Effect of Wada methodology in predicting lateralized memory impairment in pediatric epilepsy surgery candidates

The Pair Test: A computerised measure of learning and memory

There is increasing interest in the assessment of learning and memory in typically developing children as well as in children with neurodevelopmental disorders. However, neuropsychological assessments have been hampered by the dearth of standardised tests that enable direct comparison between distinct memory processes or between types of stimulus materials. We developed a tablet-based paired-associate learning paradigm, the Pair Test, based on neurocognitive models of learning and memory. The aims are to (i) establish the utility of this novel memory tool for use with children across a wide age range, and (ii) examine test validity, reliability and reproducibility of the construct. The convergent validity of the test was found to be adequate, and higher test reliability was shown for the Pair Test compared to standardised measures. Moderate test-retest reproducibility was shown, despite a long time interval between sessions (14 months). Moreover, the Pair Test is able to capture developmental changes in memory, and can therefore chart the developmental trajectory of memory and learning functions across childhood and adolescence. Finally, we used this novel instrument to acquire normative data from 130 typically developing children, aged 8-18 years. Age-stratified normative data are provided for learning, delayed recall and delayed recognition, for measures of verbal and non-verbal memory. The Pair Test thus provides measures of learning and memory accounting for encoding, consolidation and retrieval processes. As such, the standardised test results can be used to determine the status of learning and memory in healthy children, and also to identify deficits in paediatric patients at risk of damage to the neural network underlying mnemonic functions.

Memory outcome following left anterior temporal lobectomy in patients with a failed Wada test

PURPOSE

This study aimed to compare the memory outcome following left anterior temporal lobectomy (ATL) between patients with a failed Wada test and patients who passed the Wada test.

METHODS

From 1996 to 2002, we performed the Wada test on all patients with unilateral left mesial temporal lobe epilepsy with hippocampal sclerosis (MTLE-HS) and concordant electroclinical data before ATL. We used a 12-item recognition paradigm for memory testing and awarded a score of +1 for each correct response and -0.5 for each incorrect response. No patient was denied surgery on the basis of Wada scores. We assessed cognitive and memory functions using the Wechsler Adult Intelligence Scale and the Wechsler Memory Scale preoperatively and at one year after ATL. We compared the number of patients who showed decline in memory scores, as per the published reliable change indices, between the patients with a failed Wada test and the patients who passed the Wada test.

RESULTS

Out of the 116 eligible patients with left MTLE-HS, 88 underwent bilateral Wada test, while 28 underwent ipsilateral Wada test. None of them developed postoperative amnesia. Approximately, one-third of patients with a failed Wada memory test when the failure was defined as a contralateral score of <4, as an ipsilateral score of >8, and as an asymmetry score of <0. The patients with Wada memory failure had a longer pre-ATL duration of epilepsy (p<0.003). The memory and quality-of-life outcomes did not differ between the group with a failed Wada memory test and the group who passed the Wada memory test. The results remained the same when analyses were repeated at various other cutoff points.

CONCLUSION

The patients with left MTLE-HS with concordant electroclinical, MRI, and neuropsychological data should not be denied ATL solely on the basis of Wada memory test results.

Dynamics of hemispheric dominance for language assessed by magnetoencephalographic imaging

OBJECTIVE

The goal of the current study was to examine the dynamics of language lateralization using magnetoencephalographic (MEG) imaging, to determine the sensitivity and specificity of MEG imaging, and to determine whether MEG imaging can become a viable alternative to the intracarotid amobarbital procedure (IAP), the current gold standard for preoperative language lateralization in neurosurgical candidates.

METHODS

MEG was recorded during an auditory verb generation task and imaging analysis of oscillatory activity was initially performed in 21 subjects with epilepsy, brain tumor, or arteriovenous malformation who had undergone IAP and MEG. Time windows and brain regions of interest that best discriminated between IAP-determined left or right dominance for language were identified. Parameters derived in the retrospective analysis were applied to a prospective cohort of 14 patients and healthy controls.

RESULTS

Power decreases in the beta frequency band were consistently observed following auditory stimulation in inferior frontal, superior temporal, and parietal cortices; similar power decreases were also seen in inferior frontal cortex prior to and during overt verb generation. Language lateralization was clearly observed to be a dynamic process that is bilateral for several hundred milliseconds during periods of auditory perception and overt speech production. Correlation with the IAP was seen in 13 of 14 (93%) prospective patients, with the test demonstrating a sensitivity of 100% and specificity of 92%.

INTERPRETATION

Our results demonstrate excellent correlation between MEG imaging findings and the IAP for language lateralization, and provide new insights into the spatiotemporal dynamics of cortical speech processing.

