Temporal lobe epilepsy-Psychiatric aspects

Epilepsy
TLE and its types
causes
Auras
sequele of TLE
Diagnosis-MRI,EEG,PET
Treatment -medical and surgical
Np testing

1. TEMPORAL LOBE EPILEPSY Presenter- Dr.syed.zainab 1 st yr pg Moderator- Dr.Meghana 3 rd yr pg Department of psychiatry Kmch,guntur

2. INTRODUCTION Epilepsy -a condition characterized by 2/more recurrent epileptic seizures over a period longer than 24hrs,unprovoked by any immediate identified cause . Temporal lobe epilepsy (TLE ) -condition characterised by recurrent unprovoked seizures originating from the antero medial aspect of temporal lobe ( hippocampus,parahippocampal gyrus,Amygdala )

3. It is the most common of the anatomically defined syndromes, accounting for around 60% of all patients with localisation-related epilepsy. They represent approximately two thirds of the intractable seizure population requiring surgical treatment

4. TYPES OF TLE- MESIAL TEMPORAL LOBE EPILEPSY (Most frequent)-most common form of partial epilepsy in adolscent and adults Lateral or neocortical temporal epilepsy (NTE)-teen age

5. Causes The most frequent cause of TLE is Hippocampal sclerosis , also known as mesial temporal sclerosis or Ammon’s horn sclerosis, accounting for 50–70% of cases in temporal lobectomy series. Other causes of TLE include dysembryoplastic neuroepithelial tumours cavernous angiomas gliomas , cortical dysplasia gliosis secondary to encephalitis or meningitis.

6. Temporal lobe seizures may take the form of simple and complex partial seizures, with both occurring in some 70% of Patients seizures , those arising in the temporal lobes characteristically have a gradual onset, usually feature a conspicuous motionless stare and are relatively prolonged, with automatisms often continuing for 2 minutes, occasionally even longer . A wide variety of auras occur in TLE and many are highly characteristic.

7. Auras of temporal lobe epilepsy Aura are usually subjective symptoms without objective signs Aura itself simple partial or focal aware seizure The epigastric aura is the most common , being reported by up to 50% of patients with TLE . It consists of ill-defined sensations rising from the epigastrium towards the throat, typically described as churning , ‘butterflies ’ or a feeling of nervousness . Also frequent are inexplicable odd sensations in the head (cephalic aura ),although these have less specificity for TLE .

8. Auras of partial seizures. Symptom Frequency in TLE Temporal Frontal Parietal Occipital Epigastric aura 30–53 +++ – – – Cephalic aura 23–30 ++ ++ – – Anxiety/fear 14–24 ++ + – – Hallucinations/illusions Visual 16–18 + – + +++ Elementary 5–7 + – + +++ Complex 3 ++ – ++ – Auditory 8–16 +++ – + – Elementary 1–12 +++ – – – Complex 3–4 +++ – – – Olfactory 8–12 +++ + – – Gustatory 3–11 +++ + – – Somatosensory 2–19 + ++ +++ – Dysmnesic / déjà vu 7–18 +++ – – – No aura 10–51

9. Affective experiences are a feature of approximately one-quarter of temporal lobe auras. The most common is anxiety , which is often intense ( ictal fear) and wells up suddenly without provocation . Ictal emotional experiences may be very intense and tend to have a unique, though often difficult-to-describe ,

10. Cognitive abnormalities Cognitive abnormalities include -disturbances of speech,memory and thought. Vocalisation is seen in approximately 50 % of temporal lobe seizures. It is usually non-verbal, in which case it may be associated with either dominant or non-dominant foci and has no lateralising value. However , speech automatisms (recurrent, irrelevant or emotionally toned utterances), which can be thought of as evidence of preserved speech during the seizure discharge, are strongly related to a non-dominant temporal lobe focus

11. Disturbances of memory ( dysmnestic aura) range from sudden difficulty with recall to compulsive reminiscence on topics, scenes or events from the past. The essential quality of recognition may change, with strong feelings of familiarity or unfamiliarity leading to déjà vu and jamais vu. Disorders of thought-thought blocking,forced thinking,incoherent tqlk are are rare and less specific for TLE

12. Hallucinations of taste (gustatory) and smell ( olfactory) derive from medial temporal lobe structures, particularly the amygdala , and are of considerable signifi ance for the diagnosis of TLE. uncommon, accounting for less than 10% of temporal lobe auras , and may also be seen in frontal lobe seizures . The smells and tastes are usually described as unpleasant . Uncinate fits are typically unpleasant smells

