Epilepsy & Behavior 23 (2012) 142–145

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Epilepsy & Behavior

journal homepage: www.elsevier.com/locate/yebeh

Predictive value of Spanish neuropsychological testing for laterality in patients

with epilepsy
Guido Lancman a, Gonzalo A. Vazquez-Casals a, Kenneth Perrine a, b, Enrique Feoli a, Lorna Myers a,⁎
a
Northeast Regional Epilepsy Group, New York, NY, USA
b
Department of Neurological Surgery, Weill–Cornell Medical College, New York, NY, USA

a r t i c l e i n f o a b s t r a c t

Article history: In presurgical treatment planning for patients with epilepsy, neuropsychological testing assists in lateraliza-
Received 19 July 2011 tion of the seizure focus. Previous research with English speakers has shown that patients with left
Revised 25 October 2011 hemisphere (LH) onsets versus right hemisphere (RH) onsets perform worse on naming and other verbal
Accepted 3 November 2011
skills tests, but similar findings with Hispanic patients are limited. Thirty-nine Spanish-speaking patients
Available online 22 December 2011
were administered a comprehensive battery of neuropsychological tests in Spanish. LH-onset patients
Keywords:
performed significantly worse than RH-onset patients on verbal comprehension (P = 0.006), visual matching
Hispanics (P = 0.047), the Ponton–Satz Boston Naming Test (P = 0.001), and the dominant hand trial of the Grooved
Spanish Pegboard Test (P = 0.012). A stepwise regression model to predict seizure laterality from these tests was
Neuropsychology significant (F = 12.10, P = 0.001), but only the Ponton–Satz Boston Naming Test was retained. This
Lateralization comprehensive battery of neuropsychological tests in Spanish proved useful in predicting lateralization in
Epilepsy patients with partial epilepsy.
Neuropsychological Screening Battery for © 2011 Elsevier Inc. All rights reserved.
Hispanics
Batería Woodcock Muñoz
Boston Naming Test

1. Introduction This is only the second study reporting on neuropsychological

Neuropsychological testing of global intellectual functioning and
more specific neuropsychological functional areas (e.g. attention,
language, memory, visuospatial, executive, psychomotor functions)
is typically used to assist in the lateralization of the seizure focus in
candidates for epilepsy surgery [1,2]. Although there is a large body
of literature supporting the diagnostic utility of batteries developed
for use with and administered to English-speaking North Americans,
information about neuropsychological testing of patients with
epilepsy from Hispanic backgrounds is lacking [3].
Hispanics account for 16% of the US population and are expected to
constitute 30% by 2050 [4]. As a result, the availability of assessment
instruments that are culturally and linguistically appropriate becomes
extremely relevant. In the past, the neuropsychological status of
Spanish-speaking patients was assessed with informal translations
of existing testing materials into Spanish, the use of interpreters, and
reliance on English-based norms. However, it is now understood
that this is not adequate. Rather, it has been pointed out that devel-
opers of tests must ensure that their assessment materials are both
culturally and linguistically relevant for the target population [5–7].
⁎ Corresponding author at: Northeast Regional Epilepsy Group, 820 Second Avenue,
Unit 6C, New York, NY 10017, USA. Fax: + 1 212 661 7496.
E-mail address: lmyers@epilepsygroup.com (L. Myers).
assessment of Hispanic patients with epilepsy in the United States.
Barr et al. used the Neuropsychological Screening Battery for
Hispanics (NeSBHIS) [8] and reported that it might lack sensitivity in
the lateralization of deficits of patients with temporal lobe seizures
[3]. However, this contradicts a large body of literature, in English and
other languages, that shows significant deficits in naming ability of pa-
tients with left hemisphere epilepsy [9–13]. Furthermore, Barr et al. did
not assess global intellectual functioning, apart from Raven's Standard
Progressive Matrices Test, which they found loaded most heavily on
the visuospatial factor. Our study reports the use of a more comprehen-
sive neuropsychological testing battery, which includes the NeSBHIS
(with the exception that the Pin Test is replaced by the Grooved Peg-
board Test) and the Brief Intellectual Ability (BIA) of the Batería III Prue-
bas de Habilidad Cognitiva [14]. Results were analyzed to determine its
lateralizing value in Spanish-speaking patients with partial epilepsy.
2. Material and methods
2.1. Subjects
Sixty-nine consecutive patients with epilepsy who completed
neuropsychological testing in Spanish at the Northeast Regional
Epilepsy Group's offices between 2005 and 2010 were originally in-
cluded in this study. Patients originated from South and Central

