The safety and efficacy of propofol as a replacement for amobarbital in intracarotid Wada testing of presurgical patients with epilepsy.

OBJECTIVE: The intracarotid sodium amytal procedure (the "Wada test") has for many years been the gold standard for language and memory lateralization and remains an important part of presurgical analysis for patients with medically intractable seizures. Due to shortages in the key sedative (amobarbital), neuropsychologists have turned to alternatives such as propofol. Our aim was to investigate the safety and efficacy of propofol relative to amobarbital in the Wada test. METHODS: We performed a retrospective review of the 97 Wada procedures performed at University of Iowa Hospitals and Clinics from 2007 through mid-2015. RESULTS: Propofol produced similar lateralization rates as amobarbital for both language and memory. Similar rates of patients in each group went on to have the resection surgery. With regard to safety, there were no differences found in average rate or severity of adverse effects. None of the demographic characteristics reviewed were predictive of increased risk for either drug. SIGNIFICANCE: These findings support previous studies indicating that propofol is as safe and efficacious as amobarbital, and can continue to be used in Wada procedures with confidence.

Case report: Death associated with stroke following intracarotid amobarbital testing.

OBJECTIVE: One previous accidental death during intracarotid amobarbital testing (IAT) associated with cerebral angiography (CA) has been reported in the literature. The objectives of this article are to briefly review morbidity and mortality risks for patients undergoing diagnostic CA and to describe a case with a fatal outcome. METHOD: The case of a 38-year-old man who had a right middle cerebral artery stroke while undergoing IAT is described. The patient was not high risk by Centers for Medicare and Medicaid Services criteria or invasive procedures; neither did he have risk factors for embolic stroke. CONCLUSIONS: A problem noted is that IAT procedures vary from center to center and that IAT may increase the risk for individual patients because of differences between IAT and other CA interventions.

Carbonic anhydrase-inhibiting medications and the intracarotid amobarbital procedure in children.

The intracarotid amobarbital procedure (IAP) is routinely conducted as part of the presurgical evaluation of pediatric patients with epilepsy. The aim of the present study was to investigate the possibility that anesthetization failures are the result of interactions of carbonic anhydrase-inhibiting (CAI) medications with sodium amobarbital. An archival review of 81 cases conducted between 1999 and 2008 was performed across two pediatric epilepsy centers. chi(2) analysis was used to assess whether CAI medications interfered with the outcome of these procedures. Of 81 patients, 85.2% had conclusive findings. All of the remaining 14.8% with anesthetization failures were taking CAI medications at the time of the procedure. However, 53.8% of patients taking CAI medications had conclusive results. This suggests that these medications may interact with sodium amobarbital, raising the possibility of anesthetization failures in children prescribed CAI medications.

Intracarotid propofol testing: a comparative study with amobarbital.

Twenty-five consecutive patients who underwent the Wada test using propofol as anesthetic were compared with 15 randomly selected patients who were tested using amobarbital. Time to verbal and nonverbal responses and time to motor power 3/5 did not differ between the two groups (P>0.05). The number of doses received by each patient and the percentage of patients needing more than one dose were significantly greater in the propofol group (P<0.005). Only one patient developed confusion, combativeness, and agitation. Despite the need for multiple doses, our patients had no residual drowsiness within 10 to 15 minutes of the propofol injection. This allowed us to perform the test on both sides on the same day separated only by 45 minutes. Propofol is an effective alternative to amobarbital in the Wada test, and may be used successfully in multiple repeated injections within the same test without significant residual sedation or significant adverse effects.

Complications during the Wada test.

OBJECTIVE: The intracarotid amobarbital procedure (IAP) is routinely used in the preoperative workup of patients with epilepsy. We previously reported dissections and seizures as complications of this procedure and now have reviewed our cohort for additional complications associated with the IAP. METHODS: Charts of 677 consecutive patients were reviewed for complications during the IAP. RESULTS: Complications were observed in 74 patients (10.9%) and included encephalopathy (7.2%), seizures (1.2%), strokes (0.6%), transient ischemic attacks (0.6%), localized hemorrhage at the catheter insertion site (0.6%), carotid artery dissections (0.4%), allergic reaction to contrast (0.3%), bleeding from the catheter insertion site (0.1%), and infection (0.1%). Older patients were more prone to strokes and dissections, whereas younger patients more frequently experienced seizures. Use of amobarbital was associated with encephalopathy, whereas methohexital was related to seizures. CONCLUSION: The IAP bears the risk of minor and major complications in up to 11% of patients. Risks, benefits, and possible alternative options have to be considered when a patient is to undergo the IAP.

