Homotopic organization of essential language sites in right and bilateral cerebral hemispheric dominance

Clinical article

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Object

Language dominance in the right hemisphere is rare. Therefore, the organization of essential language sites in the dominant right hemisphere is unclear, especially compared with cases involving the more prevalent left dominant hemisphere.

Methods

The authors reviewed the medical records of 15 patients who underwent awake craniotomy for tumor or epilepsy surgery and speech mapping of right hemisphere perisylvian language areas at the University of California, San Francisco. All patients were determined to have either complete right-sided or bilateral language dominance by preoperative Wada testing.

Results

All patients but one were left-handed. Of more than 331 total stimulation sites, 27 total sites were identified as essential for language function (14 sites for speech arrest/anarthria; 12 for anomia; and 1 for alexia). While significant interindividual variability was observed, the general pattern of language organization was similar to classic descriptions of frontal language production and posterior temporal language integration for the left hemisphere. Speech arrest sites were clustered in the ventral precentral gyrus and pars opercularis. Anomia sites were more widely distributed, but were focused in the posterior superior and middle temporal gyri as well as the inferior parietal gyrus. One alexia site was found over the superior temporal gyrus. Face sensory and motor cortical sites were also identified along the ventral sensorimotor strip. The prevalence and specificity of essential language sites were greater in unilateral right hemisphere–dominant patients, compared with those with bilateral dominance by Wada testing.

Conclusions

The authors' results suggest that the organization of language in right hemisphere dominance mirrors that of left hemisphere dominance. Awake speech mapping is a safe and reliable surgical adjunct in these rare clinical cases and should be done in the setting of right hemisphere dominance to avoid preventable postoperative aphasia.

Abbreviations used in this paper: GTR = gross-total resection; IAP = intracarotid amobarbital procedure; STR = subtotal resection; UCSF = University of California, San Francisco.

Article Information

Address correspondence to: Edward F. Chang, M.D., Department of Neurological Surgery, University of California, San Francisco, 505 Parnassus Avenue, M779, San Francisco, California 94143. email: changed@neurosurg.ucsf.edu.

Please include this information when citing this paper: published online January 14, 2011; DOI: 10.3171/2010.11.JNS10888.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Composite of all positive motor, sensory, and language sites by cortical stimulation (CS). Triangles represent speech arrest sites, squares represent anomia sites, and the circle represents the alexia site. Sensory sites for face, mouth, and jaw are represented by gray dots. Motor sites including face, hand, and arm are represented by white dots.

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    Negative language and motor mapping sites (+). Composite of all sites that failed to induce a language or motor response by direct cortical stimulation.

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    Right versus bilateral hemisphere language dominance. a: Positive language and motor mapping sites for patients with complete right hemisphere lateralization or right > left bilateral dominance for language on Wada testing (8 patients [Cases 1–8]). b: Language and motor sites for a patient with bilateral language dominance of unknown hemispheric contribution shows a right dominant pattern of positive language sites. c: Positive language and motor sites for patients with left > right bilateral dominance (6 patients [Cases 10–15]).

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    Magnetic resonance and intraoperative images. A: Preoperative T1-weighted Gd-enhanced MR image demonstrating a 5-cm right-sided nonenhancing mass in the posterior inferior frontal lobe. B: Postoperative image showing STR of the lesion. C and D: Intraoperative photographs obtained in the same patient, demonstrating sites of direct cortical stimulation and tailored resection to spare essential language and motor areas. Areas 1 and 2 = motor face; Area 3 = motor and sensory throat and jaw; Area 10 = speech arrest; and Areas 23, 24, 27, and 45 = anomia.

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