The Dutch Linguistic Intraoperative Protocol: A valid linguistic approach to awake brain surgery
Introduction
Intraoperative language mapping during awake surgery is considered to be the ‘gold standard’ since a positive impact of direct electrical stimulation (DES) on postoperative linguistic outcome is generally advocated (De Witt Hamer et al., 2012, Duffau et al., 2009, Ilmberger et al., 2008, Pereira et al., 2009, Sanai and Berger, 2010, Sanai et al., 2008, Spena et al., 2010). DES enables to identify critical cortical and subcortical language areas and pathways, which cannot be resected without post-operative language deficits (De Witt Hamer et al., 2012, Duffau, 2007, Duffau et al., 2005, Spena et al., 2010). During DES, picture naming (Metz-Lutz et al., 1991) and counting are commonly used as language paradigms (Bertani et al., 2009, Duffau, 2007). However, this approach, in which word-finding abilities and automatic speech are investigated in a restricted way, does not cover the integral variety of expressive and receptive language functions, necessary for an adequate communication. Verb–noun association tasks, auditory and visual comprehension tasks, repetition, reading, and writing tasks are occasionally used in experimental settings and some studies described a more tailored selection taking into account tumour location (Bello et al., 2007, Bello et al., 2008, Bertani et al., 2009, Duffau et al., 2003, Duffau et al., 2005) (for a review see De Witte & Mariën, 2013). As a result, test batteries including specific and sensitive tasks are needed for intraoperative language testing in order to preserve language function. Polczynska (2009) suggested three sets of ‘home made’ tasks consisting of: (1) ‘grammar-focused tests’, (2) ‘non-dominant right-hemisphere tests’, and (3) ‘tests for subcortical stimulation’. Coello et al. (2013) proposed a minimal common protocol consisting of language tasks such as picture naming, semantic association and reading. In the study of Miceli, Capasso, Monti, Santini, and Talacchi (2012), the following language tasks were included to assess lexical-semantic processing: naming (both objects and actions), lexical decision (both auditory and visual) and word–picture matching (nouns and verbs, auditory and visual). Papagno et al. (2012) suggested a neuropsychological battery (Milano-Bicocca Battery MIBIB) to assess cognition (language, memory, executive functions, apraxia, spatial cognition) in low-grade glioma’s pre- and postoperatively. Intraoperatively, they use naming of objects, actions and people. However, in general little is known about the feasibility, the construction, the validity of the tasks, and no normative data are available. The selection of the type of language paradigms during DES procedures is of crucial importance because of its direct effect on clinical outcome (Hamberger, Seidel, Mckhann, Perrine, & Goodman, 2005). Therefore the sensitivity of each language task used during DES needs to be investigated (Satoer et al., 2012, Talacchi et al., 2011, Talacchi et al., 2012, Teixidor et al., 2007). We attempted to achieve this goal by developing for the first time a Dutch standardised neurolinguistic test battery for awake surgery in critical language areas. The language test battery, called DuLIP (Dutch Linguistic Intraoperative Protocol) includes a variety of phonological, semantic, syntactic and articulatory tests, standardised in a healthy control population of 250 neurologically healthy adults (see part 2 and 3). The clinical use of DuLIP in awake surgery is illustrated with a ‘location-function-task’ model and this model is applied to select an appropriate intraoperative language test battery to assess linguistic functions in patients with tumoural lesions in eloquent areas (see part 4).
Section snippets
Procedure
The first two authors of this manuscript and a group of master level students in clinical linguistics, speech and language pathology and clinical psychology were trained to administer the set of linguistic tests of the DuLIP, consisting of one object naming test, four phonological tests (repetition words, phonological odd word out, phonological fluency, phonological sentence judgment), eight semantic tests (semantic odd word out, semantic picture out, semantic association, sentence completions
Results
No significant difference in mean age (p = 0.369) and mean years of education (p = 0.061) was found between the male and female participants of this study. In general, the healthy subjects with a normal cognitive level obtained high scores and a ceiling effect was found for all tasks but the fluency tasks (Appendix 1). The tasks that elicited most errors in the study population were the naming tasks, and some of the semantic tasks: the semantic odd word out task, the semantic sentence completion
Procedure
To illustrate the clinical use of the DuLIP protocol the pre-, intra- and postoperative data of 5 patients with tumours in different eloquent brain areas are demonstrated. In the pre- and postoperative phase (6 weeks and 6 months postsurgery), the DuLIP Protocol is administered together with tasks for the other cognitive (memory, attention, visuoperception, execution) functions (2 h of testing divided into two test moments). The normative data and especially the cut-off scores are used to define
Discussion
This study reports the rationale, development, standardisation and application of DuLIP, the first Dutch linguistic test battery for pre-, intra- and postoperative use in awake brain surgery. DuLIP includes tasks that relate to a broad variety of linguistic levels and modalities and as such allows assessment of various linguistic functions in detail. The normative data and clinical application of DuLIP as well as some limitations and future needs are discussed in the sections below.
Conclusion
In this study a set of linguistic tasks (DuLIP) to assess a variety of linguistic functions during awake surgery was carefully constructed and standardised in a cohort of 250 Dutch healthy controls. With DuLIP, a valid linguistic test battery and methodologically sound instrument has become available to reliably evaluate linguistic functions in the pre-, intra- and postoperative phase of awake surgery. Based on the tumour localisation (preoperative neuroimaging data) and the patient’s personal
Acknowledgments
Elke De Witte is a Ph.D. fellow of the Research Foundation – Flanders (FWO). Steven Verheyen is a postdoctoral fellow of the Research Foundation – Flanders (FWO).
We want to thank Prof. Dr. Roelien Bastiaanse and Drs. Adria Rofes for their cooperation in the development and analysis of the action naming task.
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