1525-5050/$ – see front matter © 2011 Elsevier Inc. All rights reserved.
doi:10.1016/j.yebeh.2011.11.012
 G. Lancman et al. / Epilepsy & Behavior 23 (2012) 142–145
America, Iberia, and the Caribbean countries and spoke Spanish as
their primary language. Lateralized partial epilepsy was confirmed
with prolonged inpatient video/EEG monitoring, based on ILAE
criteria. Nonepileptic seizures were excluded by recording all typical
episodes/seizures described by the patient or relatives that failed to
reveal any evidence of ictal epileptiform activity. Severe psychiatric
illness, dementia, and probable developmental delay were ruled out
by record review and testing results. Thirty-nine patients met all
inclusion criteria and were considered for our final analysis.
2.2. Procedures
In 2005, the Spanish neuropsychology division of the Northeast
Regional Epilepsy Group (G.A.V., L.M.) established this battery as
standard for all Spanish-speaking patients. It should be noted that in
some instances, specific characteristics of the case (e.g., fatigue,
resistance to testing) did not permit for all tests to be administered.
Participants were tested individually in one session totaling approxi-
mately 3 to 3.5 hours. All patients were tested in outpatient offices in
a distraction-free environment by psychologists licensed by the State
of New York who had completed a 2-year postdoctoral fellowship in
neuropsychology and who had been in full-time practice in neuropsy-
chology for 5 or more years. Both neuropsychologists administering
the batteries are native and fluent Spanish speakers. No graduate
students or trainees administered or interpreted tests. The following
measures were used.
2.2.1. Neuropsychological Screening Battery for Hispanics
The Neuropsychological Screening Battery for Hispanics (NeSBHIS)
was developed by Ponton et al. in 1996 to address the lack of appropri-
ate measures for the neuropsychological assessment of Hispanics in
the United States [8]. It provides psychometric standardization on
tests of memory (visual and verbal), language, mental control, reason-
ing, visuospatial skills, and psychomotor speed, stratified by age, gen-
der, and education on a sample composed of 300 Spanish-speaking
subjects.
2.2.1.1. Subtests
2.2.1.1.1. Pontón–Satz Boston Naming Test. The Pontón-Satz Boston
Naming Test (P-S BNT) [15] is a 30-item Spanish version of the longer
60-item English-language Boston Naming Test [16]. Cultural appropri-
ateness and relevance for Spanish-speaking populations were secured
by removing items with high cultural loadings in North American cul-
ture (e.g., “pretzel,” “beaver”).
2.2.1.1.2. Controlled Oral Word Association Test. The Controlled Oral
Word Association Test (COWAT) [17] is a measure of verbal fluency in
which participants are given 1 minute to generate as many words as
possible beginning with a specific target letter (‘F’, ‘A’, and ‘S’ are
used).
2.2.1.1.3. Digit Span Subtest. The Digit Span Subtest (Escala de
Inteligencia Wechsler para Adultos [EIWA]) [18] measures auditory
attention and working memory, but uses different scoring criteria
than the English version.
2.2.1.1.4. Block Design Subtest. Although structurally similar to the
corresponding subtest from the older Wechsler Adult Intelligence
Scale—Revised [19], the content of the Block Design Subtest of the
EIWA is somewhat different and fewer time-dependent bonus points
are awarded.
2.2.1.1.5. Digit Symbol Subtest. In contrast to the English version,
the EIWA Digit Symbol subtest has six target symbols and 110
possible total responses with a time limit of 90 seconds.
2.2.1.1.6. WHO/UCLA Auditory–Verbal Learning Test. In the WHO/
UCLA Auditory–Verbal Learning Test (WHO/UCLA AVLT) [20], exam-
inees are presented with a list of 15 Spanish words in a serial fashion
and then asked to repeat as many as they are able to remember im-
