Le test mis au point par Juhn Wada fait partie des explorations réalisées dans le bilan préchirugical des épilepsies partielles pharmaco-résistantes, pour identifier les patients qui risqueraient de ...présenter des troubles phasique ou mnésiques en postopératoire. Par ailleurs, les résultats du test ont également été utilisés dans la démarche de localisation de la zone épileptogène et d’évaluation des chances de succès de la chirurgie sur le plan épileptologique. Le test de Wada reste-t-il-utile aujourd’hui ? Peut-il être remplacé par des explorations moins invasives ? Dans cet article, nous avons examiné la littérature récente pour tenter de déterminer quelle est la valeur de cet examen dans la stratégie actuelle des explorations préchirurgicales des patients souffrant d’une épilepsie partielle pharmaco-résistante.
Juhn Wada developed a test while in Montreal designed to definitively confirm hemispheric lateralization of speech in candidates for surgical treatment of epilepsy. By unilateral intra-carotid administration of a bolus of a general anesthetic, clasically sodium amobarbital, function can be tested in the non-injected hemisphere, while the injected side is dysfunctional. The test has been expanded to test memory functions in the hemisphere (temporal lobe) contralateral to expected surgery (memory reserve) in the hope of contra-indicating surgery that may result in global amnestic syndromes (patient HM). Conversely, risk of material-specific memory loss following surgery can be assessed by testing memory in the hemisphere/temporal lobe to be operated (‘functional adequacy’). Memory dysfunction, when concordant with EEG seizure onset and chosen side of temporal lobe surgery has also been shown to correlate with favourable post-operative seizure outcome. Nevertheless, the test remains invasive, requiring an angiogramme. Non-invasive alternatives such as fMRI and PET and their reported reliability compared to a Wada test are discussed. A world-wide shortage of amobarbital has led to the use of some other anesthetic agents. Overall, the indications for the test and the manner in which it is performed vary greatly from one institution to the next. It is used almost systematically in some institutions and very rarely in others. Future perspectives are discussed.
Wrodzona wada rozwojowa jest to zewnętrzne lub wewnętrzne morfologiczne odchylenie od prawidłowego rozwoju. Najczęstszymi przyczynami powstawania wady są czynniki genetyczne i środowiskowe. Znaczna ...część wad ma etiologię wieloczynnikową (50%). Wady rozwojowe mogą występować jako zaburzenia izolowane lub też tworzyć zespoły wad. Wady układu moczowego mogą dotyczyć liczby, wielkości, kształtu i położenia nerek oraz budowy miąższu samej nerki. Wady w układzie płciowym dotyczą głównie wad rozwojowych pochwy i macicy. Celem pracy jest przedstawienie przypadku późnego rozpoznania złożonej wady układu moczowo-płciowego pod postacią zdwojenia pochwy i macicy oraz agenezji nerki prawej. Wadom układu moczowego często towarzyszą wady układu płciowego. Jedną z częściej występujących wad rozwojowych narządu rodnego jest wrodzony brak pochwy i macicy, zwany zespołem Mayera-Rokitansky’ego-Küstera (zespół M-R-K). Jego etiopatologia nie została wyjaśniona. Charakteryzuje się on wrodzonym brakiem pochwy i macicy bądź też brakiem pochwy i różnymi wadami rozwojowymi macicy. Budowa i funkcja jajników są prawidłowe. Wczesne wykrycie wady układu moczowo-płciowego jest możliwe, gdy anomalie są widoczne w trakcie badania pacjenta, czasami bezpośrednio po porodzie. Najczęściej jednak wady rozpoznawane są później. W okresie dojrzewania zazwyczaj pierwszym sygnałem jest pierwotny brak miesiączki. Trudności z podjęciem współżycia płciowego lub z zajściem w ciążę występują znacznie później. W wielu przypadkach objawem wady układu moczowo-płciowego są bóle brzucha. Do innych mniej specyficznych należą zaburzenia w oddawaniu moczu, krwiomocz oraz uporczywe, słabo poddające się leczeniu i nawracające zakażenia układu moczowego. W ostatnich latach znacznie wzrosła rozpoznawalność wad układu moczowo-płciowego. Przyczynił się do tego znaczny rozwój możliwości diagnostycznych i terapeutycznych, a zwłaszcza ultrasonografii i metod laparoskopowych. Wiek pacjenta, w którym rozpoznano wadę układu moczowo-płciowego, jest bardzo ważny. Często tylko wczesne rozpoznanie wady umożliwia prawidłową jej korektę. Przy obecnych możliwościach badań obrazowych należy przypuszczać, że późne rozpoznania wad układu moczowo-płciowego będą należały już do przeszłości. Podsumowanie: 1) Współistnienie wad układów moczowego i płciowego jest na tyle częste, że należałoby je uwzględnić w postępowaniu diagnostycznym. 2) Objawy wady układu moczowo-płciowego często są niespecyficzne. 3) Znaczny rozwój metod diagnostycznych przyczynił się do wzrostu rozpoznawalności wszelkich wad, w tym również układu moczowo-płciowego. 4) Wczesne rozpoznanie wady układu moczowo-płciowego zwiększa szansę na jej korektę chirurgiczną oraz pomoc psychologiczną.
