(092) Psychiatric Sequelae of Temporal Lobectomy: A Case Study

Abstract: Psychiatric Sequelae of Temporal Lobectomy: A Case Study

Background

Surgical management is an important treatment for epilepsy refractory to anti-epileptic drugs (AEDs). The temporal lobectomy is among the most common operations performed on this patient population. The psychiatric sequelae of this procedure are poorly understood.

Case

A 39yo right-handed woman with a history of temporal lobe epilepsy since adolescence presented with months of increasingly erratic behavior and paranoid delusions. She had been seizure-free after a right temporal lobectomy in 2012 with maintenance levetiracetam. Lamotrigine was added after several breakthrough seizures in 2020. Approximately 1 year later, the patient began to experience persecutory delusions, culminating in a car accident when she believed she was being chased on the highway. After stabilization by trauma services, she was referred for involuntary psychiatric hospitalization. Her only other psychiatric history was a voluntary hospitalization in 2008 for depression with psychotic features, after which time she was maintained on sertraline.

Initial mental status exam revealed an irritable woman with obvious psychomotor agitation, rocking back and forth. Speech was rapid and profane with tangential thought processes. She was seen responding to internal stimuli. Cognitive screening revealed no impairment. She showed no signs of seizure activity during her month-long admission but refused EEG testing. Her paranoia improved on olanzapine although she never developed insight and stated she would stop all psychotropics on discharge home.

Discussion

Psychiatric disorders are the most common postoperative complication after temporal lobectomy, noted in 7% of patients in one meta-analysis (Brotis, 2019). One explanation for this phenomenon is the theory of forced normalization, wherein acute psychosis presents in epilepsy patients after seizure control is achieved. These symptoms are less likely to completely resolve in patients triggered by surgery versus pharmacologic therapy (Calle-López, 2019). Forced normalization symptoms are also more difficult to manage compared to peri-ictal psychoses, requiring multidisciplinary management, including withdrawal of all AEDs and long-term antipsychotic therapy (Loganathan, 2015).

Implications

Though a unifying mechanism has not been identified, there is a clear link between temporal lobectomy and psychosis in the epidemiological literature. Providers caring for lobectomy patients should have a low threshold of suspicion for psychosis when unusual behavior or disorganized thinking becomes evident, as it can quickly become debilitating. Possible forced normalization should be differentiated from ictal psychosis through EEG studies.

References

Brotis AG, Giannis T, Kapsalaki E, Dardiotis E, Fountas KN. Complications after Anterior Temporal Lobectomy for Medically Intractable Epilepsy: A Systematic Review and Meta-Analysis. SFN. 2019;97(2):69-82.

Calle-López Y, Ladino LD, Benjumea-Cuartas V, Castrillón-Velilla DM, Téllez-Zenteno JF, Wolf P. Forced normalization: A systematic review. Epilepsia. 2019;60(8):1610-1618.

Loganathan MA, Enja M, Lippmann S. FORCED NORMALIZATION: Epilepsy and Psychosis Interaction. Innov Clin Neurosci. 2015;12(5-6):38-41.

Presenting Author(s)

Emma Craige, BS (she/her/hers)

Medical Student
University of Virginia School of Medicine
Falls Church, VA, United States

Co-Author(s)
RB

Rachel Bronsther, MD

Division Chief, Adult Psychiatry
Inova Health System
Falls church, Virginia, United States

AM

Alex Mallory-Badia, MD

Resident Physician
Walter Reed National Military Medical Center
Silver Spring, Maryland, United States