S05. Temporal lobe epilepsy in a patient with clivus chordoma

Abstract

Introduction Neuroimaging studies are helpful in the evaluation of patients with epilepsy, but identification of a structural lesion does not necessarily mean that it is the etiology. Patients with epilepsy can have psychiatric comorbidities, which should be addressed during management. We describe a patient with seizures, mood disorders and anxiety, who was found to have a clivus chordoma. Although seizures have been described with chordomas, treatment of the tumor was unhelpful in our patient. He was ultimately diagnosed with temporal lobe epilepsy and had an excellent outcome after temporal lobectomy. Methods Case report. Results A 31-year-old man presented with a history of seizures, panic attacks, anxiety and depression since age 15 years. His seizures were described as staring spells and confusion, preceded by intense fear. He also had two secondarily generalized tonic-clonic seizures. He was treated with antiepileptic medications and antidepressants, but the seizures progressively increased despite multiple antiepileptic medications at high doses. Routine EEG revealed sharp waves in the right temporal region. Brain MRI showed evidence of a clivus chordoma. He underwent surgical resection of the tumor along with radiation, but his seizures and psychiatric symptoms persisted. Video-EEG monitoring was performed. Three typical events were recorded. Ictal EEG onset was in the right temporal region. A repeat brain MRI with a dedicated epilepsy protocol showed right hippocampal atrophy, and postsurgical changes related to resection of the clivus chordoma. FDG-PET scan showed significant hypometabolism in the right temporal region. His neuropsychological evaluation indicated difficulties in visuospatial memory and increased emotional and psychosocial distress. As the patient had drug-resistant epilepsy and his mood symptoms were worsening, the patient underwent right temporal lobectomy. He has been seizure-free, and his mood and anxiety symptoms have improved remarkably since surgery. Conclusion Our case highlights the importance of carefully analyzing seizure semiology and correlating this with other findings. Even if a structural lesion that can be associated with seizures is identified, one cannot presume the lesion to be the cause of epilepsy. Additional tests including brain MRI with an epilepsy protocol, video EEG monitoring, PET scan and neuropsychological evaluation are necessary to determine the etiology of drug-resistant epilepsy and to provide the best treatment option. When seizures and mood disorders coexist, optimal treatment of seizures can result in alleviation of mood symptoms.