Advantages and disadvantages of intraoperative language tasks in awake surgery: a three-task approach for prefrontal tumors

Multidisciplinary efforts are being made to provide surgical teams with sensitive and specific tasks for language mapping in awake surgery. Researchers and clinicians have elaborated different tasks over time. A fair amount of work has been directed to study the neurofunctional correlates of some of these tasks, and there is recent interest in their standardization. However, little discussion exists on the advantages and disadvantages that each task poses from the perspective of the cognitive neuroscience of language. Such an approach may be a relevant step to assess task validity, to avoid using tasks that tap onto similar processes, and to provide patients with a surgical treatment that ensures maximal tumor resection while avoiding postoperative language deficits. An understanding of the language components that each task entails may also be relevant to improve the current assessments and the ways in which tasks are administered, and to disentangle neurofunctional questions. We review 17 language mapping tasks that have been used in awake surgery. Overt production tasks have been a preferred choice over comprehension tasks. Tasks tapping lexico-semantic processes, particularly object-naming, maintain their role as gold standards. Automated speech tasks are used to detect speech errors and to set the amplitude of the stimulator. Comprehension tasks, reading and writing tasks, and tasks that assess grammatical aspects of language may be regularly administered in the near future. We provide examples of a three-task approach we are administering to patients with prefrontal lesions. We believe that future advances in this area are contingent upon reviewing gold standards and introducing new assessment tools.