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Accepted Manuscript

Challenging the myth of right "non-dominant" hemisphere: Lessons from cortico-


subcortical stimulation mapping in awake surgery and surgical implications

Tatiana Vilasboas, MD, Guillaume Herbet, PhD, Hugues Duffau, MD, PhD

PII: S1878-8750(17)30516-8
DOI: 10.1016/j.wneu.2017.04.021
Reference: WNEU 5538

To appear in: World Neurosurgery

Received Date: 8 February 2017


Revised Date: 2 April 2017
Accepted Date: 5 April 2017

Please cite this article as: Vilasboas T, Herbet G, Duffau H, Challenging the myth of right "non-
dominant" hemisphere: Lessons from cortico-subcortical stimulation mapping in awake surgery and
surgical implications, World Neurosurgery (2017), doi: 10.1016/j.wneu.2017.04.021.

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Challenging the myth of right "non-dominant" hemisphere:


Lessons from cortico-subcortical stimulation mapping in awake surgery
and surgical implications

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Tatiana Vilasboas, MD1, Guillaume Herbet, PhD2,3, Hugues Duffau, MD, PhD2,3*

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1
Department of Neurosurgery, Sao Paulo, Brazil
2
Department of Neurosurgery, Gui de Chauliac Hospital, Montpellier University Medical Center,

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Montpellier, France
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3
Team Plasticity of Central Nervous System, Stem Cells and Glial Tumors, INSERM U1051,
Institute for Neurosciences of Montpellier, Montpellier, France
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*
Address correspondence to:
Pr. Hugues Duffau, M.D., Ph.D.
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Department of Neurosurgery, Gui de Chauliac Hospital,


Montpellier University Medical Center
80, avenue Augustin Fliche, 34295 Montpellier
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E-mail: h-duffau@chu-montpellier.fr
Telephone number: +33 (0)4 67 33 66 12; Fax number: +33 (0)4 67 33 69 12
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Financial disclosure: none


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Conflicts of interest: none


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Short title: Awake surgery for right-sided lesions

Abbreviations list: RH = right hemisphere; LH = left hemisphere; LGG = low-grade


glioma; QoL = Quality of life; DES = Direct electrical stimulation; SLF = Superior
longitudinal fascicle; MNI = Montreal Neurological Institute; PPTT = Pyramids and Palm
Trees Test; IFOF = Inferior fronto-occipital fascicle; MRI = Magnetic resonance imaging

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ABSTRACT

For a long time, the right hemisphere (RH) was considered as "non-dominant",
especially in right-handers. In neurosurgical practice, this dogma resulted in the selection of
awake procedure with language mapping only for lesions of the left "dominant" hemisphere.
Conversely, surgery under general anesthesia (possibly with motor mapping) was usually

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proposed for right lesions. However, when objective neuropsychological assessments were
performed, they frequently revealed cognitive and behavioral deficits following brain

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surgery, even in the RH. Therefore, to preserve an optimal quality of life, especially in
patients with a long survival expectancy (as in low-grade gliomas), awake surgery with

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cortical and axonal electrostimulation mapping has recently been proposed for right tumors
resection. Here, we review new insights gained from intraoperative stimulation into the

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pivotal role of the RH in movement execution and control, visual processes and spatial
cognition, language and non-verbal semantic processing, executive functions (e.g. attention),
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and social cognition (mentalizing and emotion recognition). Such original findings, that break
with the myth of a "non-dominant" RH, may have important implications in cognitive
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neurosciences, by improving our knowledge of the functional connectivity of the RH, as well
as for the clinical management of patients with a right lesion. Indeed, in brain surgery, awake
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mapping should be considered more systematically in the RH. Moreover, neuropsychological


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examination must be achieved in a more systematic manner before and after surgery within
the RH, to optimize the care by predicting the likelihood of functional recovery and by
elaborating specific programs of rehabilitation.
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Keywords: Right hemisphere; awake surgery; electrical mapping; glioma; neuroplasticity;


