A Super-selective Wada Test Successfully Detected an Artery That Supplied Broca’s Area in a Case of Left Frontal Lobe Glioblastoma: Technical Case Report

Abstract

In cases of malignant gliomas located at language eloquent area, it is often difficult to preoperatively detect those area with functional MRI. Awake surgery is often used to spare the language eloquent area during surgery for such tumors; it is not available for a patient whose intracranial pressure is elevated due to the malignant tumor. The Wada test involves infusing anesthetic agents into the internal carotid artery to determine language dominancy before surgery for epilepsy or brain tumor. The super-selective Wada test is a technique to detect more detailed functional localization by infusing anesthetics into far distal middle cerebral artery branches. We present a 37-year-old man suffering from a left frontal lobe glioblastoma, in whom detection of an artery supplying Broca's area was attempted by a super-selective Wada test. The super-selective Wada test successfully detected the branch of middle cerebral artery supplying Broca's area. Total resection of the contrast-enhancing area was achieved without damaging the artery supplying Broca's area without any neurological sequelae. This is the first report describing the usefulness of the super-selective Wada test in glioblastoma treatment. Our findings suggest that the super-selective Wada test is a powerful and useful means to distinguish the artery that supplies the language area from the tumor feeding artery in cases of tumors in the language eloquent area.

Determination of language areas in patients with epilepsy using the super-selective Wada test

“…The ssWada method is less invasive than ECS mapping and can evaluate within-hemisphere distribution of higher cognitive functions. Yamashita et al (2021) . reported a case in which fMRI hardly identified Broca's area, but ssWada successfully revealed a language area in the frontal lobe and achieved tumor resection without language impairment.…”

“…can efficiently assess language function and reduce complications related to intracarotid propofol injection. In parallel to this invention, some papers have reported cases in which selective anesthetic infusion into the cerebral artery branch contributed to the prediction of postoperative complications ( Hajek et al, 1998 , Urbach et al, 2002 , Yamashita et al, 2021 ).…”

Bilateral and asymmetrical localization of language function identified by the superselective infusion of propofol in an epilepsy patient with a mild malformation of cortical development: illustrative case

“…26,27 The ssWada has advantages in selectivity and the avoidance of consciousness disturbance in patients with malignant glioma in the left inferior frontal gyrus. 7 Functional mapping by ECS can directly evaluate the regional functions of the brain using intracranial electrodes [28][29][30] or awake craniotomy. 31,32 However, the evaluation is based on the limited volume of ECS.…”

“…5 We previously developed the superselective Wada (ssWada) to evaluate voluntary functions in specific brain regions by the superselective infusion of an anesthetic agent from the intracranial artery. 6,7 The ssWada can induce a focal neurological deficit corresponding to the area perfused by the selected artery without inducing unwanted consciousness disturbance, which mainly results from unintended distribution to perforating arteries. Consequently, the subject can directly explain their experience and symptoms, which provides a more accurate simulation of likely postsurgical neurological symptoms.…”

Assessment of language lateralization in epilepsy patients using the super-selective Wada test

“…Fujii et al [ 1 ] suggested that selective anesthetic infusion into the middle cerebral artery (MCA) reduces adverse effects in the Wada test. We established a modified version of the Wada test using super-selective catheterization that involves injecting anesthetics selectively into the target arteries corresponding to the planned resection area [ 3 , 16 ], named the “super-selective Wada test” (ssWada). As most of the brain areas responsible for language are perfused by the MCA, we believe that the ssWada in the MCA region will help adequately anesthetize language-related areas with minimal effect in adjacent regions, compared with the cWada.…”