Wada You Do for Language: f MRI and Language Lateralization?

Language Lateralization in Epilepsy Patients: fMRI Validated with the Wada Procedure .  Arora J, Pugh K, Westerveld M, Spencer S, Spencer DD, Todd Constable R. Epilepsia 2009;50(10):2225–2241.  PURPOSE: This work examines the efficacy of functional magnetic resonance imaging (fMRI) for language lateralization using a comprehensive three‐task language‐mapping approach. Two localization methods and four different metrics for quantifying activation within hemisphere are compared and validated with Wada testing. Sources of discordance between fMRI and Wada lateralization are discussed with respect to specific patient examples. METHODS: fMRI language mapping was performed in patients with epilepsy ( N = 40) using reading sentence comprehension, auditory sentence comprehension, and a verbal fluency task. This was compared with the Wada procedure using both whole‐brain and midline exclusion‐based analyses. Different laterality scores were examined as a function of statistical threshold to investigate the sensitivity to threshold effects. RESULTS: For the lateralized patients categorized by Wada, fMRI laterality indices were concordant with the Wada procedure results in 83.87% patients for the reading task, 83.33% patients for the auditory task, 76.92% patients for the verbal fluency task, and in 91.3% patients for the conjunction analysis. The patients categorized as bilateral via the Wada procedure showed some hemispheric dominance in fMRI, and discrepancies between the Wada test findings and the functional laterality scores arose for a range of reasons. DISCUSSION: Discordance was dependent upon whether whole‐brain or midline exclusion method‐based lateralization was calculated, and in the former case the inclusion of the occipital and other midline regions often negatively influenced the lateralization scores. Overall fMRI was in agreement with the Wada test in 91.3% of patients, suggesting its utility for clinical use with the proper consideration given to the confounds discussed in this work. Cerebral Lesions Can Impair fMRI‐Based Language Lateralization .  Wellmer J, Weber B, Urbach H, Reul J, Fernandez G, Elger CE. Epilepsia 2009;50(10):2213–2224.  PURPOSE: Several small patient studies and case reports raise concerns that the reliability of functional magnetic resonance imaging (fMRI) may be impaired in the vicinity of cerebral lesions. This could affect the clinical validity of fMRI for presurgical language lateralization. The current study sets out to identify if a systematic effect of lesion type and localization on fMRI exists. METHODS: We classify lesions typically occurring in epilepsy patients according to 1) their potential to disturb blood oxygenation level‐dependent—effect generation or detection or to disturb spatial brain normalization, and 2) the proximity of lesions to protocol‐specific volumes of interest (VOIs). The effect of lesions is evaluated through the examination of 238 epilepsy patients and a subgroup of 37 patients with suspected unilateral left‐language dominance according to the Wada test. RESULTS: Patients with fMRI‐critical lesions such as cavernomas, gliomas, and mass defects close to VOIs, or with severe atrophy, show lower lateralization indices and more often discordant language lateralization with the Wada test than do patients without such lesions. DISCUSSION: This study points seriously toward fMRI‐language lateralization being sensitive to cerebral lesions. Some lesion types and locations are more critical than others. Our results question the noncritical application of fMRI in patients with cerebral lesions.