Association of fear auras with mood and anxiety disorders after temporal lobectomy

PURPOSE: Epilepsy has been associated with increased occurrence of behavioral disorders. Auras reflect abnormal stimulation of brain areas in close proximity to regions from which clinical seizures originate. The purpose of our study was to investigate whether fear auras are associated with a higher rate of mood and anxiety disorders before and 1 year after temporal lobectomy. METHODS: Twenty-two patients with fear auras were compared with matched groups with other auras and no auras. Neurologic and neuropsychological evaluations before, 1-2 months after, and 1 year after temporal lobectomy were reviewed for mood and anxiety disorders and psychotropic medication treatment. A logistic regression model examined effects of patient group and psychiatric status on postoperative psychiatric status. RESULTS: The majority of patients in the three groups experienced mood and anxiety disorders before surgery. Mood and anxiety disorders declined in the control, but not in the fear aura group after surgery. Presence of auras at 1 year after surgery was not related to psychiatric outcome. Postoperative mood and anxiety disorders were more common in patients with persistence of seizures and in those in the fear group who were seizure free. The minority of patients in all groups underwent psychotropic treatment before surgery, but the majority with fear auras underwent treatment after surgery. CONCLUSIONS: Postoperative mood and anxiety disorders were more common in fear aura patients after temporal lobectomy, in particular, if seizure free. Possible mechanisms include the role of the amygdala in fear conditioning, the concepts of forced normalization, and kindling.     

Psychoses in drug-resistant temporal lobe epilepsy.

In the survey of 74 Danish patients with temporal lobe epilepsy who underwent temporal lobectomy, a total of 20 patients were psychotic. Nine of these became psychotic during the follow-up period, six of them after cessation of their epileptic seizures. There were 13 schizophrenia-like psychoses, six paranoid delusional and depressive psychoses, and one childhood psychosis. Operation was on the right side in 39 and on the left side in 35 patients. When the various psychotic groups were compared with each other or with the nonpsychotic patients, the side of operation was not found to be statistically important. The patients with psychoses were older at operation and showed a higher rate of focal lesions in the resected specimens. Although more psychotic patients were bright or normally gifted, and had achieved a higher standard of schooling than nonpsychotic patients, their social status after operation was inferior. Surgery had no effect on psychosis present preoperatively nor on its possible postoperative onset. The diagnosis of psychosis was not considered to be contraindication to temporal lobectomy.     

Schizophrenia-like psychosis arising de novo following a temporal lobectomy: timing and risk factors

OBJECTIVES: To clarify risk factors for the development of schizophrenia-like psychotic disorders following temporal lobectomy, and to explore the possibility that the early postoperative period is a time of high risk for the onset of such chronic psychotic disorders. METHODS: Patients who developed schizophrenia-like psychosis were identified from a series of 320 patients who had a temporal lobectomy for medically intractable epilepsy. The relationship of their disorders to both the operation and subsequent seizure activity was examined. Using a retrospective case-control design, risk factors for the development of schizophrenia-like psychosis were established. RESULTS: Eleven patients who developed schizophrenia-like psychosis postoperatively were identified and compared with 33 control subjects who remained free of psychosis postoperatively. The onset of de novo psychotic symptoms was typically in the first year following the operation. No clear relationship between postoperative seizure activity and fluctuations in psychotic symptoms emerged. Compared with the controls, patients who become psychotic had more preoperative bilateral electroencephalogram (EEG) abnormalities, pathologies other than mesial temporal sclerosis in the excised lobe and a smaller amygdala on the unoperated side. CONCLUSIONS: Temporal lobectomy for medically intractable epilepsy may precipitate a schizophrenia-like psychosis. Patients with bilateral functional and structural abnormalities, particularly of the amygdala, may be at particular risk for the development of such psychoses.     

Selective emotional detachment from family after right temporal lobectomy

Behavioral changes, such as mood disorders, anxiety, psychosis, and nonepileptic seizures often occur after temporal lobectomy. We report a man who selectively lost emotional attachments to family members after right temporal lobectomy. However, emotional responsiveness to strangers was normal or increased.     

Mental aspects of temporal lobe epilepsy. Follow-up of 74 patients after resection of a temporal lobe.

