Structural signatures of language reorganization after left hemispherotomy in patients with Rasmussen's encephalitis

Rasmussen's encephalitis (RE) is a rare neurological disorder affecting a single cerebral hemisphere, often requiring hemispherotomy as a curative treatment. While significant brain plasticity occurs due to the pathology and surgical intervention, the mechanisms underlying cognitive functioning in the remaining hemisphere remain poorly understood. This multiple-case study longitudinally investigates neurocognitive reorganization in childhood after left hemispherotomy for RE and identifies structural patterns in the right hemisphere associated with language recovery. Indeed, the mechanisms that allow the right hemisphere to support language, after left hemispherotomy remain unclear. Cognitive trajectories were analyzed in three RE patients, and their cortical thickness (CT) changes were compared with data from a publicly available cohort of 393 healthy subjects. Language neuropsychological scores and T1-weighted MRI data were assessed in the healthy right hemisphere before hemispherotomy, one year, and five years post-surgery. Specifically, principal component analysis, structural covariance, and graph theory approaches were employed to investigate language network organization in patients and controls. Results reveal diverse language recovery trajectories among the three patients. Regarding CT, three potential signatures associated with favorable language outcomes were identified: (1) normal or below-normal CT values in cortical regions; (2) a more associative and integrative organization of the language network; and (3) increased global efficiency. These preliminary longitudinal findings provide novel insights into the mechanisms of neurocognitive reorganization following left hemispherotomy in childhood. By emphasizing structural patterns linked to favorable postoperative language recovery, this study highlights their value for guiding future research and clinical interventions.