapping for glioma resection. N Engl J Med 2008;358(1):18–27. DOI: 10.1056/NEJMoa067819.

15. De Witt Hamer P.C., Robles S.G., Zwinderman A.H. et al. Impact of intraoperative stimulation brain mapping on glioma surgery outcome: a meta-analysis. J Clin Oncol 2012;30(20):2559–65. DOI: 10.1200/JCO.2011.38.4818.

16. Brown T., Shah A.H., Bregy A. et al. Awake craniotomy for brain tumor resection: the rule rather than the exception? J Neurosurg Anesthesiol 2013;25:240–7. DOI: 10.1097/ANA.0b013e318290c230.

17. Diffuse Low-Grade Gliomas in Adults: Natural History, Interaction with the Brain, and New Individualized Therapeutic Strategies. Ed. by H. Duffau. Springer, 2014.

18. Hervey-Jumper S.L., Berger M.S. Maximizing safe resection of low- and high-grade glioma. J Neurooncol 2016;130(2):269–82. DOI: 10.1007/s11060-016-2110-4

19. Anderson J.M., Gilmore R., Roper S. et al. Conduction aphasia and the arcuate fasciculus: a reexamination of the WernickeGeschwind model. Brain Lang 1999;70(1):1–12. DOI: 10.24835/1607-0763-109

20. Zöllner J.P., Haag A., Hermsen A. et al. Ictal conduction aphasia and ictal angular gyrus syndrome as rare manifestations of epilepsy: The importance of ictal testing during video-EEG monitoring. Epilepsy Behav Case Rep 2017;3(8):55–62. DOI: 10.1016/j.ebcr.2017.07.003