Psychiatric disorders were investigated in 74 patients with drug-resistant temporal lobe epilepsy (complex partial epilepsy). In all cases unilateral anterior temporal lobectomy had been performed during the period 1960-69. At follow-up in 1970-71, 45 patients were free from seizures, and in a further group of 15 patients seizure frequency had been substantially reduced. There were four postoperative deaths. Six patients were psychiatrically normal and had no history of any such disorder. Behavioural disturbances were observed in 55 patients. Before operation 11 patients displayed schizophrenia-like psychoses, and nine others became psychotic during follow-up. Fourteen patients attempted suicide on one or more occasions. Half the patients had diminished sexual drive. Improvement in psychiatric status was clearly correlated with relief from seizures and, in those cases with only a few or no seizures after operation, led directly to social rehabilitation. The presence or absence of a psychiatric disorder was not useful as a criterion for or against surgery.     

Postoperative psychoses in epileptic patients after temporal lobectomy

Introduction – Psychosis is the most severe psychiatric complication after epilepsy surgery. Patients and methods – We evaluated postoperatively at 1 year the psychoses of a series of 57 adult patients with intractable epilepsy who underwent temporal lobe surgery. Results – Five patients (8.8%) developed postoperative psychosis. Two (3.5%) of these 5 revealed postictal psychotic episodes in connection with persisting seizures, both of them had had similar episodes even preoperatively. Two patients (3.5%) exhibited a definite and one patient (1.8%) a probable de novo schizophrenia. Conclusion – Our findings clearly emphasize the need for careful postoperative psychiatric follow-up for patients with temporal lobectomy.     

Bilateral Magnetic Resonance Imaging-Determined Hippocampal Atrophy and Verbal Memory Before and After Temporal Lobectomy

Summary: We investigated pre- and postoperative verbal memory in temporal lobectomy patients who had volumetrically symmetric hippocampi. Pre- and postoperative verbal memory data based on the Logical Memory subtest of the Wechsler Memory Scale-Revised (WMS-R) were obtained from 15 left and 18 right temporal lobectomy patients. The difference between hippocampal volumes (R/L) was between -0.1 and 0.3 cm³, which is indeterminate for lateralizing hippocampal atrophy. Patients were divided into four groups based on side of operation and combined hippocampal volume expressed as a function of total intracranial volume (R + L volume/total intracranial volume). Patients with a combined hippocampal volume that was smaller than any combined hippocampal value of a normal control group were defined as bilaterally atrophic. Left temporal lobectomy patients demonstrated the expected decrease in verbal memory postoperatively regardless of whether the volumetrically symmetric hippocampi were nonatrophic or atrophic. Left temporal lobectomy patients with bilaterally atrophic hippocampi, however, had the poorest verbal memory before and after operation. Right temporal lobectomy patients tended to have improved verbal memory after operation whether or not the volumetrically symmetric hippocampi were atrophic. We conclude that side of operation is a more potent predictor of verbal memory outcome than is hippocampal atrophy when hippocampi are bilaterally symmetric and that left temporal lobectomy patients with bilateral atrophy may be at risk for greater functional deficits after operation.     

Dysphoric mood in paranoid psychoses

Many authors have stressed the particular affective behavior in paranoid psychoses, mainly its dysphoric pattern. In 1983, Berner formulated the dysphoric axial syndrome as a third type of the endogenomorphous cyclothymic axial syndrome. In this paper two points are examined: (1) The interrelation between dysphoric and depressive and/or manic affective disorders in paranoid psychoses, cross-sectionally and longitudinally, in order to test the hypothesis of their independence, and (2) the relation of dysphoric mood disorders in paranoid psychoses to their course, again in comparison with other types of affective symptoms. The paper is based on an empirical study by Gabriel in 1978 on the phenomenology and the course of paranoid psychoses.     

Somatoform disorders after temporal lobectomy.

