Journial ofNeurology, Neurosurgery, and Psychiatry 1993;56:277-279 277

Post-ictal psychosis after right temporal J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.56.3.277 on 1 March 1993. Downloaded from lobectomy

R Manchanda, H Miller, R S McLachlan

Abstract Approximately 450 patients had neurosur- Of 298 patients who had temporal lobec- gical intervention for intractable seizure disor- tomies for intractable epilepsy, 4 (1.3%) ders between 1974-90. A total of 298 patients developed post-ictal psychosis for the had a temporal lobectomy for control of first time after surgery. All were males of seizures. Of these, 4 patients developed a normal intelligence with no pre-operative post-ictal psychosis after surgery in the psychiatric disorder. Psychosis followed absence of chronic interictal psychosis. All both complex partial and generalised patients had continuous EEG recording dur- seizures. The psychotic symptoms ing the psychosis. The hospital charts for showed polymorphic features. Right these 4 patients were reviewed for the clinical temporal lobectomy may increase the information, EEG data and histology of the susceptibility to post-ictal psychosis in resected temporal lobes. Although no formal patients who are not seizure free after pre-operative psychiatric assessments were surgery, particularly in the first post- carried out, there was no history of previous operative year. psychiatric illness in these patients. One patient had compulsive personality traits. All (7 Neurol Neurosurg Psychiatry 1993;56:277-279) 4 patients met the diagnostic criteria for post- ictal psychosis.' Psychiatric ratings were Chronic interictal psychoses of epilepsy have obtained using the Syndrome Check List, a been studied extensively, but research in post- schedule derived from the Present State ictal psychotic states is relatively scant. 1-3 Examination (PSE)s for retrospective evalua- Post-ictal psychosis has a clear temporal rela- tion of case records. A total of 38 syndromes tionship with seizure activity. A flurry of com- can be recorded from 140 symptoms rated in plex partial seizures which may or may not the PSE. Each syndrome has a score, com- become secondarily generalised or a single prising the summed score of its constituent prolonged seizure may precipitate a post-ictal symptoms and a degree of certainty (0,?, +, psychosis. Spontaneous resolution is usual, but recurrence is common. The clinical pic- ture is polymorphic with behavioural distur- bance, delusions and/or hallucinations, with Results or without confusion. Four of 298 patients (1-3%) who had a tem- http://jnnp.bmj.com/ There are several reports of paranoid or poral lobectomy developed a post-ictal psy- schizophrenia-like psychosis which developed chosis. All four patients were males with de novo following surgical resection of one normal intelligence, between the ages of 24 temporal lobe for intractable epilepsy,4 but and 44, with a duration of epilepsy of 6 to 42 these psychotic disorders did not relate to years (table 1). All patients had the onset of seizure activity. There are no reports of post- post-ictal psychosis post-operatively. None

ictal psychosis appearing in individuals who had evidence of interictal psychosis pre- on September 28, 2021 by guest. Protected copyright. have had surgery for epilepsy. Four such cases operatively or during post-operative follow up are described. ranging from 3 to 15 years. None experienced post-ictal psychosis before surgery. It was not Department of necessary for the seizures to generalise for Psychiatry, University Method psychosis to occur. As few as two focally orig- of Western Ontario Patients were admitted to the Epilepsy Unit seizures in the 24 hour could London inating period R Manchanda at University Hospital, London, Canada, for precipitate a psychosis in two of the patients Department of investigation and treatment of medically while in the other two, post-ictal psychosis Clinical Neurological refractory seizure disorders, to assess in par- appeared after a flurry of complex partial Services, University of ticular the possibility of surgical management. seizures progressing to secondary generalisa- Western Ontario, London In addition to clinical observation of the tion. There was a latency of 1 to 2 days before H Miller seizure phenomena, patients have standard psychosis developed in two patients and it R S McLachlan EEG telemetry using scalp electrodes with was present immediately after recovery from Correspondence to: continuous monitoring until sufficient the seizures in the other two. The duration of Dr Manchanda, University Hospital, Box 5339, seizures were recorded to delineate the focus. psychosis was 1 to 8 days. London, Ontario, Canada When scalp electrodes failed to do this, Right temporal originating seizures were N6A 5A5 telemetry was continued using implanted sub- recorded in 3 patients and the fourth was Received 31 March 1992 dural electrodes. In addition, patients had operated on the basis of interictal and other and in revised form 30 June 1992. neuropsychological assessments and CT or data. Interictal and ictal abnormalities were Accepted 10 July 1992 MRI. seen in the left temporal lobe in 2 patients 278 Manchanda, Miller, McLachlan

Table 1 Clinical characteristics offour patients with post-lobectomy post-ictal psychosis J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.56.3.277 on 1 March 1993. Downloaded from Age at seizure onset; Time Number of Psychosis Duration at right Number of from precipitating free of Clouding temporal psychotic surgery seizures; period psychosis; during Case number lobectomy episodes to episode type (days) (days) psychosis Sex (years) 1 18; 1 13 years 7; 2 1 no Male 24 grand mal 2 13; 1 4 months 2; 1 7 no Male 29 complex partial 3 1!; 5 6-15 2-7; 0 4-8 no Male 44 months at first complex partial, later grand mal 4 33; 2 9 months, 2; 0 2 yes Male 42 19 months complex partial

