A previously healthy 40-year-old right-handed female presented with new onset complex partial seizures and occasional secondary generalization. Over the next 5 years, she rapidly became refractory to medical treatment with seizure frequency increasing to almost daily despite attempts to control seizures with multiple anti-epileptic drugs. The patient failed initial monotherapy with valproic acid and progressed to require polytherapy with carbamazepine 600 mg twice a day (BID), lamotrigine 150 mg BID, clobazam 10 mg BID and levetiracetam 1000 mg BID (which was discontinued when the behavioral issues came to light) and yet did not achieve adequate seizure control. Over this same period, the patient developed increasing emotional lability, outbursts of anger and escalating violent behavior coinciding with seizure onset and which was especially worse postictally, lasting 5 to 10 minutes. These explosive episodes led to numerous altercations with police, resulting in multiple arrests for violent behavior. The patient was convicted a total of 32 times prior to the murder for various minor offences and violent incidents, the majority of these occurring in the last 4 years when the patient developed intractable epilepsy. The patient's past medical history was otherwise only remarkable for chronic alcoholism and depression. Although it was offered, the patient repeatedly refused psychiatric evaluation during her disease evolution and was intermittently treated by her family physician for depression with venlafaxine and citalopram.
The patient's neurological exam was normal. She presented with two types of seizures. The most common were complex partial seizures characterized by lack of aura, staring, bimanual and oral automatisms and postictal confusion. The patient was able to talk during some of these seizures. The frequency of these complex partial seizures varied but was on average six per month, with one cluster per month. The patient also had complex partial seizures with secondary generalization (one per month). Several interictal electroencephalograms (EEGs) showed right temporal spikes. Video-EEG telemetry was performed and 6 seizures were recorded; all of them had clear onset over the right temporal region at F8-T4 with involvement of the ipsilateral scalp sphenoidal electrode. One pseudo seizure was also recorded. The magnetic resonance imaging (MRI) was reported as normal. At this point, the patient was offered a right temporal lobe resection. After discussion with her family, she declined the procedure. Six months after the video-EEG telemetry investigation was performed, the patient had a disagreement with her basement tenant. During this dispute, the patient stabbed her friend several times, killing her. Thus, the patient was arrested and charged with second-degree murder. Unfortunately, the patient is amnestic of the event and there were no other witnesses, so both the duration of the aggressive episode and whether it was preceded by seizure are unknown.
While in jail, the patient and her family wished to revisit the possibility of neurosurgery. At age 46, the patient underwent a standard right temporal lobectomy, twelve months after the video-EEG telemetry investigation. The patient remained in hospital for two weeks post-operatively and was then transferred back to prison. After six months in a maximum security facility, she was transferred to a psychiatric center due to the noted positive behavior change. At two years post-surgical follow up, the patient reported no seizure activity and was on monotherapy with carbamazepine 400 mg BID. The patient's behavior improved dramatically after the temporal resection with no evidence of emotional lability or aggressive outbursts since.
This patient was administered a standard battery of neuropsychological tests, assessing the domains of attention, working memory, language, learning and memory and psychological/emotional functioning, on two separate occasions. Her first neuropsychological assessment occurred about 22 months prior to neurosurgery and indicated significantly compromised cognitive functioning, with difficulties most evident on tasks assessing verbal comprehension, working memory and learning of novel material, particularly if the material was visual in nature. She still demonstrated good reasoning and problem solving skills, and adequate learning if provided with an opportunity to first deal with hands-on material. She was also experiencing significant levels of psychological distress due to the limitations imposed by her seizure disorder. The second neuropsychological assessment was undertaken about 15 months post neurosurgery and indicated that this patient was no longer psychologically distressed as she was no longer experiencing seizures. However, her neuropsychological profile indicated that she had experienced further global decline in cognitive functioning with marked impairment and limited function. This decline was attributed to the longstanding history of epilepsy, but could also be partially due to the resection.