Methods, systems, and computer readable media for awake neurosurgical planning and testing

Abstract

A method for awake neurosurgical planning and testing includes presenting, to a subject undergoing an awake neurosurgical procedure, during the awake neurosurgical procedure, and using a head mountable device, tests for evaluating neurocognitive or motor functions controlled by a region of the subject's brain being evaluated for tumor resection. The method further includes receiving, by a test controller module, responses of the subject to the tests. The method further includes automatically selecting or generating, by the test controller module, and based on the responses, further tests to present to the subject during the awake neurosurgical procedure. The method further includes presenting, via the head mountable device and to the subject, the tests selected or generated based on the subject's responses.

Description

[0001] METHODS, SYSTEMS, AND COMPUTER READABLE MEDIA FOR AWAKE NEUROSURGICAL PLANNING AND TESTING

[0002] PRIORITY CLAIM

[0003] This application claims the priority benefit of U.S. Provisional Patent Application Serial No. 63 / 723,987, filed November 22, 2024, the disclosure of which is incorporated herein by reference in its entirety.

[0004] TECHNICAL FIELD

[0005] The subject matter described herein relates to awake neurosurgical planning and testing. More particularly, the subject matter described herein relates to an immersive system that automatically delivers neurocognitive and motor tests to a subject during an awake neurosurgical procedure, measures responses of the subject, and provides updated tests to the subject during the procedure.

[0006] BACKGROUND

[0007] Precise brain tumor surgery requires the removal of tumor tissue while preserving functional brain tissue. This is especially important in the “eloquent” areas of the brain, which have readily identifiable functions. For example, the motor cortex executes motor function, and lesions to those areas of the brain would result in impaired function. Thus, pre-surgical and intra-surgical mapping of these functional areas is critical to minimizing unnecessary damage. For simple tasks, this process is straightforward, with the use of electrodes placed onto the surface of the brain that pass electricity, clinicians can evaluate the ability to perform related tasks. As task complexity increases, this becomes more complex and often necessitates the involvement of a neuropsychologist or neurologist to elicit and interpret responses from the patient during the procedure. Furthermore, the types of tests that may be administered while a patient is immobilized within surgical positioning is limited. Currently, testing performed during brain tumor surgery in some instances is performed manually, e.g., using flash cards, where the neuropsychologist or neurologist is behind or under the surgical drapes with the subject requests that the subject identify objects displayed on the cards to test language, motor skills, memory, executive function, or affect. The subject’s responses are interpreted manually by the neuropsychologist or neurologist, who communicates the results to the surgeon to guide the surgeon during the procedure. Surface electrodes on the subject’s brain also monitor electrical signals of the brain, which are interpreted by another expert in the surgical room who communicates with the surgeon and the neuropsychologist or the neurologist administering the testing. Such a manual process for awake surgical planning, while effective, may be limited in the variety of tests and the adaptability of the tests to the individual subject’s responses.

[0008] Accordingly, in light of these and other difficulties, these exists a need for improved methods, systems, and computer readable media for awake surgical planning and testing.

[0009] SUMMARY

[0010] A method for awake neurosurgical planning and testing includes presenting, to a subject undergoing an awake neurosurgical procedure, during the awake neurosurgical procedure, and using a head mountable device, tests for evaluating neurocognitive or motor functions controlled by a region of the subject’s brain being evaluated for tumor resection. The method further includes receiving, by a test controller module, responses of the subject to the tests. The method further includes automatically selecting or generating, by the test controller module, and based on the responses, further tests to present to the subject during the awake neurosurgical procedure. The method further includes presenting, via the head mountable device and to the subject, the tests selected or generated based on the subject’s responses.

[0011] According to another aspect of the subject matter described herein, presenting the tests to the subject via the head mountable device includes displaying the test to the subject using an augmented reality or virtual reality headset or glasses worn by the subject during the awake neurosurgical procedure.

[0012] According to another aspect of the subject matter described herein, receiving the responses of the subject includes receiving verbal responses of the subject captured via a microphone embedded in the head mountable device.