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brain connectivity

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INTRODUCTION

Following the lesion works of Broca1 and Wernicke2, a preeminent role of the left
hemisphere (LH) in language was established. Later, Geschwind (1965)3 emphasized the
critical role of left white matter connections for language. These studies led to the concept of
left hemispheric dominance, and implicitly, to the dogma of a right "non-dominant"

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hemisphere.
Yet, using the Wada procedure, Rasmussen and Milner4 showed that, in non-right-
handed patients, speech was represented in the LH in nearly a third of the group, in the right

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hemisphere (RH) in half the group, and bilaterally in the remainder. Moreover, cases of
crossed aphasia, resulting from a right lesion in right-handers, have regularly been reported5.

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The notion of inter-individual variability of language lateralization was reinforced by
functional neuroimaging,6 knowing that concordance between handedness and language

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lateralization does not exceed chance level at least in a statistical model deliberately enriched
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in left-handers.7 The RH implication in other cerebral functions, including sensorimotor,
attention, visuo-spatial, emotion and social functions, has been supported by many lesion and
neuroimaging studies.8-11
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Despite these reports, in neurosurgical routine, the dogma of the "non-dominant" RH


resulted in the selection of awake procedure with language mapping only in patients bearing a
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lesion of the left "dominant" hemisphere. In contrast, surgery under general anesthesia
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(possibly with motor mapping) is usually proposed in right lesions, including in patients
enjoying a normal life before resection, as in diffuse low-grade glioma (LGG). Typically, this
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tumor involves young patients with no or only mild neurologic deficits, due to neuroplasticity
allowing functional reorganization in reaction to the slow growth of the glioma.12 LGG is
generally revealed by seizures, but its incidental detection is currently increasing as access to
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brain imaging broadens worldwide, raising the question of preventive surgery.13,14 Indeed, an
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increased amount of data supported the significant impact of early and maximal surgical
resection of LGG on overall survival.15-18 Thus, surgery is currently the first treatment in
LGG patients, on the condition to preserve the quality of life (QoL).13,19
Yet, when objective postoperative neuropsychological assessments are performed,
they frequently reveal cognitive and behavioral deficits following glioma surgery, even in the
RH.20,21 Therefore, to preserve an optimal QoL, especially in patients with a long survival
expectancy (e.g. LGG), awake surgery with cortical and axonal direct electrical stimulation
(DES) mapping has recently been proposed for resection of right sided tumors. This

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technique represents a unique opportunity to perform a real-time investigation of the
functions of both the cortex and the white matter fibers.22 The principle of DES is to mimic a
genuine "virtual transient lesion", by disrupting a neural subcircuit (and not a focal single
site) during a few seconds, with the possibility to check whether the same functional
disturbances are reproduced when repeated stimulations are applied over the same structure.
By gathering all cortical and axonal sites where the same type of errors were observed when

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stimulated, one would build up the subnetwork of the disrupted subfunction. Thus, DES
permits to detect the structures essential for brain functions, in vivo in humans, with a great
accuracy and reproducibility.22

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Here, we review new insights gained from intraoperative DES into the pivotal role

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of the RH in movement execution and control, some aspects of language, vision, spatial
cognition, executive functions (e.g. attention and working memory), and social cognition
(mentalizing). Such original findings, that break with the myth of a "non-dominant" RH, may

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have important implications in cognitive neurosciences, by improving our knowledge of the
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functional connectivity of the RH, and for the surgical management of patients with a right
lesion.
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NEW LIGHTS INTO THE FUNCTIONAL ROLE OF THE RH: DATA


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ISSUED FROM DES


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Role of the RH in sensorimotor function


