OBJECTIVE:

This study aimed to examine language outcome after left or right anterior temporal lobectomy (ATL) in patients with epilepsy with bilateral language representation on intracarotid sodium amobarbital (Wada) testing.

METHODS:

Twenty-two patients with epilepsy with bilateral language (Wada laterality index between -50 and 50) underwent right ATL (RATL, n=10) or left ATL (LATL, n=12). All the patients were administered the Boston Naming Test preoperatively and six months postoperatively.

RESULTS:

Left anterior temporal lobectomy patients showed greater postoperative naming decline than RATL patients. Group differences were also observed on subtests of the Wada test. Performance on the Wada naming and comprehension subtests was better in the nonsurgical hemisphere than in the surgical hemisphere in the RATL group, but there was no difference between the nonsurgical and the surgical hemisphere naming and comprehension performance in the LATL group.

CONCLUSIONS:

Left anterior temporal lobectomy patients with bilateral language are at greater risk for naming decline than RATL patients with bilateral language. This difference may be due to relatively better naming and comprehension abilities in the nonsurgical hemisphere in the RATL group.

BACKGROUND::

The Wada procedure (the intracarotid amobarbital procedure) has been used widely to evaluate the hemispheric dominance of language and memory before temporal lobe surgery in patients with medically refractory seizures. Because of repeated shortage of sodium amobarbital, attempts have been made to find a suitable alternative to sodium amobarbital. The aim of our study was to review our experience with the use of etomidate as an alternative to sodium amobarbital for Wada testing in patients with medically refractory seizures.

METHODS::

After the ethics approval, we retrospectively reviewed the charts of 29 consecutive patients who underwent Wada test with etomidate. Data from a total of 50 hemispheric injections were reviewed and analyzed. This included the electroencephalographic and motor effects of etomidate injection and their time course (onset and recovery), Wada test results (language laterality and memory performance), and all adverse events during the procedure.

RESULTS::

Intracarotid administration of etomidate produced a predictable electroencephalographic and motor effects in all patients. The desirable effect was seen with a single bolus dose of 2 mg followed by an infusion. Shivering was the most common side effect, seen in all the patients. Successful testing was possible in nearly all patients without any major side effects. The "pass rate" of valid tests was in good accord with our previous experience with the use of sodium amobarbital.

CONCLUSION:

: From our experience, etomidate is a safe alternative to sodium amobarbital for the Wada test for determining the hemispheric dominance for speech and in predicting the memory outcome.

The transient, reversible blockade of electron transport (BET) during ischemia or at the onset of reperfusion protects mitochondria and decreases cardiac injury. Apoptosis inducing factor (AIF) is located within the mitochondrial intermembrane space. A release of AIF from mitochondria into cytosol and nucleus triggers caspase-independent cell death. We asked if BET prevents the loss of AIF from mitochondria as a mechanism of protection in the buffer perfused heart. BET during ischemia with amobarbital, a rapidly reversible inhibitor of mitochondrial complex I, attenuated a release of AIF from mitochondria into cytosol, in turn decreasing the formation of cleaved and activated PARP-1. These results suggest that BET-mediated protection may occur through prevention of the loss of AIF from mitochondria during ischemia-reperfusion. In order to further clarify the role of mitochondrial AIF in BET-mediated protection, Harlequin (Hq) mice, a genetic model with mitochondrial AIF deficiency, were used to test whether BET could still decrease cell injury in Hq mouse hearts during reperfusion. BET during ischemia protected Hq mouse hearts against ischemia-reperfusion injury and improved mitochondrial function in these hearts during reperfusion. Thus, cardiac injury can still be decreased in the presence of down-regulated mitochondrial AIF content. Taken together, BET during ischemia protects both hearts with normal mitochondrial AIF content and hearts with mitochondrial AIF deficiency. Although preservation of mitochondrial AIF content plays a key role in reducing cell injury during reperfusion, the protection derived from the BET is not fully dependent on AIF-driven mechanisms.

In this paper we present the case of a left-sided speech dominant patient with right medial temporal sclerosis (RMTS) and pharmacoresistant epilepsy who showed improved verbal memory during intracarotid amobarbital test (IAT) at his right hemisphere as compared with his own performance before the drug injection (baseline), as well as after right selective amygdalohippocampectomy. We suggest that the defective verbal memory shown by this patient is due to abnormal activity of his right hippocampus that interfered with the function of his left hippocampus. This hypothesis was demonstrated by the fact that disconnection of the two hippocampi, either by anesthetisation or by resection of the right hippocampus, disengaged the left hippocampus and, consequently improved its function. This paper main objective is twofold: first to contribute to the field of neuropsychology of epilepsy surgery by emphasising on postoperative memory outcomes in right medial temporal lobe epilepsy (RMTLE) patients, particularly those undergoing amygdalohippocampectomy, as the pattern of memory changes after resection of the right temporal lobe is less clear; second, by focusing on memory performance asymmetries during IAT, and comparatively considering them with neuropsychological memory performance, because of their possible prognostic-simulating value.