mediately after each of five learning presentations, then after a
143
second 15-word distracting list, and finally 20–25 minutes later. The
target words of the test are different from those used in the Rey
Auditory–Verbal Learning Test (RAVLT) [21] and thus do not
represent a direct translation. A delayed recognition trial consisting
of 30 words, among them the 15 target words, is also given.
2.2.1.1.7. Color Trails Test, Forms 1 and 2. The Color Trails Test,
Forms 1 and 2 (CTT) [22], is a measure of sustained visual attention
or tracking and set shifting. Both forms present the subject with
colored circles numbered 1–25; odd numbers are pink and even
numbers are yellow. On CTT1 participants are asked to connect the
circles in a sequential order as fast as possible. On CTT2 examinees
are instructed to connect the circles in sequential order while also
alternating the colors.
2.2.1.1.8. Rey–Osterrieth Complex Figure Test. The Rey–Osterrieth
Complex Figure Test (ROCFT) [23] copy is a measure of visuospatial
construction and the delayed recall condition is a measure of visual
memory.
2.2.1.1.9. Grooved Pegboard Test. The Grooved Pegboard Test (GPT)
[24] test was added as a replacement for the out-of-print Pin Test in
the NeSBHIS. The GPT is a manipulative dexterity test that requires
complex visual–motor coordination. Participants taking this test are
asked to place key-shaped pegs into a board that has 25 multidirec-
tional key-holes, arranged in five rows with five holes each, as fast
as possible. The first trial is completed with the dominant hand, and
the second trial with the nondominant hand.
2.2.2. Batería III Pruebas de Habilidad Cognitiva
The complete Batería III Pruebas de Habilidad Cognitiva [14] is
made up of 20 subtests that are either translations or adaptations of
the parallel tests in the Woodcock–Johnson III [25]. The Batería III is
the only measure of broad cognitive abilities in existence in the
United States that has been standardized and normed on a represen-
tative adult Spanish-speaking population. The normative sample
included 8818 randomly selected individuals from geographically
diverse areas within a stratified sampling design (socioeconomic,
specific community, and individual variables).
The Habilidad Intelectual Breve (Brief Intellectual Ability, BIA) of
the Batería III provides a brief measure of intelligence that consists
of three tests: Comprensión Verbal (Verbal Comprehension), For-
mación de Conceptos (Concept Formation), and Pareo Visual (Visual
Matching). The BIA was included to improve the range of our neu-
ropsychological battery and because previous Spanish studies had
not obtained specific measures of intellectual functioning. Although
this is the first time this measure was used in an epilepsy popula-
tion, it has been thoroughly validated in the US Spanish-speaking
population and has the potential to contribute to our understand-
ing of cognitive function in Spanish-speaking patients with
epilepsy.
2.2.2.1. Subtests
2.2.2.1.1. Verbal Comprehension. This measure is made up of four
subtests: picture vocabulary, synonyms, antonyms, and verbal
analogies.
2.2.2.1.2. Concept Formation. This subtest measures nonverbal
inductive reasoning by requiring the respondent to determine a rule
that distinguishes two sets of figures. On each test item the examinee
is asked to verbalize the difference (i.e., color, shape, size, or number)
between two sets of figures.
2.2.2.1.3. Visual Matching. This subtest assesses perceptual and
visuomotor speed and involves circling identical pairs of numbers in
rows of six digits during a 3-minute period.
2.3. Data analysis
Descriptive statistics (means and SD for continuous data, frequen-
cies for nominal data) were calculated on the demographic variables.
144 G. Lancman et al. / Epilepsy & Behavior 23 (2012) 142–145

