Feasibility of awake brain surgery in glioblastoma patients with severe aphasia: Five case illustrations

Figures & data

Figure 1. Pre- and postoperative post-contrast T1-weighted MRI scans in the axial and sagittal plane in patients A1, B2, C3, D4 and E5. Pre = preoperative. Post = postoperative

Table 1. Demographic and clinical characteristics.

Case	Gender	Age (y)	Education (y)	Onset symptoms	Cortical area	Pre-operative volume (cm^3)	Post operative volume (cm^3)	EOR (%)	Histology	MGMT	AED	DEXA	Adjuvant therapy	Survival (months)
A1	M	62	10	Cognitive problems	Left middle frontal gyrus	53.73	0.37	99	GBM	Yes	No	No	RT+TMZ	43
B2	F	81	7	Seizures, language problems	Left middle frontal gyrus	81.75	0.00	100	GBM	Yes	No	No	RT+TMZ	> 34
C3	M	70	10	Headache, language problems	Left superior temporal gyrus	37.19	0.00	100	GBM	No	No	Yes	RT+TMZ	11
D4	M	43	11	Language problems	Left superior and middle temporal gyrus. Angular gyrus	50.36	16.11	68	rGBM	No	Yes	No	Lomustine	15
E5	M	51	15	Language problems	Left superior, middle and inferior temporal gyrus. Angular gyrus	59.51	2.17	96	APXA	No	Yes	No	Dabrafenib, Trametinib	18

(M = male, F = female, y = years, GBM = glioblastoma, rGBM = recurrent glioblastoma, APXA = anaplastic pleomorf xantoastrocytoma, MGMT = methylated MGMT promotor, EOR = extent of resection, AED = antiepileptic drugs, DEXA = dexamethasone at preoperative neurolinguistic assessment, RT + TMZ = postoperative radiotherapy plus concomitant and adjuvant temozolomide)

Table 2. Neurolinguistic assessment

	Cognitive abilities and description of task
Language
Shortened Token Test (TT) (De Renzi & Faglioni, 1978)	Severity of aphasia, language comprehension. Pointing to and manipulating geometric forms (36 items, correct score)
Boston Naming Test (BNT) (Kaplan et al., 2001)	Word retrieval. Naming pictures, presented in order of word frequency and word difficulty (60 items)
Category fluency (Luteijn & Barelds, 2004)	Flexibility of verbal semantic thought. Categories animals and professions (within 1 minute)
Letter fluency (Schmand et al., 2008)	Flexibility of verbal phonological thought. Letters D, A and T (within 1 minute)
Diagnostic Instrument Mild Aphasia (DIMA) (Satoer et al., 2022)
Repetition	Phonology. Repeating 3-syllabic words (10 items), 3-6 syllabic compounds (10 items), nonwords (10 items) and sentences (10 items)
Semantic odd-picture-out	Semantic judgment + word retrieval under time pressure. Naming the picture that does not semantically fit in a series of three pictures (5 items, 4 seconds per item)
Sentence completion	Spontaneous speech in context. Completion of semantically and less semantically induced sentences via auditory presentation (10 items)
DuLIP (De Witte et al., 2015)
Repetition, shortened version	Phonology. Repeating words (10 items) and sentences (5 items)
Semantic odd-picture-out	Semantic judgment + word retrieval. Naming the picture that does not semantically fit in a series of three pictures (25 items)
Semantic odd-word-out	Semantic judgment + reading. Reading aloud the word that does not semantically fit in a list of four words (25 items)
Sentence completion	Spontaneous speech in context. Sentence completion of semantically induced sentences via visual presentation (25 items)
Aphasia Bedside Check (ABC) (Visch-Brink & El Hachioui, 2013)	Screening of language comprehension (7 items: semantic and syntactic judgment) and production (7 items: object naming, repetition, reading aloud)
Attention and executive function
Trail Making Test (Tombaugh, 2004)
Trail Making Test A (TMT-A)	Visuomotor speed, attention. Connecting numbers in ascending order (registered in seconds)
Trail Making Test B (TMT-B)	Divided attention/mental flexibility. Connecting alternating numbers and letters (registered in seconds)
Verbal memory
Hopkins Verbal Learning Test (HVLT) (Benedict et al., 1998)
HVLT: recall	Verbal memory. Learning a list of 12 words, with three immediate recall trials
HVLT: delayed recall	Verbal memory. Delayed recall of a list of 12 words
HVLT: true positives	Verbal memory. Delayed recognition: true positives out of 24 words
HVLT: false positives	Verbal memory. Delayed recognition: false positives out of 24 words
General cognition
Montreal Cognitive Assessment (MOCA) (Thissen et al., 2010)	Brief screening tool for mild cognitive impairment