OBJECTIVE: Depression, anxiety, and psychosis are the most frequent psychiatric disorders after epilepsy surgery. The only new-onset somatoform disorder reported postoperatively is conversion disorder. We identified 10 patients who developed somatoform disorder other than nonconversion epileptic seizures after anterior temporal lobectomy. METHOD: We retrospectively reviewed the charts of 325 anterior temporal lobectomy and 125 extratemporal surgeries between 1991 and 2000. RESULTS: Seven of the patients developed undifferentiated somatoform disorder after anterior temporal lobectomy, 1 had pain and body dysmorphia, another had pain disorder, and another had body dysmorphia alone, but none were found after extratemporal surgeries (chi-square = 3.93; P < or = 0.05). Somatoform disorder was significantly more common in right anterior temporal lobectomy (n = 9) than left anterior temporal lobectomy (n = 1) (chi-square = 6.5; P < or = 0.025). CONCLUSIONS: Our findings suggest that right temporal resection contributes to the development of somatoform disorders in our patients and that right temporal dysfunctions may contribute to idiopathic somatoform disorders.     

Psychiatric aspects of temporal lobe epilepsy before and after anterior temporal lobectomy

OBJECTIVES: Psychopathology has been reported to be prevalent both before and after surgical treatment for medically intractable temporal lobe epilepsy. Individual patients were evaluated prospectively to assess the effect of anterior temporal lobectomy (ATL) on prevalence and severity of psychiatric disease. METHODS: Psychiatric status was assessed in a consecutive series of epilepsy patients before and 6 months after ATL using a structured psychiatric interview, psychiatric rating scales, and self report mood measures. RESULTS: A DSM-III-R axis I diagnosis was present in 65% of patients before and after surgery. The most common diagnoses were depression, anxiety, and organic mood/personality disorders. There was a trend for major psychiatric diagnoses to be more common in patients with right compared to left temporal lobe seizure focus, both before and after surgery. The apparent stability in the overall rate of psychiatric dysfunction concealed onset of new psychiatric problems in 31% of patients in the months shortly after surgery, and resolution of psychiatric diagnoses in 15% of patients. In the group as a whole, the severity of psychiatric symptoms was lower at 6 months postsurgery than before temporal lobectomy. CONCLUSIONS: The overall prevalence of psychiatric dysfunction was comparably high before and after ATL, but individual changes in psychiatric status and changes in severity of symptoms occurred in many patients in the 6 months after surgery.     

Psychiatric outcome after temporal lobectomy: a predictive study

PURPOSE: The occurrence of psychiatric symptoms after temporal lobectomy is well documented. The aim of the present study was to identify preoperative factors that predict postoperative psychiatric outcome. METHODS: We studied the case notes of 121 patients (from an initial sample of 167) who underwent temporal lobectomy at the National Hospital of Neurology and Neurosurgery, Queen Square, London, between 1988 and 1997. Data concerning gender, laterality of lesion, pathology, seizure outcome, psychiatric history, psychiatric outcome, resection volume, telemetry, and MRI scans were systematically collected. Factors that predict the occurrence of postoperative psychiatric symptomatology were investigated using correlational, chi(2), and logistic regression techniques. RESULTS: Poor postoperative psychiatric outcome in general was positively associated with preoperative bilateral independent spike discharges at telemetry. The size of surgical resection was positively correlated with the occurrence of postoperative emotional lability. The laterality of the epileptogenic lesion was not associated with a poor psychiatric outcome. Developmental lesions were associated with a good psychiatric outcome at a marginally significant level. Patients with a preoperative psychiatric history and de novo psychiatric symptomatology had a poorer surgical outcome in terms of seizure frequency, also at a marginally significant level. A significant correlation was found between a past psychiatric history and seizure outcome. CONCLUSIONS: We identified a high frequency of psychiatric symptoms both before and after temporal lobectomy, demonstrating that it is not a benign procedure from the point of view of psychopathology. Our results show that there are certain predictive factors that may help identify patients most at risk for postoperative psychiatric disorders.     