Since the description of the homonculus using intraoperative DES23, a somatotopic
organization of the sensorimotor system was demonstrated in humans, with a crucial role of
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the RH in the execution of left hemibody (face, upper limb, lower limb) movements.
Recently, hundreds sites of positive intraoperative cortical and axonal stimulations were
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plotted onto a MNI template brain space using regional anatomic landmarks.24, 25 Motor and
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somatosensory map for the RH was constructed, confirming using these probabilistic cortico-
subcortical atlases based on DES the expected localization of motor and somatosensory
functions within the precentral and postcentral gyri, and at the level of their corresponding
pyramidal and thalamo-cortical tracts, respectively (Figures 1A and 1B).
Furthermore, by means of DES in awake patients, a network subserving motor control
has recently been described. Axonal stimulation of this circuit in patients performing
continuous movement generates disturbances of motor initiation and control, which may
range from complete arrest to involuntary acceleration of movement.26 A somatotopic

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distribution of this motor control network was shown using axonal DES.27 Moreover,
unilateral subcortical DES of the RH can not only disrupt left movement, but also movement
of both hands during a task of bimanual coordination.28 These findings support the RH
involvement in a bilateral modulatory cortico-subcortical network supervising the interlimb
movement, and constituted by fibers anterior to the corticospinal tract, coming from the
supplementary motor area, lateral premotor cortex and the depth of the precentral sulcus,

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which runs to the striatum - i.e. the fronto-striatal tract.27,29 An additional tract goes to the
anterior arm of the internal capsule, indicating a likely course toward the spinal cord, while
another part of the network runs posterior to primary somatosensory fibers.26

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Role of RH in vision and visuospatial cognition
By showing two images spread over two opposite quadrants on the same screen,
visual pathways have been mapped by DES in awake patients, especially in the RH. Beyond

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the primary visual cortex, a transient left visual field deficit subjectively described by the
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patient can be elicited during DES of the right optic radiations, with objective confirmation
thanks to this test (only the right picture can be seen and therefore named).30 DES may evoke
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either "inhibitory phenomena" (e.g. blurred vision or impression of shadow) or "excitatory


phenomena" (e.g. phosphenes or visual hallucinations as zoopsia or metamorphopsia).31
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Additionally, DES of the right inferior longitudinal fascicle may produce left visual
hemiagnosia, by disrupting the occipital visual input and higher-level processes in the
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fusiform gyrus and temporal pole.32 These data support the pivotal role of the inferior
longitudinal fascicle in visual recognition, with an involvement of this pathway in high-order
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processing in the RH. Moreover, DES of the supramarginal gyrus and the second branch of
the superior longitudinal fascicle (SLF) in the RH evokes disturbances of spatial cognition,
with rightward deviation during a line bisection test.33-35 Such findings suggest that spatial
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awareness is underpinned by a right cortico-subcortical fronto-parietal network enabling to


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process visual scenes. Axonal DES of another subpathway in the right SLF can also generate
a central vestibular syndrome with vertigo, by disrupting the vestibular inputs assembled in
the temporo-parietal areas and the prefrontal cortex. This supports the role of RH in
coordinating body posture and spatially oriented actions that controls vestibular function.36

Role of RH in language
Recent DES investigations have been achieved to map language during awake surgery
for right lesion in left-handers, ambidextrous and in right-handed patients with language
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disturbances during seizures or on presurgical neuropsychological assessment.24,37,38
Cortically, in frontal regions, DES elicited articulatory disorders (ventral premotor cortex),
anomia (dorsal premotor cortex) and semantic paraphasia (dorsolateral prefrontal cortex).
Parietal stimulation induced phonemic paraphasias, and temporal stimulation semantic
paraphasias and/or anomia.37 These cortical sites were projected onto a probabilistic atlas
plotted in the MNI space (Figure 1A).24 These cortical DES data in the right and left

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hemispheres of left-handed/ambidextrous patients suggest an analogous anatomical pattern of
speech output and naming to right-handers. Subcortically, the SLF/arcuate fascicle (inducing

