Copyright Ó Blackwell Munksgaard 2005

Acta Neurol Scand 2005: 112: 189–191 DOI: 10.1111/j.1600-0404.2005.00459.x

ACTA NEUROLOGICA
SCANDINAVICA

Clinical commentary

Endovascular ablation of a temporal lobe
epileptogenic focus – a complication of
Wada testing
Ammerman JM, Caputy AJ, Potolicchio SJ. Endovascular ablation of a
temporal lobe epileptogenic focus – A complication of Wada testing.
Acta Neurol Scand 2005: 112: 189–191 Ó Blackwell Munksgaard 2005.
The authors report on a patient with a long history of medically
refractory temporal lobe epilepsy. During pre-operative evaluation for
anterior temporal lobectomy he underwent a Wada test for speech and
memory lateralization. During the procedure, he suffered a focal
cerebral infarct, within the right medial temporal lobe, at the site of the
epileptic focus. This resulted in the resolution of his seizure disorder.
The possibility of endovascular management of seizure disorders of
the temporal lobe should be investigated further as a potentially
minimal invasive therapeutic option for medically intractable
epilepsy.

J. M. Ammerman1, A. J. Caputy1,
S. J. Potolicchio2
Departments of 1Neurological Surgery and 2Neurology,
George Washington University School of Medicine,
Washington, D.C., USA
Key words: endovascular; epilepsy; stroke; seizure;
temporal lobe
Joshua M. Ammerman, 2150 Pennsylvania Ave., NW
Washington, DC 20037, Suite 7-420, USA
Tel.: 202 741 2735
Fax: 202 364 4362
e-mail: jammerm@gwu.edu
Accepted for publication May 25, 2005

The modern era of epilepsy surgery began in the late
19th century with the work of Macewen and Horsley
(1, 2). Since that time, the efficacy and safety of the
surgical management of epilepsy has been dramatically refined with the development of modern
neuro-anesthesia, electrophysiologic monitoring,
microsurgical techniques and ever improving
neuro-imaging modalities. More recently, surgical
resection has been shown to be particularly effective
for drug-resistant temporal lobe epilepsy (3). Noninvasive ablative techniques, such as stereotactic
radiosurgery, for control of seizure disorders have
also been investigated and applied (4, 5). However,
control of epileptogenic foci via the endovascular
route has not previously been investigated. To the
authorsÕ knowledge this is the first report of endovascular control of temporal lobe epilepsy.

Case report
History

A 17-year old left-handed male with medically
intractable epilepsy was evaluated at the George
Washington University epilepsy center, as a potential candidate for epilepsy surgery. He has suffered
from seizures since age 5. At that time he began to

report intermittent visual disturbances, consisting of
a passing image of a Ôpurple animal with ferris wheels
for feet.Õ At age 13, he had an episode of confusion
and global amnesia lasting 3–5 min firmly establishing his diagnosis of epilepsy. In January 2000 he
suffered his first generalized tonic-clonic seizure. He
has continued to have seizures, approximately once
per month. His episodes consist of staring spells
associated with hand wringing, which progressed to
a generalized convulsion lasting 4–5 minutes, followed by prolonged post-ictal confusion. The seizures have been refractory to medical management.
Previous medications included Depakote, Lamictal
and Topomax. His current regimen consists of
Dilantin and Tegretol. There is no past history of
traumatic brain injury or febrile seizures. His mother
also suffers from an unspecified seizure disorder.
Examination

General medical and neurologic examinations were
within normal limits and without focal findings.
Neuropsychologic testing showed him to be of
average intelligence, currently performing at the
sixth grade level. Verbal IQ was 82 with a performance IQ of 81; both in the low average range. Verbal
memory was found to be in the normal range with
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Ammerman et al.

Figure 1. T2-weighted coronal MRI of the brain demonstrating increased signal within the right amygdale consistent with
sclerosis.

Figure 2. Non-contrast CT scan of the head showing hypodensity in the area of the right mesial temporal lobe.

