Operative Neurosurgery 31(2):p 285-292, August 2026
Preoperative aphasia is often viewed as an obstacle to reliable language mapping during awake glioma surgery. This cohort examines whether clinically relevant language impairment truly prevents meaningful intraoperative testing. Every selected patient could perform language tasks, and stimulation identified functional language boundaries in nine of ten operations. Language comprehension was generally preserved and production improved at follow-up. The findings argue against excluding patients from awake mapping solely because baseline testing is abnormal.
Objective
To evaluate the feasibility and clinical applicability of awake language mapping in patients with glioma and significant preoperative language deficits, and to describe postoperative language trajectories.
Methods
The retrospective cohort comprised 48 patients with a preoperative language score at least 1 standard deviation below the normative mean. Individual and group-level language performance was compared before and 3–6 months after surgery. The investigators reviewed the tasks used intraoperatively, whether the patient could complete them and whether direct stimulation identified functional boundaries.
Main results
All 48 patients were able to perform language tasks during awake surgery. Functional language boundaries were identified in 90% of cases. At 3–6 months, language comprehension was stable at group level, whereas language production showed significant improvement.
Individual trajectories were heterogeneous: naming improved in approximately 30%, remained stable in 63% and worsened in 7%; comprehension improved in 33%, remained stable in 52% and worsened in 14%.
Interpretation
Baseline language impairment does not automatically make awake mapping unreliable. With individualized task selection and neuropsychological preparation, mapping remains feasible and may permit function-guided resection in patients who might otherwise be denied this approach. Individual variability nevertheless requires counseling beyond group averages.
Limitations
The analysis was retrospective, involved only 48 selected patients and lacked a comparison group undergoing asleep surgery. Selection may have excluded patients with deficits too severe for attempted awake mapping. Improved scores could reflect practice effects, recovery or tumor treatment rather than mapping alone, and oncological endpoints were not the main focus.
Clinical takeaway
Do not use preoperative aphasia as an isolated contraindication to awake craniotomy. Refer suitable patients for detailed language assessment and adapt the intraoperative battery to preserved abilities; the decisive question is whether reliable patient-specific tasks can be established before surgery.