(table 2). The left hemisphere was dominant ception of time and organic impairment with for speech in all four patients. All had a right confusion were seen in patient 4. In addition, temporal lobectomy which revealed mesial patient 1 had religious delusions and patient temporal sclerosis in 3 patients and normal 4 had irritability, lack of energy and anxiety. tissue in one. Seizure frequency decreased, All patients responded to neuroleptic medica- but sporadic seizures continued to occur in tion (oral haloperidol) which was discontin- all 4 patients. The clinical and EEG features ued when the psychoses resolved. of these seizures suggested that they arose either from the right temporal resection bor- der or the right frontal region. Patients 3 and Discussion 4 became seizure free eighteen months and 3 Although there are no prevalence studies of years post-operatively after antiepileptic med- the condition, post-ictal psychosis, as such, is ications were altered. a rare disorder. Given the acute presentation, The features of the post-ictal psychosis are short duration of illness and possible non- recorded on the Syndrome Check List of the admission to hospital, it would be difficult to Present State Examination. The ratings were make any conclusions of its frequency. An made on their frequency of occurrence with a estimate of 1-3% in patients undergoing tem- degree of certainty of + or ++. Ratings were poral lobectomy in our series is at best tenta- made conservatively and data expressed tive and may be an under-estimate as the vaguely in the case notes were not included. cases reported are the ones that came to our Fifteen of 38 syndromes could be recorded in attention. Conversely, a blatant psychosis as these cases. Although there were common in these patients would probably not be features in some of these patients, no general- missed since the majority of our patients are isations can be made regarding symptoms. followed up at 6 monthly intervals for 2 years http://jnnp.bmj.com/ Three patients had depressive delusions and and yearly thereafter. As there are no other hallucinations (1, 2 and 4) and non-specific descriptions of post-ictal psychosis occurring psychosis (2, 3, 4). Two patients had nuclear after temporal lobe resection, we can only syndromes, paranoid delusions and delusion- compare our findings with the literature on al moods (2 and 3). Simple depression was post-ictal psychosis in general. rated in two patients (2 and 4). Changed per- The salient findings are as follows. All

patients met the diagnostic criteria of on September 28, 2021 by guest. Protected copyright. Logsdail and Toone.' Psychosis usually occurred after an exacerbation in seizure fre- Table 2 EEG changes in fourpatients with post-lobectomy post-ictal psychosis quency. It was not necessary for seizures to Preoperative generalise for psychosis to occur. All patients side of Post- EEG temporal operative during were males and had had right temporal lobec- a) spikes interictal post-ictal tomy. The psychotic symptoms showed a Case b) seizures EEG psychosis variable rather than discrete pattern. a) Right Independent Generalised delta; Clinically, there was no difference between b) None recorded bitemporal occasional brief theta. bursts of 2 Hz sharp post-ictal psychosis and a post-operative post- and slow. ictal psychosis. The patients responded to 2 a) Bilateral Right temporal Spikes: sporadic right independent spikes. temporal. Bitemporal treatment and had a good prognosis. None of b) 7 right; Delta: right delta. these patients has developed a chronic inter- 3 left temporal and frontal; ictal psychosis and none had pre-operative occasional psychiatric illness. left temporal. 3 a) Bilateral Right posterior Diffuse theta In this series, as few as two focally originat- independent temporal delta. and delta. ing seizures in a 24 hour period could precipi- b) 3 right, 2 bitemporal tate psychosis. Early reports on post-ictal 4 a) Right Right temporal Right temporal psychosis6 7 emphasise the importance of b) 3 right spikes. Right spikes and temporal delta. delta. grand mal seizures, usually in clusters, with- out a clinically focal onset. Levine7 noted Post-ictal psychosis after right temporal lobectomy 279

