Postictal psychosis in temporal lobe epilepsy: Risk factors and postsurgical outcome?

Neuropsychology of temporal lobe epilepsies

This chapter focuses on the neuropsychology of adults with temporal lobe epilepsy (TLE). First, a thorough description of the brain-behavior relationship characterizing focal TLE with and without hippocampal sclerosis is presented. Then, the aim and the specificity of the NPA in the care of epilepsy are described. Considering the high frequency of medically intractable TLE that can be treated by surgery, an assessment carried out in the context of pre- and postoperative evaluation is presented and discussed in light of insights from functional neuroimaging findings. Finally, we propose concluding remarks about the place of neuropsychology in the care of epilepsy in improving our understanding of the cognitive and emotional phenotypes associated with TLE.

Suspected Post-ictal Psychosis in Temporal Lobe Epilepsy Secondary to Human Herpesvirus 6 Encephalitis

Human herpesvirus 6 (HHV-6) may lead to temporal lobe epilepsy (TLE). Psychotic syndrome frequency in the setting of TLE is 7% to 11%. We report a case of post-ictal psychosis (PIP) secondary to TLE in the setting of HHV-6 encephalitis. A 58-year-old male presented with a two-day history of severe confusion, personality changes, and new-onset psychosis. Lumbar puncture was positive for HHV-6. Electroencephalogram (EEG) revealed left temporal sharp waves during drowsiness and sleep, suggestive of focal epileptiform discharges without clinical seizures. Valproate and olanzapine were employed for epilepsy and agitation. Psychosis and confusion resolved with subsequent discharge. Out of the other diagnoses, PIP in the setting of TLE secondary to HHV-6 given the clinical response to acyclovir. While HHV-6 encephalitis may cause TLE, this patient did not have a history of seizures and EEG did not capture active seizures. It is unclear if the sharp waves were incidental or indicative of TLE. Additionally, PIP is seen more commonly with left-sided EEG changes. Low-dose olanzapine was efficacious in resolving symptoms, which is typical in PIP. Both HHV-6 encephalitis and TLE have the potential to cause memory impairments and personality changes, which were seen in this patient. Patients with both TLE and PIP are less likely to exhibit focal ictal discharges than those with only TLE, which may explain the absence of active seizure activity on EEG.

Psychiatric alterations after previous temporal lobectomy: Report of cases and review

INTRODUCTION

Anterior temporal lobectomy (LTA) is a surgical procedure commonly used for the treatment of temporal lobe epilepsy refractory to medical management, with high success rates in the control of seizures. However, an important association with psychiatric illnesses has been described that can alter the postoperative outcome in these patients.

METHODS

A series of 2 cases of patients who, despite successful crisis control, developed psychiatric complications in the postoperative period of anterior temporal lobectomy.

RESULTS

The cases included a male patient with no history of previous mental illness, who developed a major depressive episode in the postoperative period, and a female patient with previous psychosis who presented as a surgical complication exacerbation of psychosis, diagnosed with paranoid schizophrenia.

CONCLUSIONS

Psychiatric disorders can occur in postoperative temporal lobe epilepsy patients with or without a history of mental illness. The most frequent alterations reported are depression, anxiety, psychosis and personality disorders. The inclusion of psychiatric evaluations in the pre- and post-surgical protocols can lead to an improvement in the prognosis of the neurological and mental outcomes of the patients undergoing the intervention.

Psychiatric Alterations after Previous Temporal Lobectomy: Report of Cases and Review

INTRODUCTION

Anterior temporal lobectomy (LTA) is a surgical procedure commonly used for the treatment of temporal lobe epilepsy refractory to medical management, with high success rates in the control of seizures. However, an important association with psychiatric illnesses has been described that can alter the postoperative outcome in these patients.

METHODS

A series of 2 cases of patients who, despite successful crisis control, developed psychiatric complications in the postoperative period of anterior temporal lobectomy.

