Awake Craniotomy with Cortical and Subcortical Speech Mapping for Supramarginal Cavernoma Resection

Area of Science:

• Neurosurgery
• Cognitive Neuroscience
• Neuroradiology

Background:

• Awake craniotomy is crucial for mapping eloquent brain areas and monitoring neurocognitive function during surgery.
• Intraoperative cognitive monitoring aids in maximal safe resection of cavernous malformations in eloquent regions, improving seizure control.
• Advanced imaging like fMRI and DTI are essential for presurgical planning, identifying lesion location and critical white matter tracts.

Observation:

• A 33-year-old male presented with seizures and visual hallucinations, diagnosed with a calcified lesion in the left temporal/parietal area.
• Presurgical evaluation revealed left hemispheric language dominance and language activation in the supramarginal gyrus, with the lesion involving the arcuate and superior longitudinal fasciculi.
• The patient underwent awake craniotomy with high-density grid mapping, subcortical stimulation, and continuous intraoperative cognitive monitoring using language paradigms.

Findings:

• Temporary phonologic/paraphasic errors occurred during resection of the hemosiderin ring, likely due to surgical manipulation.
• The patient was discharged on postoperative day 4 with recommendations for speech therapy.
• Postoperative language skills at 1 week were within normal limits.

Implications:

• This case highlights the efficacy of awake craniotomy and intraoperative cognitive monitoring for safe and maximal resection of brain lesions in eloquent areas.
• Continuous cognitive monitoring can detect subtle neurocognitive deficits during surgery, allowing for adjustments to preserve function.
• The successful outcome suggests this multimodal approach can minimize cognitive morbidity and improve seizure-free outcomes in patients with complex brain lesions.