The safety and efficacy of propofol as a replacement for amobarbital in intracarotid Wada testing of presurgical patients with epilepsy Kaci McCleary ⁎, Joseph Barrash, Mark Granner, Kenneth Manzel, Audrey Greider, Robert Jones Department of Neurology, University of Iowa, United States abstract article info Article history: Received 4 October 2017 Revised 25 October 2017 Accepted 26 October 2017 Available online 21 November 2017 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. © 2017 Elsevier Inc. All rights reserved. Keywords: Intractable epilepsy Seizure Lateralization Adverse event Anesthesia 1. Literature review The intracarotid sodium amytal (amobarbital) procedure (more commonly known as the Wada test) has for many years been adminis- tered to patients as the gold standard for language and memory lateral- ization [1]. It remains an important part of presurgical analysis, particularly for resection candidates with medically intractable seizures. Despite attempts by newer, less invasive technologies such as fMRI to replace it, the Wada test remains a mainstay of many centers' presurgical workups thanks to its known validity and reliability, partic- ularly in patients with incomplete or atypical language lateralization [2,3]. Additionally, it is likely to remain important for patients who cannot easily undergo a conscious fMRI, such as children and people with metal implants. Due to a recent worldwide shortage of amobarbital, the original Wada anesthetic, physicians have been investigating alternatives. Among the most used of these is propofol, although etomidate, methohexital, and pentobarbital have also shown promise [4]. The suitability of propofol for injection was initially demonstrated in a few case studies. The first resulted in no adverse events and successful lateralization of speech in a 43 year old male [5]. In the second, both language and memory lateralization were successfully determined in a 26 year old female [6]. The success of these encounters led to several more systematic reviews. A 2004 study found similar rates of successful lateralization of both memory and language between propofol and amobarbital. Some unusu- al side effects were noted for propofol (laughing, head, and eye version), but they resolved quickly and did not impact completion of the test [7]. Several small studies came to similar conclusions, even when used in pediatric populations [8–10]. The largest study to date included 129 procedures and found no difference in lateralization success, but was notable for lower rate of serious adverse events relative to previous studies [11]. Another smaller study came to a similar conclusion, with the caveat that propofol might not be appropriate for patients with low blood pressure due to its vasodilator effects [12]. An adverse event (AE) grading system was devised by Mikuini (2005) to evaluate more precisely the side effect profile of propofol rel- ative to amytal in Wada testing. Of the patients injected with propofol, one-third experienced some sort of AE, although all but one were still able to complete the assessment. Age was found to be positively corre- lated with risk of experiencing any adverse event, while age, higher doses, and preexisting arteriovenous malformations were all risk factors for a more serious event. Low grade, less serious events were found to be similar between propofol and amobarbital, but more serious grade 3 events were five times higher for propofol when compared with past studies with amobarbital [13]. Unfortunately, there were no direct Epilepsy & Behavior 78 (2018) 25–29 ⁎ Corresponding author. E-mail address: kaci-mccleary@uiowa.edu (K. McCleary). https://doi.org/10.1016/j.yebeh.2017.10.037 1525-5050/© 2017 Elsevier Inc. All rights reserved. Contents lists available at ScienceDirect Epilepsy & Behavior journal homepage: www.elsevier.com/locate/yebeh