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Can the Wada test evaluate mesial temporal function?

A SPECT study

From the Departments of Nuclear Medicine (Drs. Setoain, Lomeña, Pavía, Pareto, Fuster, Fuertes, and Pons), Neurology (Dr. Arroyo), Neuropsychology (Dr. Boget), Radiology (Dr. Bargalló), and Neurosurgery (Dr. Rumià), Hospital Clínic of Barcelona, University of Barcelona, Spain.

Address correspondence and reprint requests to Dr. Xavier Setoain, Hospital Clinic de Barcelona, Nuclear Medicine, C/Villaroel 170, Barcelona 08036, Spain; e-mail: setoain{at}clinic.ub.es

Objective: To assess the value of SPECT during intracarotid amobarbital procedure (IAP) to discriminate which patients performed the test with the hippocampus inactivated and correlate it with the risk of amnesia after anterior temporal lobectomy (ATL).

Methods: The authors studied 40 consecutive patients undergoing ATL for refractory epilepsy. SPECT was performed after IV injection of 99mTc-HMPAO during the IAP (IAP-SPECT). Interictal SPECT and IAP-SPECT were realigned to obtain the perfusion change percentage (PCP), allowing a quantitative measurement. Wechsler Memory Scale Revised (WMS-R) before and during the first year of follow-up was used to assess memory impairment after surgery.

Results: A decrease between 10 and 12% of the mean PCP values was observed in the frontal, parietal, and lateral temporal lobes of the injected side and in the contralateral cerebellum. However, no significant PCP changes were observed in the occipital or mesial temporal lobes. Thirty-eight passed the memory evaluation of the IAP and in 6 of those 38 patients a decline in memory was demonstrated 1 year after ATL. However, high preoperative neuropsychological score (in two patients) and IAP asymmetry scores (in other three patients) predicted postoperative memory risk in five of these six patients. Fourteen of the 38 patients (40%) had hypoperfusion of the hippocampus during the IAP-SPECT (i.e., the hippocampus was inactivated) and only 1 of these 14 patients (2.5%) developed memory impairment after temporal lobectomy. On the other hand, 5 of the 24 patients (13%) who had a functional hippocampus on IAP-SPECT developed memory impairment.

Conclusions: The results suggest that the combination of SPECT, intracarotid amobarbital procedure, and neuropsychological testing predicted risk for all patients who had postoperative memory decline, indicating that risk prediction should be based on multiple factors. IAP-SPECT results demonstrated that the hippocampus is not inactivated in over 60% of patients and that the lack of accuracy of the IAP alone in predicting the risk of amnesia is probably related to an insufficient inactivation of the ipsilateral hippocampus during the test.

Received August 28, 2003. Accepted in final form February 23, 2004.