Writing-specific sites in frontal areas: a cortical stimulation study

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Object. The aim of this study was to determine whether cortical areas involved in the writing process are associated with reading or naming areas in patients undergoing surgery for brain tumors in frontal areas. This study was undertaken to spare all language areas found in patients during surgery.

Methods. Fourteen patients (eight women and six men [mean age 47 years] of whom 12 were right handed, two left handed, 12 monolingual, and two bilingual) who harbored brain tumors in the left (11 patients) or right (three patients) frontal gyri or in rolandic areas, were tested by direct stimulation by using the awake surgery technique for direct brain mapping. Mapping of the frontal gyri was performed using naming, reading, and writing under dictation tasks in the appropriate language(s).

Considerable individual variability in language organization among patients was observed. Interferences in writing were found during direct stimulation in the frontal gyri, in cortical sites common or not common to interferences in naming or reading. In dominant regions, patterns of writing dysfunctions were variable and included writing arrest, illegible script, letter omissions, and paragraphia. These dysfunctions were nonspecific (stimulation-induced eye movements) in nondominant frontal regions and in rolandic gyri (hand contractions). In the same patient, different writing impairments could sometimes be observed during stimulation of different sites. As is the case for naming or reading interference sites, writing interference sites could be extremely localized (1 cm2 in diameter). In this group of patients, writing interference sites found in Broca areas were associated with other sites of language interference, whereas writing-specific interference sites were found twice in the dominant middle frontal gyrus.

Conclusions. In this series, we found that writing interference sites could be detected by direct cortical stimulation in dominant inferior and middle frontal gyri regardless of whether they were associated with naming or reading interference sites. Writing disorders elicited by direct stimulation in the frontal lobes are varied and probably depend on the functional status of the stimulated cortical area.

Article Information

Address reprint requests to: Franck-Emmanuel Roux, M.D., Ph.D., Service de Neurochirurgie et INSERM 455, Hôpital Purpan, F-31059 Toulouse, France. email: rouxfran@compuserve.com.

© AANS, except where prohibited by US copyright law.

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Figures

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    Schematic showing locations associated with interferences in writing in 14 patients. The dotted lines mark the areas of craniotomy.

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    Data on interference in patients' writing during stimulation of the F1 through F3. Asterisk indicates that the Edinburgh Handedness Inventory test was used. Dagger indicates that typical paraphasias were found when there was stimulation of a cortical site in the superior temporal gyrus. WHO = World Health Organization.

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    Case 2. Location and patterns of writing interference in the F2 in a 47-year-old bilingual (French—Arabic) right-handed woman with a small left rolandic lesion (metastasis) in the upper portion of the precentral sulcus, who experienced a single partial seizure. Born in Morocco, this patient lived in France for many decades and wrote and spoke both languages fluently. No aphasic disorder or hand motor deficit was noted preoperatively. A: Examples of preoperative handwriting in French and Arabic. The patient exhibited no writing disorder; her calligraphy was preserved and she had no difficulty writing in response to dictation or while copying a text (either in French or in Arabic). B: Intraoperative photograph showing a zone (W) in which the patient displayed several writing problems in both French and Arabic (intensity of stimulation 3.6 mA). This zone is located at the foot of the F2, according to the probe of the neuronavigational system with 3D anatomical reconstructions. Stimulation over the precentral gyrus identified the hand area (H) contraction of individual or all fingers and a thumb area (T). Blue thread indicates the rolandic sulcus. C: Orthographic errors, letter substitutions, or repetitions were noted in both French and Arabic (underlined in red). No speech impairment was noted in this zone. D: Stimulation of another zone [N] produced no writing disorder under stimulation. E: Three-dimensional intraoperative reconstruction of the patient's brain showing the neuronavigational probe over the exact area where interferences in writing were found.

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    Case 3. Location and patterns of writing interference seen in the Broca area in a monolingual 50-year-old right-handed woman with a cavernoma in the left inferior frontal gyrus. No aphasic disorder and no motor or writing deficit was noted preoperatively. A and B: Intraoperative pictures with sites of interferences in writing and naming, respectively. In the Broca region, all areas of anomia [L] were in common with areas of writing interference [W] during stimulation. Dotted black line signifies the area of cortectomy. C: Examples of writing interference during stimulation (dotted white arrows) in the F3. The words and letters are well shaped, but the words are inappropriate and the sentences impossible to understand. The patient was not aware of her transient writing difficulties during stimulation. D: Another example of writing interference during stimulation (dotted white arrows) found in the F2. The letters are not well shaped and the words become illegible. This site also produced interferences in reading but not in naming. L = language essential site (naming interference site); M = motor zone (precentral gyrus

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    Case 3. Postoperative evolution of writing abilities in a woman in whom a cavernoma was removed from the Broca area. See Fig. 4 for the area of the cortectomy (between 1 and 2 cm from the cortical writing sites). A: Example of the patient's normal handwriting 1 year before the operation. No aphasic disorder and no motor or writing deficit was noted preoperatively. B: Evolution of the patient's writing abilities just after the operation. On the 1st day, no aphasic and writing disorder was noted. Dictated materials were correctly written without problems. On the 3rd postoperative day, a typical expressive aphasia appeared, probably due to an edema in the Broca area. The patient understood perfectly what was said to her but was unable to speak. Her handwriting was well shaped but no sensible sentences or words were written. Perseverations and paragraphias were noted on the 6th day and the expressive aphasia began to resolve. Dictated sentences were written but contained some orthographic errors or paragraphias (dotted white lines). C: Two months after the operation, no dysphasic disorder related to naming, reading, and writing was noted. Her written material was normal.

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    Case 4. Postoperative evolution of handwriting abilities in a 14-year-old girl in whom a high-grade astrocytoma was removed from the dominant superior frontal gyrus. A: Example of the patient's normal handwriting 6 months before the operation. No aphasic disorder and no motor or writing deficit was noted preoperatively. B: Evolution of the patient's writing abilities just after the operation. On the 1st day, no significant aphasic and writing disorder was noted. Dictated materials were correctly written without problems, although her handwriting (letter shapes) was slightly modified. Two weeks later, just before radiotherapy was begun, the girl's handwriting was still slightly modified although correct. No aphasic disorder was noted. One month later, during radiotherapy, her handwriting began to worsen and more orthographic errors were noted (dotted black line). C: Two months after the operation, at the end of radiotherapy, her handwriting was deeply modified with some orthographic errors (dotted black lines).

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