[0013] According to another aspect of the subject matter described herein, receiving responses of the subject includes receiving indications of motion of the subject captured by sensors worn by the subject or located proximally to the subject.

[0014] According to another aspect of the subject matter described herein, automatically selecting or generating further tests to present to the subject includes identifying, from a patient-specific dataset generated for the subject from pre-surgical neurocognitive testing of the subject while the subject’s brain is being imaged using functional magnetic resonance imaging, a statistical likelihood that the region of the subject’s brain being evaluated for tumor resection controls a particular neurological or motor function and automatically selecting or generating the tests to evaluate the particular neurological or motor function.

[0015] According to another aspect of the subject matter described herein, automatically selecting or generating the tests includes automatically selecting the tests from a battery of stored tests mapped to the region of the subject’s brain being evaluated for tumor resection in the patient-specific dataset.

[0016] According to another aspect of the subject matter described herein, automatically selecting or generating the tests includes automatically generating the tests using a large language model (LLM) trained to generate or refine the tests based on the subject’s responses.

[0017] According to another aspect of the subject matter described herein, identifying the statistical likelihood that the region of the subject’s brain being evaluated for tumor resection controls a particular neurocognitive or motor function includes determining probabilities that the region of the subject’s brain being evaluated for tumor resection controls language, motor function, memory, executive function or affect.

[0018] According to another aspect of the subject matter described herein, the method for awake neurosurgical planning and testing includes displaying, to a surgeon and during the awake neurosurgical procedure, a visual indication of the probabilities.

[0019] According to another aspect of the subject matter described herein, the method for awake neurosurgical planning and testing includes continually and automatically updating the tests presented to the subject via the head mountable device based on responses of the subject to the tests.

[0020] According to another aspect of the subject matter described herein, a system for awake neurosurgical planning and testing is provided. The system includes a head mountable device configured to be worn by a subject undergoing an awake neurosurgical procedure during the awake neurosurgical for presenting, to the subject during the awake neurosurgical procedure, tests for evaluating neurocognitive or motor functions controlled by a region of the subject’s brain being evaluated for tumor resection. The system further includes a computing platform including at least one processor and a memory. The system further includes a test controller module stored in the memory and executable by the at least one processor for receiving responses of the subject to the tests, automatically selecting or generating, by the test controller module, and based on the responses, further tests to present to the subject during the awake neurosurgical procedure, and presenting, via the head mountable device and to the subject, the tests selected or generated based on the subject’s responses.

[0021] According to another aspect of the subject matter described herein, the head mountable device an augmented reality or virtual reality headset or glasses worn by the subject during the awake neurosurgical procedure. According to another aspect of the subject matter described herein, the head mountable device includes a microphone to receive verbal responses of the subject to the tests.

[0022] According to another aspect of the subject matter described herein, the system for awake neurosurgical planning and testing includes at least one sensor configured to be worn by or located proximally to the subject for receiving motor responses of the subject to the tests.

[0023] According to another aspect of the subject matter described herein, the test controller module is configured to automatically select or generate the further tests to present to th subject by identifying, from a patient-specific dataset generated for the subject from pre-surgical neurocognitive testing of the subject while the subject’s brain is being imaged using functional magnetic resonance imaging, a statistical likelihood that the region of the subject’s brain being evaluated for tumor resection controls a particular neurological or motor function and automatically selecting or generating the tests to evaluate the particular neurological or motor function.

[0024] According to another aspect of the subject matter described herein, the test controller module is configured to automatically select the tests from a battery of stored tests mapped to the region of the subject’s brain being evaluated for tumor resection in the patient-specific dataset.

[0025] According to another aspect of the subject matter described herein, the test controller module is configured to automatically generate the tests using a large language model (LLM) trained to generate or refine the tests based on the subject’s responses.