frequent precipitation by alcohol or drug dominant for speech and had right temporal J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.56.3.277 on 1 March 1993. Downloaded from withdrawal and found that the interval lobectomies. The right sided preponderance between precipitating seizures and the psy- is reminiscent of that found by Levine and chosis was usually less than a day. In con- Finkelstein'2 in their eight patients with right trast, in 14 patients with post-ictal psychosis, posterior cerebral hemisphere stroke or trau- secondary generalisation of complex partial ma followed by psychosis; seven of these seizures was common and that a post-ictal patients had seizures probably arising from "lucid" non-psychotic interval of more than a the right hemisphere and in two, the psy- day was usual.' Two of our patients had such chosis was both post-ictal and transient. In a a "lucid" interval lasting 1 to 2 days support- recent report of 6 consecutive patients with ing the latter finding. chronic post-operative psychosis referred for In patients 1 and 3, the new occurrence of psychiatric assessment after temporal lobecto- flurries of seizures may have contributed to my, all were males who had surgery on the increasing susceptibility to post-ictal psy- right hemisphere."3 This is strikingly similar chosis. One of these as well as patient 2 had to our findings. Furthermore, right sided such flurries pre-surgically without psychosis temporal surgery is associated with nearly suggesting that the surgery itself may have three times the frequency of subsequent psy- increased susceptibility to post-ictal psy- chosis than surgery to the left temporal lobe.4 chosis. In case 1 and 2, flurries of seizures The association of schizophreniform psy- have subsequently occurred without psy- chosis with dominant left temporal lobe chosis. It is not clear why susceptibility to epilepsy'4 has been a controversial topic with post-ictal psychosis has varied in these support from some studies'5 and no support patients; it could be indicative of a transient from others.'6 The finding that removal or period of increased susceptibility after tempo- destruction of the right temporal lobe can ral lobectomy, such as, that occurring for result in transient or permanent psychosis, other types of psychopathology.8 Stevens' in a particularly when seizures continue to appear follow up of patients having temporal lobec- from the right hemisphere suggests that, in tomy notes a 6 to 12 month interval between contrast to increased activity in the left tem- the operative procedure and development or poral lobe, decreased activity or hypofunction deterioration of psychopathology. She pro- of the right temporal lobe may play a role in poses aberrant reinnervation in projection the pathogenesis of psychotic disorders. sites of the damaged or removed medial tem- Further studies of post-operative psychiatric poral structures to explain post-surgical psy- states may help clarify these issues. chosis of the chronic type. Persistence of local epileptic activity could contribute to such a phenomenon as it stimulates anomalous 1 Logsdail SJ, Toone BK. Post-ictal psychosis: a clinical and O1 phenomenological description. Br J Psychiatry 1988; sprouting and synaptic expansion.'0 Another 152:246-52. explanation is that surgery was incidental and 2 So NK, Savard G, Andermann F, Olivier A, Quesney LF. Acute postictal psychosis: a stereo EEG study. Epilepsia psychosis could have occurred anyway in 1990;31: 188-93. these patients. That could most easily be 3 Savard G, Andermann F, Olivier A, Remillard GM. Postictal psychosis after partial complex seizures: a mul- argued for patient 1 who developed psychosis tiple case study. Epilepsia, 1991 ;32:225-3 1. 13 years post-operatively. 4 Trimble MR. The psychoses of epilepsy. NY, Raven Press, 1991. http://jnnp.bmj.com/ Logsdail and Toone' reported that EEGs 5 Wing JK, Cooper JE, Sartorius N. The measurement and taken during psychosis did not show ictal dassification ofpsychiatric symptoms. London: Cambridge University Press, 1974. activity and that precipitating seizures com- 6 Clark RA, Lesko JM. Psychosis associated with epilepsy. monly occur in clusters of about 3. So et al2 Am J Psychiatry, 1939;96:595-607. 7 Levin S. Epileptic clouded states: a review of 52 cases. J also demonstrated absence of ictal activity Nerv Ment Dis 1952;116:215-25. during post-ictal psychosis in a patient moni- 8 Fenwick PBC. Long-term psychiatric outcome after epilepsy surgery. In: Luders HO, ed. Epilepsy surgery. tored by bilateral depth and epidural elec- NY: Raven Press, 1992:647-52.

trodes. Savard et al3 described 9 cases and in 9 Stevens JR. Psychiatric consequences of temporal lobecto- on September 28, 2021 by guest. Protected copyright. my for intractable seizures: a 20-30 year follow up of 7 of these the seizure flurry was precipitated 14 cases. Psycholog Med 199 1;20:529-45. by withdrawal of antiepileptic drugs during 10 Sutula T, Xiao-Xian H, Cavazos J, Scott G. Synaptic reorganization in the hippocampus induced by abnor- investigation with a view to surgical treatment mal ftmctional activity. Science 1988;239:1147-50. of epilepsy. EEGs during the psychotic period 11 Geinisiman Y, Morell FR, de Toledo-Morrell L. Perforated synapses on double-headed dendritic spines: in our patients revealed no ongoing seizure a possible structural substrate of synaptic plasticity. activity. In 3 patients, the findings were the Brain Res 1989;480:326-9. 12 Levine DN, Finkelstein S. Delayed psychosis after right same as in previous interictal recordings and temporoparietal stroke or trauma: relation to epilepsy. in 1 carried out within hours of the seizure a Neurology 1982;32:267-73. 13 Mace CJ, Trimble MR. Psychosis following temporal lobe mild post-ictal change was seen. All patients surgery: a report of six cases. J Neurol Neurosurg remained on at least 2 antiepileptic drugs Psychiatry 1991 ;54:639-44. 14 Flor-Henry P. Psychosis and temporal lobe epilepsy. after surgery. No alteration in drug therapy Epilepsia 1969;10:363-95. had been made within the 2 months before 15 Perez M, Trimble M R. Epileptic psychosis: an evaluation of PSE profiles. BrJ7 Psychiatry 1985;146: 155-164. post-ictal psychosis occurred. 16 Parnas J, Korsgaard S. Epilepsy and psychosis: a review. All four patients were left hemisphere Acta Psychiat Scand 1982;66:89-99.