RESULTS

The cases included a male patient with no history of previous mental illness, who developed a major depressive episode in the postoperative period, and a female patient with previous psychosis who presented as a surgical complication exacerbation of psychosis, diagnosed with paranoid schizophrenia.

CONCLUSIONS

Psychiatric disorders can occur in postoperative temporal lobe epilepsy patients with or without a history of mental illness. The most frequent alterations reported are depression, anxiety, psychosis and personality disorders. The inclusion of psychiatric evaluations in the pre- and post-surgical protocols can lead to an improvement in the prognosis of the neurological and mental outcomes of the patients undergoing the intervention.

Investigation of the Video-EEG Findings and Clinical Data in Patients Diagnosed With Epilepsy and Psychosis

BACKGROUND

Studies on electrophysiological characteristics of patients with epilepsy and concomitant psychosis are limited. We aimed to investigate the clinical and video-electroencephalography (EEG) findings of patients with epilepsy-related psychosis (EP).

MATERIALS AND METHODS

Fifteen patients diagnosed with EP, assessed at the video-EEG monitoring unit and were under follow-up at both epilepsy and psychiatry clinics, were included. A total of 67 nonpsychotic epilepsy patients, investigated at the video-EEG monitoring unit were randomly selected as the control group and compared statistically with the EP group.

RESULTS

In medical history, patients with EP had experienced significantly higher level of status epilepticus (P=0.002) and perinatal cerebral injury (P=0.04), whereas drug-resistant epilepsy was detected at a lower level (P=0.015). With respect to seizure onset zone, the EP group had significantly more seizures of unknown foci, whereas the control group had mostly temporal lobe origin (P=0.0004). EEG findings showed that slow background activity was significantly common among patients with EP (P=0.009). Although only 5 of 15 patients with EP had been operated, 43 of 67 patients had undergone epilepsy surgery (P=0.04) in the control group. However, there was no significant difference between the 2 groups with respect to postoperative seizure control as per Engel classification.

CONCLUSIONS

Although our sample size could be considered small, slowed EEG background activity, and the marked frequency of initial precipitant factors such as status epilepticus, perinatal cerebral injury, and detected neuronal autoantibodies suggested that EP is associated with more extensive involvement. EP is not a contraindication for epilepsy surgery, when appropriately investigated preoperatively.

Brain network alterations of mesial temporal lobe epilepsy with cognitive dysfunction following anterior temporal lobectomy

The aims of this study were to investigate the brain network connectivity alterations of intractable unilateral mesial temporal lobe epilepsy (MTLE) with cognitive dysfunction before and after anterior temporal lobectomy (ATL) using resting-state functional magnetic resonance imaging (rs-fMRI) study and to further observe the correlation between the brain network connectivity with cognitive performance. Fourteen patients with unilateral left MTLE before and after ATL were compared with thirty healthy controls (HCs) on functional connectivity (FC) between resting-state networks (RSNs). The correlation between the neuropsychological tests of patients and abnormal FC was further investigated. When compared with the HCs, patients before surgery showed significantly changed FC between special RSNs. No difference of FC was found between each RSN when patients were compared with the HCs after surgery. Compared with patients before surgery, patients after surgery showed significantly decreased FC between RSNs. Abnormal FC between RSNs significantly correlated with Montreal Cognitive Assessment (MoCA) scores. Our study suggested that dynamic alterations of RSN after ATL in unilateral MTLE may be closely related with seizure generating. However, unchanged FC between RSN before and after ATL may be closely related with cognitive performance. The present findings may help us understand the feature of brain network alterations in patients with left MTLE who became seizure-free following ATL.