Seizures during intracarotid methohexital and amobarbital testing.

BACKGROUND: Methohexital and amobarbital have been used as agents for Wada testing in the presurgical evaluation of patients with epilepsy. Previous experience with methohexital as an anesthetic indicates that methohexital may decrease seizure threshold and may trigger seizures. METHODS: A retrospective chart review of 760 intracarotid amobarbital and methohexital tests was performed to determine the frequency of seizures associated with preoperative intracarotid barbiturate testing for language and memory lateralization. RESULTS: Sixteen patients (2.1%) who had seizures were found. In 3 patients, seizures occurred prior to barbiturate injection, and in 13, following barbiturate injection. After injection of amobarbital, 4 of 538 patients (0.7%) had a seizure. Nine of 222 patients had a seizure after methohexital injection (4.1%) (P=0.001). CONCLUSION: Patients with a previous history of epilepsy may be at higher risk for seizures after methohexital injection as compared with amobarbital injection.

Safety of cerebral digital subtraction angiography in children: complication rate analysis in 241 consecutive diagnostic angiograms.

BACKGROUND AND PURPOSE: Catheter-based cerebral angiography remains an important diagnostic tool in the pediatric population, particularly considering the currently growing interest in diagnosing and treating cerebrovascular disorders in children. There are no recent estimates of the complication rate associated with modern diagnostic digital subtraction angiography (DSA) in the pediatric population. The purpose of this study was to estimate the rate of complications occurring during cerebral angiography in children. METHODS: Data from 241 consecutive pediatric cerebral angiograms performed at a single institution were entered into an institutional review board-approved database. Information on patient demographics, DSA indication, neurovascular diagnosis, and intra procedural and postprocedural complications was collected. RESULTS: Our population included 115 boys and 90 girls, with age ranging from 1 week to 18 years (mean+/-SD, 12+/-5 years). All angiograms were technically successful. No intraprocedural complication was noted; in particular, there was no occurrence of iatrogenic vessel injury (dissection) and no transient or permanent neurological deficit secondary to a thromboembolic event. One child with a complex dural arteriovenous fistula experienced a fatal intracranial rehemorrhage secondary to a posterior fossa varix rupture 3 hours after completion of an uneventful diagnostic angiogram. The rates of intraprocedural and postprocedural complications were therefore 0.0% (95% CI, 0.0% to 1.4%) and 0.4% (95% CI, 0.012% to 2.29%), respectively. CONCLUSIONS: The rate of immediate complications occurring during diagnostic cerebral angiography in children is very low. No intraprocedural complication was documented in the reported series. DSA performed by experienced angiographers is a safe procedure that can provide critical diagnostic information.

[Attempted suicide with barbiturates purchased online]. / Tentamen suicidii met barbituraten van internet.

BACKGROUND: Barbiturate intoxication is potentially lethal. With the availability of the newer anticonvulsants the use of barbiturates in treating epilepsy has decreased significantly, with a concurrent decrease in the incidence of overdose with these medications. There have, however, been recent alarm signals from governmental sources concerning the increase in the Internet purchase of illegal medications, including barbiturates, for use in attempted suicide. CASE DESCRIPTION: Here we describe two patient cases involving barbiturate intoxication with amobarbital and thiopental, respectively. They had both obtained the barbiturates via the Internet. Both patients were comatose and showed signs of respiratory depression; one of them was also haemodynamically unstable. Both patients recovered fully following intensive supportive therapy. CONCLUSION: In patients with coma, respiratory depression, absence of brainstem reflexes and shock with no evident cause one should be aware of the possibility of barbiturate intoxication, even when there is no indication that these have been prescribed or that the patient has direct or indirect access to barbiturates. Prompt, optimal supportive therapy will give a good chance of full somatic recovery.

A comparison of high- and low-dose lorazepam with amylobarbitone in patients with anxiety states.

A double-blind crossover trial comparing lorazepam at two dosage levels with amylobarbitone supported previous reports of the effective anxiolytic action of the drug. Evaluation of the patients' responses during each week of treatment was based on a physician's weekly rating and on daily self-rating by patients. The results were analyzed by sequential and nonsequential analyses. The main side effect of the drug was drowsiness, which occurred to a clinically significant degree among the high-dose group of patients. The authors emphasize the value of two dosage trials, particularly in devising subsequent flexible individual treatment regimens.

Severe behavioral complications following intracarotid sodium amobarbital injection: implications for hemispheric asymmetry of emotion.

