QURAT KHAN, M.D. Epilepsy, Stroke

BRIEF OVERVIEW TLE Epilepsy

Chronic disorder of brain characterized by recurrent seizures due to excessive electrical discharges in a group of brain cells Two or more unprovoked seizures Seizures are brief episodes of involuntary shaking which may involve a part of the body (partial) or the entire body (generalized) and may cause LOC and control of bowel or bladder.

Idiopathic Epilepsy Is the most common type Has no identifiable cause Often underlying genetic basis

Secondary Epilepsy Epilepsy with a known cause Possible causes: brain damage from prenatal or perinatal injuries (hypoxia or trauma during birth, low birth weight) Congenital abnormalities or genetic conditions with associated brain malformations TBI Stroke Brain infection Certain genetic syndromes Brain tumor and vascular lesions Neurodegenerative conditions

COMPLEX PARTIAL SEIZURES Temporal Lobe Epilepsy (TLE)

The most common form of adult epilepsy Symptomatic localization-related epilepsy Epileptogenic abnormalities in mesial temporal limbic structures The associated pathological substrate is usually hippocampal sclerosis One of the most medically refractory forms of human epilepsy

Clinical Features

History Higher incidence of complicated febrile convulsions or other cerebral insults in the first 5 years of life Family history of epilepsy common Onset of habitual seizures usually in latter half of first decade of life. Auras commonly occur in isolation. Infrequent secondarily generalized seizures. Seizures often remit for several years until adolescence or early adulthood. Seizures often become medically intractable. Interictal behavioral disturbances can develop, most commonly depression.

Clinical Presentation Aura is usually present. The most common is epigastric, often with other autonomic or psychic symptoms, including emotion (e.g., fear). Olfactory or gustatory sensations can occur. Last several seconds Often begin with arrest and stare; oroalimentary automatisms and complex automatisms are common Posturing of one arm may occur contralateral to the ictal discharge. Seizure lasts 1 to 2 minutes Postictal phase: disorientation, recent-memory deficit, amnesia for the event, and dysphasia if seizures begin in the language-dominant hemisphere. Lasts several minutes

Neurologic and Laboratory features Neurologic examination usually normal Memory dysfunction on neuropsychological testing and amnesia with contralateral intracarotid injection of amobarbital. EEG Interictal EEG: anterior temporal spikes with maximal amplitude in basal electrodes. Ictal EEG: 5 to 8 Hz rhythmic discharge beginning in one mesial temporal area, either initially or within 30 seconds of a more generalized electrographic change MRI Hippocampal atrophy on T1 and mesial temporal increased signal on T2-weighted MRI Functional MRI Temporal-lobe hypometabolism on interictal FDG-PET Hypoperfusion on ictal SPECT Decreased n-acetyl aspartate on magnetic resonance spectroscopy

Frequently misdiagnosed with psychiatric illnesses. Often symptoms have unusual qualities atypical for primary psychiatric syndromes such as gustatory and olfactory hallucinations; micropsia or macropsia; intense delusions involving bodily harm, déjà vu, or “out-of-body” experiences. Personality features: moral rigidity, hyperreligiosity, hypergraphia, and viscosity

Anterior Temporal Lobectomy (ATL) for medically refractory medial temporal lobe epilepsy due to medial temporal sclerosis (MTS) is the most commonly performed surgical procedure in the comprehensive epilepsy management centres. Surgery is ideally directed towards complete seizure freedom without or with very minimal cognitive or functional deficits.

NEUROPSYCHIATRY OF STROKE Stroke

Definition of Stroke Rapidly developing clinical signs of focal (or global) disturbance of cerebral function, with sx lasting 24 hours or longer or leading to death, with no apparent cause other than of vascular origin.

Neuropsychiatric sx of Stroke SyndromePrevalence Post stroke Depression35% ManiaRare Bipolar disorderRare Anxiety disorder25% Apathy20% PsychosisRare Pathological Affect20% Catastrophic Reaction20%

Post stroke Depression (PSD) DSM-IV criteria for “mood disorders due to medical condition” are used for diagnosis Loss of energy and appetite, insomnia Mean duration of depression appears to be 9 months but significant number of patients remain depressed for several years after stroke Anatomical Correlates: L>R, frontal, parietal Mechanism: depletion of monoaminergic amines after lesions of frontal lobe or basal ganglia

Association Between Physical Impairment and PSD Association Between Cognitive Impairment and PSD- L hemisphere strokes Treatment: anti depressants, stimulants, ECT

Post stroke Anxiety Disorder Significant comorbidity with PSD Anatomical Correlates: L or R cortical lesions ADL impairment is associated with GAD Treatment

Catastrophic Reaction In 1939, Goldstein created the term to describe a series of symptoms (i.e., anxiety, aggressiveness, refusal, and renouncement) in patients with TBI Appear to be due to the “inability of the organism to cope with physical or cognitive deficits” Common in patients with nonfluent aphasia after stroke

Pathological Affect Characterized by frequent and easily provoked episodes of crying and/or laughing not appropriate to the situation or in excess of the underlying emotion Treatment

Post stroke Psychosis Rare complication of stroke Anatomical correlate: R frontoparietal lesions Treatment

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