Surgical approaches to tumors and epileptogenic zones close to Wernicke's area

Cukiert, Arthur; Gronich, Gary; Marino Jr, Raul

doi:10.1590/S0004-282X1995000400006

Abstracts

Surgical procedures near to language related brain regions may cause severe morbidity in relation to speech. Operations performed under local anesthesia and intraoperative cortical mapping may minimize these risks. Six patients with tumors near the Wernicke's area were treated (2 low-grade astrocytomas, 1 ganglioglioma, 1 xanthoastrocytoma, 1 metastasis, 1 glioblastoma). Their clinical presentation consisted of epilepsy (n=4) and dysphasia (n=2). The skin and periosteum were infiltrated with local anesthetic and an ample craniotomy was performed. Cortical stimulation with an unipolar electrode was then carried out with concomitant speech testing (mainly comprehension and sequential speech). After mapping, the best surgical approach aiming to avoid the mapped area was elected. In 5 cases the resection was total and in 1, partial (glioblastoma). There was a transitory (10 days) worsening of the pre-operative deficit in 1 case (glioblastoma). In 3 patients, the speech areas were displaced: posteriorly (n=2) or anteriorly (n=l). Surgical procedures under local anesthesia are safe and may avoid post-operative language disturbances in patients with tumors near to Wernicke's area.

brain tumors; epilepsy; Wernicke's area; cortical mapping

A ressecção de processos expansivos em áreas relacionadas à fala pode causar morbidade severa de linguagem. A realização de procedimentos cirúrgicos sob anestesia local e mapeamento intra-operatório das áreas relacionadas à linguagem pode ser empregada para minimizar estes deficits. Seis pacientes com tumores da área de Wernicke foram mapeados (2 astrocitomas de baixo grau, 1 ganglioglioma, 1 xantoastrocitoma, 1 metástase, 1 glioblastoma). Sua apresentação clínica incluía epilepsia (n=4) e disfiasia de compreensão (n=2). Após infiltração dos planos superficiais com anestésico local e craniotomia, procedia-se à estimulação com eletrodo unipolar do córtex temporal amplamente exposto, com testagem simultânea de linguagem, principalmente compreensão e fala sequencial. Após o mapeamento, elegia-se a melhor via de acesso de modo a evitar a área mapeada. Em 5 casos a ressecção foi completa e em 1 parcial (glioblastoma). Em 1 caso houve piora transitória (10 dias) de déficit pré-existente de compreensão e expressão (glioblastoma). Em 3 casos as áreas da fala haviam sido deslocadas: posteriormente (n=2) ou em direção suprasilviana (n=l). Procedimentos cirúrgicos com anestesia local são seguros e podem evitar distúrbios pós-operatórios de linguagem em pacientes com tumores próximos à área de Wernicke.

tumores cerebrais; epilepsia; área de Wernicke; mapeamento cortical

Surgical approaches to tumors and epileptogenic zones close to Wernicke's area

Abordagens cirúrgicas a tumores e zonas epileptógenas junto à área de Wernicke

Arthur Cukiert; Gary Gronich; Raul Marino Jr

Division of Neurosurgery, Department of Neurology, Faculty of Medicine, University of São Paulo

SUMMARY

Surgical procedures near to language related brain regions may cause severe morbidity in relation to speech. Operations performed under local anesthesia and intraoperative cortical mapping may minimize these risks. Six patients with tumors near the Wernicke's area were treated (2 low-grade astrocytomas, 1 ganglioglioma, 1 xanthoastrocytoma, 1 metastasis, 1 glioblastoma). Their clinical presentation consisted of epilepsy (n=4) and dysphasia (n=2). The skin and periosteum were infiltrated with local anesthetic and an ample craniotomy was performed. Cortical stimulation with an unipolar electrode was then carried out with concomitant speech testing (mainly comprehension and sequential speech). After mapping, the best surgical approach aiming to avoid the mapped area was elected. In 5 cases the resection was total and in 1, partial (glioblastoma). There was a transitory (10 days) worsening of the pre-operative deficit in 1 case (glioblastoma). In 3 patients, the speech areas were displaced: posteriorly (n=2) or anteriorly (n=l). Surgical procedures under local anesthesia are safe and may avoid post-operative language disturbances in patients with tumors near to Wernicke's area.

Key words:brain tumors, epilepsy, Wernicke's area, cortical mapping.

RESUMO

A ressecção de processos expansivos em áreas relacionadas à fala pode causar morbidade severa de linguagem. A realização de procedimentos cirúrgicos sob anestesia local e mapeamento intra-operatório das áreas relacionadas à linguagem pode ser empregada para minimizar estes deficits. Seis pacientes com tumores da área de Wernicke foram mapeados (2 astrocitomas de baixo grau, 1 ganglioglioma, 1 xantoastrocitoma, 1 metástase, 1 glioblastoma). Sua apresentação clínica incluía epilepsia (n=4) e disfiasia de compreensão (n=2). Após infiltração dos planos superficiais com anestésico local e craniotomia, procedia-se à estimulação com eletrodo unipolar do córtex temporal amplamente exposto, com testagem simultânea de linguagem, principalmente compreensão e fala sequencial. Após o mapeamento, elegia-se a melhor via de acesso de modo a evitar a área mapeada. Em 5 casos a ressecção foi completa e em 1 parcial (glioblastoma). Em 1 caso houve piora transitória (10 dias) de déficit pré-existente de compreensão e expressão (glioblastoma). Em 3 casos as áreas da fala haviam sido deslocadas: posteriormente (n=2) ou em direção suprasilviana (n=l). Procedimentos cirúrgicos com anestesia local são seguros e podem evitar distúrbios pós-operatórios de linguagem em pacientes com tumores próximos à área de Wernicke.