The intracarotid sodium amobarbital (ISA) procedure is effective in determining cerebral language dominance. However, severe emotional and behavioral reactions during ISA evaluation may invalidate the results or necessitate aborting the procedure. In an effort to identify patients at risk for behavioral complications, we reviewed 92 patients undergoing ISA evaluation and found five with severe changes in affect and behavior following amobarbital injection, ranging from prolonged coma to an extended confusional state. Severe behavioral disturbances were more likely to occur in patients with left frontal structural lesions upon injecting amobarbital into the right hemisphere. Analysis of patients with structural lesions of the anterior regions of the right hemisphere showed no evidence of similar behavioral complications. These findings suggest a special role for the left frontal region in the inhibition of affective expression and provide further evidence of the importance of right hemisphere mechanisms in emotion.

Carotid artery dissection after the intracarotid amobarbital test.

A retrospective chart review of 435 consecutive intracarotid amobarbital tests (IAT) was performed to determine the frequency of carotid artery dissection (CAD) associated with IAT. Three patients with a CAD were found (0.7%). Mean age of patients with dissection (51.3 years) was higher than the average age of 432 patients without dissection (31.7 years) (p < 0.05). All patients had clinical symptoms including face or neck pain. Patients undergoing the IAT are at risk of CAD. Age may be a risk factor.

Emotional outbursts and post-traumatic stress disorder during intracarotid amobarbital procedure.

Severe emotional outbursts (SEOs) during intracarotid amobarbital procedures (IAP) rarely jeopardize preoperative language and memory testing. Four of four patients (100%) with outbursts had experienced significant emotional trauma (three were raped and one witnessed a decapitation), compared with 26 of 546 patients (4.8%) without outbursts (chi2 = 69.8, p < 0. 0001). Evocative injections were ipsilateral to seizure focus. IAP may disrupt emotional balance in some traumatized patients. Counseling may prevent SEOs.

Selective posterior cerebral artery injection of amytal: new method of preoperative memory testing.

The carotid Amytal test (Wada test) was introduced, in 1948 by Wada, to localize speech function before temporal lobectomy in patients with medically refractory epilepsy, and it remains the standard for that purpose. The same test has also been used since 1962 to evaluate memory function; however, the adequacy of the test in this application has been viewed with increasing skepticism in recent years. Therefore, we developed an alternative to the Wada test. It consists of selective injection of Amytal into the posterior cerebral artery (PCA). This PCA Amytal test is designed to test only memory function (not language). We present several anatomic and functional reasons why this approach should be superior to the Wada test for this purpose. We also present preliminary data in support of this hypothesis. To date, we have had successful results of the PCA Amytal test in 38 of 45 patients (84%), and one major complication has occurred (2%).

Efficacy and side effects of flurazepam and a combination of amobarbital and secobarbital in insomniac patients.

Flurazepam, 30 mg, was not more effective in inducing sleep than placebo. Barbiturates (100 mg amobarbital plus 100 mg secobarbital) were more effective in inducing and maintaining sleep than flurazepam or placebo. Contrary to work conducted in the sleep laboratory, the barbiturate hypnotics were still effective on the 14th night. Insomniacs performed poorly on psychomotor tests, but as a group they did not show statistically significant psychomotor impairment after the use of the hypnotics.

Effectiveness and processes of interviewing with drugs.

A triple-blind study was made on forty-nine patients in regard to differences between sodium amobarbital, hydroxydione, methamphetamine and saline when used in psychiatric interviews. The drugs were found to differ from each other and from the placebo in their effects upon patients' speech, direction of attention and on anxiety. Other factors studied were not differentially affected by the drugs and placebo. Observers were able to identify correctly the drugs from observations, but two of the drugs, hydroxydione and sodium amobarbital, were often indistinguishable. Significant differences between judges' abilities to identify the drugs were also observed. Reports of the patients 24 h after the interviews reflected several significant differences between the drugs and placebo in changes in subjective feelings and attitudes. Such changes were reported more often with methamphetamine and sodium amobarbital than with hydroxydione or placebo. Implications of the study were discussed and suggestions for further research given.

Severe negative emotional reactions in intracarotid sodium amytal procedures: further evidence for hemispheric asymmetries?

Intracarotid sodium amytal (ISA) procedures are commonly used to determine the lateralization of language and memory functions in presurgical evaluation of epileptic patients. Besides, they provide a means for studying putative hemispheric asymmetries in the organization of emotional behavior. In this study, we report the incidence of negative emotional reactions in eighty epileptic patients undergoing ISA procedures as a part of presurgical evaluation. There were only four such reactions in a total of 159 tests (2.5%), all in right-handed patients with left cerebral dominance for language functions. In one case, emotional outbursts occurred with barbiturization of the nondominant hemisphere. This observation invalidates the hypothesis that a loss of left-hemispheric functions generally leads to negative emotional reactions due to a right hemisphere specialization for the processing of negative emotions. Rather than pointing to fixed hemispheric asymmetries, our findings suggest that severe negative emotional reactions result from a flexible cognitive evaluation of the organism's overall situation.

