Technical, Anatomical, and Functional Study after Removal of a Symptomatic Cavernous Angioma Located in Deep Wernicke’s Territories with Cortico-Subcortical Awake Mapping
Introduction. The subcortical region underneath Wernicke’s area (WA) is a critical crossing of the eloquent language pathways involved in all semantic, phonological, syntactic, and working memory elaboration. We report the resection of a CA located underneath the dominant WA discussing the functional and anatomical evidence provided by fMRI, dissections with Klingler’s technique, and intraoperative mapping during awake surgery. Case Report. A 64-year-old right-handed female affected by daily complex focal seizures underwent f-MRI, showing language activations in the middle and inferior temporal gyri and an unusual free entry zone in the “classical” WA. The cortical intraoperative mapping partially confirmed the f-MRI results, and we approached the lesion directly through WA. Subcortical DES allowed the identification of the eloquent language pathways and the radical resection of the perilesional gliotic rim. The patient did not report deficits and she is seizures and drug free after 1-year surgery. Discussion. Cortical DES demonstrated the variability of the eloquent areas within the cortex of the dominant temporal lobe. The subcortical DES confirmed the crucial role in language elaboration and the anatomical course of the bundles underneath WA. Conclusions. Awake surgery with DES represents a reliable and dynamic technique also for safer and functional-customized resection of CAs. 1. Introduction The prevalence of central nervous system (CNS) cavernous angiomas (CAs) ranges between 0.02 and 0.5% in the population, and they account for the 5–10% of all cerebro-vascular malformations (CVMs) [1–3]. These lesions usually present between the 3rd and 5th decades of life [4], the patients experience seizures in 50–70% of cases [5–8], and the natural history of CAs is characterized by growth and/or micro or macrobleeding [5, 9–12]. According to the literature, microsurgical removal of supratentorial CAs allows a seizures’ reduction in 70–100% of cases [13, 14]. In case of a single symptomatic CAs, with microbleeding signs and located in high eloquent area, the microsurgical removal seems reliable and effective in order to avoid the potential risks due to a future macrobleeding, growth or chronic seizures [5, 15]. However, CAs located in eloquent cortico or subcortical regions represent a real challenge for the neurosurgeon for at least three reasons. Firstly, CAs’ resection is frequently not sufficient to obtain the best postoperative seizures control. Even if still debated, in fact, the removal of perilesional hemosiderin gliotic rim seems crucial to reach
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