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Development of alexia in real time from disruption of the vertical occipital fasciculus during awake brain surgery: A case study

Published online by Cambridge University Press:  05 November 2025

David S. Sabsevitz Open the ORCID record for David S. Sabsevitz [Opens in a new window] ,
Catherine Dion ,
Alfredo Quinones-Hinjosa ,
Joao Paulo Cavalcante de Almeida ,
Jeffrey R. Binder ,
Carlos Perez-Vega ,
Krishnan Ravindran ,
Brin E. Freund ,
Shaun E. Gruenbaum  and
Erik H. Middlebrooks
David S. Sabsevitz*
Affiliation:
Department of Psychology and Psychiatry, Mayo Clinic, Jacksonville, FL, USA Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, USA
Catherine Dion
Affiliation:
Department of Psychology and Psychiatry, Mayo Clinic, Jacksonville, FL, USA
Alfredo Quinones-Hinjosa
Affiliation:
Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, USA
Joao Paulo Cavalcante de Almeida
Affiliation:
Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, USA
Jeffrey R. Binder
Affiliation:
Department of Neurology, Medical College of Wisconsin, Milwaukee, WI, USA
Carlos Perez-Vega
Affiliation:
Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, USA
Krishnan Ravindran
Affiliation:
Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, USA
Brin E. Freund
Affiliation:
Department of Neurology, Mayo Clinic, Jacksonville, FL, USA
Shaun E. Gruenbaum
Affiliation:
Department of Anesthesia and Perioperative Medicine, Mayo Clinic, Jacksonville, FL, USA
Erik H. Middlebrooks
Affiliation:
Department of Neuroradiology, Mayo Clinic, Jacksonville, FL, USA
*
Corresponding author: David S. Sabsevitz; Email: Sabsevitz.David@mayo.edu
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Abstract

Objective:

Reading is a complex cognitive process requiring the integration of orthographic, phonological, and semantic information. The visual word form area, located in the ventral occipitotemporal cortex, is critically involved in orthographic decoding, and damage to this region is known to cause alexia. In contrast, the contributions of white matter pathways supporting reading are less well understood.

Method:

We present a unique neurosurgical case undergoing awake brain surgery for resection of a metastasis in the left occipitotemporal cortex. A tubular retractor was used to access the lesion and during the insertion of the retractor the patient underwent careful, continuous neuropsychological testing, including evaluation of reading. fMRI language mapping and diffusion MRI were performed preoperatively. Postoperative neuropsychological testing was completed two weeks after surgery to assess cognitive outcome.

Results:

The patient developed an alexia with letter-by-letter reading in real time during insertion of the tubular retractor. Stealth imaging enabled localization of the tubular retractor at the exact onset of the alexia and, by correlating this with tractography, showed that the tubular retractor was in the vertical occipital fasciculus (VOF).

Conclusions:

We present the first detailed case report linking the VOF to the acute onset of alexia observed intraoperatively during awake brain surgery. We discuss the connectomics of reading and possible contributions of the VOF in reading.

Keywords

Vertical occipital fasciculusreadingAlexiaawake craniotomybrain mappingbrain connectomics

Information

Type
Case Report
Information
Journal of the International Neuropsychological Society , First View , pp. 1 - 8
Copyright
© The Author(s), 2025. Published by Cambridge University Press on behalf of International Neuropsychological Society

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