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Abstract(s)
A epilepsia é uma perturbação neurológica comum e debilitante frequentemente associada a comorbilidades psiquiátricas que, assim como as crises epiléticas, influenciam profundamente a qualidade de vida e podem ser difíceis de tratar, particularmente em doentes com epilepsia refratária.
Os doentes com epilepsia refratária que não são candidatos à cirurgia de ressecção, podem ser propostos para estimulação cerebral profunda (ECP), uma alternativa terapêutica emergente que corresponde à modulação elétrica da rede epileptogénica cerebral. O mecanismo de ação da ECP é ainda pouco claro e ainda menos se sabe relativamente aos possíveis efeitos adversos desta terapêutica inovadora. Alguns estudos têm vindo a reportar efeitos adversos psiquiátricos em doentes tratados com ECP, particularmente quando se trata da estimulação do núcleo anterior do tálamo (NAT), enquanto outros demonstram, pelo contrário, a melhoria da qualidade de vida e do humor em doentes submetidos a ECP-NAT.
Face a esta divergência, este trabalho relata o caso clínico de uma doente com epilepsia refratária que desenvolveu sintomatologia psiquiátrica de novo, nomeadamente, episódios compatíveis com depressão, hipomania e perturbação psicótica, após o tratamento com ECP-NAT e propõe hipóteses que possam explicar essa sintomatologia, com base na evidência atualmente disponível.
As conexões do núcleo anterior do tálamo ao sistema límbico, bem como a estimulação inadvertida de estruturas anatómicas adjacentes envolvidas nos mecanismos de recompensa e da regulação do sono podem explicar a sintomatologia desenvolvida pela doente em questão. Adicionalmente, a manutenção de crises epiléticas incapacitantes e os efeitos adversos motores, poderão ter contribuído para o aumento do sofrimento psicológico.
Epilepsy is a common and debilitating neurological disorder often associated with psychiatric comorbidities which, like epileptic seizures, deeply influence quality of life and can be difficult to treat, especially in patients with refractory epilepsy. Patients with refractory epilepsy who are not candidates for resection surgery may be treated with deep brain stimulation (DBS), an emerging therapeutic alternative that corresponds to the electrical modulation of the cerebral epileptogenic network. The mechanism of action of DBS is still not clear and even less is known about the possible adverse effects of this innovative therapy. While some studies have reported adverse psychiatric effects in patients treated with DBS, especially when it comes to stimulation of the anterior thalamus nucleus (ANT), others on the contrary, demonstrated an improvement in the quality of life and mood disorders in patients undergoing DBS-ANT. Given this divergence, this paper reports the clinical case of a patient with refractory epilepsy who developed de novo psychiatric symptoms, including depression, hypomania and psychotic disorder, after treatment with DBS-ANT and proposes hypotheses that could explain this symptoms, based on the evidence currently available. The connections of the anterior nucleus of the thalamus with the limbic system, as well as the inadvertent stimulation of adjacent anatomical structures involved in the mechanisms of reward and sleep regulation, may explain the symptoms developed by the patient in question. Furthermore, the maintenance of disabling epileptic seizures and motor adverse effects may have contributed to the increase in psychological distress.
Epilepsy is a common and debilitating neurological disorder often associated with psychiatric comorbidities which, like epileptic seizures, deeply influence quality of life and can be difficult to treat, especially in patients with refractory epilepsy. Patients with refractory epilepsy who are not candidates for resection surgery may be treated with deep brain stimulation (DBS), an emerging therapeutic alternative that corresponds to the electrical modulation of the cerebral epileptogenic network. The mechanism of action of DBS is still not clear and even less is known about the possible adverse effects of this innovative therapy. While some studies have reported adverse psychiatric effects in patients treated with DBS, especially when it comes to stimulation of the anterior thalamus nucleus (ANT), others on the contrary, demonstrated an improvement in the quality of life and mood disorders in patients undergoing DBS-ANT. Given this divergence, this paper reports the clinical case of a patient with refractory epilepsy who developed de novo psychiatric symptoms, including depression, hypomania and psychotic disorder, after treatment with DBS-ANT and proposes hypotheses that could explain this symptoms, based on the evidence currently available. The connections of the anterior nucleus of the thalamus with the limbic system, as well as the inadvertent stimulation of adjacent anatomical structures involved in the mechanisms of reward and sleep regulation, may explain the symptoms developed by the patient in question. Furthermore, the maintenance of disabling epileptic seizures and motor adverse effects may have contributed to the increase in psychological distress.
Description
Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2022
Keywords
Estimulação cerebral profunda do núcleo anterior do tálamo Epilepsia refratária Sintomatologia psiquiátrica de novo Efeitos adversos Psiquiatria Psicologia médica