De novo depression after successful resective surgery with mesial temporal preservation: A case with preoperative postictal psychosis

Objectives To describe the evolution of psychiatric symptoms after successful temporal lobe epilepsy surgery and highlight the importance of continued psychiatric monitoring in patients with preoperative postictal psychosis (PIP). Methods We report a 14-year-old girl with right temporal lobe epilepsy and preoperative PIP. The clinical course was characterized using seizure outcomes, MRI and EEG findings, medication changes, and serial Self-rating Depression Scale (SDS) scores. Results Psychiatric symptoms occurred in association with seizures before surgery, without apparent interictal mood disturbance. Right anterior temporal lobectomy with lesion resection, preserving the amygdala and hippocampus, resulted in seizure freedom. Nevertheless, persistent depressive symptoms, depersonalization, and derealization emerged in the third postoperative week. The SDS score increased from 33 preoperatively to 52 at two months and decreased to 44 at ten months following medication adjustments. A routine 20-minute scalp EEG at 11 months showed no interictal epileptiform discharges. Psychiatric symptoms developed despite factors associated with favorable postoperative psychiatric outcomes, and FN was considered a possible explanation, although the proposed diagnostic criteria were not fully met. Conclusions Postoperative psychiatric disorders can develop even when seizure freedom and preservation of mesial temporal structures suggest a favorable psychiatric prognosis. Continued psychiatric monitoring is therefore important, particularly in patients with preoperative PIP, with attention to changes in the timing and nature of psychiatric symptoms.