Palavras-chave:tumores cerebrais, epilepsia, área de Wernicke, mapeamento cortical.

Texto completo disponível apenas em PDF.

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Aceite: 10-abril-1995.

Dr. Arthur Cukiert - R. Nova York 744 apto 131- 04560-001 São Paulo SP - Brasil.

1. Adams CBT. The surgery for epilepsy with speech arrest. Acta Neurochirur 1993, 56(Suppl):72-82.
2. Burchiel KJ, Clark H, Ojemann GA. Use of stimulation mapping and corticography in the excision of arteriovenous malformation in sensorimotor and language related neocortex. Neurosurgery 1989, 24:323-327.
3. Caner-Cukiert AR, Cukiert A. Dichotic words listening test, technical aspects and results in normal right handed individuals. Arq Neuropsiquiatr 1994, 52:204-209.
4. Haglund MM, Berger MS, Shamseldin M, Lettich E, Ojemann GA. Cortical localization of temporal lobe language sites in patients with glioma. Neurosurgery 1994, 34:567-576.
5. Heilman KM, Wilder BJ, Malzone WF. Anomic aphasia following anterior temporal lobectomy. Trans Am Neurol Assoc 1972, 97:291-293.
6. Lesser H, Lueders H, Dinner DS. The location of speech and writing functions in the frontal language area: results of extraoperative cortical stimulation. Brain 1984, 107:275-291.
7. Lueders H, Lesser RP, Hahn J. Basal temporal language area demonstrated by electrical stimulation. Neurology 1986, 36:505-510.
8. Ojemann GA. Brain organization for language from the perspective of electrical stimulation mapping. Behav Brain Sci 1983, 6:189-206.
9. Ojemann GA, Dodrill CB. Intraoperative techniques for reducing language and memory deficits with left temporal lobectomy. Adv Epileptol 1987, 16:327-330.
10. Ojemann GA, Creutzfeld O, Lettich E. Neuronal activity in human lateral temporal cortex related to short term verbal memory, naming and reading. Brain 1988, 111:1383-1403.
11. Ojemann GA, Ojemann JG, Lettich E, Berger MS. Cortical language localization in the left, dominant hemisphere. J Neurosurg 1989, 71:316-326.
12. Ojemann GA. Cortical organization of language. J Neurosci 1991, 11:281-287.
13. Rubens AB, Mahowald MW, Hutton JT. Asymmetry of the lateral (sylvian) fissures in man. Neurology 1976, 26:620-624.
14. Van Buren JM, Fedio P, Frederick GC. Mechanism and localization of speech in the parietotemporal cortex. Neurosurgery 1978, 2:233-239.
15. Wada J, Rasmussen T. Intracarotid injections of sodium amytal for the lateralization of cerebral speech dominance. J Neurosurg 1960, 17:266-282.

Publication Dates

Publication in this collection
20 Dec 2010
Date of issue
Sept 1995

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

[1] 1. Adams CBT. The surgery for epilepsy with speech arrest. Acta Neurochirur 1993, 56(Suppl):72-82.

[2] 2. Burchiel KJ, Clark H, Ojemann GA. Use of stimulation mapping and corticography in the excision of arteriovenous malformation in sensorimotor and language related neocortex. Neurosurgery 1989, 24:323-327.

[3] 3. Caner-Cukiert AR, Cukiert A. Dichotic words listening test, technical aspects and results in normal right handed individuals. Arq Neuropsiquiatr 1994, 52:204-209.

[4] 4. Haglund MM, Berger MS, Shamseldin M, Lettich E, Ojemann GA. Cortical localization of temporal lobe language sites in patients with glioma. Neurosurgery 1994, 34:567-576.

[5] 5. Heilman KM, Wilder BJ, Malzone WF. Anomic aphasia following anterior temporal lobectomy. Trans Am Neurol Assoc 1972, 97:291-293.

[6] 6. Lesser H, Lueders H, Dinner DS. The location of speech and writing functions in the frontal language area: results of extraoperative cortical stimulation. Brain 1984, 107:275-291.

[7] 7. Lueders H, Lesser RP, Hahn J. Basal temporal language area demonstrated by electrical stimulation. Neurology 1986, 36:505-510.

[8] 8. Ojemann GA. Brain organization for language from the perspective of electrical stimulation mapping. Behav Brain Sci 1983, 6:189-206.

[9] 9. Ojemann GA, Dodrill CB. Intraoperative techniques for reducing language and memory deficits with left temporal lobectomy. Adv Epileptol 1987, 16:327-330.

[10] 10. Ojemann GA, Creutzfeld O, Lettich E. Neuronal activity in human lateral temporal cortex related to short term verbal memory, naming and reading. Brain 1988, 111:1383-1403.

[11] 11. Ojemann GA, Ojemann JG, Lettich E, Berger MS. Cortical language localization in the left, dominant hemisphere. J Neurosurg 1989, 71:316-326.

[12] 12. Ojemann GA. Cortical organization of language. J Neurosci 1991, 11:281-287.

[13] 13. Rubens AB, Mahowald MW, Hutton JT. Asymmetry of the lateral (sylvian) fissures in man. Neurology 1976, 26:620-624.

[14] 14. Van Buren JM, Fedio P, Frederick GC. Mechanism and localization of speech in the parietotemporal cortex. Neurosurgery 1978, 2:233-239.

[15] 15. Wada J, Rasmussen T. Intracarotid injections of sodium amytal for the lateralization of cerebral speech dominance. J Neurosurg 1960, 17:266-282.