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phonological disturbances when stimulated), inferior occipito-frontal fascicle (IFOF, eliciting
semantic disturbances during stimulation), frontal aslant tract (generating control

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disturbances as perseverations when stimulated), and fronto-striatal tract (inducing
articulatory disorders during stimulation) were identified in the RH - as summarized in a
recent functional atlas of white matter tracts derived from intrasurgical subcortical DES

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(Figure 1B).25 If these cortical and subcortical structures are surgically preserved, permanent
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aphasia is avoided, despite a transient immediate postoperative language worsening.37,38
Such findings based upon intraoperative DES results and postsurgical transitory
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dysphasia support the major role of the RH in language in left-handers, ambidextrous and
even in some atypical right-handed patients in whom an intrasurgical crossed aphasia was
elicited by DES.38 They also provide new insights into the structural-functional cortico-
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subcortical organization of language networks in the RH, suggesting a mirror configuration


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in comparison to the LH39 - especially with a dorsal stream involved in articulatory and
phonological processing, and with a parallel ventral stream involved in semantics.37
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Role of RH in high-order cognitive functions


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Although studies concerning the involvement of the left ventral route in verbal
semantics are proficient, little is known about the possible role of this left ventral stream in
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non-verbal semantics. By using a semantic association task (as Pyramids and Palm Trees Test
[PPTT]), axonal DES of the left IFOF (connecting a wide subnetwork comprising the left
posterior temporal areas and dorso-lateral prefrontal cortex) generated disturbances of non-
verbal semantic processing.40 Recently, the implication of the right ventral pathway in non-
verbal semantics was also explored. Patients with a right LGG involving the ventral stream
underwent awake surgery, while performing both a visual non-verbal semantic task and a
verbal (control) semantic task (oral picture naming task).41 At the cortical level, non-verbal
semantic-related sites were detected in the RH in structures commonly associated with verbal
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semantic processes in the LH, including the right superior temporal gyrus, the right pars
triangularis and the right dorsolateral prefrontal cortex. Semantic verbal impairments
(semantic paraphasia during the naming task) were also observed in left-handed patients, at
the level of the pars triangularis and opercularis, and the dorsolateral prefrontal cortex, as
mentioned above. At the subcortical level, non-verbal semantic-related sites were also
identified in the RH, a minority of them being multimodal (i.e. axonal DES also induced

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verbal semantic impairments). All these responsive stimulation points were located on the
spatial course of the right IFOF, supporting a crucial role of the right ventral stream in
multimodal semantic cognition.41

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Multimodal (verbal and non-verbal) working memory and attention functions have
also be investigated in patients with a right lesion.42,43 Simultaneous recruitment of these

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subnetworks mediating high-order functions is necessary in addition to the distinct circuits
specifically involved in each modal function (e.g. language or spatial cognition) when the

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patient performs a sustained double task during surgery, combining for instance limb
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movement and naming or PPTT every 4 seconds during hours - as regularly asked to awake
patients during DES to increase the reliability of functional mapping44. Recently, in 30 right
gliomas, attention was tested longitudinally.43 The resection of the right angular gyrus was
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associated with transient neglect-like symptoms in all tasks, whereas resection of more
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anterior regions correlated with transient deficits only in visual exploration or detection. The
attention networks showed functional recovery, thanks to the preservation of the right SLF,
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supporting the critical role of RH in high-order cognitive functions.43


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Role of RH in mentalizing and consciousness


Recently, complex emotion recognition tasks have been administrated during awake
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surgery for a right tumor, in order to preserve structures subserving mentalizing (theory of
mind).45 Intraoperative DES combined with pre- and post-operative behavioral assessments
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demonstrated that this function is made possible by parallel functioning of two subsystems in
the RH.46 The first subnetwork processes low-level perceptual aspects (mirror system), i.e.
the ability to appreciate other people's emotions (emotional empathy): this circuit is
underpinned by the right arcuate fascicle/SLF complex. The second subcircuit is pivotal for
high-level mental processing of this sociocognitive function (high-level inferential
mentalizing), i.e. the ability to attribute intention to others. This social metacognitive skill is
mediated mainly by the right cingulum.46

