Language assessment during awake brain surgery: Challenges in multilingual and underrepresented language contexts

Awake surgery for brain tumors in language areas relies on intraoperative language assessment to maximize tumor resection while preserving essential language functions. However, most language assessment tools used in this context were developed in Western, monolingual populations, limiting their validity in multilingual and underrepresented language settings. This position paper examines the challenges of intraoperative language assessment in such contexts, with a focus on Morocco as a representative case of multilingualism and diglossia. We argue that current assessment practices might be constrained by, among others, linguistic diversity, educational and literacy disparities, stimulus limitations, interpreter-mediated testing, and structural gaps in research. The paper proposes several recommendations, including moving beyond direct translation toward principled adaptation of assessment tools, developing culturally and linguistically validated stimuli, improving standardization and reporting of multilingual practices, strengthening multidisciplinary collaboration, and expanding preoperative linguistic profiling. Addressing these challenges is essential for improving the validity and equity of intraoperative language mapping in multilingual and underrepresented language contexts and for ensuring accurate preservation of language function in diverse clinical populations.