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Clinical Crossroads | Clinician's Corner

A 48-Year-Old Man With Temporal Lobe Epilepsy and Psychiatric Illness

Orrin Devinsky, MD, Discussant
JAMA. 2003;290(3):381-392. doi:10.1001/jama.290.3.381.
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DR DELBANCO: Mr C is a 48-year-old man with a long history of cognitive and psychological problems, marked by mood swings, memory loss, and seizures involving the frontal and temporal lobes of the brain. A primary physician, a neurologist with special interest in seizures (Dr J), and a psychiatrist (Dr N) manage Mr C's care. He has private insurance, works part-time, and lives near Boston with his wife.

Mr C's problems likely date to birth. He was the product of an uncomplicated pregnancy but during labor there may have been some anoxia. He recalls a "foggy feeling" in his head from the first time he can remember. As a child, he fell out of a tree and hit his head without notable sequelae. In elementary school, he did well but had difficulty with his memory. He continued a successful academic experience in high school, during which time he had intermittent abdominal pains, and then was graduated from a top university with extraordinarily high academic achievement. In college, he describes having had difficulty understanding lectures and remembering details. He read avidly and worked endless hours but felt his ability to learn was hampered by a poor memory. He had difficulty handling several different tasks at once. In graduate school, depression because of his struggles with his cognitive limitations led to a suicide attempt, which caused a contusion to the right side of the head. Thereafter, Mr C was hospitalized; lithium followed by carbamazepine and phenytoin gave him more, but not complete, control of his symptoms.

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Figure. Lesions Commonly Associated With Temporal Lobe Epilepsy
Graphic Jump Location
Figure (facing page). The temporal lobes have memory, emotional, auditory, olfactory, and higher visual functions. They consist of a phylogenetically older medial portion and a newer, lateral portion. Seizures arising in either region cause auras (simple partial seizures) that often progress to impaired consciousness with oral and hand automatisms. Medial (limbic) areas often cause abdominal sensations and fear while lateral (neocortical seizures) often cause déjà vu, dreamy state, abdominal sensation, tinnitus, and vertigo.
Top panel, position of imaging planes A and B in middle and bottom panels. Left, three-quarter view of the brain showing the hippocampus and adjacent structures. Right, midsagittal section showing the medial surface of the left hemisphere (brainstem removed) and structures deep to the plane of section.
Middle panel, Mesial temporal sclerosis (MTS). Left, a magnetic resonance image (MRI) of a patient with MTS; arrowhead indicates atrophic left hippocampus. Mesial temporal sclerosis is associated with a history of febrile seizures, especially prolonged ones. Right, anatomic structures in this coronal view and enlargement of detail from MRI showing atrophic left hippocampus.
Bottom panel, neocortical dysplasia. Left, inversion recovery image showing coronal view of the anterior temporal lobes in a patient with neocortical dysplasia (a malformation of cortical development) involving the left anterior temporal neocortex (temporal pole). Note thickening of the cortex (arrowhead), abnormal architecture, loss of differentiation between gray and white matter, and paucity of white matter. Lesions of the left temporal pole impair retrieval of unique names of places, persons, and objects. Right, anatomic structures in this coronal view.

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