About Dr. Zhou Liang
Dr. Zhou Liang is Director of Neurosurgery at Huashan Hospital, Fudan University — widely regarded as one of China's foremost neurosurgeons for brain and skull base tumours. He leads one of the highest-volume neurosurgical programmes in China, performing complex craniotomies, pituitary surgery, skull base resections, and awake brain surgery with intraoperative cortical and subcortical mapping. Dr. Zhou's team is a national referral destination for functionally challenging neurosurgical cases, and his centre's outcomes in eloquent cortex glioma surgery — combining multimodal imaging, awake craniotomy, and direct electrical stimulation — are among the most extensively documented in China.
Case Overview
A 32-year-old lawyer — whose professional livelihood depended entirely on fluent language function — presented with a single seizure episode and 2 weeks of right-sided facial and limb hypoaesthesia. Multimodal MRI including 7T high-field imaging, DTI fibre tractography, fMRI language localisation, and MR spectroscopy demonstrated a 4.5 x 3.8 cm left insular diffuse glioma with the Broca area language centre located only 5 mm from the tumour's posterior margin and the corticospinal tract intimately involved. Conventional general anaesthesia surgery carried a high risk of permanent aphasia or hemiplegia. Dr. Zhou Liang performed awake craniotomy using the asleep-awake-asleep technique with intraoperative direct electrical stimulation mapping of cortical and subcortical language and motor boundaries. Gross total resection (Simpson Grade I) was achieved over 360 minutes, with the patient naming objects and moving his contralateral limbs throughout the critical resection phase. Pathology confirmed WHO Grade II oligodendroglioma with 1p/19q codeletion and IDH mutation — indicating chemosensitivity and favourable prognosis. No neurological deficit was detected post-operatively. The patient returned to courtroom advocacy at 3 months and remained recurrence-free at 1 year.
Patient Background
- Age / Sex: 32-year-old male
- Occupation: Lawyer — language fluency and verbal precision are the foundation of his professional identity
- Chief Complaint: Single generalised seizure; right-sided facial and limb numbness for 2 weeks
- Medical History: No significant comorbidities
- Neurological Examination: Alert and fully fluent; limb power Grade V bilaterally; mild reduction in pain sensation over the right face and limbs
Imaging and Pre-operative Assessment
Conventional MRI
- Left insular irregular mass 4.5 x 3.8 cm; long T1 and T2 signal; ill-defined margins — consistent with diffuse infiltrative glioma
Multimodal MRI (7T High-Field + Functional Imaging)
- DTI fibre tractography: Tumour intimately encasing the corticospinal tract (motor pathway) and arcuate fasciculus (language association fibres) — both at immediate surgical risk
- fMRI language localisation: Broca's area (posterior inferior frontal gyrus) confirmed in the left hemisphere; located only 5 mm from the tumour's posterior margin; motor cortex displaced posteriorly by mass effect
- MR spectroscopy: Elevated choline peak; reduced NAA peak — consistent with WHO Grade II–III glioma
Pre-operative Diagnosis
- Left insular diffuse glioma — suspected oligodendroglioma
- Surgical risk: Tumour located within the eloquent zone; conventional general anaesthesia resection carried high probability of permanent aphasia and contralateral hemiplegia; incomplete resection would result in early recurrence
Clinical Decision Making and MDT Discussion
The central challenge: how to achieve maximum safe resection while guaranteeing 100% preservation of language and motor function in a 32-year-old professional whose career depends on both.
Dr. Zhou Liang's strategy: For a young patient with a functionally critical occupation, pursuing radiological gross total resection at the cost of neurological function is not acceptable. We must use awake craniotomy combined with direct electrical stimulation mapping of both cortical and subcortical boundaries. The tumour will be resected in a stepwise fashion: non-eloquent regions first, then the eloquent margin under continuous real-time functional monitoring. Our goal is not simply to remove the tumour — it is to remove the maximum possible tumour volume while the patient continues to speak and move throughout the procedure.
Surgical Procedure
Approach: Left frontotemporal craniotomy + insular glioma resection (awake craniotomy + intraoperative neurophysiological monitoring)
Anaesthesia: Asleep-awake-asleep technique
Operative time: 360 minutes
Phase 1 — Anaesthesia and Positioning (Asleep)
General anaesthesia was induced without long-acting neuromuscular blocking agents, preserving the capacity for spontaneous respiration and voluntary limb movement during the awake phase. The head was fixed in a frame and a pre-auricular horseshoe incision was designed to access the Sylvian fissure — the natural anatomical corridor to the insula — minimising brain retraction.
