Temporal Lobectomy: Emergent Psychopathology
Abstract & Commentary
Source: Carran MA, et al. Mania following temporal lobectomy. Neurology. 2003;61:770-774.
Carran and colleagues describe the development of mania and depression in patients undergoing surgery for intractable epilepsy. They compared 16 patients who developed new-onset mania following temporal lobectomy (TLX) with 2 other groups matched for age, gender, and laterality of the epileptic focus. The 2 control groups were patients who developed depression following TLX and those who demonstrated no newly emergent psychopathology following surgery. Two factors appeared to place patients at greater risk of post-TLX mania. First, mania developed more frequently in patients who underwent right-sided resection (12:4) vs no laterality difference (8:8) for those who developed post-TLX depression. In addition, patients who had bilateral epileptiform EEG abnormalities preoperatively had a higher rate of post-TLX mania.
Commentary
The association of epilepsy with psychopathology is well known. Post-ictal psychosis, at times evolving to inter-ictal psychosis, is commonly described. In addition, affective disorders, especially depression, have been associated with epilepsy arising from the right temporal lobe. Less common, and therefore, less well recognized, is the emergence of new psychiatric symptoms in patients following TLX for pharmacologically refractory epilepsy. This is certainly a risk that should be discussed with patients considering surgical treatment. Fortunately, the incidence of this complication seems to be low (8 patients with mania out of an operative database of 415 patients = 2%) and short-lived (all but 1 case remitted within 1 year following onset of mania).
Carran et al describe a number of theories that could account for the de novo development of mood disorders following TLX. One question that remains unanswered is whether there is an increased risk of psychopathology the longer the delay in referral for surgery. As with nearly every surgical treatment study, the mean duration of epilepsy prior to surgery was about 20 years for this group. While there was no significant difference in duration of epilepsy for the mania, depression, and control groups, Carran et al’s analysis does not allow us to conclude that duration of epilepsy is not a factor in psychiatric co-morbidity, either pre- or postoperatively. With on-going trials of earlier surgery for epilepsy, a more definitive answer to this question may become available and bolster the argument for more timely surgical treatment. — Andy Dean
Andy Dean is Assistant Professor of Neurology and Neuroscience, Director of the Epilepsy Monitoring Unit, Department of Neurology, New York Presbyterian Hospital—Cornell Campus.
Carran and colleagues describe the development of mania and depression in patients undergoing surgery for intractable epilepsy.
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