Abstracts

Rationale:
The amygdala is integral to the regulation of emotions and behavior.  Homeostatic and reward pathways implicate the amygdala as a key structure influencing hunger through the lateral hypothalamus. The amygdala also plays a role in epileptogenesis in temporal lobe epilepsy. We describe a case of acute onset binge-eating disorder following anterior temporal lobectomy with amygdalohippocampectomy for intractable focal epilepsy.
Method:
Literature and chart review.
Results:
A 14-year-old right handed female with ADHD, depression/anxiety and insomnia suffered from intractable left temporal lobe epilepsy with seizure onset at age 5 years. Initial MRI was read as normal. After failing multiple antiseizure medications due to lack of efficacy and/or side effects, a repeat MRI demonstrated a subtle left temporal cortical dysplasia involving the left amygdala. The patient underwent left anterior temporal lobectomy with amygdalohippocampectomy. Medications, which were stable for two months prior to surgery, included lacosamide, clorazepate, and clonazepam as well as sertraline, guanfacine, and low-dose mirtazapine for sleep. Postsurgical imaging confirmed a satisfactory resection with minimal intracranial hemorrhage. Beginning in the immediate post-operative period, the patient’s alimentary intake increased markedly, primarily in the form of binge-eating carbohydrates when she would awaken at night. She was distressed by the behavior but felt unable to control it. By eight weeks post-op her weight had increased 16% since surgery, with an increase in BMI from 23.6 to 27.3 kg/m2. Mirtazapine was discontinued without effect. Counseling targeting binge eating behaviors was initiated. At three months follow-up a random serum glucose was elevated at 146 mg/dl and she had new-onset hypertension above the 99th percentile with new borderline LDL and high triglycerides. At four months post-operatively the patient reported decreased binge-eating behavior and by five months after surgery the symptom resolved, and her weight began to decline. At 6 months post-op her BMI had returned to 24.39 kg/m2, follow-up serum glucose levels were normal, and blood pressures remained below the 90th percentile.
Conclusion:
The amygdala with retrograde input to the frontal lobes, is an emotional regulator, but is also responsible for interpretation of hunger. Overeating to relieve negative affective states and overeating despite aversive consequences have been related to amygdala function. In our patient, with a psychiatric history but no history of eating disorder, amygdalohippocampectomy with anterior temporal lobectomy led to abrupt onset, clinically significant binge-eating that was refractory to medical management and psychologic interventions. The behavior negatively affected her postoperative quality of life and general health.  This potential complication of amygdala resection has not been previously reported. Early recognition of the behavior and its association with surgery could influence post-operative management from both medical and therapeutic perspectives.
Funding:
:None