13. Visual illusions may include objects appearing larger ( macropsia ) or smaller ( micropsia ) , inclined at an angle ( plagiopsia ), elongated or flattened ( dysplatopsia ) , drained of colour ( achromatopsia ) or infused with a specific colour ( erythropsia , red; xanthopsia , blue ). complex visual hallucinations of scenes, faces or visions of past experiences have been described with both medial temporal lobe foci and lateral temporal lobe foci

14. Auditory hallucinations, associated with foci in the superior lateral temporal gyrus , may be simple or complex , ranging from ringing and buzzing noises to organised experiences such as music or voices.

15. These varied aspects of the auras can occur in any combination. There is often a characteristic ‘march’ , passing- for example from an initial epigastric sensation to gustatory hallucinations to forced thinking, or from intense déjà vu to an overwhelming sense of fear. Sometimes various aspects of the aura appear to occur simultaneously, or the content is so rich and strange that the patient lacks the vocabulary to describe the experiences.

16. ictal semiology in TLE. Dystonic posturing , most commonly of the hand or arm, occurs in up to 70% of temporal lobe seizures and strongly suggests a contralateral focus . Slow gradual recovery with postictal delirium extending over several minutes is characteristic and headache is common.

17. Clinical features of temporal lobe seizures with lateralising value . Lateralising value Semiological feature Ipsilateral - Unilateral gestural automatisms Postictal nose rubbing Contralateral - Dystonic posturing Late versive movement (preceding secondary generalisation ) Unilateral clonic activity ( uncommon) Todd’s paresis (uncommon ) Dominant hemisphere - Postictal dysphasia Non-dominant hemisphere - Ictal speech Note that the aura of temporal lobe epilepsy have little lateralising value with the possible exception of ictal fear, which may suggest a focus in the non-dominant hemisphere.

18. automatisms in TLE Repetitive involuntary purposeless movements that are usually inappropriate but occassionally simulate relatively normal events The most frequent automatisms are oro -alimentary ( lipsmacking,chewing , swallowing) and gestural ( fumbling,picking , rubbing movements ). Unilateral gestural automatisms are suggestive of a n ipsilateral focus. Other common automatisms are ictal speech, grimacing, wandering and searching behaviour . Prolonged nature of automatisms is feature of TLE

19. Automatisms involving the lower limbs in pedalling or kicking movements are rare in TLE and more often associated with frontal lobe seizures Seizures may prsent as - Automatisms,illusions,hallucinations , pilomotor erections

20. Studies found a highly significant relationship between personality disorder and epileptic aura . No patient who did not experience an aura had a personality disorder. There were no associations with type of epilepsy or laterality, and no relationship with age at onset, duration of epilepsy or seizure frequency . Avoidant or dependent traits might develop as a reaction to frightening and unwanted experiences.

21. SEQUELE OF TLE POST ICTAL PSYCHOSIS -brief self limiting episodes of psychosis that are of abrupt onset following seizure Mixed psychotic and affective features most notably agitation following brief lucid interval after seizures Most common form of psychosis in pts with epilepsy Minor pts may develop chronic ictal psychosis

22. 2 INTER ICTAL PSYCHIATRIC ILLNESS - Depression-common in people with epilepsy ,especially those with poorly controlled seizures esp TLE Anxiety Suicide Schizophrenia like psychosis

23. Diagnosis MRI Video EEG Functional imaging –PET,SPECT Invasive eeg

24. Clinical finding- Reduced hippocampal volume- hippocampal atrophy (95%)

25. TREATMENT MEDICAL TREATMENT- Antiepileptic drugs About 60% TLE respond to AED and 40% have DRE (drug resistnt epilrepsy ) Drug of choice for the First line monotherapy in TLE is Carbamazepine or Oxcarbazepine Others – lamotrigine,levetiracetam,valproate

26. SURGICAL TREATMENT – Temporal lobe resection Procedures more practiced are anterior temporal resection and amygdala hippocampectomy Seziure freedom will be between 60;70%

27. Neuropsychological (NP)testing Mandatory part of presurgical evaluation TLE-memory and language Dominant TLE –verbal memory deficits NON Dominant TLE- visuospatisl memory deficits MEMORY DECLINE –MOST COMMON deficit after TLE surgery

28. References Lishmans Organic psychiatry 4 th edition Kaplan saddocks synopsis of psychiatry 11 th edition Google images of brain neuroimaging