[0026] According to another aspect of the subject matter described herein, the test controller module is configured to identify the statistical likelihood that the region of the subject’s brain being evaluated for tumor resection controls a particular neurocognitive or motor function by determining probabilities that the region of the subject’s brain being evaluated for tumor resection controls language, motor function, memory, executive function or affect. According to another aspect of the subject matter described herein, the test controller module is configured to display, to a surgeon and during the awake neurosurgical procedure, a visual indication of the probabilities.

[0027] According to another aspect of the subject matter described herein, the test controller module is configured to continually and automatically update the tests presented to the subject via the head mountable device based on responses of the subject to the tests.

[0028] According to another aspect of the subject matter described herein, a non-transitory computer readable medium having stored thereon executable instructions that when executed by a processor of a computer controls the computer to perform steps is provided. The steps include presenting, to a subject undergoing an awake neurosurgical procedure, during the awake neurosurgical procedure, and using a head mountable device, tests for evaluating neurocognitive or motor functions controlled by a region of the subject’s brain being evaluated for tumor resection. The steps further include receiving, by a test controller module, responses of the subject to the tests. The steps further include automatically selecting or generating, by the test controller module, and based on the responses, further tests to present to the subject during the awake neurosurgical procedure. The steps further include presenting, via the head mountable device and to the subject, the tests selected or generated based on the subject’s responses.

[0029] The subject matter described herein can be implemented in software in combination with hardware and / or firmware. For example, the subject matter described herein can be implemented in software executed by a processor. In one exemplary implementation, the subject matter described herein can be implemented using a non-transitory computer readable medium having stored thereon computer executable instructions that when executed by the processor of a computer control the computer to perform steps. Exemplary computer readable media suitable for implementing the subject matter described herein include non-transitory computer-readable media, such as disk memory devices, chip memory devices, programmable logic devices, and application specific integrated circuits. In addition, a computer readable medium that implements the subject matter described herein may be located on a single device or computing platform or may be distributed across multiple devices or computing platforms.

[0030] BRIEF DESCRIPTION OF THE DRAWINGS

[0031] Exemplary implementations of the subject matter described herein will now be explained with reference to the accompanying drawings, of which:

[0032] Figure 1 is a flow diagram illustrating exemplary overall steps of a process for awake surgical planning and testing;

[0033] Figure 2 is a diagram of subject wearing a head mountable device during an awake surgical procedure;

[0034] Figure 3 is a block diagram illustrating exemplary components of a system for awake surgical planning and testing; and

[0035] Figure 4 is a flow chart illustrating an exemplary process for awake surgical planning and testing.

[0036] DETAILED DESCRIPTION

[0037] The subject matter described herein includes a method and a system that integrates pre-surgical anatomic and functional imaging (functional MRI) that drives a “Virtual Neuropsychologist” that would assist the neurosurgeon in awake neurosurgical procedures. Presurgical imaging may be combined with a functional atlas and connectivity maps to generate the initial neurocognitive or motor tests that would be automatically delivered by the system. Baseline functional testing may be performed during imaging or pre- operatively. The testing may be delivered through a head mountable device, such as an augmented reality (AR) or virtual reality (VR) headset or glasses that the patient would wear during the procedure and that would not compromise the sterile field. Patient responses to the testing may be captured through a combination of eye tracking, voice recognition, VR gloves, or other sensors worn by or positioned near the patient. During the surgery, the system may also measure the patient’s responses and provide updated testing to better “capture” the function of the region of the patient’s brain under interrogation. The testing may be updated automatically to reflect the necessary tests and may use Al generated material, including text, audio, images, scenarios, or videos. Furthermore, when integrated with surgical tools, task testing frequency can be adjusted to test appropriate function for the given operative focus (e.g., transition from motor testing to speech as the operative target changes).

[0038] Presurgical evaluation

[0039] Pre-surgical MRI: Patients undergo a pre-surgical magnetic resonance imaging (MRI) scan, which includes a battery of up to 8 (or more) neurocognitive functional MRI (fMRI) tasks, acquisition of resting state fMRI (rs-fMRI) and acquisition of diffusion weighted imaging (DWI) along with anatomic series.