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Because the cingulum connects the rostral medial prefrontal cortex/anterior cingulate
and the medial posterior parietal cortex (including the posterior cingulate cortex and ventral
precuneus), this pathway seems to be involved in the default mode network and could
participate in some aspects of conscious information processing. Disrupting the subcortical
connectivity of the right (and left) posterior cingulate cortex through its DES may generate a
breakdown in conscious experience of awake patients.47 They experienced a transitory

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behavioral unresponsiveness with loss of external connectedness during axonal stimulation.
This supports a crucial role of the RH in maintaining arousal since functional integrity of the

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right posterior cingulate connectivity is necessary for consciousness of external
environment.47

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IMPLICATIONS IN CLINICAL PRACTICE
From fundamental neurosciences to surgical applications: the case of RH

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Although strong interactions between cognitive neurosciences and brain surgery are
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generally fruitful, they may however be harmful. In particular, the classical dogma of
localizationism implicitly resulted in the principle of a similar cerebral functional anatomy
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between individuals. According to this rigid view of neural distribution, numerous patients
with a brain tumor or intractable epilepsy that justified surgery were a priori not selected for
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resection and lost a chance to be treated because the lesion was located within so-called
"eloquent" areas in the left "dominant hemisphere", as Broca's area or Wernicke's area.
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Applying this concept of a fixed organization to the right "non-dominant" hemisphere led
neurosurgeons to consider surgical resection (under general anesthesia) in the RH in a more
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systematic way because, in this philosophy, the risk to generate permanent deficits is
theoretically low - except regarding a possible motor impairment.
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Nonetheless, brain mapping techniques (non-invasive neuroimaging and


intraoperative DES) demonstrated a considerable interindividual structural and functional
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variability, especially at the cortical level, explained by a networking organization of the


brain, in which one function is not mediated by one specific area, but by interactions between
large-scale delocalized subcircuits.48 Beyond physiological variation in healthy volunteers, in
brain-damaged patients, neural reshaping may occur to compensate injury, increasing this
interindividual variability.12 Furthermore, functional remapping was also described in the
same patients over time. Thus, in practice, brain functions cannot be reliably localized on
anatomic criteria alone.48,49 Unfortunately, the variance in functional cortical sites is not

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completely recognized by neurosurgeons, as demonstrated by the recent use of statistical
probabilistic anatomical maps to perform "presurgical mapping".50
Therefore, thanks to the better understanding of this dynamic brain organization,
individual mapping is crucial to optimize extent of resection while preserving QoL. Due to
methodological limitations regarding functional neuroimaging, this technique is not reliable
enough at the individual level.51-53 The actual impact of DES has recently been validated in a

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meta-analysis with 8,091 adult patients who had resective surgery for glioma: tumor
removals using intraoperative stimulation mapping were associated with fewer late severe

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neurologic deficits and more extensive resection, and they involved "eloquent" locations
more frequently. Thus, intraoperative DES should be considered in all patients with no or
only mild preoperative deficits.54

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Based on this paradigmatic shift, an increased amount of surgical series for brain
tumor or epilepsy used DES in the recent literature. Yet, in most of cases, awake surgery was

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selected for language mapping only when the lesion was located within the "left dominant
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hemisphere", with little considerations concerning the RH. It was thought that surgical
resection within the right "non-dominant" hemisphere could not result in permanent
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functional worsening, on the condition that the central region and its corresponding white
matter tracts was preserved. Therefore, surgery in the RH is traditionally achieved under
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general anesthesia, with only motor mapping using DES and/or electrophysiological
monitoring to avoid paresis.55-57 Yet, the recent results summarized above, issued from
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surgery for a right lesion, changed our view of RH processing (Figure 2). This new
connectomal model of the RH should lead in proposing more systematically awake mapping
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for resection in the right side.


