Case Report: New-onset Post-ictal Hyper-religiosity Following Laser Interstitial Thermal Therapy in a Patient with Right Temporal Lobe Epilepsy
Philipp Schmitt1, William Nobis2
1Department of Neurology, Vanderbilt University Medical Center, 2Vanderbilt University Medical Center
Objective:
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Background:

A 32 year-old female with medically refractory epilepsy and a vagus nerve stimulator (VNS). She previously had focal impaired awareness seizures characterized by abnormal stomach sensation, deja vu, loss of awareness, hand automatisms/posturing and post-ictal confusion. Pre-surgical evaluation identified a lesional epilepsy with right anterior temporal electrographic onset of seizures, right hippocampal atrophy on MRI, and PET hypometabolism in the right mesial temporal lobe. She subsequently underwent Laser Interstitial Thermal Therapy (LITT) to ablate this focus. 

On follow up with her epileptologist, seizures were unchanged in frequency and, per family, were now followed by intense religious delusions not previously present. These included fixation on attending church (incongruent with prior religious beliefs) and believing she is communicating with God and the devil. Review of post-ablation MRI demonstrated residual right hippocampal tissue. 

The right temporal lobe is implicated in religious phenomena, especially ones incongruent with previously held beliefs. Such symptoms are well-documented in diseases such as temporal lobe epilepsy and frontotemporal dementia/frontotemporal lobar degeneration. Anatomic locations moreso associated with congruent religious phenomena include the postero-superior parietal lobe and the right angular gyrus. Functional studies also implicate hippocampal networks to the amygdala and angular gyrus. 

Design/Methods:
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Results:
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Conclusions:
To our knowledge, this is the first documented case of post-ictal hyper-religious symptoms in a post-ablation patient. These symptoms best localize to the right temporal lobe. Our differential diagnosis of this new abnormality includes the recruitment of a new temporal lobe-amygdala epileptic network that causes post-ictal symptoms or the lesioning of a compensatory structure/network (IE mesial hippocampus) with residual posterior hippocampal tissue now generating seizures. The patient is discussing anterior temporal lobectomy, further laser ablation or selective resection of residual hippocampal tissue. Potential diagnostics to evaluate the etiology of hyper-religious post-ictal symptoms include epilepsy network analysis through intracranial stereo EEG. 
10.1212/WNL.0000000000215100
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