Awake surgery for a deaf patient using sign language: A case report

Abstract

Background: Although awake surgery is the gold standard for resecting brain tumors in eloquent regions, patients with hearing impairment require special consideration during intraoperative tasks.

Case description: We present a case of awake surgery using sign language in a 45-year-old right-handed native male patient with hearing impairment and a neoplastic lesion in the left frontal lobe, pars triangularis (suspected to be a low-grade glioma). The patient primarily communicated through sign language and writing but was able to speak at a sufficiently audible level through childhood training. Although the patient remained asymptomatic, the tumors gradually grew in size. Awake surgery was performed for tumors resection. After the craniotomy, the patient was awake, and brain function mapping was performed using tasks such as counting, picture naming, and reading. A sign language-proficient nurse facilitated communication using sign language and the patient vocally responded. Intraoperative tasks proceeded smoothly without speech arrest or verbal comprehension difficulties during electrical stimulation of the tumor-adjacent areas. Gross total tumor resection was achieved, and the patient exhibited no apparent complications. Pathological examination revealed a World Health Organization grade II oligodendroglioma with an isocitrate dehydrogenase one mutant and 1p 19q codeletion.

Conclusion: Since the patient in this case had no dysphonia due to training from childhood, the task was presented in sign language, and the patient responded vocally, which enabled a safe operation. Regarding awake surgery in patients with hearing impairment, safe tumor resection can be achieved by performing intraoperative tasks depending on the degree of hearing impairment and dysphonia.

Keywords: Awake surgery; Deaf patient; Low-grade glioma.

Figure 1:

Magnetic resonance imaging, performed during the patient’s previous visit, showed (a) a T2 fluid-attenuated inversion recovery high homogeneous lesion with a 25 mm diameter in the left frontal lobe (pars triangularis), (b) The lesion was non-enhanced , suggesting a low-grade glioma.

Figure 2:

Preoperative magnetic resonance imaging (MRI) showing (a) the tumor was confined to pars triangularis and pars opercularis , (b) Preoperative axial, (c)coronal , (d) sagittal and T2 MRI scan showing the posterior part was in contact with the central gyrus.

Figure 3:

(a) Intraoperative patient’s position and (b) operative room setup.

Figure 4:

Intraoperative pictures (a) before and (b) after tumor resection. The brain surface directly above the tumor, surrounded by “A,” “B,” “C,” and “D” markers, was edematous and had a color different from that of the surrounding area. No speech arrest or motor deficit was observed with electrical stimulation to the tumor surface and premotor area (“1” marker).

Figure 5:

Postoperative magnetic resonance imaging showing total tumor removal. T2 fluid-attenuated inversion recovery high signal intensity area remained, which has been suggested as brain edema (arrow).