Introduction

Glioblastomas (GBM) are malignant primary brain tumors associated with a limited median survival. Surgical removal under general anesthesia is the traditional treatment, although a recent meta-analysis revealed that awake surgery in GBM resulted in better surgical outcomes (Gerritsen, Arends, Klimek, Dirven, & Vincent). However, severe aphasia, which is common in GBM-patients (Noll, Sullaway, Ziu, Weinberg, & Wefel), is considered a contraindication for awake surgery due to difficult distinction between pre-existent and  surgery induced paraphasias.

Methods

We present four cases elected for awake surgery with GBM in eloquent language areas (frontal, temporal and/or parietal lobe) suffering from severe aphasia. Pre- and postoperatively, an extensive test-protocol was administered. Intraoperative tasks at different linguistic levels were selected from the Dutch Linguistic Intraoperative Protocol (De Witte et al.).

Results

Preoperatively, all patients had severely impaired scores (z≤-2.0) on shortened Token Test, Boston Naming Test and verbal fluency. DuLIP-tasks were simplified by selecting high-frequency words, diminished phonological complexity and presentation via dual input routes (auditory and visually) according to patients’ baseline level. Postoperatively all patients had stable or improved language outcome.

Conclusions

Awake surgery in severely aphasic GBM-patients is challenging, but feasible without further deterioration of aphasia. For adequate patient-tailored intraoperative monitoring of severely aphasic patients, extensive preoperative neurolinguistic examination of different in- and output routes is necessary. As this only concerns case-descriptions, the added value of awake surgery in GBM remains to be demonstrated with an RCT (Gerritsen et al.).