Memory for objects presented early after intracarotid sodium amytal: a sensitive clinical neuropsychological indicator of temporal lobe pathology.

Results from a simple test of post-recovery recognition of objects presented immediately after intracarotid sodium amytal (ISA) injection were compared with those obtained using the 'Montreal' anterograde memory test procedure of post-recovery recognition of items presented later after injection in 16 patients with unilateral temporal lobe pathology undergoing routine bilateral ISA testing prior to epilepsy surgery. All 16 patients were given both memory tests following injection on both sides. Significantly fewer 'early objects' were recognized when injection was contralateral to pathology than when injection was ipsilateral to pathology (i.e. contralateral to an intact hemisphere), whereas there was no significant difference in the number of 'Montreal' anterograde items recognized regardless of side of pathology. Memory for objects presented early after ISA appears to be a sensitive measure although its potential as a valid indicator of temporal lobe pathology needs to be further refined.

Lateralized memory deficits on the Wada test correlate with the side of lobectomy only for patients with unilateral medial temporal lobe epilepsy.

The aim of this study was to determine whether the predictive value of the intracarotid amobarbital test (IAT) for the side to be resected is applicable only to medial temporal lobe epilepsy and to investigate whether there are different patterns of memory performances on the IAT between patients with unilateral mesial temporal sclerosis (UMT group) and those without (non-UMT group). We studied 30 patients in the UMT group and 10 in the non-UMT group, who underwent pre-surgical evaluation for intractable temporal lobe epilepsy. Memory performances on the IAT was defined as the percentage of memory items presented during unilateral hemispheric anesthesia that was recognized after recovery. More than a 20% decline of the memory performance on the IAT compared with the memory performance on the pre-test was regarded as a memory deficit. Age at onset of epilepsy was significantly younger in the UMT than in the non-UMT group. Surgical outcome was significantly better in the UMT than in the non-UMT group. The lateralizing value of unilateral memory deficits on the IAT was statistically confirmed. There was a significant association between falsely lateralizing memory performances and the non-UMT group. Excluding the exceptional cases with right-sided language dominance in spite of right-sided lesions, the high incidence of the unilateral right-sided memory deficits in the non-UMT group was statistically significant. This study suggested that the excellent lateralizing value of the memory performances on the IAT is limited to patients with mesial temporal lobe epilepsy. IAT memory performances in patients without such lesions can be misleading, even if lateralized, because their memory status presumably reflects a natural lateralization of the memory organization which is independent of the epileptogenic focus.

A clinical trial of temazepam, a sleep inducer, in hospital patients.

Temazepam, a common metabolite of diazepam and oxazepam, was evaluated as a sleep inducer. A dose of 20 mg, in a Scherer capsule formulation, was compared with 200 mg of amylobarbitone sodium in a between-patients, randomized study. Patient and staff assessments were used. No statistically significant difference as to onset of sleep, duration or quality of sleep or morning drowsiness was found using the patients' assessments. The staff recorded significantly less daytime dozing and morning hangover in patients receiving temazepam. Side-effects were mild and confined mainly to drowsiness on awakening. Two patients, both on amylobarbitone sodium, withdrew from the study because of increasing confusion.

Bizarre behavior during intracarotid sodium amytal testing (Wada test): are they predictable?

The intracarotid sodium amytal test (ISAT or Wada Test) is a commonly performed procedure in the evaluation of patients with clinically refractory epilepsy candidates to epilepsy surgery. Its goal is to promote selective and temporary interruption of hemispheric functioning, seeking to define language lateralization and risk for memory compromise following surgery. Behavioral modification is expected during the procedure. Even though it may last several minutes, in most cases it is subtle and easily manageable. We report a series of patients in whom those reactions were unusually bizarre, including agitation and aggression. Apart of the obvious technical difficulties (patients required physical restraining) those behaviors potentially promote testing delay or abortion and more importantly, inaccurate data. We reviewed those cases, seeking for features that might have predicted their occurrence. Overall, reactions are rare, seen in less than 5% of the ISAT procedures. The barbiturate effect, patients' psychiatric profiles, hemisphere dominance or selectiveness of the injection were not validated as predictors. Thorough explanation, repetition and simulation may be of help in lessening the risk of those reactions.