Unpaired Student's t tests were performed on the neuropsy-
chological variables between the left and right hemisphere laterality
groups. Logistic regression was performed to predict seizure laterality
from the variables significant from the individual t tests. Sensitivity,
specificity, and positive and negative predictive values were
calculated for the variables significant from the logistic regression.
P b 0.05 was considered significant.
3. Results
3.1. Descriptive
Thirty-nine Hispanic participants with epilepsy constituted the
study sample after meeting inclusion criteria. There were 15 (39.5%)
males, the mean age was 41.7 ± 14.1 years, and the mean level of
education was 9.4 ± 3.6 years. Seventeen participants were from
South America, 11 from Central America, 10 from the Caribbean,,
and 1 from Iberia. There were 37 right-handers (92.3%) and 2 (7.7%)
left-handers; both left-handed patients had Wada-confirmed left
hemisphere dominance for language. Mean age at seizure onset was
22.6 ± 19.4 years. Seizure onsets were exclusively temporal in 28
(71.8%) subjects. Ten subjects had frontal onset and one had occipital
onset. Seizure onsets identified by video/EEG were left-sided in 25
subjects (64.1%) and right-sided in 14 (35.9%).
Ten patients with right-sided onset were on antiepileptic drug
(AED) polytherapy, 3 were on AED monotherapy, and 1 was on no
AED medication. The distribution included 9 on levetiracetam, 4 on
phenytoin, 3 on carbamazepine, 3 on lamotrigine, 3 on topiramate,
2 on oxcarbazepine, 2 on zonisamide, 1 on lacosamide, and 1 on
lorazepam.
Among the patients with left-sided onsets, 15 were on AED
polytherapy, 8 were on AED monotherapy, and 2 were on no AED
medication. The distribution included 10 on levetiracetam, 8 on
oxcarbazepine, 5 on carbamazepine, 4 on topiramate, 4 on valproic
acid, 3 on clonazepam, 3 on lamotrigine, 3 on phenobarbital, 3 on
phenytoin, 2 on lacosamide, 2 on pregabalin, 1 on primidone, and 1
on zonisamide.
Mean number of AEDs was 2.00 (SD 1.04) for patients with right-
sided onsets and 1.96 (SD 1.14) for those with left-sided onsets. This
difference was determined not to be significant with Student's t test
(P = 0.91).
3.2. Neuropsychological testing
Subjects with left hemisphere onsets had significantly lower
scores than those with right hemisphere onsets on Visual Pairing
(t = 2.07, P = 0.047) and Verbal Comprehension (t = 2.92, P = 0.006)
from the Batería III, the P-S BNT (t = 3.48, P = 0.001) from the
NeSBHIS, and the dominant hand trials of the Grooved Pegboard
Test (t = −2.68, P = 0.034). Results of all tests are detailed in Table 1.
Logistic regression analysis to predict laterality from the neuro-
psychological variables was performed using the variables found
significant in the individual t tests. A stepwise regression model was
significant (F = 12.10, P = 0.001) but retained only the P-S BNT.
In predicting left hemisphere onset, the P-S BNT had a sensitivity
of 0.80 (95% CI: 0.56–0.93), specificity of 0.67 (95% CI: 0.24–0.94),
positive predictive value of 0.89 (95% CI: 0.64–0.98), and negative
predictive value of 0.50 (95% CI: 0.17–0.83).
4. Discussion
Results from the present study show that patients with a left
hemisphere focus performed significantly worse in measures of
verbal comprehension, naming ability, dominant hand dexterity,
and visual scanning/visuomotor speed. The first two of these findings
are within expectation, as similar results have been reported previ-
ously in the literature for English speakers. For example, Loring
et al. found that patients with left temporal lobe epilepsy did
significantly worse than those with right temporal lobe epilepsy in
measures of confrontation naming (i.e., BNT, Multilevel Aphasia
Examination Visual Naming) [9], and Busch et al. found that low
BNT scores, together with high FSIQ values and late age at seizure
onset, were the best predictors of left temporal surgery [10]. This
finding also appears to hold cross-culturally. Schwarz and Pauli
reported naming decline among German-speaking patients with left
temporal lobe epilepsy [11], Alessio et al. found significantly worse
performance on different memory and language measures including
the BNT in their Brazilian subjects with left hippocampal atrophy
[12], and Raspall et al. reported that their Spanish patients with left
temporal lobe epilepsy had significantly lower scores than patients
with right temporal lobe epilepsy on the BNT [13]. Barr et al., the
only similar study on Hispanics in the United States, failed to demon-
strate lateralization based on the P-S BNT or any other measure [3].

