Differentiating ictal panic with low-grade temporal lobe tumors from psychogenic panic attacks.

OBJECTIVE: Indolent low-grade temporal lobe tumors may present with ictal panic that may be difficult to differentiate from psychogenic panic attacks. The current study aims to demonstrate the differences between the two disorders and help physicians generate a diagnostic paradigm. METHOD: This was a retrospective study of 43 patients who underwent a temporal lobectomy between 1981 and 2008 for the treatment of intractable temporal lobe epilepsy secondary to low-grade neoplasms at Rush University Medical Center. A total of 10 patients in this group presented with ictal panic who were previously being treated for psychogenic panic attacks. Medical records were reviewed for age at seizure onset, duration of symptoms, lateralization of the epileptogenic zone, pathological diagnosis, and postsurgical seizure outcome according to the modified Engel classification. RESULTS: Neuropathologic findings of the 10 tumors were pleomorphic xanthoastrocytoma, ganglioglioma, oligodendroglioma, and dysembryoplastic neuroepithelial. The mean age of the patients undergoing surgery was 28 years (range, 15-49). The mean duration of panic symptoms prior to surgery was 9.8 years (range, 3-23). All patients had unprovoked ictal panic. None had symptoms suggestive of a brain tumor, such as signs of increased intracranial pressure or any focal neurologic deficit. In 5 of the patients, other symptoms associated with the ictal panic, including unusual sounds, nausea, automatism, uprising gastric sensation, and déjà vu were identified. Gross total resection of the lesion resulted in improved seizure outcome in all patients undergoing surgery. Patient follow-up was, on average, 7.4 years (range, 2-14) from time of surgery. CONCLUSIONS: Although similar, ictal panic from epilepsy and classic panic attacks are clinically distinguishable entities with different modalities of treatment. A careful history may help differentiate patients with ictal panic from those with psychogenic panic attacks and determine for which patients to obtain neuroimaging studies.

Panic attack semiology in right temporal lobe epilepsy.

BACKGROUND: Panic attack semiology as a manifestation of epileptic seizures may lead to difficulties and delay in diagnosis. We present a case series to demonstrate the association of ictal panic and anxiety symptoms with partial seizures lateralized to the right temporal lobe. METHODS: From 112 consecutive patients with intractable temporal lobe epilepsy (59 right, 53 left) referred for video-EEG monitoring, five patients were identified whose seizures had been diagnosed as panic attacks in the past. Their ictal symptomatology included feelings of panic and impending doom, hyper-ventilation, palpitation, diaphoresis, shortness of breath and generalized paresthesiae. Ictal panic was not identified in 72 patients with extra temporal epilepsy investigated during the same period. RESULTS: EEG documented a right anterior to mid-temporal focus in all five patients. Brain MRI or pathology showed right mesial temporal sclerosis in four and a right temporal ganglioglioma in one. Ictal tachycardia was documented with EEG-EKG recording in the latter patient, prior to right anterior temporal lobectomy and amygdalohippocampectomy. Reinvestigation of this patient five years later for recurrent seizures, no longer associated with panic symptomatology, showed right temporal ictal onsets with seizure spread to the left temporal lobe, now associated with ictal bradycardia. CONCLUSIONS: Our case series provides further evidence to support a relationship between panic attack symptomatology and ictal involvement of the right mesial temporal region [Published with video sequences].

Capsulotomy for refractory anxiety disorders: long-term follow-up of 26 patients.

OBJECTIVE: The objective of the present study was to evaluate the long-term efficacy and safety of capsulotomy in patients with anxiety disorders. METHOD: Twenty-six patients who had undergone bilateral thermocapsulotomy were followed up 1 year after the procedure and after a mean of 13 years. Primary diagnoses were generalized anxiety disorder (N=13), panic disorder (N=8), and social phobia (N=5). Measures of psychiatric status included symptom rating scales and neuropsychological testing. Ratings were done by psychiatrists not involved in patient selection or postoperative treatment. A quantitative magnetic resonance imaging (MRI) evaluation was conducted to search for common anatomic denominators. Seventeen of the 23 patients who were alive at long-term follow-up were followed up in person, and one was interviewed by telephone; the relatives of these 18 patients were interviewed. RESULTS: The reduction in anxiety ratings was significant both at 1-year and long-term follow-up. Seven patients, however, were rated as having substantial adverse symptoms; the most prominent adverse symptoms were apathy and dysexecutive behavior. Neuropsychological performance was significantly worse in the patients with adverse symptoms. No common anatomic denominator could be found in responders in the analysis of MRI scans. CONCLUSIONS: Thermocapsulotomy is an effective treatment for selected cases of nonobsessive anxiety but may carry a significant risk of adverse symptoms indicating impairment of frontal lobe functioning. These findings underscore the importance of face-to-face assessments of adverse symptoms.