Organic and Non-Organic Language Disorders after Awake Brain Surgery

• ¹ Vrije Universiteit Brussel, Department of Clinical and Experimental Neurolinguistics, Belgium
• ² AZ Sint-Lucas, Department of Neurosurgery and Speech Pathology, Belgium
• ³ ZNA Middelheim, Department of Neurology and Memory Clinic, Belgium

INTRODUCTION: Awake surgery with Direct Electrical Stimulation (DES) is considered the ‘gold standard’ to resect brain tumours in the language dominant hemisphere (De Witte & Mariën, 2013). Although transient language impairments are common in the immediate postoperative phase, permanent postoperative language deficits seem to be rare (Duffau, 2007). Milian et al. (2014) stated that most patients tolerate the awake procedure well and would undergo a similar procedure again. However, postoperative psychological symptoms including recurrent distressing dreams and persistent avoidance of stimuli have been recorded following awake surgery (Goebel, Nabavi, Schubert, & Mehdorn, 2010; Milian et al., 2014). To the best of our knowledge, psychogenic language disturbances have never been described after awake surgery. In general, only a handful of non-organic, psychogenic language disorders have been reported in the literature (De Letter et al., 2012). We report three patients with left brain tumours (see table 1) who presented linguistic symptoms after awake surgery that were incompatible with the lesion location, suggesting a psychogenic origin. METHODS: Neurocognitive (language, memory, executive functions) investigations were carried out before, during and after awake surgery (6 weeks, 6 months postsurgery) on the basis of standardised tests. Pre- and postoperative (f)MRI images, DTI results and intraoperative DES findings were analysed. A selection of tasks was used to map language intraoperatively (De Witte et al., 2013). In the postoperative phase spontaneous speech and behavioural phenomena to errors were video-recorded. RESULTS: Preoperative language tests did not reveal any speech or language problems. Intraoperatively, eloquent sites were mapped and preserved enabling good language skills at the end of the awake procedure. However, assessments in the first weeks postsurgery disclosed language and behavioural symptoms that support the hypothesis of a non-organic origin: fluent and nonfluent language disorders unrelated to the documented lesions, strong variablilty in the error profile, marked fluctuations of symptoms over time and condition, atypical personal comments. All three patients had a prior history of psychiatric disease and one patient witnessed language problems in an aphasic relative. In the study of De Letter et al. (2012) similar findings were mentioned, but no comprehension problems were found. In all 3 cases the "psychogenic language problems" resolved after three to six weeks. DISCUSSION: As a possible explanation for the psychogenic linguistic manifestations the following hypotheses will be discussed: 1) psychogenic language problems as part of an acute stress disorder (the awake setting); 2) psychological decompensation as the result of the fact that the patient was clearly informed that the tumour was situated near language regions; 3) getting a lot of attention in the hospital and a feeling of anxiety to return home; 4) unintended imitation of a witnessed aphasic disorder. CONCLUSION: Careful evaluation and selection of the patients and good preoperative preparation seem to be fundamental for good tolerance during awake surgery. Moreover, in the postoperative phase, extensive assessments are necessary to differentially diagnose patients with organic and non-organic language disorders in order to develop appropriate treatment strategies.