Preoperative sign language acquisition in patients undergoing awake craniotomy: a prospective pilot study

Abstract

Preservation of language function is a critical objective during awake craniotomy for gliomas involving language-eloquent regions. However, intraoperative language mapping relies predominantly on spoken output, which can be transiently disrupted by cortical stimulation during functional testing. Under these conditions, the behaviour of alternative communication systems remains largely unexplored. To investigate whether recently acquired, task-specific signed responses remain executable during stimulation-induced speech arrest in patients undergoing awake craniotomy. We conducted a prospective single-centre pilot study including seven adult patients with gliomas in language-eloquent regions of the dominant hemisphere undergoing awake craniotomy. Participants completed a structured 15-day preoperative Catalan Sign Language (LSC, Llengua de Signes Catalana) training programme. Acquisition was assessed through predefined comprehension and production assessments. Patients performed both spoken and signed language tasks under direct electrical stimulation during intraoperative cortical mapping. The primary outcome was the ability to perform task-specific signed responses during stimulation-induced speech arrest. The seven analysed patients completed the training programme and achieved predefined performance thresholds. Cortical stimulation induced speech arrest in all cases. During these episodes, patients maintained accurate and clinically interpretable signed responses across all tasks. No intraoperative seizures or protocol-related adverse events were observed. In this pilot study, patients were able to perform task-specific signed responses despite stimulation-induced speech arrest. These findings indicate that transient disruption of spoken output did not prevent the execution of recently acquired signed responses under the tested intraoperative conditions. Given the exploratory design and task-specific nature of the training, these findings should not be interpreted as evidence of postoperative communicative efficacy or as support for changes in surgical decision-making. Further studies are required to determine whether this observation has any broader clinical relevance.