Seizure-like activity during etomidate-modified Wada test interfere with the evaluation of cognitive functions?

Abstract

846Letters by the tumor mass, such as anterior pituitary dysfunctions, visual field alterations, cephalalgia and ophthalmoplegia [1][2][3][4] , the last two present in this patient. The association of ophthalmoplegia and cephalalgia is described as a sign of probable metastasis 5 . Pituitary metastases are rare, but should be included in the differential diagnosis of invasive sellar lesions, especially if associated with ophthalmoplegia, ptosis and DI. The intracarotid amobarbital procedure (IAP), known as "Wada-test" is a useful tool in the investigation of patients who are candidates for temporal lobectomy or amygdala-hippocampectomy. Etomidate is a viable alternative to amobarbital. However, may induce epileptiform activity. We report on the emergence of irritative activity in epilepsy surgery candidates, during a modified Wada procedure using etomidate, and discuss this finding based on available literature 1-4 . REFERENCESCASE Case 1 -35-year-old female with uncontrolled secondarily generalized seizures since the age of 14 years. Her magnetic resonance images (MRI) revealed right hippocampus sclerosis, and her video-EEG disclosed left-sided temporal interictal intermittent delta activity (TIRDA) and spiking, and an epileptogenic zone at the anterior aspects of the left temporal lobe. On the e-SAM shortly after etomidate injection on the right internal carotid artery there was slowing of the EEG tracing on the right hemisphere, associated with repetitive rhythmic sharp theta activity (Fig 1A). The patient remained hemiplegic on the contralateral side for four minutes, and the EEG recovered its original features 1.5 minutes after motor strength recovery (Fig 1B). When the study was performed on the left side the same abnormal features on EEG tracing were observed right after injection (Fig 1C). Memory and language cognitive tests were performed on both sides under abnormal EEG tracings and there were no signs of compromise of the neuropsychological evaluation as a consequence of the observed irritative EEG activity triggered by etomidate.Case 2 -A 58 years-old female, suffered from seizures since the age of 34 years. Her MRI had disclosed a right-sided hippocampus sclerosis. An interictal SPECT had revealed a left temporal lobe hypoperfusion. Her Video-EEG recordings showed a right temporal interictal intermittent delta activity, and the recorded seizures revealed an anterior right temporal lobe epileptogenic zone. After etomidate injection on the left side, a slowing of the EEG background activity with associated TIRDA activity ensued on the ipsilateral hemisphere (Fig 2A). The patient remained hemiplegic on the contralateral side and aphasic for 7.5 minutes. Her EEG tracing, however, remained abnormal for a further minute after motor strength and speech normalization. When etomidate was injected in the right side an ipsilateral irritative activity was observed (Fig 2B) and remained during the

Tolerability of Propofol in WADA Testing (P01.051)

“… 3 Moreover, it has been reported to cause interictal epileptiform activity. 17 In addition, it puts patients at risk of adrenal suppression especially if critically ill. 30 , 31 …”

“…Since SA was not available, PF was chosen as an alternative, based on efficacy, safety profile, feasibility, potential side-effects, and several studies in the literature pertaining to the usage of PF in Wada. 10 - 17 The manufacturer of PF is AstraZeneca, London, England, United Kingdom. The procedure was carried out by a team that included an interventional neurologist, epileptologist, and a neuropsychologist.…”