Phase 2 — Craniotomy and Exposure
Under the operating microscope, the Sylvian cistern was opened and cerebrospinal fluid released, allowing gravity-assisted brain relaxation and natural insular exposure without retractor pressure. Neuronavigation registration matched pre-operative MRI data to intraoperative anatomy with less than 1 mm error. Intraoperative ultrasound provided real-time tumour boundary updates, compensating for brain shift that accumulates as CSF is released and tumour is removed.
Phase 3 — Awake Mapping (Critical Phase)
As the resection approached the tumour's functional margin, sedation was discontinued. The patient became fully alert within 10 minutes — comfortable throughout, as scalp and dural anaesthesia had been established with local anaesthetic at the outset.
Language testing: A nurse presented picture cards (objects including a watch, an elephant, a bicycle) and the patient was asked to name each item continuously — providing a real-time stream of language output that would immediately reveal any disruption.
Direct electrical stimulation mapping: Dr. Zhou applied a bipolar Ojemann stimulator systematically across the cortical surface surrounding the tumour.
- Stimulation of the posterior inferior frontal gyrus (Broca's area) produced speech arrest — the patient could understand the picture but could not produce the word. This site was marked as a no-resection zone.
- Stimulation of the lower precentral gyrus produced right facial twitching — marking the inferior motor cortex boundary.
Subcortical stimulation: As resection proceeded into the tumour's deep margin, a stimulation probe was used to map subcortical white matter fibres, confirming arcuate fasciculus integrity at each depth increment before advancing further.
Dr. Zhou's operative note: The awake patient is the most sensitive monitoring instrument available to the neurosurgeon. No evoked potential system, no imaging technology, and no anatomical landmark can replace the patient who tells you in real time whether their language is intact. The moment naming hesitates, we stop. That boundary is the true surgical margin — not the MRI contour.
Phase 4 — Tumour Resection
Working within the mapped safe boundaries, the tumour was resected in staged increments using a CUSA (Cavitron Ultrasonic Surgical Aspirator) and bipolar coagulation. After each resection increment, the patient was re-tested for language and motor function before the next increment proceeded. Gross total resection was confirmed by intraoperative ultrasound and neuronavigation. Throughout the entire resection phase, the patient named objects fluently and moved his right limbs on command without deficit.
Phase 5 — Closure (Asleep)
With haemostasis confirmed and functional integrity verified, anaesthesia was deepened, the dura closed, and the bone flap replaced.
Pathology and Post-operative Recovery
Final Pathology Report
- Histology: Oligodendroglioma, WHO Grade II
- Molecular pathology: 1p/19q codeletion positive; IDH mutation positive — the defining molecular signature of oligodendroglioma, indicating chemosensitivity and significantly favourable prognosis compared with IDH-wildtype glioma
Post-operative Course
- Day 1: Fully fluent speech; no naming errors; right limb power Grade V; no neurological deficit of any kind
- 24-hour MRI: Gross total resection confirmed; minimal perilesional oedema
- Day 3: Surgical drain removed
- Day 5: Discharged home
Follow-up
- 3 months: Returned to full-time legal practice; performing high-intensity courtroom advocacy without limitation
- 1 year: No radiological recurrence; quality of life fully restored
Extended Case: Complex Petroclival Skull Base Meningioma
Dr. Zhou Liang's surgical expertise extends beyond supratentorial glioma to the most demanding territory in neurosurgery: the skull base.
A 50-year-old woman presented with a 5 cm petroclival meningioma compressing the brainstem, trigeminal nerve, and facial-vestibulocochlear nerve complex. Dr. Zhou performed a far-lateral transcondylar approach — partial resection of the occipital condyle to achieve wide exposure of the tumour base without excessive brainstem retraction. The tumour encased the basilar artery and lower cranial nerves. Under endoscope-assisted microsurgical visualisation, the tumour was removed in piecemeal fashion with continuous intraoperative facial nerve electromyography and brainstem auditory evoked potential (BAEP) monitoring. Post-operatively, facial sensation was preserved, hearing was partially preserved, and no lower cranial nerve palsy (dysphagia or dysphonia) occurred.
