Hypomaniac confusional state in a patient with drug-resistant partial epilepsy: Ictal or post-ictal origin? | [Stato confusionale ipomaniacale in paziente con epilessia parziale farmaco-resistente: Origine critica o post-critica?]

Introduction. Behavioural manifestations with psychiatric features can be observed in patients with focal epilepsy in the ictal and/or past-ictal period. We report a 46-year-old female patient with right mesial temporal sclerosis suffering from seizures that started at the age of 23, characterized by epigastric aura, early oroalimentary automatisms, and possible secondary generalisation. From the age of 25, recurring anxious-depressive episodes and persecutory aspects appeared, requiring repeated hospital admissions. Intercritical EEG showed paroxysmal activities in the right-temporal leads; ictal EEG showed and initial discharge in the right-temporal derivations, them omo- and controrolateral spread. The ictal SPECT indicated a right temporal focus. During a drug reduction for recording seizures, the patient presented, after a cluster of seizures, an episode of dysphoric behaviour, extreme agitation, preserved consciousness, continuous verbal production. No concomitant paroxismal EEG activity was evident. At first, this episode was transitorily interrupted by a typical seizure, then it was stopped by lorazepam e.v. administration. A psychiatric evaluation of the video-EEG recording of the episode diagnosed a "hypomaniac confusional state". Conclusions. The behavioural manifestations observed during the confusional state in our patient were extremely peculiar. The interruption of the episode, at first following a seizure, than after benzodiazepine administration might suggest a possible ictal nature.