Table 3. Pre- and postoperative neurolinguistic test-protocol (raw score/z-score).

	A1		B2		C3		D4		E5
	Pre	Post (7 w)	Pre	Post (3 m)	Pre	Post (3 m)	Pre	Post (1 d)	Pre
Shortened Token Test	23 / -5.74	35 / -0.32*	7.5 / -13.60	21 / -6.75*	4.5 -15.08	10.5 / -12.05*	24 / -5.23	dp	na
Boston Naming Test	40 / -2.89	53 / -0.07*	13 / -5.70	dp	34 / -2.37	45 / -0.62*	28 / -9.60	dp	4 / -12.80
Category fluency animals	5 / -3.20	19 / -0.60*	0 / -3.80	3 / -3.20	na	na	6 / -3.20	dp	6 / -3.60
Category fluency professions	2 / -3.30	11 / -1.20*	0 / -3.30	2 / -2.90	na	na	3 / -3.30	dp	3 / -3.80
Letter fluency	6 / -2.70	19 / -1.50	na	5 / -2.50	na	na	na	dp	3 / -3.70
DIMA Repetition	35 / -1.91	40 / 0.25*	dp	dp	12 / -14.29	na	25 / -7.29	dp	11 / -14.83
DIMA Semantic odd-picture-out	3 / -1.96	4 / -0.69*	dp	dp	0 / -5.77	0 / -5.77	0 / -5.77	dp	0 / -5.77
DIMA Sentence completion	6 / -4.14	9 / -0.63*	dp	dp	na	na	6 / -4.14	dp	10 / -0.63
DuLIP Repetition – shortened version	dp	dp	12	dp	dp	dp	dp	dp	dp
DuLIP Semantic odd-picture-out	dp	dp	dp	dp	24 / > 0	dp	dp	dp	dp
DuLIP Semantic odd-word-out	dp	dp	dp	dp	22 / > 0	24 / > 0	dp	dp	dp
DuLIP Sentence completion	dp	dp	dp	dp	21 / -1.50	22 / >-1.50	dp	dp	dp
Aphasia Bedside Check	dp	dp	dp	11^raw (5+6)	dp	dp	dp	12^raw (7+5)	dp
Trail Making Test
A	105 / -3.50	40 / -0.20*	na	na	na	na	85 / -3.50	dp	na
B	408 / -4.50	184 / -2.10*	na	na	na	na	340 / -4.70	dp	na
B/A	-3.10	-2.20*	na	na	na	na	-3.40	dp	na
Hopkins Verbal Learning Test
Recall	na	na	na	na	na	na	9 / -5.21	dp	na
Delayed recall	na	na	na	na	na	na	1 / -5.47	dp	na
True positives	na	na	na	na	na	na	11 / -2.00	dp	na
False positives	na	na	na	na	na	na	1 / -0.33	dp	na
MOCA	dp	dp	6 / -9.27	12 / -6.55*	dp	dp	dp	dp	dp

(Severely impaired scores (z = ≤ 2.00) in bold, mildly impaired scores (z = ≤ -1.50) underlined, d = days. w = weeks. m = months. * = significant improvement pre- versus postoperatively (Δz ≥ 1.5). na = not administered due to aphasia severity. Raw = only raw score available. dp = not administered due to different protocol or lack of additional intraoperative value).

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