Raty, Sally

OBJECTIVE Protocols for intraoperative mapping during awake craniotomy vary widely. The aim of this study was to evaluate how the number and type of intraoperative neuropsychological paradigms administered via NeuroMapper, a tablet-based platform, during awake glioma surgery affect positive mapping rates, return to work (RTW), and oncological outcomes. Factors associated with the operative duration and early postoperative neurological deficits were of additional interest. METHODS This single-center retrospective study included patients with diffuse low- and high-grade gliomas who underwent awake craniotomy with NeuroMapper-guided mapping between 2018 and 2024. Primary outcomes were RTW, progression-free survival (PFS), and overall survival (OS); operative duration and early postoperative deficits were secondary outcomes. Covariate balancing propensity score (CBPS) analysis was used to address confounding by tumor grade, with all postweighting standardized mean differences < 0.10. A weighted logistic regression model assessed RTW, and CBPS-weighted Cox models assessed PFS and OS. Linear regression was used to analyze intraoperative variables, operative duration, and early postoperative deficits. RESULTS Of 189 patients included in the analysis, 65 had LGG (median age 39 years) and 124 had HGG (median age 56 years). Mapping complexity varied, with 1–6 tasks used (median 4). Weighted multivariate logistic regression analysis identified the following independent predictors of RTW: preoperative Karnofsky Performance Status score ≥ 80 (OR 1.37, p = 0.039), absence of recurrent disease (OR 0.30, p < 0.001), use of 5–6 paradigms (OR 1.54, p = 0.047), positive mapping (OR 2.41, p = 0.017), and subtotal resection (OR 4.43, p = 0.002). Intraoperative seizure, early postoperative deficit, and the resection technique were not significant. IDH mutation status was associated with improved PFS (HR 0.15, p < 0.001), while subtotal resection was associated with worsened PFS (HR 3.00, p < 0.001). Positive mapping was associated with better OS (HR 0.57, p = 0.04). The operative duration was unaffected by mapping variables but was longer in patients with obesity (β = 0.28, p = 0.038). CONCLUSIONS Positive NeuroMapper-guided mapping of more diverse linguistic functions was associated with RTW and longer OS. Additionally, mapping complexity did not prolong surgery times, supporting potential standardization.

Abstract BACKGROUND Intraoperative electrocorticography (ECoG) may aid localization of language function and help guide eloquent brain tumor resection. However, relevance of ECoG findings to language outcomes remains unclear. METHODS Fifteen patients with brain tumors (Mdn age=60; 67% high-grade glioma) underwent awake craniotomy and intraoperative language mapping. Time-frequency ECoG gamma activity was visualized in real-time followed by direct electrical stimulation (DES) across 3 paradigms (NeuroMapper Tasks: Object, Action, Auditory). Early and late ECoG gamma modulations and positive DES sites were co-registered with postoperative MRI. A subset (N=11) completed expressive language testing (Phonemic and Semantic Fluency, Confrontation Naming) prior to and &lt;2 months following surgery. Correlational analyses and Mann-Whitney U tests examined relationships between test results and surgical impact upon expressive task-elicited gamma activity (Object and Action Naming). RESULTS Across tasks, positive DES sites were identified in 93% of cases (Auditory, 73%; Action, 71%, Object, 57%). No positive DES sites were resected. Early and/or late gamma activations were elicited in all patients, resected in 40%, and within 1 cm of surgical impact in 90%. Four patients (36%) showed reliable decline on at least 1 outcome, which was associated with Action Naming activity &lt;1 cm of surgical impact (phi=.67, p=.035). On individual tests, Confrontation Naming and Phonemic Fluency decline were rare (9% and 18%), though Semantic Fluency declined in 36% of patients. Change in Semantic Fluency was associated with resection of Object Naming gamma sites (Z=-1.83, p=.044) and presence of Action Naming gamma features near surgical impact (Z=-2.25, p=.014). CONCLUSIONS Despite preservation DES sites and sparing of basic confrontation naming ability, verbal fluency declined in a substantial group of patients. Decline was associated with gamma features resected or near surgical impact. While preliminary, findings suggest task-based ECoG can augment DES in informing risk of surgically-acquired language decline.