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Tizian Rosenstock, Thomas Picht, Heike Schneider, Peter Vajkoczy and Ulrich-Wilhelm Thomale

is especially important in the pediatric population since awake surgery is not possible in younger children and lesions can lead to significant plastic reshaping in the developing brain. Surprisingly, however, only two case reports on nTMS and nTMS-based tractography in pediatric neurosurgery have been published so far. 8 , 9 We scheduled 14 children for nTMS motor and/or speech mapping combined with nTMS-enhanced tractography prior to neurosurgical interventions in motor- and/or speech-eloquent areas, including both tumor and epilepsy surgical cases. The aim of

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Nico Sollmann, Thomas Picht, Jyrki P. Mäkelä, Bernhard Meyer, Florian Ringel and Sandro M. Krieg

inferior frontal gyrus who presented with intermittent motor aphasia. Preoperative speech mapping showed right-hemisphere dominance in fMRI and left-hemisphere dominance in nTMS mapping. Intraoperative DCS during awake surgery induced clear speech arrests from the left hemisphere. Differences in the 3 modalities and their application are discussed. Case Report History This 43-year-old left-handed man initially presented with repeated speech arrests within 7 days and was admitted to a neurology department. An MRI study showed a contrast-enhancing lesion

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Edward F. Chang, Doris D. Wang, David W. Perry, Nicholas M. Barbaro and Mitchel S. Berger

prevalent left hemisphere dominance. A basic understanding of right dominant language processing is critical to the prevention of postoperative language deficits in those undergoing perisylvian resections. Here, using direct electrocortical stimulation for language mapping during awake speech mapping for tumor resection or temporal lobectomy for epilepsy treatment, we provide direct evidence for organization of language centers in the dominant right hemisphere. Our results demonstrate that language organization in the dominant right hemisphere shares parallel

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Edward F. Chang, Jonathan D. Breshears, Kunal P. Raygor, Darryl Lau, Annette M. Molinaro and Mitchel S. Berger

areas could also be involved in speech production. 14 Large, modern speech mapping series have all re-demonstrated that naming function can lie in the frontal, temporal, and/or parietal cortices, with the majority of anomia errors occurring in the posterior frontal and temporal cortices. 10 , 12 , 17 , 19 A number of patients in these series did not produce errors with stimulation of the classic Broca's area, further highlighting the variability of cortical language representation among individuals. 5 , 10 , 13 , 17 While previous studies have described speech

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Jessica A. Wilden, Jason Voorhies, Kristine M. Mosier, Darren P. O'Neill and Aaron A. Cohen-Gadol

extending overall and progression-free survival. 36 Postoperative neurological deficits have become increasingly uncommon with the use of specialized preoperative and intraoperative neuroimaging, 30 , 40 as well as intraoperative motor and speech mapping. 6 , 12 When deficits do occur, they are usually temporary, and patients tend to recover fully without adverse affects on their long-term quality of life. 4 , 12 , 36 Persistent seizures can also adversely affect quality of life in this patient population. Although LGGs can cause headaches or progressive neurological

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Benjamin B. Whiting, Bryan S. Lee, Vaidehi Mahadev, Hamid Borghei-Razavi, Sanchit Ahuja, Xuefei Jia, Alireza M. Mohammadi, Gene H. Barnett, Lilyana Angelov, Shobana Rajan, Rafi Avitsian and Michael A. Vogelbaum

symptoms, tumor location, significant intraoperative events, postoperative deficits, tumor type, histopathology, EOR, type of neuromonitoring used, and significant electrocorticography (ECoG) findings. All surgeries utilized image-guided neuronavigation. Both DTI and fMRI sequences were performed preoperatively in 46 cases. Volumetric navigation imaging without either fMRI or DTI was performed in 10 cases, and fMRI only was performed in 6 cases. All surgeries involved awake functional mapping intraoperatively. Twenty-two cases underwent speech mapping, 26 underwent motor