[0040] Presurgical testing in the clinic or the MRI facility: The patient wears the head mountable device prior to surgery or during MR imaging to perform baseline testing that is then stored and analyzed for comparison to intraoperative / postoperative function.

[0041] Surgical Preparation

[0042] Atlas construction:

[0043] Using task-based and task-free neuroimaging data available in open datasets such as the Human Connectome Project, Nathan Kline Institute Rockland Sample, OASIS, HABS-HD, dozens of smaller datasets available in openneuro.org and others, we first construct an atlas of normative data, registered to the Montreal Neurological Institute (MNI) template, mapping the contribution of cognitive, perceptual and motor domains to single voxels in the brain. This will be achieved via meta-analytic techniques that would then assign probability scores for each cognitive, perceptual and motor domain to each voxel. In addition, resting state fMRI (rs-fMRI) data will be used to evaluate the strength of functional connectivity within and between large-scale functional networks, with the results mapped to single voxels using meta- analytic techniques. Diffusion weighted imaging (DWI) data and fractography will similarly be used to assess the integrity of white matter tracts and mapped to the same normative atlas. Overall, the atlas will provide probability scores, for each voxel in the brain, denoting the neurocognitive and motor domains the voxel is implicated in, and the probability with which the voxel is connected to specific large-scale functional networks and major white matter tracts

[0044] A single-subject dataset is also constructed by referring to the data in the normative atlas. The single-subject dataset may include voxel-level summary statistics depicting engagement in each of the neurocognitive tasks, spatial overlap with large-scale functional networks (based on resting state fMRI (rs-fMRI)), and location relative to major white matter tracts (based on diffusion weighted imaging (DWI) and fractography). Each voxel is also registered to a battery of neuropsychological videos, based on the results of the neurocognitive tasks, location within large scale functional networks, and proximity to major white matter tracts. The term “single-subject dataset”, as used herein, refers to a three-dimensional map of the subject’s brain in which each voxel has assigned probabilities for each cognitive / behavioral domain. For example, for a specific voxel, the probabilities may be 0.64 for motor control, 0.2 for language, and 0.61 for memory. An example of a subjectspecific dataset where each voxel is mapped to cognitive and behavioral domain probabilities is the image of the subject’s brain in Figure 1 and the probabilities displayed by the bar graph.

[0045] The tumor extent may then be mapped to the patient-specificdataset. The neurosurgeon can then initiate testing as the surgeon navigates the tumor cavity to interrogate the expected functionality of affected areas using the integration to current neuronavigation systems.

[0046] During surgery During surgery: The single-subject dataset, registered to the surgical apparatus, can be viewed in real-time during surgery. A simple graphical user interface (GUI) shows, for every voxel of interest, the major neurocognitive fMRI tasks it is associated with, major functional networks and major white matter tracts associated with the voxel’s spatial location. Corresponding normative data is shown as well. The GUI also recommends neuropsychological domains associated with each voxel, and the system automatically selects and loads the test associated with the neuropsychological domain corresponding to the region of the subject’s brain being evaluated for tumor resection to the VR headset. The virtual neuropsychologist can be initiated either based on these recommendations, or manually, based on the medical team’s assessments. The tests may be automatically updated by the system with “new” material for testing generated on the fly as needed.

[0047] Post-surgical

[0048] Additional testing could be performed to assess the patient’s return to the anticipated baseline and compared to similar patients with factors, including medication administration, length of surgery, or postoperative complications.

