Non-Invasive Mapping for Effective Preoperative Guidance to Approach Highly Language-Eloquent Gliomas-A Large Scale Comparative Cohort Study Using a New Classification for Language Eloquence

Simple Summary Many gliomas are located within highly eloquent areas of language processing, necessitating awake surgery. This study actually proves that the resection of such gliomas can also be performed without awake surgery in two out of three cases, due to preoperative non-invasive mapping by navigated repetitive transcranial magnetic stimulation. Functional and radiological outcome parameters were comparable in both groups. Moreover, we present and validate a newly developed literature-based classification system for language eloquence of brain tumors. Such a classification will enable determining and comparing the language-eloquence of tumor localizations clinically and scientifically, which has not been possible until today due to the heterogeneity of cerebral language and functional reorganization. Objective: A considerable number of gliomas require resection via direct electrical stimulation (DES) during awake craniotomy. Likewise, the feasibility of resecting language-eloquent gliomas purely based on navigated repetitive transcranial magnetic stimulation (nrTMS) has been shown. This study analyzes the outcomes after preoperative nrTMS-based and intraoperative DES-based glioma resection in a large cohort. Due to the necessity of making location comparable, a classification for language eloquence for gliomas is introduced. Methods: Between March 2015 and May 2019, we prospectively enrolled 100 consecutive cases that were resected based on preoperative nrTMS language mapping (nrTMS group), and 47 cases via intraoperative DES mapping during awake craniotomy (awake group) following a standardized clinical workflow. Outcome measures were determined preoperatively, 5 days after surgery, and 3 months after surgery. To make functional eloquence comparable, we developed a classification based on prior publications and clinical experience. Groups and classification scores were correlated with clinical outcomes. Results: The functional outcome did not differ between groups. Gross total resection was achieved in more cases in the nrTMS group (87%, vs. 72% in the awake group, p = 0.04). Nonetheless, the awake group showed significantly higher scores for eloquence than the nrTMS group (median 7 points; interquartile range 6-8 vs. 5 points; 3-6.75; p < 0.0001). Conclusion: Resecting language-eloquent gliomas purely based on nrTMS data is feasible in a high percentage of cases if the described clinical workflow is followed. Moreover, the proposed classification for language eloquence makes language-eloquent tumors comparable, as shown by its correlation with functional and radiological outcomes.

Automated summary

The study proves that glioma resection in language-eloquent areas can be done without awake surgery in most cases using preoperative nrTMS mapping. Functional and radiological outcomes were comparable in both groups, but the awake group had significantly higher eloquence scores compared to the nrTMS group. The newly developed classification for language eloquence of brain tumors enables better comparison of tumor localizations and correlates with clinical outcomes.