A Comprehensive Overview of Intraoperative Language Assessment

Transcription

1 A Comprehensive Overview of Intraoperative Language Assessment

2 Kelly L. Maatz, M.A., CCC-SLP Speech-Language Pathologist Kevin Reinard, M.D. Neurosurgery Resident

3 Background Kelly Maatz Kent State University BS, Speech-Language Pathology MA, Speech-Language Pathology Wayne State University ABD, Medical Speech-Language Pathology Henry Ford Hospital, Detroit, Michigan Staff SLP, Acute Care Medical Hospital

4 Background Kevin Reinard University of Arizona BS, Molecular and Cell Biology BS, Nutritional Sciences Medical College of Wisconsin Doctor of Medicine Henry Ford Hospital Neurosurgery Residency

5 Agenda Section 1 Historical perspective of intraoperative language assessment Benefits and limitations of performing tumor resection under awake conditions Recent advances in performing tumor resection under awake conditions

6 Agenda Section 2 Patient Selection Types of Tumors to resect under awake conditions Pre-operative Testing Ideal Candidate Marginal Candidate Poor Candidate

7 Agenda Section 3 Surgical Procedure Patient preparation and positioning Role of the SLP in language mapping Decision making by the Neurosurgeon based on input from the SLP and EEG Recovery and Post-operative Expectations Follow-up

8 Agenda Section 4 The patient s perspective Responsibilities of SLP for pre- and post-operative counseling

9 Video video 1

10 SECTION 1 Historical Roots

11 DR. PAUL BROCA ( ) 1861: Brain of a patient with motor aphasia preserved and uncut

12 Broca, cont. Experimented with hypnotism with surgical cases Studied 2 pts. With motor speech disorders Identified expressive speech center in the frontal lobe Localized human language to a definite circumscribed area of the left hemisphere Formed the basis for what was later coined Broca s Aphasia : a severe disruption of language output which far exceeded a difficulty in language comprehension 2 hemispheres of the brain are asymmetrical in function

13 Broca, cont. Contributed to research supporting the notion that specific functions appear to be associated clearly with localized sites in the brain Became a significant historical force in the establishment of the medical discipline of neurology Much of neurology is dependent upon the physician s ability to lateralize and localize lesions in the nervous system Possibly no period in history has so advanced the understanding of communication disorders as those years between the date of Broca s discovery and WWI

14 DR. CARL WERNICKE ( ) 1874: Wernicke s drawing of the Motor and Sensory Speech area

15 Wernicke, cont. Born in Poland moved to Germany Original interest = Psychiatry and then anatomy and eventually neuropathology Posited that brain centers were involved in spoken language 1874: identified an auditory speech center in the temporal lobe rather than the frontal lobe that was associated with speech comprehension Later known as Wernicke Aphasia : the deficit in language comprehension far exceeded the disruption of language output

16 Historical Overview The idea that the left hemisphere was the site of human spoken language became accepted in scientific circles With it came the idea that there were brain centers responsible for this function An anterior center responsible for the production of language located in the frontal operculum A posterior center responsible for language comprehension located in the posterior half of the superior temporal gyrus

17 DR. KORBINIAN BRODMANN ( ) Brodmann s cytoarchitectonic map

18 Brodmann Born in Germany Devoted his life to neurology and psychiatry After meeting Alois Alzheimer, began focusing on neuroanatomy Argued that the human cortex is organized anatomically in the same way as the cortex of all other mammals 1909: Developed a numbering system based on the anatomical difference in the cortex layers Has become the standard for designating areas of the cortex

19

20 Important Brodmann Areas 1, 2, 3: Primary sensory cortex (post central gyrus) 4: Primary motor cortex (precentral gyrus) 5, 7: Sensory association cortex (superior parietal lobule) 17: Primary visual cortex (medial occipital lobe) 22: Association language cortex of Wernicke (superior temporal gyrus) 41, 42: Primary auditory cortex (Heschl s gyrus) 40: Supramarginal gyrus 44: Motor speech cortex of Broca (lower third frontal convolution

21

22 Historical Roots 1885: Lichtheim Identifies a concept system distributed throughout the brain 1891: Freund Language processing is more complex than prior models imply (i.e., Wernicke & Lichtheim) Identified the Agnosias 1892: Joseph Dejerine Identified underlying reading disorders 1900: Hugo Liepmann Identified the Apraxias

23 Historical Roots WWII: Speech-Language Pathologist used in treatment programs for the first time 1960 s and 1970 s Language acquisition linked to neurological development 1965: Geschwind Split brain studies Anatomical basis for cerebral dominance for language Enlarged the original set of language-related areas to include the left supramarginal gyrus and the left angular gyrus both located in the inferior sector of the parietal lobe

