Background

Since our team started awake language mapping in 2002, it quickly became obvious that Picture Naming was insufficient to reliably map cortical and subcortical structures. Postoperatively, marked deficiencies in semantics were observed in patients where Object Naming remained correct throughout the testing. Therefore, in the first stage, we incorporated Semantic Odd Picture Out tasks or the equivalent Pyramid and Palm Tree test, which evaluated the visual semantic pathways. An initial improvement was to present four items (one in each corner of the screen) instead of the classical three objects, allowing simultaneous evaluation of the visual fields.

The need to combine different tasks analyzing phonological, semantic, syntactic, and articulatory pathways became clear. This led to the creation of the DuLIP (Dutch Linguistic Intraoperative Protocol) in 2012, in collaboration with Rotterdam and Brussels, and finalized in 2014 after full standardization.

In 2015, we proposed multimodal testing with different DuLIP tasks sequenced in the "Quick Mixed Test," alternating tasks such as repetition, object naming, calculation, and line bisection. However, this sequenced structure proved suboptimal, as evaluating one language pathway could lead to neglecting another. Additionally, this mode was more tiring for the patient.

Different tasks performed successively are time-consuming, mask the evaluation of other functions, and can be boring for the patient, leading to subjectivity in the evaluator's assessment. Furthermore, selecting which task to use and where to use it can result in selection errors.

To address these issues, we developed the idea of combined monitoring of different pathways in one task. This involved presenting a written subject in the center of the slide, which had to be associated with one of the four objects to form a short sentence, including verb generation and syntactic structure. Later, written items could be replaced or supplemented by spoken items. Objects, subjects, and verbs can be interchanged, offering a multiplicity of possible combinations, from which the most relevant must be selected.