[0049] Figure 1 is a flow diagram illustrating exemplary overall steps of a process for awake surgical planning and testing. Referring to the process flow in Figure 1 , in step A), a subject undergoes pre-surgical fMRI, both resting state and while undergoing a battery of tests. While the subject is undergoing the testing, the fMRI data is monitored and used to generate the patient specific or subject-specific dataset. In steps B) and C), during surgery, the patient is presented with a battery of tests that are selected or generated based on the region of the subject’s brain being evaluated for tumor resection. As indicated above, the testing may be presented to the subject via a head mountable device worn by the subject during the surgical procedure. The tests may be continually updated based on the subject’s responses to the testing. The system may include a test controller module that performs the automatic updating of the testing. As illustrated in Figure 1 , the test system may also display, on a surgical team monitor, a visual indication of probabilities that the region of the subject's brain being targeted for tumor resection is associated with a particular function. The probabilities may be continually calculated and updated during the surgery. An example of how the probabilities may be determined and updated will now be described. Probabilities will be determined using a combination of functional atlases merged with patient specific scans. With the acquisition of a patient specific scan with a deformation from a tumor, a deformable registration will be performed and compared to the data provided by analysis of the resting state and diffusionbased tensor circuitry of a computed connectome. Probabilities will be assigned based on voxel location and proximity to other known functional hubs and functional network circuitry.

[0050] Figure 2 is an image of a subject wearing a head mountable device during an awake surgical procedure. Referring to Figure 2, a subject 200 is undergoing an awake neurosurgical procedure while wearing a head mountable device 202, which includes displays positioned in front of the each of the user’s eyes. The display screens present still and video images that are part of a test to subject 200. Head mountable device 202 also includes speakers for presenting tests to subject 200 in audio format. Head mountable device 202 has the form factor of a virtual reality headset, which includes a housing positionable in front of the subject’s eyes to hold the display(s) and a strap to hold the housing in place on the subject’s head.

[0051] Figure 3 is a block diagram illustrating exemplary components of a system for awake surgical planning and testing. Referring to Figure 3, the system includes a computing platform 300 including at least one processor 302 and a memory 304. A test controller module 306 may implement the above-described virtual neuropsychologist function to present tests to the subject via the head mountable device during surgery. Test controller module 306 may receive as inputs, responses of the subject during surgery, location data that indicates the region of the subject’s brain currently being evaluated for tumor resection, and the subject-specific dataset that maps regions of the subject’s brain subject’s brain to functions from the presurgical testing. Test controller module 306 will use standard neuro-navigational devices to transmit the exact location of the neurosurgical tool and point of interest (X,Y,Z coordinates of the MRI) to the VR system. The VR system will analyze the functional network specific to the patient to provide list of tasks to display to the patient and allow the clinician to observe and assess how the patient performs that task. Test controller module 306 may generate, as output, new tests to be presented to the subject, either by identifying the tests in a database 308 or by generating new tests or updating current tests on the fly, for example, using a large language model. Test controller module 306 may also output brain function probabilities, as illustrated above Figure 1. Test controller module 306 may be implemented using computer executable instructions stored in memory 304 and executed by processor 302.

[0052] Figure 4 is a flow chart illustrating an exemplary process for awake surgical planning and testing. Referring to Figure 4, in step 400, the process includes presenting, to a subject undergoing an awake neurosurgical procedure, during the awake neurosurgical procedure, and using a head mountable device, tests for evaluating neurocognitive or motor functions controlled by a region of the subject’s brain being evaluated for tumor resection. For example, an initial test or tests may be selected based on the current region of the subject’s brain being evaluated and the function(s) of that region determined from the pre-surgical dataset. The test may be presented via a video display of the head mountable device.

[0053] In step 402, the process further includes receiving, by a test controller module, responses of the subject to the tests. For example, the head mountable device may receive speech responses of the subject using a microphone embedded in the device, digitize the responses, and provide the responses to test controller module 306. Motor responses of the subject may be captured using motion sensors worn by the subject or positioned near the subject. The sensors may likewise provide the input to test controller module

[0054] 306

[0055] In step 404, the process further includes automatically selecting or generating, by the test controller module, and based on the responses, further tests to present to the subject during the awake neurosurgical procedure. For example, if the subject-specific dataset indicates that a region of the subject’s brain is associated with language, language tests may initially be presented to the subject. As the subject responds to the language tests, test controller module 306 may select or generate new tests. In one example, test controller module 306 takes location data provided by standard neuronavigation systems’ tools (e.g., Brainlab or Stealth - https: / / int-brain- lab.github.io / iblenv / 010_api_reference.html IBL API) - and then analyzes the surrounding voxels’ probability maps for functional tasks. The results of the analysis will allow test controller module 306 to queue up the relevant tests for the neurocognitive testing.