Table 1
Results of all neuropsychological tests, with unpaired Student's t tests used to compare left and right hemisphere onsets.

Test Mean (SD) Total N t statistic P value

Right-sided onset Left-sided onset

NeSBHIS
P-S BNT 19.31 (4.19) 14.48 (3.99) 38 3.48 0.001a
COWAT 21.80 (11.76) 17.53 (10.94) 29 0.98 0.338
Digit Span Subtest 7.70 (1.06) 7.17 (1.55) 34 0.99 0.329
Block Design Subtest 22.50 (10.20) 19.10 (12.00) 26 0.705 0.490
Digit Symbol Subtest 35.57 (11.36) 34.42 (14.54) 26 0.19 0.852
WHO/UCLA AVLT 5th trial 10.15 (2.67) 9.08 (2.59) 37 1.19 0.243
WHO/UCLA AVLT, short delay 7.62 (3.82) 5.88 (3.58) 37 1.38 0.176
WHO/UCLA AVLT, long delay 7.38 (4.41) 6.21 (3.18) 37 0.94 0.355
Color Trails Test 1 67.31 (36.20) 85.36 (42.80) 35 − 1.27 0.212
Color Trails Test 2 171.54 (85.38) 169.35 (84.17) 33 0.07 0.943
ROCFT 10.40 (5.48) 8.50 (4.08) 32 1.11 0.280
GPT, dominant handb 77.00 (16.87) 99.43 (29.58) 31 − 2.22 0.034a
GPT, nondominant handb 91.22 (22.48) 109.45 (31.06) 29 − 1.58 0.126
Bateria III
Verbal Comprehension 86.46 (9.59) 77.80 (8.18) 38 2.92 0.006a
Concept Formation 79.45 (12.00) 77.68 (9.37) 33 0.47 0.644
Visual Matching 80.55 (9.55) 70.24 (14.89) 32 2.07 0.047a
a
Significant.
b
The GPT is a replacement for the out-of-print Pin Test from the NeSBHIS.
 G. Lancman et al. / Epilepsy & Behavior 23 (2012) 142–145
The studies cited above examined primarily patients with tem-
poral lobe epilepsy. Our study examined patients with left hemispher-
ic onsets, both temporal and extratemporal. Nevertheless, our findings
are explicable, given that confrontation naming and verbal compre-
hension are cortical functions with wide localization throughout the
left hemisphere [26,27].
The Grooved Pegboard Test, usually classified as a test of motor abil-
ity and hand dexterity [26], has a demonstrated ability to identify
contralateral impairment in patients with various types of lesions
[28–30]. Our sample consisted of almost all (92.3%) right-handers, so
it is in line with previous findings that patients with left hemisphere on-
sets performed worse than those with right hemisphere onsets on the
dominant (mostly right) hand trials of this test. The finding of impaired
Visual Matching in patients with left hemisphere onsets is harder to in-
terpret, though potentially consistent with the GPT result as it also relies
on processing speed and dominant hand dexterity. However, this find-
ing needs to be studied further to determine its validity.
Our study is the first to support the predictive value of the P-S BNT in
determining laterality in Hispanic patients with epilepsy in the United
States and is consistent with comparable English literature. It is unclear
why our results differ from the results of Barr et al. [3], who used the
NeSBHIS. Essentially, the ethnicity of patients in both studies is similar
as the studies were conducted in the same geographic region. A possible
explanation for the dissimilarity could be that testing settings may have
differed. Although the most recent Barr et al. study does not specify
where tests were administered, a previous study by the same group
reported that all patients were administered the NeSBHIS while under-
going continuous video/EEG monitoring [31]. Inpatient settings tend to
be more prone to interruptions, and patients are often status-post stress
tests (e.g., sleep deprivation) and may be going through changes in anti-
epileptic drug doses as part of their study. Any of these factors has the
potential to disrupt the standardization of test administration and
results. Another possible source of variation is that in the recent Barr
et al. study, patients “opted” to be tested in Spanish, whereas patients
in the present study were evaluated by the bilingual examiner to
determine that Spanish was in fact their dominant language.
Assessment of linguistic dominance by the examiner is essential as
there can be many gradations in bilingualism.
Future studies are necessary to further substantiate the lateraliz-
ing value of this Spanish neuropsychological battery (NeSBHIS
and BIA of Batería III), beyond the P-S BNT. Verbal Comprehension,
Grooved Pegboard Test, and Visual Matching all demonstrated
significant differences between left and right onsets but were not
predictive of laterality. Given the relatively small sample size of this
study, these measures might prove predictive in larger prospective
studies of Hispanic patients with epilepsy in the United States.
Conflict of interest statement
None of the authors has any conflict of interest to disclose.
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