Cognitive functioning early after surgery of gliomas in eloquent areas

Clinical article

Restricted access


Patients with gliomas frequently have cognitive deficits, and surgery can exacerbate these deficits. Preoperative assessment is therefore crucial in patients undergoing surgery for glioma in eloquent areas, because the proximity of functional areas increases the risk of permanent postoperative cognitive disturbances. Although pre- and postoperative language and motor function in patients with glioma have been investigated frequently, data on good cognition studies are scarce. Most studies have focused on clinical neurological functioning or have only used brief neurological instruments. The authors investigated whether surgery for glioma in eloquent areas influences cognition early after surgery, by using an elaborate test protocol.


Twenty-eight patients with gliomas of the left hemisphere in language and nonlanguage areas were assessed before and 3 months after surgery with a comprehensive neuropsychological test protocol. The authors performed a correlation analysis between change in cognitive performance and tumor characteristics (that is, location, volume, pathological features, and histological grade) and between cognitive change and treatment-related factors (the extent of the resection and postoperative treatment with chemo- and radiotherapy).


Both pre- and postoperatively, the mean performance of the patients was worse than the performance of the normal population in the language domain, the memory domain, and the executive functions (p < 0.05). Postoperatively, a decline was found in the language domain (t = 2.34, p = 0.027) and in the executive functions (t = 2.45, p = 0.022). However, cognitive change postsurgery was influenced by the location of the tumor; the decrease of cognitive score in the language domain was only observed in patients with tumors in or close to language areas (t = 2.33, p = 0.029). No effect on cognitive change was found for the other tumor characteristics and treatment-related factors.


This study underlines the importance of the use of a neuropsychological test protocol before and after surgery in patients with glioma, because several tasks in the domains of language, memory, and executive functions appeared to deteriorate after surgery. Tumor resection in language areas increases the risk of cognitive deficits in the language domain postoperatively.

Abbreviations used in this paper:AAT = Aachener Aphasia Test; ASRS = Aphasia Severity Rating Scale; BNT = Boston Naming Test; HGG = high-grade glioma; LGG = low-grade glioma; TMT = Trail-Making Test; TMTA, TMTB, TMTBA = TMT Parts A, B, BA; 15WT = 15 Words Test.

Article Information

Address correspondence to: Djaina Satoer, M.A., Department of Neurosurgery, Erasmus MC, University Medical Center, Dr. Molewaterplein 50-60, PO Box 2040, 3015 GE, Rotterdam, The Netherlands. email:

* Ms. Satoer and Ms. Vork contributed equally to this work.

Please include this information when citing this paper: published online August 31, 2012; DOI: 10.3171/2012.7.JNS12263.

© AANS, except where prohibited by US copyright law.



  • View in gallery

    Bar graphs showing the mean preoperative and postoperative z scores of the patients on the tests in the 4 cognitive domains. A: The mean z scores of the patients in the language domain. B: The mean z scores of the patients in the memory domain. C: The mean z scores of the patients in the domain of attention and executive functions. D: The mean z scores of the patients in the visuoconstructive domain. The asterisk denotes a significant difference (p < 0.05) between pre- and postoperative performance. A mean z value of 0 equals the mean performance in the healthy population, whereas negative z values indicate that patients performed worse than individuals in the healthy population. Inf = interference.


  • 1

    Bosma IReijneveld JCKlein MDouw Lvan Dijk BWHeimans JJ: Disturbed functional brain networks and neurocognitive function in low-grade glioma patients: a graph theoretical analysis of resting-state MEG. Nonlinear Biomed Phys 3:92009

  • 2

    Brodaty HMoore CM: The Clock Drawing Test for dementia of the Alzheimer's type: a comparison of three scoring methods in a memory disorders clinic. Int J Geriatr Psychiatry 12:6196271997

  • 3

    Correa DDDeAngelis LMShi WThaler HTLin MAbrey LE: Cognitive functions in low-grade gliomas: disease and treatment effects. J Neurooncol 81:1751842007

  • 4

    De Benedictis AMoritz-Gasser SDuffau H: Awake mapping optimizes the extent of resection for low-grade gliomas in eloquent areas. Neurosurgery 66:107410842010

  • 5

    Douw LKlein MFagel SSvan den Heuvel JTaphoorn MJAaronson NK: Cognitive and radiological effects of radiotherapy in patients with low-grade glioma: long-term follow-up. Lancet Neurol 8:8108182009

  • 6

    Drane DLMeador KJ: Cognitive and behavioral effects of antiepileptic drugs. Epilepsy Behav 3:5S49532002

  • 7

    du Boisgueheneuc FLevy RVolle ESeassau MDuffau HKinkingnehun S: Functions of the left superior frontal gyrus in humans: a lesion study. Brain 129:331533282006

  • 8

    Duffau H: Awake surgery for nonlanguage mapping. Neurosurgery 66:5235292010

  • 9

    Duffau H: A personal consecutive series of surgically treated 51 cases of insular WHO Grade II glioma: advances and limitations. Clinical article. J Neurosurg 110:6967082009

  • 10

    Duffau HCapelle LDenvil DSichez NGatignol PTaillandier L: Usefulness of intraoperative electrical subcortical mapping during surgery for low-grade gliomas located within eloquent brain regions: functional results in a consecutive series of 103 patients. J Neurosurg 98:7647782003

  • 11

    Folstein MFFolstein SEMcHugh PR: “Mini-mental state:” a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 12:1891981975

  • 12

    Gehring KSitskoorn MMGundy CMSikkes SAKlein MPostma TJ: Cognitive rehabilitation in patients with gliomas: a randomized, controlled trial. J Clin Oncol 27:371237222009

