Abstracts

Rationale: Postictal psychosis (PIP) is an underrecognized phenomenon that presents a diagnostic challenge in patients with refractory epilepsy. PIP is associated with temporal lobe epilepsy when epileptogenic networks predominantly involve the bilateral temporal and frontal lobes. It occurs within hours to days following a period of postictal lucidity after clusters of tonic-clonic seizures. We present two patients with delayed recognition of PIP to illustrate the consequences of failing to promptly make this diagnosis. Methods: Both patients had multiple hospitalizations during which PIP was not recognized. Patient-1 is a 61-year-old woman who was admitted 5 times for confusion, delusions, and hallucinations. Drug abuse was suspected during her initial admissions because metabolic and infectious work-ups as well as electroencephalograms (EEGs) did not account for her symptoms. She subsequently presented in non-convulsive status epilepticus (NCSE) requiring intubation and sedation.  During her second admission for NCSE, sedation and intubation were avoided with aggressive dosing of anti-epileptic medications, intravenous steroids, and psychiatric therapies. Patient-2 is a 35-year-old woman who had episodes of violent and manic behavior. She had 5 admissions in which the diagnosis was bipolar disorder and depression complicating her seizure disorder. Admissions included daily EEGs after witnessed seizure activity followed by erratic behavior. During one admission to the ICU she was thought to have psychogenic nonepileptic seizures (PNES) as there was no electrographic correlate to her behavior. Results: It took 2 and 3.5 years to diagnose postictal psychosis in Patient-1 and Patient-2, respectively. Patient-1 was diagnosed with PIP after two ICU admissions for management of refractory NCSE complicated by persistent postictal psychosis. One episode of PIP lasted six days. Diagnosis was delayed until she was evaluated by a psychiatrist with experience in epilepsy-related psychiatric comorbidities. Patient-2 was diagnosed while in the EMU for seizure characterization. After being weaned from her anti-epileptic medications, she had numerous complex partial and generalized tonic-clonic seizures. Upon resuming her outpatient medication regimen, psychiatry was consulted due to aggressive and violent behavior that persisted for three days. She remained an inpatient until her mental status improved with psychiatric treatment. Conclusions: Timely recognition of PIP can obviate unnecessary diagnostic studies and invasive treatment. Diagnosis may be complicated by irregular seizure clusters marked by admissions for psychosis. More common differential diagnoses, such as postictal encephalopathy, PNES, and substance abuse, must be ruled out; however, a positive history of hospitalizations, refractory epilepsy, and bizarre behaviors should warrant consideration of PIP. Funding: This research did not receive any grant or other source of funding.