[0056] Examples of adaptive test selection by controller module 306 are as follows:

[0057] 1 . If the patient was having difficulty responding to specific questions, additional questions may be asked that are functionally or spatially related to better assess related anatomic locations. This would increase the precision of the functional assessment. More refined questions, or alternate methods of assessing the same functional area may also be presented, to prevent boredom. If the patient is unable to answer a question, test controller module 306 could cause the system to ask the patient to read the question out loud and confirm that the question is read correctly.

[0058] 2. If the patient is having no difficulty responding to questions, then test controller module 306 may prompt the neurosurgeon to choose functional areas that are further away from a current area of the patient’s brain being probed to sample other areas that may be more relevant to the surgical site. 3. Test controller module 306 may cause the system to switch the mode of presentation, for more audio, visual, or requesting a functional response to identify better ways to present data to the patient, based on their prior responses, either in training or during the actual surgical procedure.

[0059] 4. Functional feedback from the patient that is received by test controller module 306 may be in the form of audio responses, physical motion, performing specific motions or actions. For example, the patient may be asked to read a statement, poem or passage, answer a question, sing or hum a song, perform an action on an input device, etc.

[0060] It should be noted that test controller module 306 can be implemented using a combination of machine learning and more deterministic models. The machine learning portion of test controller module 306 may be trained using existing functional tasks and functional MRI databases to train the model as to which functional tasks may be related to each other or how variations in asking those questions or creating prompts may be adapted. In one implementation, a generative Al model may be used to generate or select new tests based on patient responses.

[0061] In step 406, the process further includes presenting, via the head mountable device and to the subject, the tests selected or generated based on the subject’s responses. For example, test controller module 306 may present the updated or new tests to the subject via the video display of the head mountable device.

[0062] It will be understood that various details of the subject matter described herein may be changed without departing from the scope of the subject matter described herein. Furthermore, the foregoing description is for the purpose of illustration only, and not for the purpose of limitation, as the subject matter described herein is defined by the claims as set forth hereinafter.

Claims

CLAIMSWhat is claimed is:1 . A method for awake neurosurgical planning and testing, the method comprising: presenting, to a subject undergoing an awake neurosurgical procedure, during the awake neurosurgical procedure, and using a head mountable device, tests for evaluating neurocognitive or motor functions controlled by a region of the subject’s brain being evaluated for tumor resection; receiving, by a test controller module, responses of the subject to the tests; automatically selecting or generating, by the test controller module, and based on the responses, further tests to present to the subject during the awake neurosurgical procedure; and presenting, via the head mountable device and to the subject, the tests selected or generated based on the subject’s responses.

2. The method of claim 1 wherein presenting the tests to the subject via the head mountable device includes displaying the test to the subject using an augmented reality or virtual reality headset or glasses worn by the subject during the awake neurosurgical procedure.

3. The method of claim 1 wherein receiving the responses of the subject includes receiving verbal responses of the subject captured via a microphone embedded in the head mountable device.

4. The method of claim 1 wherein receiving responses of the subject includes receiving indications of motion of the subject captured by sensors worn by the subject or located proximally to the subject.

5. The method of claim 1 wherein automatically selecting or generating further tests to present to the subject includes identifying, from a patient-specific dataset generated for the subject from pre-surgical neurocognitive testing of the subject while the subject’s brain is beingimaged using functional magnetic resonance imaging, a statistical likelihood that the region of the subject’s brain being evaluated for tumor resection controls a particular neurological or motor function and automatically selecting or generating the tests to evaluate the particular neurological or motor function.

