SLP Role in Pediatric Awake Brain Surgery
Awake brain surgery (awake craniotomy) is a highly specialized procedure sometimes completed when a tumor or medically compromised area of the brain is located near or in a functionally critical area. Numerous disciplines are involved with the goal being to preserve functioning in the patient while addressing their medical needs. Despite the high level of skill required by all disciplines to complete this procedure successfully, standardization of this procedure across institutions is lacking at this time. In children in particular, preservation of numerous components of speech, language, and cognition is key not only for current functioning, but also for later development of cognitive skills.
SLP Role
Speech-Language Pathologists (SLP) have specialized training in speech, language, and cognitive functioning. Speech refers to the coordination of the motoric aspects of communication such as coordinating breathing, voicing, and articulation to make the sounds needed for speech. Language involves vocabulary and grammatical structures, but also the functionality of these across contexts such as sharing stories, following directions, participating in conversations, etc. Cognition involves a variety of processes including foundational skills such as memory, attention, and processing speed as well as higher level abilities such as reasoning, problem solving, and executive functioning. When working with a patient before, during, and after an awake brain surgery, the SLP* considers each of these many components and how they work together for the patient’s daily functioning.
*In some institutions, a neuropsychologist serves as the team member providing assessment of these skills. Neuropsychologists also have specialized training in these areas.
Pre-Surgical Assessment
Prior to the surgery, typically in the days or weeks leading up to the surgical date, the SLP completes a thorough assessment of the patient’s current speech, language, and cognitive communication abilities. This assessment serves two purposes: to determine a baseline for the patient’s current functioning and to create a test set appropriate for use during the surgical procedure itself. Some patients’ abilities will be well within the average range prior to surgery and others will have impairments due to their medical condition which can be re-assessed following the surgery and treated if persisting. The test set the clinician and patient are working together to create involves creating sets of speech, language, and cognitive tasks that the patient can quickly and accurately respond to for use during the surgery.
Surgical Mapping
During the procedure, the patient will be sedated initially to have their skull opened and then awakened when it is time for the tumor to be removed. Prior to removal, the team works with the patient to “map” the area of the brain in which the procedure is taking place. The goal of this is to determine which areas are functionally critical in order to preserve them. Mapping occurs by using direct electrical stimulation (DES) to the brain while the patient is completing the test sets created during the pre-surgical assessment. Stimulation is applied for a short time period (roughly 2-4 seconds) and if the SLP identifies that the patient makes an error in their response (such as not being able to respond or providing an incorrect word as the response) the area can be interpreted as functional. This process is dependent on the SLP having a thorough understanding of the patient’s baseline functioning to be assured that the patient would not have made this same error without the presence of DES.
The timing at which DES is initiated can impact which area of functioning is being assessed. For example, if the DES is applied during a clinician provided prompt, comprehension may be impacted whereas if it is applied following the prompt, word finding or motor speech may be impacted. Creating a test set that can assess various areas of speech, language, and cognition and working with the neuro-monitoring and neuro-surgical teams to implement this effectively can improve functional preservation for the patient.
Resection Assessment
The second stage of assessment within the surgery occurs during resection. Functional areas of the brain do not work in isolation and though mapping can identify areas in which components of speech, language, and cognition may be active, it does not give a complete picture of how the areas of the brain work together to complete functional and complex tasks such as participating in conversation or organizing and sharing information. During resection, the SLP assesses areas of language and cognition that require lengthier responses than can be utilized during the mapping portion of the procedure. These may include practiced responses from the pre-assessment or informal evaluation tasks to identify subtle or overt deficits that may occur as resection takes place. The SLP reports these deficits in real time to the surgical team to give them the information they need about the area they are operating on.
Post-Surgical Assessment
Following surgery and the immediate recovery period. the SLP re-assesses the patient’s speech, language, and cognitive communication abilities. Should deficits be noted (either new deficits or persistent deficits from baseline), the SLP can provide ongoing treatment to help with rehabilitation.
Pediatric Specific Considerations
When thinking from a pediatric framework, the goals of surgery should differ from that of the adult model. Children’s brains are not mini adult brains and do not function as such. In adults, thinking from a rehabilitation perspective, the goal is to preserve or regain functioning. In children, who may have numerous years of development of higher level cognitive skills left, the goal is both to preserve or regain functioning as well as to ensure the child will continue to gain each subsequent set of developmental skills. The surgical procedure needs to take this difference into account and precise task selection can support this.
About the Author
Brynn Schor, MS, CCC-SLP, CBIS (founder of Peninsula Specialty Speech Therapy, based in Menlo Park, California) specializes in assessment and treatment of cognitive communication deficits and executive function coaching for pediatric patients in the Bay Area and across California. Consultations provided worldwide.
