CASE REPORT
Complete recovery after surgical resection of left
Wernicke'sarea in awake patient: a brain stimulation and
functionalMRI study
Silvio Sarubbo & Emmanuelle Le Bars &Sylvie
Moritz-Gasser & Hugues Duffau
Received: 25 November 2010 /Revised: 10 March 2011 /Accepted: 15
May 2011 /Published online: 27 September 2011# Springer-Verlag
2011
Introduction
The left Wernicke's area is a cornerstone of language.Although
its anatomical boundaries were debated andrenewed over the years
[1, 3, 30], Wernicke's territory [2]is now defined as the posterior
two thirds of the superiorand middle temporal gyrus [1]. This area
plays a multi-modal role in language, with involvement in
phonological,semantic, and syntactic processing [4, 13, 28]. Its
damagegenerates dramatic aphasia, with a poor recovery.
Conse-quently, Wernicke's area has been considered one of themain
inoperable brain regions for many decades.
Here, we report the first observation of surgical resectionof
the left Wernicke's area invaded by a WHO grade IIglioma in a
right-handed patient, with a complete functionalrecovery. The
mechanisms of compensation were discussedon the basis of the
combined data provided by intra-operative electrical mapping and
postoperative functionalMRI.
Case report
History
A 38-year-old right-handed (score of 90 on the
EdinburghInventory) woman experienced partial seizures with
transientlanguage disorders. MRI revealed a left temporal tumor.
Afirst awake surgery was performed on March 2005, withincomplete
resection due to the involvement of language areasby the lesion.
Histological examination revealed a WHOgrade II glioma, with 1p-19q
co-deletion. The patient had nolanguage deficit and enjoyed a
normal life. However, becauseof seizure recurrence and growth of
the residual glioma,12 cycles of chemotherapy (temozolomide) were
administrat-ed. At the end of the chemotherapy, the tumor grew
again(Fig. 1a). Thus, a second surgery was proposed 3.5 yearsafter
the first operation. The preoperative neurologicalexamination
showed very mild language disturbances.Indeed, the picture naming
test (oral denomination 80(DO80)) revealed two semantic paraphasias
and one anomia(77/80). The semantic and phonological fluency (2
min)scored respectively 30 and 31. The global languageevaluation
(Montreal Toulouse 86 (MT86)), for spoken andwritten comprehension
and expression) was normal. Regard-ing verbal working memory,
direct and indirect spans were 7and 5, respectively.
S. SarubboDivision of Neurosurgery,Department of Neurosciences
and Rehabilitation,Azienda Ospedaliero-Universitaria S. Anna,203
C.so Giovecca,Ferrara, Italy
E. Le BarsDepartment of Neuroradiology, Hpital Gui de
Chauliac,CHU Montpellier,80 Av Augustin Fliche,34295 Montpellier,
France
S. Moritz-Gasser :H. Duffau (*)Department of Neurosurgery,
Hpital Gui de Chauliac,CHU Montpellier,80 Av Augustin Fliche,34295
Montpellier, Francee-mail: [email protected]
S. Moritz-Gasser :H. DuffauInstitute for Neuroscience of
Montpellier, INSERM U1051,Plasticity of Central Nervous System,
Human Stem Cells andGlial Tumors, Hpital Saint Eloi, CHU
Montpellier,80 Av Augustin Fliche,34091 Montpellier, France
Neurosurg Rev (2012) 35:287292DOI 10.1007/s10143-011-0351-4
Surgery
A second awake surgery was performed using
directcortico-subcortical electrostimulation, a method
extensivelydetailed by the authors in previous reports [10, 12].
Forcortical mapping, the patient was asked to perform countingand
picture naming. Stimulation of the ventral premotorcortex induced
speech arrest (Fig. 1b). No functional siteswere found within the
anatomical Wernicke's area, i.e.,the posterior part of the superior
and middle temporal gyri,allowing its resection. The tumor removal
was tailoredaccording to deep functional boundaries identified
byrepeated electrostimulation (Fig. 1c). Indeed, stimulationof the
left insular cortex induced articulatory disturbances.In addition,
stimulation of the white matter below the insulaelicited semantic
paraphasias, suggesting that the resectionwas into the contact of
the inferior fronto-occipitalfasciculus (IFOF) [11]. Finally,
stimulation of the subcor-tical fibers running within the posterior
part of the cavityelicited phonemic paraphasias, suggesting that
the resectionwas into the contact of the temporal part of the
arcuatefasciculus [7] and should be interrupted.
Postoperative neuropsychological assessment
The postoperative neurological examination (day 5) showedan
improvement of the naming, with 80/80 using the DO80.The
semantic/phonological fluency (51/37) improved too.
MT86 was normal, despite some hesitations in nonwordrepetition.
Finally, the semantic association test was normal.However, due to a
slight impairment of verbal workingmemory (direct/indirect span,
4/4), functional rehabilitationwas performed. Two months after the
surgery, the patientreturned to her normal social and professional
life. At6 months, the scores were normalized: DO80 was
80/80;semantic/phonological fluency was 55/43, respectively;MT86
was normal; and direct/indirect span was 6/5,respectively.
Control MRI showed 13 cm3 of residual tumor, due to aposterior
and deep residue involving the language pathwaysas well as the
anterior perforating substance (Fig. 1d).Neuropathological
examination confirmed a WHO grade IIglioma. No adjuvant treatment
was administrated.
Postoperative functional MRI
A postoperative language functional MRI was also obtainedafter
language rehabilitation. All images were acquired
Fig. 1 a Preoperative sagittalT2-weighted MRI; b intraoper-ative
photograph obtained be-fore tumor removal. The tumorboundaries,
identified via ultra-sonography, are marked by lettertags (AE). The
stimulation ofventral premotor cortex-elicitedspeech arrest (1); c
intraopera-tive photograph after tumor re-moval. The stimulation of
insulainduced articulatory disturban-ces (45), the stimulation
ofposterior part of arcuate fascic-ulus induced phonemic
para-phasias and it constituted theposterior limit of resection
(39),the stimulation of inferiorfronto-occipital fasciculus
pro-duced semantic paraphasias (27)and it constituted the
infero-medial limit of resection.; dpostoperative sagittal
T2-weighted MRI
Fig. 2 3D reconstruction of activations showed by
postoperativefMRI for: a naming task (p