(1) Little is known about the relative susceptibility to the effect of amobarbital of language areas compared with damaged motor cortex. ...it may be that a low dose of amytal (which 100 mg is) does ...impair a partially damaged motor cortex when language areas still maintain sufficient function to solve the tasks tested during the Wada procedure. No clinical data are available on the effect of amobarbital on the damaged motor cortex. ...the effectiveness of an initial high dose of amobarbital, as well as incomplete inactivation of different MCA areas, remains an interesting speculation.
Fifty years ago Juhn A.Wada developed the intracarotid amobarbital procedure (IAP), a test in which first one and then the other cerebral hemisphere is temporarily anaesthetised through direct ...intracarotid application of sodium amytal. The IAP was devised initially as a method to allow unilateral electroconvulsive shock therapy for psychosis. The method subsequently proved its value for the lateralisation of language and, following adaptation of the test protocol, for the assessment of memory functions. Thus the IAP became a standard test in the presurgical evaluation for resective surgical treatment of medically intractable epilepsy. This paper will briefly review the history of the IAP, the controversies concerning its current applications and its expected eventual replacement by less invasive and more easily repeatable methods, notably functional magnetic resonance imaging.
Celotno besedilo
Dostopno za:
BFBNIB, DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
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.
Summary
Purpose: The intracarotid amobarbital procedure (LAP) is widely used to help predict who might be at risk for postoperative amnesia after unilateral temporal lobectomy for intractable ...seizures. We describe the memory outcome in 10 patients who underwent standard temporal lobectomy, including mesial temporal structures, despite failing the memory portion of the LAP after injections both ipsilateral and contralateral to the resected seizure focus.
Methods: Data for seven of the study subjects were obtained through a retrospective review of patients assessed on a surgical epilepsy unit during a 15‐year period who failed the Montreal Neurological Institute LAP memory protocol after both ipsilateral and contralateral injections and subsequently underwent unilateral temporal lobectomy. More recently, we have studied temporal lobectomy patients who failed the Medical College of Georgia memory protocol after both ipsilateral and contralateral injections (n = 3). Preoperative and postoperative memory test scores were compared, and data regarding seizure outcome and self‐perception of postoperative memory were collected.
Results: At follow‐up, none of the patients presented with a pattern indicative of a global amnesia, and 80% demonstrated >90% improvement in their seizure disorder or were seizure‐free.
Conclusions: These findings indicate that bilateral memory failure on the LAP does not preclude the removal of an epileptogenic temporal lobe or a successful surgical outcome. In addition, the findings raise questions regarding the validity of the LAP and the possibility that memory may be reorganized in patients with a long history of temporal lobe epilepsy.
Memory testing during the intracarotid amobarbital procedure (IAP) is used extensively to identify temporal lobe surgery candidates "at risk" for developing severe postoperative anterograde amnesia. ...However, the utility of the IAP in predicting commonly observed material-specific memory deficits has not been thoroughly investigated. We examined the utility of contralateral IAP memory testing, as an index of the functional capacity of the surgical temporal lobe, to predict postoperative material-specific memory changes on the Wechsler Memory Scale-Revised (WMS-R) in patients with left hemisphere speech dominance undergoing left (n = 32) and right (n = 31) temporal lobectomy (TL). Left TL patients who "passed" contralateral IAP memory testing (> or = 68% recognition of memory items) had significantly greater verbal memory decrements than those who "failed" the IAP, presumably as a result of removal of functional tissue. A similar relationship between contralateral IAP performance and visual memory performance was not observed among right TL patients. Thus, the functional adequacy of the tissue to be resected appears to be inversely related to postoperative verbal memory decrement, at least among left TL patients. This relationship is consistent with results of recent studies demonstrating an inverse relationship between verbal memory decrements after left TL and preoperative neuropsychological verbal memory performance, magnetic resonance imaging (MRI) hippocampal volumes, and degree of mesiotemporal sclerosis (MTS).
Rheumatologists, with their musculoskeletal background, often care for athletes. The effect of a positive anti-doping test, whether through illegitimate use or accidental prescribing of banned drugs, ...is devastating to an athlete's career. It is therefore incumbent upon rheumatologists to be aware of issues relating to drugs in sport. This involves both therapeutic drugs and doping. It is vital to ensure that any substance prescribed should be approved for use and should not adversely affect (or benefit) the athlete's performance. In March 2004, 5 months prior to the 2004 Olympic Games in Athens, the joint World Anti-Doping Agency/International Olympic Committee published the revised list of banned substances in athletes. This article aims to provide an overview of the current status of medications commonly prescribed in rheumatological practice.
The World Anti-Doping Code was renewed by an international sports organization committee prior to the Olympic Games in Athens in 2004. Up to now, most of the important international sports ...federations have accepted the code. Governments will soon follow and set the legislative milestones for the fight against doping. Surveillance and code-conversion are being done by national anti-doping organizations. In 2005, the structural organization and the content of the 2004 prohibited list have been modified: "substances and methods prohibited all times" (in and out of competition); "substances and methods prohibited in competition", "substances prohibited in particular sports", and "specified substances" are separately discussed. News regarding "specific substances", "whereabout-infos" and "therapeutic use exemptions" are outlined clearly.
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