Biomarkers of Epileptogenesis: The Focus on Glia and Cognitive Dysfunctions

The need to find measures that reliably predict the onset of epilepsy after injurious events or how the patient will respond to anti-seizure drugs led to intensive pre-clinical and clinical research to discover non-invasive biomarkers that could increase the sensitivity of existing clinical indicators. The use of experimental models of epileptogenesis and of drug-resistance is instrumental to select the most promising approaches to explore such biomarkers in the pre-clinical setting for further clinical validation. The approaches most frequently used to find clinically useful biomarkers of epileptogenesis include molecular brain imaging, EEG signal analysis and the measure of soluble molecules in biofluids which may reflect brain intrinsic events involved in epilepsy development. Among those, we focused our attention on proton magnetic resonance imaging (¹H-MRS)-based analysis of astrocytic activation, and related blood biomarkers, since this cell population appears to be pivotally involved in various epileptogenesis processes triggered by differing insults. Moreover, we also investigated behavioral biomarkers by focusing on cognitive dysfunctions since this deficit represents a typical co-morbidity in epilepsy which may manifest even before the onset of spontaneous seizures. In this review article, we will report our recently published evidence supporting the utility of measuring astrocyte activation, the soluble molecules they release, and the associated cognitive deficits during epileptogenesis for early stratification of animals developing epilepsy. We will discuss the potential clinical translation of our findings for enriching the patient population in preventive clinical trials designed to study anti-epileptogenic treatments.

WONOEP appraisal: Biomarkers of epilepsy-associated comorbidities

Neurologic and psychiatric comorbidities are common in patients with epilepsy. Diagnostic, predictive, and pharmacodynamic biomarkers of such comorbidities do not exist. They may share pathogenetic mechanisms with epileptogenesis/ictogenesis, and as such are an unmet clinical need. The objectives of the subgroup on biomarkers of comorbidities at the XIII Workshop on the Neurobiology of Epilepsy (WONOEP) were to present the state-of-the-art recent research findings in the field that highlighting potential biomarkers for comorbidities in epilepsy. We review recent progress in the field, including molecular, imaging, and genetic biomarkers of comorbidities as discussed during the WONOEP meeting on August 31-September 4, 2015, in Heybeliada Island (Istanbul, Turkey). We further highlight new directions and concepts from studies on comorbidities and potential new biomarkers for the prediction, diagnosis, and treatment of epilepsy-associated comorbidities. The activation of various molecular signaling pathways such as the "Janus Kinase/Signal Transducer and Activator of Transcription," "mammalian Target of Rapamycin," and oxidative stress have been shown to correlate with the presence and severity of subsequent cognitive abnormalities. Furthermore, dysfunction in serotonergic transmission, hyperactivity of the hypothalamic-pituitary-adrenocortical axis, the role of the inflammatory cytokines, and the contributions of genetic factors have all recently been regarded as relevant for understanding epilepsy-associated depression and cognitive deficits. Recent evidence supports the utility of imaging studies as potential biomarkers. The role of such biomarker may be far beyond the diagnosis of comorbidities, as accumulating clinical data indicate that comorbidities can predict epilepsy outcomes. Future research is required to reveal whether molecular changes in specific signaling pathways or advanced imaging techniques could be detected in the clinical settings and correlate with epilepsy-associated comorbidities. A reliable biomarker will allow a more accurate diagnosis and improved treatment of epilepsy-associated comorbidities.

Epilepsy-related psychoses and psychotic symptoms are significantly reduced by resective epilepsy surgery and are not associated with surgery outcome or epilepsy characteristics: A cohort study

