Developing an evidence-based intra-operative language mapping protocol for awake craniotomy to maximise outcomes for patients

Ms Aoife O’reilly1

1Capital & Coast District Health Board, Wellington, New Zealand

Awake brain surgery with direct electrical stimulation is generally considered the “gold standard” to allow for individualised cortico-subcortical mapping of linguistic functions in patients with gliomas in eloquent brain regions. Historically, the methods for assessing patients intra-operatively have had quite a narrow focus. There is growing evidence that a broader range of language tasks should be included for effective intra-operative mapping.

The aim of this study was to develop an evidence-based intra-operative language mapping protocol in order to maximise patient outcomes.

Literature review and liaison with other specialist centres was undertaken. An intra-operative assessment protocol was developed, with input from SLT, neuropsychology and neurosurgery. The devised protocol incorporated a range of tasks which could be selected based on individual patient profiles. The relevance of stimuli was verified on a small New Zealand control population. The clinical application of the protocol was demonstrated in six case studies. Patients were followed up six weeks post-operatively.

In five out of six patients, intra-operative assessment protocol was successful in identifying essential sub-cortical language tracts. It was unsuccessful in the case where the patient had significant pre-existing language impairment. At six week follow-up, four patients had returned to language baseline. For two patients, langauge outcomes were worse at six weeks. Notably, these patients both presented with high grade malignant tumours and pre-operative language deficits.

The proposed protocol, which can be tailored to individual patient profiles, has the potential to allow for reliable identification of essential language tracts during awake craniotomy. This in turn can facilitate maximum tumour resection with preservation of language function. Limitations are acknowledged.


Aoife O’Reilly is the team leader for speech-language therapy at Wellington Regional Hospital. She graduated from Trinity College Dublin in 2011. Her clinical background is primarily in neuroscience and critical care. She has published research on apraxic disorders. She came to New Zealand in 2016 on the premise of staying for 4 months to do a “ski season” while on sabbatical, but was enticed to stay by the beauty of the country and the professional opportunities it afforded.

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