Intraoperative Techniques for Language Mapping in Brain Surgery: A Comparison Between Direct Electrical Stimulation (DES) and Electrocorticography (ECoG)

Purpose The purpose of this overview is to compare Direct Electrical Stimulation (DES) and Electrocorticography (ECoG) techniques, assessing their respective strengths, limitations, and roles in ensuring successful language mapping during awake brain surgeries. Method This overview aims to compare two techniques used in intraoperative language mapping during awake brain surgery: Direct Electrical Stimulation (DES) and Electrocorticography (ECoG). By summarizing recent advances in both methods, we highlight their respective mechanisms, applications, and roles in improving surgical outcomes. DES is widely considered the gold standard for cortical brain mapping and is applicable in both awake and anesthetized surgeries for treating epilepsy and brain tumors. In contrast, ECoG involves monitoring the brain's electrical activity with or without direct stimulation, as it provides valuable insight into high gamma activity (70–150 Hz), which is strongly associated with speech production. Finding ECoG offers a high‐resolution approach to language mapping by detecting high‐gamma activity, reducing the risk of intraoperative seizures, and serving as a complementary or alternative tool to DES in specific clinical scenarios. While DES continues to be the most reliable technique for identifying functional brain areas, it does carry a higher risk of inducing seizures. Furthermore, recent advancements in ECoG‐based speech decoding and brain–computer interfaces (BCIs) underscore the growing potential of ECoG in restoring communication in patients with severe language impairments, extending its applications beyond surgical mapping. Conclusion In conclusion, while DES remains the gold standard for intraoperative language mapping, ECoG is emerging as a promising complementary or alternative technique in some clinical cases. This overview highlights the evolving role of ECoG, particularly in the context of speech decoding and BCIs, offering new possibilities for improving surgical outcomes and postoperative quality of life in patients.