The walking dead: an unusual case Ged O’ Connor MB, MRCPI

Background 22 year old right handed female Onset of epilepsy aged 16 – Found collapsed at home – Blood glucose of 1, prolonged period of LOC and status epilepticus Subsequent symptomatic localisation related epilepsy Usual semiology – Bright yellow light in left visual hemifield – Left head version, left arm dystonic posturing – Can occasionally talk (“I don’t feel well”, etc.)

Presentation – 1 On phenytoin, carbamazepine, folic acid Cluster of complex partial seizures +/- secondary generalisation on 22 nd – 23 rd November Controlled by use of buccal midazolam Presented to A&E some hours later – Convinced that she was dead – “I knew I was dead”, remembers being cross with father as he would not accept this

Presentation – 2 Seen on 25 th of November – recovering at that stage, gaining insight No definite seizures since admission, nil new on neurological exam No evidence of infection clinically or on blood assays, MRI – high attenuation in region of basal ganglia (chronic) EEG (routine) – no epileptiform activity, some nonspecific slowing Recovered fully over subsequent 48 hours, discharged home

Diagnosis Cotard’s syndrome Short-lived post-ictal delusion

Cotard’s syndrome / delusion “Delire de negation”, now also known as the walking corpse / dead syndrome, thought to be related to Capgras delusion Thought to result from disconnect between areas that recognize faces (fusiform face areas) and the areas that associate emotions with that recognition (amygdala and other limbic structures) Seen mainly in psychoses such as schizophrenia, but also described in MS, migraine, epilepsy Reported imaging, EEG findings vary from normal to nonspecific abnormal to severely abnormal

Epilepsy and psychotic illness Prevalence of psychosis in patients with epilepsy varies by series, estimated at 2-9% (0-16% in refractory TLE) Factors linked to development of psychosis in epilepsy – Factors associated with postictal psychosis (see later) – Earlier onset of epilepsy – Borderline intellectual functioning – Bilateral / widespread CNS injury Possible common underlying mechanisms – Superior temporal cortex dysfunction – Asymmetry of amygdala, hippocampus – Role of copy number variants still under research

Post ictal psychosis Comprises c % of psychoses in epilepsy Affects 6-10% of presurgical candidates Distinct from post ictal confusion – Well-systemised delusion and hallucinations – Preserved orientation and alertness

Post ictal psychosis – diagnosis and risks Criteria for diagnosis – Psychotic / psychiatric symptoms occurring after a seizure and a subsequent lucid interval, up to 7 days post seizure – Psychosis lasting at least 15 hours and less than 2 months – No evidence of a history of psychosis in previous 3 months, recent head trauma, recent intoxication, drug toxicity Associated with certain clinical features – Extratemporal seizure onset – Bilateral interictal activity – Secondary generalisation of seizures – History of encephalitis – Family hx of psychotic disorder

Post ictal psychosis - management Mean duration 9-10 days, 95% recovered by 1 month Antipsychotic medications – Symptomatic management, no clear effect on duration or prognosis Antiseizure medications – Effective against on-going seizure activity, some associated with worsening symptoms Violence a rare phenomenon – 6 in 1300 patients in one clinic (only 2 associated with psychosis)

Summary Post ictal behavioural disturbance common Can include bizarre phenomena! Often relatively short duration Best management still unclear

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