Electroconvulsive therapy for psychosis in a patient with epilepsy related to hypothalamic hamartoma.

Psychosis is more common in people with temporal lobe epilepsy than it is in the general population. Treatment can be difficult in these patients because of the complex interactions between antipsychotic and antiepileptic drugs. Some antipsychotic drugs also decrease the seizure threshold. We report the case of a 49-year-old man with a hypothalamic hamartoma, with a history of both gelastic and temporal lobe seizures. The patient was rendered seizure-free after three neurosurgical procedures but developed a drug-resistant paranoid psychosis. He was treated with electroconvulsive therapy (ECT). After two weeks with six stimulations that resulted in seizures, the psychiatric phenomena disappeared completely. There was no relapse of either the psychiatric symptoms or the seizures during the 42 months of follow-up. This case report suggests that ECT might be safe for psychosis in patients with a history of seizures that have previously been successfully treated with neurosurgery, although caution should be exercised in drawing general conclusions from a single case report.

Neuropsychiatric aspects of patients with hypothalamic hamartomas.

Hypothalamic hamartomas (HH) are developmental malformations that are associated with gelastic seizures, other types of seizures, cognitive decline, and symptoms related to hypothalamic dysfunction. Although aggressive behavior is frequently described, data on the neuropsychiatric profile are limited. In this article, five patients with HH are described who displayed a wide variety of psychiatric symptoms that, dependent on the time frame, met the criteria for several categorical diagnoses. Major neuropsychiatric symptoms comprised aggression that is only partial context dependent, compulsive behavior, psychotic symptoms not responding to treatment, and organic mood instability. HH should therefore be considered a neuropsychiatric syndrome with a highly variable expression that can be best captured by a thorough description of behaviors, symptoms, sequelae of epilepsy, and hypothalamic dysfunction.

Recognition of the various expressions of anxiety, psychosis, and aggression in epilepsy.

Anxiety, psychosis, and aggressive behavior are among the frequent comorbid psychiatric disorders identified in patients with epilepsy. Often the clinical manifestations of these disorders vary according to their temporal relation relative to seizure occurrence. Thus, postictal symptoms of anxiety or psychosis differ in severity, duration, and response to treatment with interictal symptomatology. Psychiatric symptomatology in epilepsy can appear concurrently with the seizure disorder and improve or remit on the abolition of epileptic activity. We refer to these as paraictal psychiatric phenomena. Such is the case of aggressive disturbances associated with gelastic seizures caused by hypothalamic hamartomas. In this article, three case studies are presented to illustrate the importance of distinguishing psychiatric symptoms of anxiety, psychosis, and aggression, with respect to their temporal relation with seizure occurrence.

[Back to the high school days: an abnormal remembering characterized by concurrent as well as alternating feeling to be in the past and present].

After the successful treatment of a hypothalamic germinoma, a 31-year-old right-handed male developed a difficulty in memory and admitted to our department for detailed evaluation. Neuropsychologically he showed no personality change, confabulation, misidentification, delusion or disorientation to physical time. Neither aphasia, dementia or frontal lobe dysfunction was found. However, he showed a moderate degree of anterograde amnesia and a retrograde amnesia for the last 5 years judged by a public events test. Moreover, his temporal markings of a correctly remembered event in the post high school days shifted strongly toward the high school days. This temporal location abnormality was largely limited to the events from the days of his graduation from the high school to the period 5 years prior to the present incident. He felt personal events happened during this period as if they had occurred in the high school days, although he well knew that they actually happened much later. At the same time he felt that memories of the high school days were abnormally vivid and recent. Most interestingly, he was found to have been experiencing a funny feeling that he was living in the high school days and the present at the same time. The feeling occurred either simultaneously or alternatively. In the latter instance, he would suddenly start behaving as if he were a high school student. He would start urging his wife to go to the school together immediately. This behavior would be over in several minutes. His consciousness was clear in these instances and there was no amnesia for these periods. A brain MRI with gadolinium enhancement showed a lesion extending in the hypothalamus, anterior thalamus, basal forebrain and midbrain bilaterally. After eight months this abnormality of temporal sensation disappeared. However, tendency to make the date of public event nearer to the high school period persisted. We hypothesize that impaired temporal estimation for an event recalled from the retrograde memory store and mis-arousal of familiarity evoked at the time of spontaneous recollection are responsible for double feeling of time of an experience. These phenomenon might be attributable to the partial destruction of the Papez' and the basolateral limbic circuits.

Impaired temporal context memory on anterograde but not retrograde tests in the absence of frontal pathology.

This study examined the memory performance of patient RK who developed substantial memory impairments due to a hypothalamic glioma but in the absence of any evidence of frontal disturbance. RK was evaluated on both tests of anterograde and retrograde memory for temporal context. In the first experiment he exhibited marked deficits on a list discrimination task even when recognition performance was well within control range. Experiment 2 confirmed this disproportionate impairment of temporal order memory and showed that RK's list discrimination deficit was as severe as that found in alcoholic Wernicke-Korsakoff Syndrome patients. Experiment 3 showed that RK's temporal discrimination deficit was not a general deficit in discrimination because he performed normally on a spatial discrimination test of comparable difficulty to the temporal task. Experiment 4 examined RK's memory for deceased famous people and his ability to indicate the half decade in which they died. RK's performance was indistinguishable from controls whereas WKS patients were extremely impaired. This study adds to the view that frontal damage is not a necessary condition for impairment on anterograde measures of temporal context memory. However, further evidence from this study indicates that temporal judgments about pre-existing memories may depend on intact frontal lobe functioning.

Hypothalamic astrocytoma. Syndrome of hyperphagia, obesity, and disturbances of behavior and endocrine and autonomic function.

A 26-year-old woman had hyperphagia, obesity, aggressive behavior, visual hallucinations, reversal of wake-sleep patterns, hypothermia, hypothyroidism, and amenorrhea. She died of pancreatitis, probably secondary to hypothermia. Autopsy revealed a low-grade astrocytoma in the third ventricle and medial anterior and mid hypothalamus, primarily on the right. Although she exhibited thyroid and ovarian hypofunction, the patient had intact median eminence and pituitary function, suggesting end-organ failure, possibly of an autoimmune nature.