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Awake mapping for surgery in the RH


Although it is classically claimed that the use of intraoperative evoked potentials
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under general anesthesia is sufficient during surgery in the RH to avoid paresis, this
technique is nonetheless not sensitive enough to allow an optimal preservation of complex
movements.58 Indeed, even after a "recovery" from a transient postoperative supplementary
motor area (SMA) syndrome with akinesia, patients may experience objective deficits in
complex movement such as bimanual coordination - which can prevent a return to work, e.g.
for a musician or a surgeon.28,59 As mentioned, this deficit is related to a damage to the motor
control network, that can be accurately mapped only in awake patients, by eliciting arrest or
acceleration of movements.26,27 In practice, all patients who will undergo surgical removal of
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a tumor involving SMA should be extensively informed before surgery, with the goal to
decide whether the limits of resection should be represented by the traditional corticospinal
tract (to avoid left paresis) or by the motor control circuit - with a lesser extent of resection
but a better preservation of QoL. In other words, intraoperative detection and preservation of
the fronto-striatal tract underpinning motor control,29 which is located in front of the
pyramidal pathways mediating motor output, can prevent the onset of postoperative SMA

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syndrome - or at least will result in a very transitory (a few days and not a few weeks) and a
mild deficit (without complete akinesia) with a complete functional recovery - including
bimanual coordination.26,27 Of note, even though the same principle can be applied to the LH

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with respect to movement, when removing a left lesion, the frontal aslant tract (that connects

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the SMA to the frontal operculum and that evokes slowness or arrest of speech during
stimulation) has also to be mapped and spared if the patient wants to prevent the occurrence
of an immediate postoperative mustism.29 This example illustrates well the concept of "onco-

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functional balance" in tumor surgery.60 Furthermore, a subtle somatosensory mapping is not
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possible under general anesthesia, while an awake patient can precisely describe somesthetic
responses during DES:61 preservation of the sensory feedback is crucial for complex
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movement, e.g. to run after surgery within the right paracentral lobule.
Damage of the visual pathways in the RH can induce disabling deficit in daily life.
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Indeed, injury of the right optic radiation will generate left homonymous hemianopia,
preventing in many countries the patient from driving for medicolegal issues. Oculomotor
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pathway may also be injuried.62 Moreover, lesion of the right inferior longitudinal fascicle
may elicit prosopagnosia, which can have negative impact on social cognition, or visual
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agnosia. Damage of the right SLF can result in left hemineglect, with also consequences on
QoL - e.g. in a dancer, unable to return to work. Again, currently, intraoperative DES
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mapping under local anesthesia is the sole tool to identify and preserve this circuit within the
RH with a high reliability.30-36,62
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Similarly, awake craniotomy is the best technique to map language, with less than 2%
of aphasia in surgical series for left tumors.63,64 However, recent DES results detailed above
demonstrated that RH may play a critical role for language in many patients, especially left-
handers and ambidextrous: therefore, these patients should benefit from awake mapping even
when bearing a right lesion.37,39 In right-handed patients, if language disturbances are
detected during seizures or on presurgical neuropsychological assessment, especially when
right activations are observed on language functional MRI, intraoperative awake language
mapping should be considered.38 Moreover, mapping non-verbal understanding in patients
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who would like to preserve a high-level of cognition (e.g. lawyers or managers) should be
proposed, because injury of the ventral stream may generate deficit of multimodal semantic
processing,40 even in the RH.41 The clinical relevance of intra-operative mapping of
calculation in patients undergoing surgery in the right parietal area has also been
highlighted.65,66 Finally, a lesion involving the mentalizing system in the RH may result in
postoperative social cognition disorders with possible change in behavior and personality,