24 Historical Roots At the same time, detailed evaluation of aphasic patients was beginning to be performed with measurement tools which considered the linguistic and cognitive aspects of language processing Mayo Clinic Dysarthria Classification System Minnesota Test of Differential Diagnosis of Aphasia Porch Index of Communicative Ability Boston Diagnostic Aphasia Examination

25 Hughlings Jackson Victor Horsley

26 Ottfried Foerster Wilder Penfield Herbert Jasper

27

28

29 What is Knowable Tumors in eloquent cortex reduce overall and progressionfree survival. Awake craniotomy and functional mapping plays a critical role in delineating tumors involving eloquent areas of the brain. Increased extent of resection prolongs survival partly by decreasing risk of malignant transformation.

30 Pitfalls of Awake Craniotomies Cerebral swelling/herniation Stimulus-induced convulsion Patient discomfort (physical/psychological) Hidden deficit

31 OT 66 yo M, glioblastoma;

32 OT 66 yo M, glioblastoma;

33

34

35

36

37

38 Recent Advances Intraoperative MRI SLP in the operating suite Standardization of the images used during cortical mapping

39 SECTION 2 Patient Selection

40 Indications Infiltrative tumors in putatively eloquent cerebral site or bordering upon it Penumbral epileptogenicity in putatively eloquent cerebral site Lack of imaging evidence of significant tract migration or multifocality Functional independence Intraoperative cooperability

41 CL 28 yo F, atypical oligodendroglioma;

42 CL 28 yo F, atypical oligodendroglioma;

43 RJ 22 yo M, anaplastic ependymoma;

44 RJ 23 yo M, anaplastic ependymoma;

45 Surgical Objectives Reduce tumor burden/mass effect Reduce/Eliminate epileptogenicity Reduce malignant potential/therapeutic resistance Provide complete pathological survey of tumor landscape

46 Supportive Studies Surveillance, Epidemiology and End Result (SEER) Guidelines of Joint Tumor Section of AANS/CNS Lacroix et al., J. Neurosurg. 95: , 2001 Berger et al., Cancer 74: , 1994 Duffau et al., J. Neurol. Neurosurg. Psychiatry 74: , Chang et al., J. Neurosurg. 114: , 2011.

47 Lacroix et al., J. Neurosurg. 95, 2001

48 Lacroix et al., J. Neurosurg. 95, 2001

49 Pre-op Investigations Magnetic resonance imaging structural, functional, DTI Electroencephalography Language assessment Neuropsychological profile Magnetic source imaging (magnetoencephalography) Visual fields

50 DR 43 yo M, oligodendroglioma;

51

52

53 SLP Baseline Evaluation Expressive Language Naming Verbal Fluency Comprehension Verbal Memory Reading / Writing Biographical Information General Interests and Conversation starters

54 Baseline Evaluation Boston Naming Test Boston Diagnostic Aphasia Examination Controlled Oral Word Association Test (MAE) Woodcock Johnson Language Proficiency Subtests (synonyms, antonyms) Cognitive Linguistic Quick Test Revised Token Test

55 Boston Naming Test Stand Alone Subtest of the BDAE 60 items Normed on brain injured population Male VA hospital Non-brain injured patients

56

57

58 Boston Diagnostic Aphasia Examination Harold Goodglass, PhD, Edith Kaplan, PhD, Barbara Barresi, PhD normative sample of 242 patients with aphasic symptoms tested at the Boston VA Medical Center between only male presumably English-speaking patients

59 Boston Diagnostic Aphasia Examination Currently in its third edition-includes a short form Fluency Generative Naming (Be wary of semantic categories) Auditory comprehension Oral reading Reading comprehension Repetition Automatic sequences Writing Visuospatial processing Computation

60 Controlled Oral Word Association Test Different forms of this procedure exist A measure of a person's ability to make verbal associations to specified letters (i.e., C, F, and L) No proper nouns No alternate endings

61 Woodcock Johnson Language Proficiency Subtests Woodcock-Johnson Tests of Cognitive Ability Antonyms Synonyms Grades Age 25-65

62 Cognitive Linguistic Quick Test Nancy Helm-Estrabrooks 5 cognitive domains Personal Facts Symbol Cancellation Confrontation Naming Clock Drawing Story Retelling Symbol Traits Generative Naming Design Memory Mazes Design Generation

63 Revised Token Test Auditory Processing 10 RTT subtests 24 Tokens For ages 20 to 80 years

64 Ideal Candidate Minimal errors on BNT Common substitutions Protractor = Compass No errors on intraoperative stimulus pictures Minimal errors on BDAE Reading comprehension at paragraph level Normal results on COWAT Minimal Anxiety Easy to elicit conversation