Inpatient telemetry with, video electroencephalography (EEG) monitoring off antiepileptic medications confirmed his stereotypic seizure and defined
the right temporal lobe as the origin of the
discharges. A magnetic resonance imaging (MRI)
of the brain, with and without gadolinium
enhancement, was obtained and demonstrated
increased T2-weighted signal within the right
amygdala, consistent with sclerosis (Fig. 1).

Lilly Co., Indianapolis, IL, USA) was used. Two
injections were necessary on each side due to the
short half-life of the agent. Near the end of the
procedure, the EEG monitoring began to show
right-sided periodic lateralizing epileptiform discharges, which progressed into a generalized convulsive episode. An immediate non-contrast
computed tomography scan of the head was
obtained demonstrating decreased signal in the
right medial temporal lobe (Fig. 2). The patient was
readmitted to the telemetry-monitoring unit where
his neurologic examination remained normal without evidence of visual, sensory, motor or cerebellar
dysfunction. No further clinical evidence of seizure
activity was noted. Mild slowing on the EEG was
noted over the right temporal lobe that returned to
baseline prior to discharge. He was discharged to
home the next day and continued on his preprocedural medication regimen.

Procedure

Post-procedure course

The patient was readmitted to the hospital
3 months later for Wada testing, in preparation
for right anterior temporal lobectomy. The epilepsy
team felt it was critical to define hemispheric
dominance for both speech and memory given his
left-handedness and poor memory performance on
neuropsychological testing. He was taken to the
interventional neuroradiology suite and the Wada
test, with selective middle cerebral artery injection,
was performed under video EEG monitoring. A
dose of 2.6–3.0 cc (1 mg/cc concentration diluted in
normal saline) per injection of methohexital (Eli

The patient returned in follow-up 3 weeks postprocedure. At that time an MRI of the brain with
and without gadolinium enhancement was
obtained, demonstrating a 1-cm area of enhancement in the right amygdala and uncus, consistent
with a completed infarct (Fig. 3). He has subsequently undergone repeat neuropsychologic testing
which shows no decrement in speech or memory
function and is unchanged from his pre-procedural
evaluation. At his last follow-up evaluation,
11 months after his endovascular procedure, he is
seizure free on a regimen of Dilantin and Tegretol.

moderately impaired visual spatial memory as
demonstrated by his poor performance on the
Rey-Osterrieth Complex Figure reproduction. He
also demonstrated mild dysfluency with difficulties
primarily in word retrieval.
Neuroimaging and functional studies

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Endovascular control of epilepsy
Peri-procedural complications in the past have
led to the development of new therapeutic options
such as Cooper’s inadvertent ligation of the anterior choroidal artery and subsequent control of
Parkinson’s disease (11). It is possible that in the
future selective, controlled endovascular techniques may be used to embolize the supply to
precise areas of the temporal lobe and thereby
ablate an epileptogenic focus.
Conclusion

There continues to be significant evolution of the
surgical management of temporal lobe epilepsy.
Endovascular techniques aimed at a controlled
ablation of epileptogenic foci should be investigated further as a minimally invasive option for the
treatment of seizure disorders.

Figure 3. Gadolinium-enhanced T1-weighted axial MRI of the
brain demonstrating a 1-cm area of enhancement within the
right mesial temporal lobe consistent with a completed infarct.

Discussion

Since 1948 when Dr Juhn Wada first observed the
temporary effects of intracarotid Amytal (amobarbital) injection, its utility in the evaluation of
cerebral dominance and memory lateralization
have been well documented (6, 7). Many epilepsy
centers routinely employ selective middle cerebral
artery barbiturate injection in their preoperative
evaluation of patients with temporal lobe epilepsy.
The neurologic complications of Wada testing
have been well documented in the literature. These
include stroke, seizure, retinal artery occlusion,
and emotional liability (8, 9). The patient presented
here suffered a radiographically documented
stroke during his Wada testing. The most likely
etiology for this infarct is catheter emboli, a wellknown complication of cerebral angiography,
occluding a small perforating branch of the anterior choroidal artery (10). It is unlikely that the
anterior choroidal artery itself was occluded given
that the remainder of its vascular territory (i.e.,
globus pallidus, internal capsule, and optic tract)
was uninvolved either clinically or radiographically. Following this event the patient suffered
no neurologic decline and is now fortuitously
seizure free.

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