Patients with medically refractory epilepsy when referred for surgical treatment often undergo extensive investigations to determine whether surgical treatment is feasible. Surgical feasibility is determined by identifying the location and number of seizure foci and their relationship to eloquent areas of the brain. Good surgical outcome depends on complete resection of seizure foci without any damage to eloquent brain function. Various noninvasive and invasive techniques are used in the presurgical evaluation of patients with epilepsy that include imaging techniques, electrophysiologic studies, and tests to determine functional areas. Understanding of the principles of seizure localization and of the effects of anesthetic drugs on the various preoperative investigations is essential for patient management. In this review article, we discuss the role of the anesthesiologist in patient management during many of these investigations and the role of anesthetic drugs to aid in the localization of the seizure focus and of determining eloquent brain function.

To more definitively characterize Wada/functional magnetic resonance imaging (fMRI) language dominance discordance rates with the largest sample of patients with epilepsy to date, and to examine demographic, clinical, and methodologic predictors of discordance.Two hundred twenty-nine patients with epilepsy underwent both a standardized Wada test and a semantic decision fMRI language protocol in a prospective research study. Language laterality indices were computed for each test using automated and double-blind methods, and Wada/fMRI discordance rates were calculated using objective criteria for discordance. Regression analyses were used to explore a range of variables that might predict discordance, including subject variables, Wada quality indices, and fMRI quality indices.Discordant results were observed in 14% of patients. Discordance was highest among those categorized by either test as having bilateral language. In a multivariate model, the only factor that predicted discordance was the degree of atypical language dominance on fMRI.fMRI language lateralization is generally concordant with Wada testing. The degree of rightward shift of language dominance on fMRI testing is strongly correlated with Wada/fMRI discordance, suggesting that fMRI may be more sensitive than Wada to right hemisphere language processing, although the clinical significance of this increased sensitivity is unknown. The relative accuracy of fMRI versus Wada testing for predicting postsurgical language outcome in discordant cases remains a topic for future research.

An appropriate localization of ictal onset zone in refractory temporal lobe epilepsy favors an adequate outcome associated with surgical treatment. When video-electroencephalogram (video-EEG) and magnetic resonance imaging do not provide accurate data to locate ictal onset zone, the use of subdural or deep intracranial electrodes is indicated. Hippocampal electrode placement could generate functional changes in an unaffected hippocampus.To describe mnesic changes in patients admitted for epilepsy surgery, with previous bilateral hippocampal implantation using depth electrodes.We identified eight patients undergoing video-EEG using bilateral hippocampal electrodes. Verbal and nonverbal mnesic performance was evaluated before/after the procedure. The following aspects were considered for the analysis: memory lateralization according to intracarotid amobarbital test (Wada test), invasive ictal onset zone, side of resection and pattern of electrocorticographic dissemination.In patients with memory dominance, contralateral to the ictal onset zone, there was an improvement in verbal and nonverbal memory, suggesting that invasive recordings did not impair mnesic skills of the unaffected hippocampus. In patients with bilateral representation of memory, ipsilateral mnesic impairment was associated with the resection. Contralateral improvement in memory was seen when the right side was resected, as opposed to no changes with resections made on the left side, indicating that electrode implantation of unaffected hippocampus did not generate a functional decline.Based on the preservation of verbal and nonverbal memory after depth electrode placement, invasive recordings of the hippocampus seem to be safe.

To explore the mechanism on senile osteoporosis of kidney deficiency pattern in the prevention and treatment with acupuncture and Tuina therapy.Sixty-four cases were randomized into an acupuncture and Tuina therapy group (group A, 34 cases) and a calcium carbonate group (group B, 30 cases). In group A, the patients were treated with acupuncture at the distal acupoints and Tuina therapy in the local area. Acupuncture was applied to bilateral Weizhong (BL 40) and Taixi (KI 3). Tuina therapy was given in the lumbar region. Totally 30 treatments were required. In group B, the Calcium Carbonate D3 were prescribed for oral administration, continuously for 12 weeks. The changes in lumbar curvature, lumbar lordosis index, sacral inclination angle, lumbosacral angle, L5 vertebral index and L3 vertebral index of lumbar biomechanical indices were observed and compared before and after treatment in two groups.In group A, the lumbar lordosis index and sacral inclination angle were increased after treatment, indicating the statistical significant differences before and after treatment (P < 0.05, P < 0.01). The improvement of lumbar lordosis index in group A was superior to that in group B [(19.59 +/- 19.16)mm vs (14.47 +/- 13.28)mm, P < 0.05]. After treatment, in group B, L5 vertebral index was improved as compared with that before treatment (P < 0.05). It was required to have a study on the reasons of its lumbar morphological change.The acupuncture and Tuina therapy regulate the lumbar biomechanical structure through the positive stress stimulation and reconstruct the mechanical equilibrium of the lumbar vertebra. It plays the active significance in the prevention and treatment of osteoporosis.

Many diagnostic tools have been employed to predict the likelihood of a postoperative memory decline after a standard temporal lobectomy, including the intracarotid amobarbital testing (IAT) or Wada, regarded as the gold standard test for over the past half a century. Functional MRI (fMRI) is also a promising tool in that regard. Its routine use to predict the postoperative memory decline has been limited because of the varied study paradigms, discrepancies in analysis, and interpretation of the results. Based on the existing literatures, fMRI cannot replace IAT for the routine presurgical evaluation of the patients with temporal lobe epilepsy (TLE) yet. Large multicentre studies with a panel of memory test are required to determine the full potential of fMRI and use it reliably to replace IAT in the routine clinical practice. In this paper, we review various aspects of memory fMRI, including the experimental designs, data analysis, and findings.