  • 13

    Goldstein BObrzut JEJohn CLedakis GArmstrong CL: The impact of frontal and non-frontal brain tumor lesions on Wisconsin Card Sorting Test performance. Brain Cogn 54:1101162004

  • 14

    Goodglass HKaplan E: The Assessment of Aphasia and Related Disorders ed 2PhiladelphiaLea & Febiger1983

  • 15

    Graetz SDe Blesser PWillmes K: Akense Afasie Test Lisse, The NetherlandsSwets & Zeitlinger1992

  • 16

    Hubbard EJSantini VBlankevoort CGVolkers KMBarrup MSByerly L: Clock drawing performance in cognitively normal elderly. Arch Clin Neuropsychol 23:2953272008

  • 17

    Ilmberger JRuge MKreth FWBriegel JReulen HJTonn JC: Intraoperative mapping of language functions: a longitudinal neurolinguistic analysis. Clinical article. J Neurosurg 109:5835922008

  • 18

    Kaplan EGoodglass HWeintraub S: Boston Naming Test ed 2PhiladelphiaLippincott, Williams & Wilkins2001

  • 19

    Keime-Guibert FNapolitano MDelattre JY: Neurological complications of radiotherapy and chemotherapy. J Neurol 245:6957081998

  • 20

    Kiebert GMCurran DAaronson NKBolla MMenten JRutten EH: Quality of life after radiation therapy of cerebral low-grade gliomas of the adult: results of a randomised phase III trial on dose response (EORTC trial 22844). Eur J Cancer 34:190219091998

  • 21

    Kleihues PLouis DNScheithauer BWRorke LBReifenberger GBurger PC: The WHO classification of tumors of the nervous system. J Neuropathol Exp Neurol 61:2152292002

  • 22

    Klein MHeimans JJAaronson NKvan der Ploeg HMGrit JMuller M: Effect of radiotherapy and other treatmentrelated factors on mid-term to long-term cognitive sequelae in low-grade gliomas: a comparative study. Lancet 360:136113682002

  • 23

    Lageman SKCerhan JHLocke DEAnderson SKWu WBrown PD: Comparing neuropsychological tasks to optimize brief cognitive batteries for brain tumor clinical trials. J Neurooncol 96:2712762010

  • 24

    Le Rhun EDelbeuck XDevos PPasquier FDubois F: [Cognitive disorders and adult grade II and III gliomas: analysis of a series of 15 patients.]. Neurochirurgie 55:3033082009. (Fr)

  • 25

    Lezak MD: Neuropsychological Assessment ed 4New YorkOxford University Press2004

  • 26

    Luteijn FBarelds DPF: Groninger Intelligentie Test II (GIT II) AmsterdamPearson2004

  • 27

    Mendez MFAla TUnderwood KL: Development of scoring criteria for the clock drawing task in Alzheimer's disease. J Am Geriatr Soc 40:109510991992

  • 28

    Naidich TPHof PRGannon PJYousry TAYousry I: Anatomic substrates of language: emphasizing speech. Neuroimaging Clin N Am 11:305341ix2001

  • 29

    Price CJ: The anatomy of language: a review of 100 fMRI studies published in 2009. Ann N Y Acad Sci 1191:62882010

  • 30

    Sanai NMirzadeh ZBerger MS: Functional outcome after language mapping for glioma resection. N Engl J Med 358:18272008

  • 31

    Schäffler LLüders HOBeck GJ: Quantitative comparison of language deficits produced by extraoperative electrical stimulation of Broca's, Wernicke's, and basal temporal language areas. Epilepsia 37:4634751996

  • 32

    Scheibel RSMeyers CALevin VA: Cognitive dysfunction following surgery for intracerebral glioma: influence of histopathology, lesion location, and treatment. J Neurooncol 30:61691996

  • 33

    Schmand BGroenink SCvan den Dungen M: Letterfluency: psychometrische eigenschappen en Nederlandse normen. Tijdschr Gerontol Geriatr 39:65772008

  • 34

    Talacchi ASantini BSavazzi SGerosa M: Cognitive effects of tumour and surgical treatment in glioma patients. J Neurooncol 103:5415492011

  • 35

    Taphoorn MJKlein M: Cognitive deficits in adult patients with brain tumours. Lancet Neurol 3:1591682004

  • 36

    Taphoorn MJSchiphorst AKSnoek FJLindeboom JWolbers JGKarim AB: Cognitive functions and quality of life in patients with low-grade gliomas: the impact of radiotherapy. Ann Neurol 36:48541994

  • 37

    Taphoorn MJSizoo EMBottomley A: Review on quality of life issues in patients with primary brain tumors. Oncologist 15:6186262010

  • 38

    Teixidor PGatignol PLeroy MMasuet-Aumatell CCapelle LDuffau H: Assessment of verbal working memory before and after surgery for low-grade glioma. J Neurooncol 81:3053132007

  • 39

    Tucha OSmely CPreier MBecker GPaul GMLange KW: Preoperative and postoperative cognitive functioning in patients with frontal meningiomas. J Neurosurg 98:21312003

  • 40

    Tucha OSmely CPreier MLange KW: Cognitive deficits before treatment among patients with brain tumors. Neurosurgery 47:3243342000

  • 41

    Van der Elst Wvan Boxtel MPvan Breukelen GJJolles J: Rey's verbal learning test: normative data for 1855 healthy participants aged 24–81 years and the influence of age, sex, education, and mode of presentation. J Int Neuropsychol Soc 11:2903022005




All Time Past Year Past 30 Days
Abstract Views 132 132 18
Full Text Views 191 191 7
PDF Downloads 125 125 5
EPUB Downloads 0 0 0


Google Scholar