We examine epilepsy-related psychoses and psychotic symptoms (ERPs) and the effects of epilepsy surgery on inter-ictal, aura, ictal and peri-ictal (pre- and post-ictal) psychoses. We included 189 patients with refractory epilepsy both before and 24 months after surgery. Engel's classification was the primary outcome measurement. Epilepsy surgery reduced the prevalence of ERPs from 17.5% to 4.2%, psychotic aura from 7.9% to 0.5%, ictal psychoses from 3.7% to 1.1% and peri-ictal psychoses from 4.2% to 0.5%. The prevalence of inter-ictal psychoses decreased from 5.3% to 0.5%, but 4 new cases of inter-ictal psychoses were found following surgery. Interictal dysphoric disorder significantly predicted surgery outcome. In patients with and without ERPs, epilepsy surgery induced seizure reduction in more than 90% of the cases, showing that both groups benefit equally from surgery. No associations between ERPs and epileptic characteristics were found, including laterality, type of lesion, type of epilepsy, number of seizures, duration of illness or age at onset. Epilepsy surgery significantly improves ERPs particularly psychotic aura and peri-ictal psychoses. Although inter-ictal psychoses are successfully treated, new inter-ictal psychoses appear in a few cases either as alternative psychoses or a possible switch from pre-surgery episodic into inter-ictal psychoses.

Psychiatric outcome of epilepsy surgery in patients with psychosis and temporal lobe drug-resistant epilepsy: a prospective case series

OBJECTIVES

Temporal lobe resistant epilepsy has been associated with a high incidence of psychotic disorders; however, there are many controversies; while some patients get better after surgery from their psychiatric condition, others develop psychosis or de novo depression. The aim of this study was to determine the psychiatric and seizure outcome after epilepsy surgery in patients with a previous history of psychoses.

METHODS

Surgical candidates with temporal lobe drug-resistant epilepsy and a positive history of psychosis diagnosed during the presurgical psychiatric assessment were included. A two-year prospective follow-up was determined after surgery. The DSM-IV Structural Interview, GAF (global assessment of functionality, DSM-IV), Ictal Classification for psychoses, and Engel's classification were used. The Student t test and chi-square-Fisher tests were used.

RESULTS

During 2000-2010, 89 patients were admitted to the epilepsy surgery program, 14 patients (15.7%) presented psychoses and were included in this series. After surgery, six patients (43%) did not develop any psychiatric complications, three patients (21%) with chronic interictal psychosis continued with no exacerbation, three patients (21%) developed acute and transient psychotic symptoms, and two patients (14%) developed de novo depression. Seizure outcome was Engel class I-II in 10 patients (71%). Total GAF scores were higher after surgery in patients found to be in Engel class I-II (p<0.05).

CONCLUSIONS

Patients with comorbid psychosis and temporal lobe drug-resistant epilepsy may benefit from epilepsy surgery under close psychiatric supervision.

Epilepsy-related psychosis: a role for autoimmunity?

Postictal psychosis (PIP) is a serious psychiatric complication of epilepsy that occurs in approximately 6% of patients following multiple complex partial or generalized seizures. The psychosis is classically described as having a pleomorphic phenomenology, including paranoid, grandiose, and religious delusions as well as multimodal hallucinations with prominent affective changes and agitation. Little is understood about the pathophysiology of the condition. There has been a recent increase in interest in the relevance of autoimmunity to the pathogenesis of both epilepsy and psychosis. Studies have demonstrated the presence of antibodies directed against synaptic autoantigens (such as the N-methyl-d-aspartate receptor or the voltage-gated potassium channel complex) in approximately 10% of cases of sporadic epilepsy. These same autoantibodies are known to cause encephalopathy syndromes which feature psychiatric symptoms, usually psychosis, as a prominent part of the phenotype as well as other neurological features such as seizures, movement disorders, and autonomic dysfunction. It is beginning to be asked if these antibodies can be associated with a purely psychiatric phenotype. Here, we hypothesize that PIP may be an autoimmune phenomenon mediated by autoantibodies against synaptic antigens. More specifically, we outline a potential mechanism whereby long or repeated seizures cause short-lived blood-brain barrier (BBB) dysfunction during which the brain becomes exposed to pathogenic autoantibodies. In essence, we propose that PIP is a time-limited, seizure-dependent, autoantibody-mediated encephalopathy syndrome. We highlight a number of features of PIP that may be explained by this mechanism, such as the lucid interval between seizures and onset of psychosis and the progression in some cases to a chronic, interictal psychosis.