Expert Commentary — Dr. Zhou Liang
1. Maximum Safe Resection: The Modern Standard
For eloquent cortex glioma, gross total resection is no longer the unconditional goal. If forced to choose between complete resection and functional preservation, function takes absolute priority. But through awake craniotomy and direct electrical stimulation mapping, we do not have to choose. The technology exists to achieve both — and our obligation to the patient is to use it. A surgeon who performs a blind resection in the eloquent zone and causes permanent aphasia has not helped the patient. A surgeon who stops short of the true functional boundary and leaves tumour behind has also failed. The awake craniotomy resolves this dilemma.
2. Multimodal Imaging: The Third Eye
Anatomical landmarks alone are insufficient for deep insular surgery. The combination of 7T MRI, DTI fibre tractography, fMRI language localisation, intraoperative ultrasound, and neurophysiological monitoring creates a three-dimensional navigational system that extends the surgeon's perception beyond what the eye can see. DTI tractography in particular allows us to visualise the corticospinal tract and arcuate fasciculus before the first incision — planning the resection corridor around structures that are invisible on conventional imaging. This is not technological sophistication for its own sake. It is the difference between a patient who wakes up speaking and one who does not.
3. The Safety of Awake Surgery
Many patients fear the idea of being conscious during brain surgery. In practice, under meticulous anaesthetic management and pre-operative psychological preparation, patients experience no pain during the awake phase and are able to cooperate fully with functional testing. The awake patient is not a passive subject — they are an active participant in their own surgery, providing the real-time feedback that makes the procedure safer than any general anaesthesia alternative. We have performed hundreds of awake craniotomies at Huashan; the technique is safe, reproducible, and transformative for patients with eloquent zone tumours.
4. Molecular Pathology Guides the Treatment Programme
This patient's 1p/19q codeletion and IDH mutation identified him as having oligodendroglioma — a molecularly defined entity with substantially better prognosis than IDH-wildtype glioblastoma. This molecular profile directed the adjuvant treatment decision: chemotherapy first, with radiotherapy deferred, significantly extending progression-free survival while minimising treatment-related cognitive toxicity in a 32-year-old professional. The neurosurgeon who does not understand molecular neuropathology cannot deliver optimal care. Surgery provides the tissue. Molecular pathology determines the programme.
How CMCS Shanghai Coordinated This Case
China Medical Concierge Shanghai (CMCS) supported this patient's care pathway from initial overseas inquiry through 1-year neurological follow-up. Our coordination included:
- Pre-arrival review of MRI imaging and seizure history; specialist referral to Dr. Zhou Liang's neurosurgery team at Huashan Hospital, Fudan University
- Arrangement of 7T multimodal MRI (DTI fibre tractography, fMRI language mapping, MR spectroscopy) and neuropsychological baseline assessment for complete pre-operative functional mapping
- Bilingual interpretation during the surgical planning consultation, including detailed explanation of awake craniotomy technique, direct electrical stimulation mapping, the asleep-awake-asleep anaesthetic protocol, and realistic functional outcome expectations
- Pre-operative psychological preparation coordination: patient counselling sessions with the neurosurgical nursing team to familiarise the patient with the awake phase procedure, picture-naming task, and communication protocol with the surgical team
- Surgical admission logistics: hospital registration, neuronavigation suite scheduling, and accommodation support for accompanying family
- On-site medical interpretation throughout the hospitalisation, including post-operative neurological assessment support and discharge planning
- Molecular pathology coordination: 1p/19q codeletion and IDH mutation testing with results translation and communication to the patient's home neurologist
- Adjuvant chemotherapy coordination: oncology referral for temozolomide or PCV regimen initiation, cycle scheduling, and toxicity monitoring liaison with Dr. Zhou's neuro-oncology team
- 1-year surveillance coordination: MRI follow-up scheduling, neuropsychological reassessment, and communication with the patient's home neurologist for ongoing management
For international patients facing a brain tumour diagnosis in or near the eloquent cortex — particularly those who have been told that surgery is too risky, or that functional preservation cannot be guaranteed — the combination of awake craniotomy expertise, multimodal functional imaging, and comprehensive molecular neuro-oncology at Shanghai's leading neurosurgical centres represents a standard of care that may not be available in their home country. CMCS exists to connect patients with that expertise: ensuring every functional preservation option is evaluated, every surgical risk is explained in their language, and every step from pre-operative mapping to long-term oncological follow-up is coordinated with precision and care.
This case report is de-identified and published for educational purposes. All clinical details have been anonymized in accordance with patient privacy standards. CMCS Shanghai is a medical concierge service and does not provide direct medical care.
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