Is the resection of gliomas in Wernicke's area reliable? Wernicke's area resection

Wernicke's area was, for a long time, considered a non-removable area and patients affected by low-grade gliomas (LGGs) or high-grade gliomas (HGGs) in this region were considered inoperable. Several studies have demonstrated a large functional reshaping of language networks in patients affected by gliomas or acute stroke involving Wernicke's territories, and the complete resection of this region invaded by LGG has recently been reported. We report our experience in the removal of Wernicke's territories invaded by gliomas. Four patients underwent awake surgery, with neuropsychological and neurophysiological monitoring and direct cortico-subcortical bipolar stimulation, for resection of LGG (one case) and HGGs (three cases) invading Wernicke's territories. Resection rates were evaluated by means of magnetic resonance imaging (MRI) and computed tomography (CT) perfusion for LGG and HGGs, respectively. HGGs were totally resected and LGG was partially resected (67%), according to functional limits. No patients reported neurological deficit. The patient affected by LGG underwent postoperative chemotherapy. Two of the patients harbouring HGGs died 21 and 23 months after surgery and postoperative adjuvant treatment, respectively. The third one is still alive and progression-free 21 months after surgery. Awake surgery is a reliable and effective technique for resection of gliomas invading Wernicke's territories without postoperative permanent deficit. LGGs in this region can safely be removed, according to the functional subcortical boundaries, allowing postoperative adjuvant treatment, functional reshaping and multi-step surgery. HGGs, instead, can be completely removed without deficits and sometimes beyond the contrast enhancement area, allowing the best possible oncological prognosis for the patients.