65 Marginal Candidate Moderate to Severe Errors on BNT May not be able to finish Minimal errors on intraoperative stimulus pictures Able to ID between pictures Errors are reproducible Errors on BDAE Reading comprehension at sentence level Minimal-Moderate Anxiety Able to Generate Conversational Topics

66 Poor Candidate Multiple Errors on BNT No attempts at labeling Multiple Errors on Intraoperative Stimulus Pictures Non-reproducible Multiple Errors on BDAE Auditory Comprehension Errors Unable to Complete COWAT Moderate to Severe Anxiety Difficult to Elicit Conversation

67 SECTION 3 SURGICAL PROCEDURE

68

69 Video Video 2

70 Surgical Method Patient sedation, positioning and draping Local anesthesia, neuronavigation, entry minimization Electrocorticography and cortical stimulation mapping Controlled (subpial) resection with functional feedback and subcortical stimulation

71

72

73

74

75

76

77

78

79

80

81 Marking Incision Line

82 Accessing Brain Through Skull

83 Removing Bone Plate

84 Expose Brain Surface

85

86 Cortical Stimulation

87 Cortical Stimulation

88

89 Cortical Stimulation Biphasic square-wave pulse 60 Hz 1 ms Amplitude incrementally increased from 1 ma until a clinical response is achieved Maximum 8 ma Maximum 4 seconds

90

91 EEG After discharge A 5 sec stimulation at 4.5 ma below electrode #4 elicits rhythmic spikes in areas sampled by contact # 4 and propagation to contact # 3. Speech arrest was noted during after discharges

92

93

94

95

96

97

98

99 Video of Cortical Stimulation in Progress Video 3

100

101 Tumor Resection

102 Tumor Resection

103 Closure

104 Closure

105 MC 63 yo M, anaplastic oligoastrocytoma;

106 MC 63 yo M, anaplastic oligoastrocytoma;

107 MC 64 yo M, anaplastic oligoastrocytoma;

108 MC 64 yo M, anaplastic oligodendroglioma;

109 MH 24 yo F, glioblastoma;

110 MH 24 yo F, glioblastoma;

111 YH 30 yo F, mixed glioma;

112 YH 30 yo F, mixed glioma;

113 NI 49 yo M, oligodendroglioma;

114 NI 49 yo M, oligodendroglioma;

115 RD 51 yo M, glioblastoma;

116

117 RD 51 yo, glioblastoma;

118 DR 43 yo M, oligodendroglioma;

119

120 DR 43 yo M, oligodendroglioma;

121 INTRAOPERATIVE LANGUAGE EVALUATION

122 Goal: Keep the Patient Talking Counting and Other Automatics Confrontation Naming Verb Generation Reading Running Conversation

123 Video of Intraoperative Evaluation of Language Video 4

124 Naming Presence of naming deficits in all aphasic syndromes due to lesions Multiple items of approximately equal difficulty Black and white line drawings Accurate identification in the absence of stimulation

125

126

127

128

129

130

131

132 Errors Omission Phonemic paraphasia Semantic paraphasia Neologism Perseveration

133 Reading Errors Slow, effortful reading Fluent reading with mistakes verb endings prepositions conjunctions and pronouns syntax

134 Fluency Dysfluency Pause Complete arrest of all speech

135 SECTION 4 The Patient s Perspective

136 Pre-operative Counseling Reason for pre-operative testing What will happen on the day of surgery What to expect in the operating room What to expect after surgery 1 st 24 hours 1 st few days 1 st month Family support

137 During Surgery Communicating with the surgeon Patient support Family counseling in the waiting room

138 Video of Patient During and After Surgery Video 5

139

140 Post-operative Results Aphasia Non-fluent subtypes Fluent subtypes Recovery Period 1 st 3-4 days Next 3-4 weeks Post-op Language Evaluation AAC Therapy

141 Post-operative Counseling What to expect immediately after surgery 1 st hours 1 st 3-4 days 3-4 weeks of communication frustration Family support is critical Changes associated with steroid use Changes associated with radiation and chemo

142 Key Points Awake Craniotomy allows for intraoperative mapping to optimize the extent of resection without affecting communication and improving clinical outcomes

143 Key Points SLP plays a critical role before, during, and after surgery Patient Selection Patient Support Communication with the surgeon Communication with the nurses, and anesthesiologist

144 Key Points Minimum testing BNT BDAE COWAT Intraoperative stimulus pictures Conversational topics

145 Key Points Counseling Counsel only what is within your comfort zone and know when to refer Counsel before, during, and after surgery Education is the key

146 Questions?

147