The neurobiology of cognitive disorders in temporal lobe epilepsy

Cognitive impairment, particularly memory disruption, is a major complicating feature of epilepsy. This Review will begin with a focus on the problem of memory impairment in temporal lobe epilepsy (TLE). We present a brief overview of anatomical substrates of memory disorders in TLE, followed by a discussion of how our understanding of these disorders has been improved by studying the outcomes of anterior temporal lobectomy. The clinical efforts made to predict which patients are at greatest risk of experiencing adverse cognitive outcomes following epilepsy surgery are also considered. Finally, we examine the vastly changing view of TLE, including findings demonstrating that anatomical abnormalities extend far outside the temporal lobe, and that cognitive impairments extend beyond memory function. Linkage between these distributed cognitive and anatomical abnormalities point to a new understanding of the anatomical architecture of cognitive impairment in epilepsy. Clarifying the origin of these cognitive and anatomical abnormalities, their progression over time and, most importantly, methods for protecting cognitive and brain health in epilepsy, present a challenge to neurologists.

History of neuropsychology through epilepsy eyes

In the 19th century, Hughlings Jackson relied on clinical history, seizure semiology, and the neurologic examination as methods for seizure localization to inform the first epilepsy surgeries. In the 20th century, psychological and neuropsychological tests were first employed as both diagnostic and prognostic measures. The contemporary practice of epilepsy evaluation and management includes neuropsychology as a critical component of epilepsy care and research, and epilepsy and neuropsychology have enjoyed a very special and synergistic relationship. This paper reviews how epilepsy has shaped the practice of neuropsychology as a clinical service by asking critical questions that only neuropsychologists were in a position to answer, and how clinical care of epilepsy patients has been significantly improved based on neuropsychology's unique contributions.

Preoperative endovascular brain mapping for intraoperative volumetric image guidance: preliminary concept and feasibility in animal models

Object

The authors describe a novel concept for brain mapping in which an endovascular approach is used, and they demonstrate its feasibility in animal models. The purpose of endovascular brain mapping is to delineate clearly the nonfunctional brain parenchyma when a craniotomy is performed for resection. The nonfunctional brain will be stained with sharp visual margins, differentiating it from the functional, nonstained brain. The authors list four essential criteria for developing an ideal endovascular mapping agent, and they describe seven potential approaches for accomplishing a successful endovascular brain map.

Methods

Four Sprague–Dawley rats and one New Zealand white rabbit were used to determine initial feasibility of the procedure. The animals were anesthetized, and the internal carotid artery was catheterized. Four potential brain mapping agents were infused into the right hemisphere of the five animals. Afterward, the brains were removed and each was analyzed both grossly and histologically.

Fluorescein and FD&C Green No. 3 provided good visual clarity and margins, but required blood–brain barrier (BBB) manipulation. Tantalum particles enabled avoidance of BBB manipulation, but provided inadequate visual clarity, probably because of their size. A Sudan black “cocktail” provided excellent clarity and margins despite remaining in the brain capillaries.

Conclusions

This is a novel application of the endovascular approach, and has broad potential for clinical neurosurgical brain mapping. The animal models in this study establish the feasibility of the procedure. However, further study is required to demonstrate safety, minimize toxicity, investigate stain durability, and improve the characteristics of potential mapping agents. The authors are planning to conduct future studies for identification of mapping agents that do not require BBB manipulation or vascular occlusion.

Memory performance during the intracarotid amobarbital procedure and neuropsychological assessment in medial temporal lobe epilepsy: the limits of material specificity

We investigated the relationship between material-specific memory performance elicited during the Wada test, or intracarotid amobarbital procedure (IAP), and classic neuropsychological assessment in 89 surgical candidates with refractory medial temporal lobe epilepsy (MTLE). The neuropsychological battery included measures of simple and complex verbal and visual memory, whereas the IAP material consisted of verbal and dually encodable stimuli. Neuropsychological testing revealed that reduced verbal memory performance was associated with left-sided MTLE, whereas visual memory tasks revealed no differences between patients with left-sided and right-sided MTLE. During IAP, memory performance was worse with the ipsilesional hemisphere, regardless of lesion side. Most importantly, performance on verbal memory tests was significantly, but moderately, correlated with left hemispheric IAP performance, indicating that memory tasks using verbal material are a valid marker of left hemispheric integrity in left language-dominant MTLE patients and significantly predict left hemispheric memory performance during IAP. In contrast, performance on classic visual memory tests is unrelated to right hemispheric IAP performance, suggesting that the currently used visual memory stimuli do not reflect right hemispheric sensitivity.

Clinical relevance of memory performance during Wada is stimulus type dependent

OBJECTIVES

This study aimed to investigate whether different types of memory stimulus provide different information during the Wada or intracarotid amytal procedure (IAP) in patients with refractory medial temporal lobe epilepsy (MTLE).

METHODS

Eighty nine surgical candidates with documented MTLE and selected for left hemispheric language dominance underwent memory assessment with verbal and dually encodable stimuli during a presurgical IAP.

