Interdisciplinary Neurosurgery (Sep 2021)
Immediate serial postoperative de novo psychogenic nonepileptic seizures after selective amygdalohippocampectomy
Abstract
De novo psychogenic nonepileptic seizures (PNES) following epilepsy surgery in patients without a prior history of nonepileptic seizure are well-described, but uncommon events. Recent large retrospective studies indicate a prevalence of less than 4%, and while the majority suffer a PNES event in the first year after surgery, they seldom occur within weeks of surgery. This report illustrates the case of a 57-year-old man with medically intractable localization related epilepsy secondary to mesial temporal sclerosis. Three separate inpatient video electroencephalogram (EEG) studies over the course of 10 years had not revealed PNES and had localized the epileptogenic zone to the left temporal lobe. He underwent a left subtemporal selective amygdalohippocampectomy (SAH) without complication and was maintained on his pre-operative antiseizure medications. Within 12 h of surgery, the patient began exhibiting episodes with a different semiology than the preoperatively documented seizures, increasing in frequency until the 4th postoperative day, when video-EEG revealed clear PNES devoid of electrographic correlation. More than 25 events occurred, with 11 captured on video-EEG. Interventions including reassurance of the patient and family by the epileptologist and surgeon, as well as psychiatry consultation, resulted in immediate cessation of the events. He has remained seizure-free at the time of this report, consistent with an Engel class 1 outcome. While rare, concentrated episodes of PNES activity may arise immediately after epilepsy surgery in patients without a prior history of PNES. This clinical vignette suggests that a suspicion of PNES must be taken into consideration should a patient develop a cluster of seizures immediately after epilepsy surgery.