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and thus may prevent patients to resume a normal occupational life - e.g. for medical doctors
or nurses who should preserve their empathy.21,45

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Usefulness for postoperative rehabilitation

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Based on DES in 231 patients who underwent awake surgery, neuroplasticity
potential in brain-damaged patients was mapped by elaborating a probabilistic atlas of
functional plasticity.67 This atlas demonstrated the critical role of the subcortical connectivity

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of the RH that should be preserved to avoid permanent deficit.12,25 This is a unique tool for
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predicting the likelihood of functional recovery after surgery, and for identifying patients
who require functional rehabilitation, especially following a right lesion. Postoperative
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objective neuropsychological assessments are helpful for the elaboration of individualized


programs of neurologic, cognitive and behavioral rehabilitation, adapted to an improved
knowledge of the right connectome.67
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CONCLUSIONS
Original data recently provided by intraoperative DES mapping in awake patients
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undergoing surgery for a right lesion have led to better understand the functional connectivity
of the RH and to rethink its actual role in many brain functions - as in movement execution
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and control, vision, spatial cognition, language and non-verbal semantic processing,
executive functions (as attention), and emotional process (as empathy) (Figure 2). These
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findings challenge the myth of a "non-dominant" RH.


The clinical implication of this improved knowledge of the functional anatomy of RH
is that, in neurosurgical practice, awake mapping has to be considered in a more systematic
manner for surgery of right lesions. Indeed, when extensive postsurgical neuropsychological
examinations are achieved, they frequently find cognitive and behavioral disturbances after
glioma surgery, even in the RH.20,21 Therefore, risks of such subtle deficits should be
extensively explained to the patient and his/her family before surgery within the RH, in order

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to give him/her the possibility to decide whether (slight) permanent cognitive or emotional
disorders can be compatible or not with his/her QoL - according notably to the work or the
hobbies of the patient (e.g. to avoid left visual field deficit in a taxi driver, or left hemineglect
in a sportsman, or mentalizing disturbances in a politician or an actor, etc...). Appropriate
selection of tasks for intraoperative DES mapping can be achieved accordingly, to enable the
patient to resume normal familial, social and professional lives. Standardized testing

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paradigms enabling the neurosurgeons to adapt awake craniotomy techniques for RH tumors
in their practice are now in progress (e.g. PPTT or mentalizing tests).

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Furthermore, a probabilistic atlas of functional plasticity derived from intraoperative
DES is now available in order to predict the likelihood of functional recovery, especially after
surgery within the RH.67 Thus, objective pre- and post-operative neuropsychological

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examinations must be achieved in all patients with surgery in the RH to adapt specific
programs of rehabilitation - a strategy rarely applied in the current literature.

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Disclosure
The authors have no personal, financial, or institutional interest in any of the drugs,
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materials, or devices described in this article.


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FIGURE LEGENDS
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Figure 1
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Fig 1A
Probabilistic 3D digitized map of cortical DES mapping data in the right hemisphere
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demonstrating the wide distribution of cortical representation within and between critical
functions of the human brain: motor (green), sensory (yellow), speech arrest (red),
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anomia (blue), dysarthria (orange) (from24 with permission).


Fig 1B
3D representation of functional response errors collected with subcortical DES mapping
in the right hemisphere. Different colors represent the different functional response
errors. The small colored points represent the projections of functional response errors on
the xy and xz planes of the Montreal Neurological Institute space (from25 with
permission).

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Figure 2
Proposal of a connectomal model of functional anatomy in the right hemisphere. The
model was constructed on the basis of structuralfunctional correlations derived from
intraoperative DES, and incorporates anatomical constraints. Abbreviations: IFOF,
inferior frontal occipital fascicle; SLF, superior longitudinal fascicle.

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Disclosure

The authors report no conflict of interest regarding the materials or methods used in

this study or the findings specified in this paper.

There is no any financial disclosure.

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Hugues DUFFAU

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