6. The method of claim 5 wherein automatically selecting or generating the tests includes automatically selecting the tests from a battery of stored tests mapped to the region of the subject’s brain being evaluated for tumor resection in the patient-specific dataset.

7. The method of claim 5 wherein automatically selecting or generating the tests includes automatically generating the tests using a large language model (LLM) trained to generate or refine the tests based on the subject’s responses.

8. The method of claim 5 wherein identifying the statistical likelihood that the region of the subject’s brain being evaluated for tumor resection controls a particular neurocognitive or motor function includes determining probabilities that the region of the subject’s brain being evaluated for tumor resection controls language, motor function, memory, executive function or affect.

9. The method of claim 8 comprising displaying, to a surgeon and during the awake neurosurgical procedure, a visual indication of the probabilities.

10. The method of claim 1 comprising continually and automatically updating the tests presented to the subject via the head mountable device based on responses of the subject to the tests.

11. A system for awake neurosurgical planning and testing, the system comprising: a head mountable device configured to be worn by a subject undergoing an awake neurosurgical procedure during the awake neurosurgical for presenting, to the subject during the awake neurosurgical procedure, tests for evaluating neurocognitive or motorfunctions controlled by a region of the subject’s brain being evaluated for tumor resection; a computing platform including at least one processor and a memory; a test controller module stored in the memory and executable by the at least one processor for receiving responses of the subject to the tests, automatically selecting or generating, by the test controller module, and based on the responses, further tests to present to the subject during the awake neurosurgical procedure, and presenting, via the head mountable device and to the subject, the tests selected or generated based on the subject’s responses.

12. The system of claim 11 wherein the head mountable device an augmented reality or virtual reality headset or glasses worn by the subject during the awake neurosurgical procedure.

13. The system of claim 11 wherein the head mountable device includes a microphone to receive verbal responses of the subject to the tests.

14. The system of claim 11 comprising at least one sensor configured to be worn by or located proximally to the subject for receiving motor responses of the subject to the tests.

15. The system of claim 11 wherein the test controller module is configured to automatically select or generate the further tests to present to th subject by identifying, from a patient-specific dataset generated for the subject from pre-surgical neurocognitive testing of the subject while the subject’s brain is being imaged using functional magnetic resonance imaging, a statistical likelihood that the region of the subject’s brain being evaluated for tumor resection controls a particular neurological or motor function and automatically selecting or generating the tests to evaluate the particular neurological or motor function.

16. The system of claim 15 wherein the test controller module is configured to automatically select the tests from a battery of stored tests mappedto the region of the subject’s brain being evaluated for tumor resection in the patient-specific dataset.

17. The system of claim 15 wherein the test controller module is configured to automatically generate the tests using a large language model (LLM) trained to generate or refine the tests based on the subject’s responses.

18. The system of claim 15 wherein the test controller module is configured to identify the statistical likelihood that the region of the subject’s brain being evaluated for tumor resection controls a particular neurocognitive or motor function by determining probabilities that the region of the subject’s brain being evaluated for tumor resection controls language, motor function, memory, executive function or affect.

19. The system of claim 18 wherein the test controller module is configured to display, to a surgeon and during the awake neurosurgical procedure, a visual indication of the probabilities.

20. The system of claim 11 wherein the test controller module is configured to continually and automatically update the tests presented to the subject via the head mountable device based on responses of the subject to the tests.

21. A non-transitory computer readable medium having stored thereon executable instructions that when executed by a processor of a computer controls the computer to perform steps comprising: presenting, to a subject undergoing an awake neurosurgical procedure, during the awake neurosurgical procedure, and using a head mountable device, tests for evaluating neurocognitive or motor functions controlled by a region of the subject’s brain being evaluated for tumor resection; receiving, by a test controller module, responses of the subject to the tests;automatically selecting or generating, by the test controller module, and based on the responses, further tests to present to the subject during the awake neurosurgical procedure; and presenting, via the head mountable device and to the subject, the tests selected or generated based on the subject’s responses.

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