Clinical predictors of 2-year outcome of resective epilepsy surgery in adults with refractory epilepsy: a cohort study

OBJECTIVES

Resective epilepsy surgery is currently a standard treatment for intractable epilepsy. Seizure freedom and discontinuation of antiepileptic drugs are the ultimate goals of epilepsy treatment. This study was carried out to delineate (1) possible differences in the success rate of epilepsy surgery 6 and 24 months after surgery; and (2) the clinical predictors of a good response to surgery.

SETTING

This is a cohort study performed at a tertiary care unit of a university hospital.

PARTICIPANTS

In this cohort study, 189 adults with intractable epilepsy who underwent epilepsy surgery were included. We collected clinical data at three time points, that is, preoperative and 6 and 24 months after surgery.

PRIMARY AND SECONDARY OUTCOME MEASURES

Engel class I-IV classification was the primary outcome measure of epilepsy surgery. The authors statistically adjusted Engel class I-IV classification for postoperative changes in antiepileptic drugs and used this new classification as a secondary outcome variable.

RESULTS

The success rate was 78.8% 6 months after surgery and increased to 88.3% 24 months after surgery. This success rate was reflected not only by the reduced number of seizures postsurgery, but also by a reduced dosage and use of antiepileptic drugs. Logistic regression analysis showed that a successful outcome of surgery is predicted by having temporal rather than extratemporal lobe epilepsy and less than nine presurgery seizures per month, while a positive familial history of epilepsy, younger age and dysphoric symptoms, the first 3 months after surgery, significantly worsened the outcome of surgery. Duration of illness, age at onset, epilepsy location, type of lesions and the presence of psychosis were not significant in predicting treatment outcome.

CONCLUSIONS

These findings have clinical relevance in that a better selection of patients based on the significant clinical predictors will increase the success rate of epilepsy surgery and treatment.

Disentangling the relationship between epilepsy and its behavioral comorbidities - the need for prospective studies in new-onset epilepsies

It has been long recognized that there is more to epilepsy than seizures. The prevalence of such neurobehavioral abnormalities as cognitive and mood disorders, autism spectrum disorder, and attention deficit and hyperactivity disorder (ADHD) is significantly higher among patients with epilepsy than in the general population. A long-held view that comorbidities of epilepsy represent mere epiphenomena of seizures has undergone substantial transformation during the past decade, as emerging clinical evidence and experimental evidence suggest the involvement of specific neurobiological mechanisms in the evolution of neurobehavioral deficits in patients with epilepsy. Developmental aspects of both epilepsy and its comorbidities, as well as the frequently reported reciprocal connection between these disorders, both add other dimensions to the already complex problem. In light of progress in effective seizure management in many patients with epilepsy, the importance of neurobehavioral comorbidities has become acute, as the latter are frequently more detrimental to patients' quality of life compared with seizures. This calls for a serious increase in efforts to effectively predict, manage, and ideally cure these comorbidities. Coordinated multicenter clinical, translational, and basic research studies focusing on epidemiology, neuropsychology, neurophysiology, imaging, genetics, epigenetics, and pharmacology of neurobehavioral comorbidities of epilepsy are absolutely instrumental for ensuring tangible progress in the field. Clinical research should focus more on new-onset epilepsy and put particular emphasis on longitudinal studies in large cohorts of patients and groups at risk, while translational research should primarily focus on the development of valid preclinical systems which would allow investigating the fundamental mechanism of epilepsy comorbidities. The final goal of the described research efforts would lie in producing an armamentarium of evidence-based diagnostic tools and therapeutic interventions which would at minimum mitigate and at maximum prevent or abolish neurobehavioral comorbidities of epilepsy and, thus, improve the quality of life of those patients with epilepsy who suffer from the said comorbidities.