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LETTER TO EDITOR
Year : 2013  |  Volume : 61  |  Issue : 4  |  Page : 421-422

Mesial temporal lobe epilepsy with hippocampal sclerosis preceded by eclampsia: A rare association


Department of Neurology, Institute of Neurosciences, Medanta-The Medicity, Gurgaon, Haryana, India

Date of Submission05-Feb-2013
Date of Decision01-Apr-2013
Date of Acceptance25-Jul-2013
Date of Web Publication4-Sep-2013

Correspondence Address:
Atma Ram Bansal
Department of Neurology, Institute of Neurosciences, Medanta-The Medicity, Gurgaon, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.117585

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How to cite this article:
Singh D, Garg A, Gupta A, Bansal AR. Mesial temporal lobe epilepsy with hippocampal sclerosis preceded by eclampsia: A rare association. Neurol India 2013;61:421-2

How to cite this URL:
Singh D, Garg A, Gupta A, Bansal AR. Mesial temporal lobe epilepsy with hippocampal sclerosis preceded by eclampsia: A rare association. Neurol India [serial online] 2013 [cited 2021 Jan 26];61:421-2. Available from: https://www.neurologyindia.com/text.asp?2013/61/4/421/117585


Sir,

About 20% of patient with epilepsy have drug resistant epilepsy and the common surgically remediable drug resistant epilepsy is mesial temporal lobe epilepsy with hippocampal sclerosis (MTLE-HS). [1] We describe a woman with eclampsia as a possible predisposing risk factor for MTLE-HS.

A 30-year-old lady from middle-east attended our institute for drug resistant epilepsy. She was got married at the young age and became pregnant at 16 year of age. At around full-term had a sudden surge in blood pressure followed by recurrent episodes of generalized seizures (eclampsia), which were controlled with the appropriate medications. One month post-delivery she started having complex partial seizures (CPS). Seizure semiology included: An aura of fear and epigastric discomfort followed by behavioral arrest, oromandibular automatism along with ictal aphasia lasting for 1-2 min which was classfical for CPS seen in MTLE. [2],[3] She failed multiple anti-epileptic drugs in appropriate doses and continued to have 4-5 seizures per month and did not have a history of febrile seizures in childhood, meningitis or encephalitis. Birth history was normal. Magnetic resonance imaging (MRI) brain showed left HS [Figure 1]. Video-electroencephalogram (EEG) monitoring suggest the left temporal epileptogenic zone [Figure 2] and [Figure 3]. With the diagnosis of left MTLE-HS, the patient underwent the left anterior temporal lobectomy with amygdalo-hippocampectomy. Histopathological examination confirmed the diagnosis of hippocampal sclerosis. She made a rapid post-operative recovery and was discharged home on two anti-epileptic drugs. She is seizure free for the last 1 year.
Figure 1: Magnetic resonance imaging brain showing left mesial temporal sclerosis. Arrow showing severe volume loss of the left hippocampus along with signal change

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Figure 2: Interictal electroencephalogram showing left anterior temporal epileptiform discharges

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Figure 3: Ictal electroencephalogram showing rhythmic 6-7 Hz activity over the left anterior temporal regionndicating seizure onset over the left temporal region

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Epileptogenicity of MTLE-HS results from loss of specific neurons in the hippocampus and synaptic reorganization of the surviving cellular elements to cause hyper-synchronization and hyperexcitability. [4] The most common antecedent history in patients with MTLE-HS is febrile seizures in childhood. Other risk factors include prenatal or perinatal injury, meningitis and encephalitis or head trauma in early childhood. [2] Eclampsia has not commonly been considered as a risk factor for MTLE-HS. [5] Eclampsia, is defined as new onset of grand mal seizures and/or unexplained coma during pregnancy or postpartum in a woman with features of preeclampsia. [6] Long-term follow-up studies in patients with eclampsia, seizure recurrence had not been reported. [7] However, in a series of epilepsy surgery patients with no identifiable risk factors, eclampsia has been reported as a potential risk factor for MTLE-HS especially in patients with pregnancy at an early age. [5] In this patient, there was no clear antecedent history and she had pregnancy with eclampsia at the age of 16 years. The possible mechanism behind MTLE-HS in eclampsia could be acute severe hypertension causing hippocampal injury. [5] Neurological manifestations of eclampsia center around the development of acute hypertension associated with generalized vasoconstriction, arteriolar damage and intravascular coagulation.

It could be argued that this patient might have had pre-existing mesial temporal sclresosis (MTS) and eclampsia could have triggered the drug resistant epilepsy. However, it seems unlikely as there was no history of seizures in the past and refractory seizures started only after the episode of eclampsia. In a study of 207 people with no epilepsy, MRI brain showed MTS only in two patients and subsequent retrospective chart review revealed that both of them had previously diagnosed seizure disorders. Asymptomatic MTS is and should prompt further clinical investigation to exclude a seizure disorder. [8] However, incidental hippocampal sclerosis has been reported in asymptomatic relatives of familial MTLE-HS. [9] In our patient, there was no family history of epilepsy and hence it is likely that eclampsia might have been an antecedent event for MTS in this patient.

 
  References Top

1.Picot MC, Baldy-Moulinier M, Daurès JP, Dujols P, Crespel A. The prevalence of epilepsy and pharmacoresistant epilepsy in adults: A population-based study in a Western European country. Epilepsia 2008;49:1230-8.  Back to cited text no. 1
    
2.French JA, Williamson PD, Thadani VM, Darcey TM, Mattson RH, Spencer SS, et al. Characteristics of medial temporal lobe epilepsy: I. Results of history and physical examination. Ann Neurol 1993;34:774-80.  Back to cited text no. 2
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3.Proposal for revised classification of epilepsies and epileptic syndromes. Commission on Classification and Terminology of the International League against Epilepsy. Epilepsia 1989;30:389-99.  Back to cited text no. 3
[PUBMED]    
4.Engel J Jr, Williamson PD, Wieser HG. Mesial temporal lobe epilepsy with hippocampal sclerosis. In: Engel J Jr, Pedley TA, editors. Epilepsy a Comprehensive Text Book. 2 nd ed. Philadelphia: Lippincott Williams and Wilkins; 2008. p. 2479-786.  Back to cited text no. 4
    
5.Lawn N, Laich E, Ho S, Martin R, Faught E, Knowlton R, et al. Eclampsia, hippocampal sclerosis, and temporal lobe epilepsy: Accident or association? Neurology 2004;62:1352-6.  Back to cited text no. 5
[PUBMED]    
6.Mattar, F, Sibai BM. Eclampsia. VIII. Risk factors for maternal morbidity. Am J Obstet Gynecol 1990;163:1049-55.  Back to cited text no. 6
    
7.Sibai BM, Sarinoglu C, Mercer BM. Eclampsia. VII. Pregnancy outcome after eclampsia and long-term prognosis. Am J Obstet Gynecol 1992;166:1757-61.  Back to cited text no. 7
    
8.Moore KR, Swallow CE, Tsuruda JS. Incidental detection of hippocampal sclerosis on MR images: Is it significant? AJNR Am J Neuroradiol 1999;20:1609-12.  Back to cited text no. 8
[PUBMED]    
9.Kobayashi E, Li LM, Lopes-Cendes I, Cendes F. Magnetic resonance imaging evidence of hippocampal sclerosis in asymptomatic, first-degree relatives of patients with familial mesial temporal lobe epilepsy. Arch Neurol 2002;59:1891-4.  Back to cited text no. 9
[PUBMED]    


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