Postictal psychosis syndrome: a clinical entity to be recognized

INTRODUCTION: Post-ictal psychosis syndrome (PIP) belongs to the group of epileptic psychoses which, according to the most commonly used classification, is to be distinguished from ictal psychoses, on one hand, and from inter-ictal psychoses, on the other. OBJECTIVES: The present paper aims to review recent data concerning the clinical, therapeutic and pathophysiological aspects of PIP. METHODS: We report four cases of PPI, which involved four patients hospitalized at the Salpêtrière hospital between 2001 and 2005, and discuss these cases in light of the relevant literature. RESULTS: The PIP fit generally occurs in patients suffering from intractable temporal lobe epilepsy which started several years before. The psychiatric disorders suddenly take hold after a series of complex partial seizures with frequent secondarily generalized tonic clonic seizures. During the episode, EEG recordings do not show any epileptic activity. Psychiatric symptoms consist of persecutory delusive ideas, verbal and visual hallucinations, agitation, and aggressiveness. Mood disorders are variable from one patient to another and exhibit intraindividual fluctuation. In most patients given antipsychotic drugs, the short-term outcome of PIP is favorable . In the long-term, even if recurrence is the main long-term risk, progression to severe mood disorders or to poor prognosis inter-ictal psychosis is possible. Accordingly, the clinician must be aware of this syndrome in order to correctly diagnose PIP since effective treatment with antipsychotic drugs is available. CONCLUSION: The short-term prognosis of PPI is usually favorable but this syndrome can potentially develop in the long-term to more severe psychiatric disorders. It is, therefore, important to recognize PIP syndromes which respond more readily to pharmacological treatments than other types of psychoses.     

Does antiepileptic drug withdrawal predispose patients undergoing temporal lobe epilepsy surgery to late onset of psychiatric morbidity? A report of three cases

Surgery is an established and increasingly utilized treatment option in medically refractory temporal lobe epilepsy. Many psychiatric problems are known to complicate in the postoperative period. Most studies have a follow-up period of less than 24 months. We report the cases of three patients who developed severe psychiatric problems in the late postoperative period after successful temporal lobectomy for refractory epilepsy — Psychosis, major depression with psychosis, and severe anxiety disorder, respectively. None of the patients had past or family history of psychiatric disease. All three patients had undergone anterior temporal lobectomy on the right side for intractable epilepsy. They remained absolutely seizure-free after surgery. We conclude that psychiatric morbidity may arise de novo long after temporal lobectomy. This association between temporal lobectomy for epilepsy and late onset psychiatric morbidity should be carefully studied. Mechanisms underlying this late complication require deeper understanding of the effects of epilepsy surgery.     

Does the Intracarotid Amobarbital Procedure Predict Global Amnesia After Temporal Lobectomy?

PURPOSE: The intracarotid amobarbital procedure (IAP) 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 IAP 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 IAP 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 IAP 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 IAP and the possibility that memory may be reorganized in patients with a long history of temporal lobe epilepsy.     

The relationship between quantitative T2 relaxometry and memory in nonlesional temporal lobe epilepsy

PURPOSE: We investigated the relationship between preoperative quantitative magnetic resonance imaging (MRI) T2 relaxometry and volumetry of the hippocampi and pre- and postoperative verbal memory in temporal lobectomy patients who had nonlesional temporal lobe epilepsy. METHODS: Pre- and postoperative memory data based on the Logical Memory (LM) subtest of the Wechsler Memory Scale-Revised (WMS-R) and the 30-min delayed recall trial of the Rey Auditory Verbal Learning Test (AVLT) were obtained from 26 left and 15 right temporal lobectomy patients. Coronal MRI T2 maps were generated for these 41 temporal lobectomy patients as well as 61 control patients. Hippocampal T2 relaxation times and hippocampal volumes, converted to z scores using control group data, were correlated with neuropsychological performance in the patients. RESULTS: In left temporal lobe-onset patients, high T2 in the left hippocampal body predicted higher LM performance after surgery. Asymmetrically high T2 in the left hippocampal body (i.e., the right-minus-left difference), compared with the right hippocampal body, also predicted higher LM performance after surgery. In right temporal lobe-onset patients, high T2 in the left hippocampal body predicted relatively lower AVLT performance after surgery. Multiple regression analysis in left temporal-onset patients revealed that high T2 in the left hippocampal body together with higher preoperative LM performance predict higher postoperative LM performance. CONCLUSIONS: Our findings suggest that elevated (i.e., abnormal) hippocampal T2 signal is associated with memory ability (or hippocampal functional capacity) independent of MRI-determined hippocampal atrophy. Therefore, our findings support the use of quantitative T2 relaxometry as an independent predictor of verbal memory outcome in both left and right TLE patients who are candidates for temporal lobectomy.     

Language-related cognitive declines after left temporal lobectomy in children.

