Clinician-to-Clinician Update Clinician-to-Clinician Update

Awake Craniotomy with Speech Mapping Allows Patient to Return to Work

September 2016

Contributed by Michael C. Park, MD, PhD, Deborah D Roman, PsyD, and Catherine Miller, MD

Patients with primary brain tumors are sometimes at risk of losing speech and motor function whether or not the tumor is malignant. When imaging reveals a tumor in regions of the brain that control these functions, awake craniotomy is often indicated. In these procedures, specialized anesthesiologists and speech mapping psychologists work with a neurosurgeon to achieve maximum resection of a tumor without loss of speech function.1

Patient

A male patient was treated at a regional medical center for a traumatic brain injury. When the patient’s headaches, memory problems, and reading and speech difficulties persisted, physicians ordered a CAT scan, which revealed a large mass peripheral to brain regions affecting speech. Because of the tumor’s location and required treatment, the patient was transferred for further evaluation to neurosurgeons with University of Minnesota Medical Center, where awake craniotomy is routinely performed.

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— Illustration of a cancer cell

Management

MRI confirmed the presence of a large infiltrative tumor within the patient’s left frontal, parietal, and temporal lobes. A speech psychologist provided training and helped the patient prepare for intraoperative speech mapping during awake craniotomy. This mapping includes electrically stimulating parts of the brain to find which areas are vital to normal speech function. Intraoperative frozen pathology findings suggested a grade II primary brain tumor, a less aggressive type. Surgical resection proceeded conservatively. Surgeons noted tumor growth along the fiber tracts of the occipital lobe, a placement that would produce visual impairment and symptoms consistent with the reading difficulties the patient described. Intraoperative speech mapping of the conscious patient’s brain guided the neurosurgeon’s removal of the majority of the tumor. Following recovery, the patient experienced a relief in headache symptoms and no further loss of speech, vision, or memory. The Department of Neurosurgery’s weekly Tumor Board recommended DNA testing of the tumor tissue so as to guide the choice of chemotherapy for the patient. Along with this recommendation, the patient was referred back to his hospital for follow-up treatment with chemo-radiation, at the request of the patient.

Discussion

In this unusual case, traumatic brain injury was a red herring. Rather than inhibiting diagnosis, however, the patient’s TBI likely heightened his awareness of his own symptoms, which had developed gradually.

During awake craniotomy with functional mapping, the tumor’s location relative to areas governing speech or motor function guide a neurosurgeon’s decision-making on how aggressive or conservative to be in removing a tumor.2 In this case, the surgeon also considered the patient’s interest in returning to his job and the risk the tumor posed to brain functions essential to that profession—vision, speech, and clarity of thought.

References

  1. Meng L, Berger MS, Gelb AW. The potential benefits of awake craniotomy for brain tumor resection: an anesthesiologist’s perspective. J Neurosurg Anesthesiol. 2015; 27(4): 310-317.
  2. Kim SS, McCutcheon IE, Suki D, et al. Awake craniotomy for brain tumors near eloquent cortex: correlation of intraoperative cortical mapping with neurological outcomes in 309 consecutive patients. Neurosurgery. 2009; 64(5): 836-845.
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