RESULTS

The overall IAP memory performance with the left hemisphere is significantly better than with the right hemisphere regardless of lesion side. This can be explained by the left hemispheric advantage of encoding all stimuli, whereas the right hemisphere has only limited resources to encode verbal stimuli. More importantly, it appeared that dually encodable items remain more readily recognised following injection ipsilateral to the lesion, whereas verbal items are always better recognised following right hemisphere injection regardless of lesion side.

CONCLUSIONS

Verbal IAP stimuli show left hemispheric sensitivity in left language dominant MTLE patients. The dually encodable items of the IAP appear lesion sensitive.

Evaluating functional MRI procedures for assessing hemispheric language dominance in neurosurgical patients

Two methods of quantifying hemispheric language dominance (HLD) in neurosurgical patients are compared: (1) an average magnitudes (AM) method, which is a calculation of the average signal intensity variation in regions of interest for each patient that were predefined in a group analysis for each task, and (2) a lateralization indices (LI) method, which is based on the number of activated pixels in regions of interest predefined in each individual patient. Four language tasks [a living/nonliving (LNL) judgment, word stem completion (WSC), semantic associate (SA) and a phonological associate (PA) task] were compared with "gold standard" measures such as the Wada test or electrocortical stimulation. Results showed that the LI method was more accurate (73% agreement with gold standard methods) than the AM method (only 40% agreement) across tasks and subjects. Furthermore, by varying the threshold used for determining laterality, the ability of functional magnetic resonance imaging (fMRI) to predict HLD was influenced for the AM method, whereas the LI method was relatively unaffected by changing the threshold. Using the LI method, the SA task was the most accurate for quantifying HLD (100% agreement with gold standard methods) with respect to the other three language tasks (80% accuracy for WSC, 65% for the LNL and 63% for phonological task). Depending on the method and the task, fMRI may be a promising tool for assessing HLD in neurosurgical patients.

Prediction of Verbal Memory Decline after Epilepsy Surgery in Children: Effectiveness of Wada Memory Asymmetries

PURPOSE

Differences in Wada memory performance after left and right amobarbital injection are powerful predictors of pre- to postoperative memory change among adult epilepsy patients after anterior temporal lobectomy. It is unknown, however, whether these Wada memory asymmetries apply to children who undergo focal cortical resection or to epilepsy surgery patients who undergo resection outside the temporal lobes.

METHODS

To investigate these issues, Wada memory asymmetries and pre- to postoperative neuropsychological memory test performances were examined in 132 children who underwent some form of resective epilepsy surgery. Ninety-three (70%) children showed Wada memory asymmetries in the predicted direction (memory after injection ipsilateral to side of surgery better than memory after contralateral injection), and 39 (30%) did not.

RESULTS

Children with Wada memory asymmetries showed significant improvement in verbal memory after surgery as compared with children without Wada memory asymmetries who showed significant verbal memory decline. This result was also obtained when individual cases were examined: 77% of children with Wada memory asymmetries in predicted direction showed no verbal memory decline after surgery, whereas 80% of children without asymmetries had lower postoperative verbal memory (passage recall) test scores. Wada memory asymmetries had no value in predicting postoperative changes in visual-spatial memory.

CONCLUSIONS

Wada memory asymmetries may be used as one of the factors to assess risk for verbal memory decline after epilepsy surgery in children.

Wada memory performance predicts seizure outcome after epilepsy surgery in children

PURPOSE

Wada memory asymmetries were examined in children from four comprehensive epilepsy surgery centers who subsequently underwent epilepsy surgery to determine whether Wada memory performance could predict degree of seizure relief in children.

METHODS

One hundred fifty-six children (between ages 5 and 16 years) with intractable epilepsy underwent Wada testing before resective epilepsy surgery (93 within the left hemisphere, and 63 within the right hemisphere). Memory stimuli were presented soon after intracarotid amobarbital injection, and recognition memory for the items was assessed after return to neurologic baseline. Eighty-eight children underwent unilateral temporal lobe resection, and 68 had extratemporal lobe resections. One hundred four (67%) children were seizure free (Engel class I), and 52 (33%) were not seizure free (Engel classes II-IV) at follow-up (mean follow-up interval, 2.3 years).

RESULTS

Seizure-free children recalled 19.3% more Wada memory items after ipsilateral injection than did non-seizure-free children (p = 0.008). If analysis was restricted to youngsters with temporal lobectomies (TLs), seizure-free children recalled 27.7% more items after ipsilateral injection than did non-seizure-free TL children (p = 0.004). With regard to individual patient prediction, 75% of children who had memory score asymmetries consistent with the seizure focus were seizure free. In contrast, only 56% of children whose memory score asymmetries were inconsistent with the seizure focus were seizure free (p = 0.01).

CONCLUSIONS

Results suggest that Wada memory performance asymmetries are related to the degree of seizure relief after epilepsy surgery in children and adolescents.