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Suicidal attempts and aggressive behaviours after temporal lobectomy in epilepsy

Sir, Temporal lobe epilepsy (TLE) is a common neurological disorder which is often associated with simple partial, complex partial and tonic–clonic (TC) seizures. Patients with refractory TLE are often treated with temporal lobectomy that tends to improve the clinic. However, in some cases it is possible that surgery may worsen or change the characteristics of seizures [1]. Mr B, a 32-year-old, right-handed patient with refractory TLE underwent surgery (right-sided tailored resection with amygdalohippocampectomy) in September 2005. The patient had been treated because of simple partial, complex partial seizures and secondary TC seizures in the Epilepsy Center since September 2002. Presurgical EEG showed a clear ictal and interictal focal activity in the right mesial temporal lobe. The patient had never suffered from suicidal or violent behaviours and showed no premorbid personality disorder as stated in the presurgical psychiatric evaluation. Two days after discharge from the Department of Neurosurgery he was admitted as an emergency to the Department of Psychiatry because of a sudden confusion with aggressive and suicidal behaviour. At admission, the patient had fully recovered and showed no relevant psychopathological signs. Especially, the patient believably denied any suicidal or aggressive thoughts. During the 14 days of hospitalization in the Department of Psychiatry we found no relevant psychopathological symptoms apart from the described episodes and no evidence for any other psychiatric disorder according to ICD-10 or DSM-IV. The patient suffered from two more episodes with aggression and suicidal behaviour during hospitalization, first during a (clinically diagnosed) complex partial seizure and second postictal after a TC seizure. All episodes lasted for approximately 30–60 min, with postictal tiredness and amnesia. The inter-ictal EEG showed no epileptic potentials but a well-known right temporal slowing without any differences to previous EEGs. The CCT revealed a discreet subdural hygroma without any pathological relevance. Because of the described psychotic episodes we complemented the previously existing antiepileptic medication (oxcarbazepine 1800 mg) with clobazam 10 mg. After discharge the patient was transferred to a rehabilitation centre, where he suffered from one more psychotic episode, which led to a supplementary medication with olanzapine 10 mg. Under this medication no more psychotic episodes occurred up to now (3 months later). Psychiatric disorders after temporal lobectomy have been described as a relevant clinical problem and occur mainly as a depressive reaction [2]. Suicidal attempts in our patient cannot be explained as a consequence of a mood disorder but seem to have occurred only during complex partial seizures or as postictal episode. Suicide, suicidal attempts and violence as manifestations during ictal and postictal psychosis particularly in patients with TLE have been reported earlier [3,4]. Whilst the genesis of these behavioural changes remains unclear, a postsurgical disruption of seizure-suppressing inhibitory pathways may be hypothesized [5]. Regarding differences between left and right temporal lobectomy, a recent study showed that patients with psychosis mostly suffer from bilateral functional abnormalities [6]. In our case, the psychotic episodes were successfully treated with a medication of clobazam and olanzapine. We think that patients and clinicians must be aware of a possible change in the characteristics of ictal or postictal psychosis after temporal lobectomy, which may lead to dangerous psychotic episodes including aggressive and suicidal behaviour.