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Anthony T. Lee, Claire Faltermeier, Ramin A. Morshed, Jacob S. Young, Sofia Kakaizada, Claudia Valdivia, Anne M. Findlay, Phiroz E. Tarapore, Srikantan S. Nagarajan, Shawn L. Hervey-Jumper and Mitchel S. Berger

% rate of new neurological deficit at the 6-month follow-up. 36 Although the role of MEG has been well validated for preoperative motor and somatosensory mapping, 19 , 21 , 33 , 45 less is known about its correlation to intraoperative speech mapping. Specifically, how HFC (vs LFC) network hubs contribute to expressive and receptive language processing remains unclear. In this study, we examined postoperative language outcomes using tasks of varying complexity following removal of intra- and peritumoral HFC network hubs during tumor resection. We test the hypothesis

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Justin R. Mascitelli, Seungwon Yoon, Tyler S. Cole, Helen Kim and Michael T. Lawton

performed in 9 cortically based cases (8.1%) and 1 brainstem case (0.9%). Of the AVMs with language eloquence, awake speech mapping was performed in 7 cases (13.2%). Complications occurred in 24 patients (10%). The vast majority of patients (97%) underwent postoperative angiography. Eight patients without a postoperative angiogram had an MR image. Complete AVM resection was achieved in 86.7% of patients. The average time to last follow-up was 24 months. At the last follow-up, 83.4% had a good clinical outcome (mRS score 0–2), 16.6% had a poor outcome (mRS 3–6), and 3

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Marcos V. C. Maldaun, Shumaila N. Khawja, Nicholas B. Levine, Ganesh Rao, Frederick F. Lang, Jeffrey S. Weinberg, Sudhakar Tummala, Charles E. Cowles, David Ferson, Anh-Thuy Nguyen, Raymond Sawaya, Dima Suki and Sujit S. Prabhu


The object of this study was to describe the experience of combining awake craniotomy techniques with high-field (1.5 T) intraoperative MRI (iMRI) for tumors adjacent to eloquent cortex.


From a prospective database the authors obtained and evaluated the records of all patients who had undergone awake craniotomy procedures with cortical and subcortical mapping in the iMRI suite. The integration of these two modalities was assessed with respect to safety, operative times, workflow, extent of resection (EOR), and neurological outcome.


Between February 2010 and December 2011, 42 awake craniotomy procedures using iMRI were performed in 41 patients for the removal of intraaxial tumors. There were 31 left-sided and 11 right-sided tumors. In half of the cases (21 [50%] of 42), the patient was kept awake for both motor and speech mapping. The mean duration of surgery overall was 7.3 hours (range 4.0–13.9 hours). The median EOR overall was 90%, and gross-total resection (EOR ≥ 95%) was achieved in 17 cases (40.5%). After viewing the first MR images after initial resection, further resection was performed in 17 cases (40.5%); the mean EOR in these cases increased from 56% to 67% after further resection. No deficits were observed preoperatively in 33 cases (78.5%), and worsening neurological deficits were noted immediately after surgery in 11 cases (26.2%). At 1 month after surgery, however, worsened neurological function was observed in only 1 case (2.3%).


There was a learning curve with regard to patient positioning and setup times, although it did not adversely affect patient outcomes. Awake craniotomy can be safely performed in a high-field (1.5 T) iMRI suite to maximize tumor resection in eloquent brain areas with an acceptable morbidity profile at 1 month.

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Tejas Sankar and Andres M. Lozano

respect to language is rare. Consequently, the authors are to be commended for identifying a gap in the speech mapping literature and for realizing that their extensive experience placed them in a unique position to fill that gap. The methods of preoperative and intraoperative language assessment used in the study are sound and reproducible. In particular, the use of preoperative Wada testing to classify language lateralization into categories is worth highlighting, as it is a unique feature of this study and adds considerably to the interpretation of the results