Presented is a case series demonstrating that clinically significant language-related cognitive declines not detected by intelligence quotient (IQ) testing occur after left temporal lobectomy in school-aged children. In this series, comprehensive preoperative and postoperative neuropsychologic evaluations were completed in eight school-aged patients who underwent temporal lobectomy (five left, three right) for temporal lobe epilepsy. Mean age at surgery was 13 years, 11 months +/- 2 years, 1 month. Testing included measurement of IQ, verbal learning, naming, visual memory, sight word recognition, reading comprehension, and calculation. All five left temporal lobectomy patients demonstrated significant language-related cognitive declines on postoperative neuropsychologic testing, including deficits in verbal IQ (one patient), verbal learning (four patients), naming (one patient), and reading comprehension (one patient). These deficits were clinically evident in four of the five left temporal lobectomy patients, leading to declines in educational performance. IQ testing alone did not reliably identify these deficits. No significant declines were found after surgery in three right temporal lobectomy patients. Average or high preoperative functioning may have predisposed patients to postoperative deficits in this series, whereas magnetic resonance imaging or pathologic abnormalities did not protect against postoperative deficits. Outcome studies of temporal lobectomy in childhood should use comprehensive neuropsychologic testing to identify cognitive deficits.     

颞叶切除术后视觉障碍的原因分析和预防

目的分析颞叶癫痫患者颞叶切除术后出现视觉障碍的原因,改进手术方法,以进一步提高手术疗效,减少术后视觉障碍并发症的发生。方法通过熟悉与视觉相关的颞叶解剖,改进治疗颞叶癫痫患者前颞叶切除术的技术。①针对滑车神经和动眼神经损伤所致的复视,在切除颞叶内侧结构时,在软膜内切除,避免双极电凝的热损伤。②针对视放射损伤导致的视野缺损,离断颞叶的范围距颞极不要超过3.5cm。结果 42例颞叶癫痫患者颞叶切除术后仅2例出现复视,其余没有视野缺损症状。39例随访7～26个月,癫痫发作控制达到EngelⅠ～Ⅱ级者31例(79.5%),Ⅲ～Ⅳ级8例。3例失访。结论颞叶癫痫患者颞前叶切除术后出现复视和视野缺损的主要原因是手术中滑车神经、动眼神经和视放射受损。手术中严格限制切除颞叶范围,防止视放射受损和良好的显微外科操作技巧,避免损伤动眼和滑车神经,可以有效防止术后视觉障碍并发症的发生。     

Postsurgical Changes in Self-Reported Mood and Composite IQ in a Matched Sample of Patients With Frontal and Temporal Lobe Epilepsy

Changes in self-reported mood assessed by the Beck Depression Inventory (BDI) were examined in a sample of 60 left-hemisphere speech-dominant patients who underwent epilepsy surgery (15 right frontal, 15 left frontal, 15 right temporal, 15 left temporal). Temporal lobectomy patients were matched to frontal lobectomy patients by presurgical BDI scores, premorbid K-BIT composite IQ, sex, age, and years since seizure onset. Overall, self-reported mood improved following surgery, with men showing a greater improvement than women. There were no differences among the four groups in terms of pre-surgical and post-surgical reported mood. However, frontal patients showed more extreme changes in mood in either direction than temporal patients. Additionally, while temporal patients showed gains in Composite IQ, no such gains were observed in frontal patients. Changes in mood in frontal patients were not related to postsurgical seizure outcome or time since surgery, but were related to changes in Composite IQ.     

Postsurgical changes in self-reported mood and Composite IQ in a matched sample of patients with frontal and temporal lobe epilepsy.

Changes in self-reported mood assessed by the Beck Depression Inventory (BDI) were examined in a sample of 60 left-hemisphere speech-dominant patients who underwent epilepsy surgery (15 right frontal, 15 left frontal, 15 right temporal, 15 left temporal). Temporal lobectomy patients were matched to frontal lobectomy patients by presurgical BDI scores, premorbid K-BIT composite IQ, sex, age, and years since seizure onset. Overall, self-reported mood improved following surgery, with men showing a greater improvement than women. There were no differences among the four groups in terms of pre-surgical and post-surgical reported mood. However, frontal patients showed more extreme changes in mood in either direction than temporal patients. Additionally, while temporal patients showed gains in Composite IQ, no such gains were observed in frontal patients. Changes in mood in frontal patients were not related to postsurgical seizure outcome or time since surgery, but were related to changes in Composite IQ.