B.R. was a 55-year-old mildly intellectually disabled female with left anterior temporal lobe epilepsy who had been seizure-free for 2 years following a standard left anterior temporal lobectomy and continued medication management on a relatively low level of lamotrigine. She was referred for a neuropsychological evaluation to assess her postoperative level of neurocognitive and behavioral functioning. In particular, her mother reported that B.R. had a tendency to talk about events that did not really happen, so she had concerns that B.R. was either lying or was experiencing medication-related hallucinations. Her mother also expressed concern that B.R.’s memory had worsened since the surgery.

B.R. had undergone two prior presurgical neuropsychological evaluations. The results of the first presurgical neuropsychological evaluation indicated, “This woman demonstrates intellectual abilities which fall within the range of mild intellectual disability overall with visual-spatial abilities just lightly stronger than those in the verbal area. Her level of academic knowledge is just slightly below her level of general intelligence, and academic achievement may never have been especially strong. The battery of neuropsychological tests which was administered resulted in the identification of moderate impairment in brain functions with findings implicating both cerebral hemispheres about equally. This impairment is expected to have a substantial impact upon functioning in daily life…In terms of predictors for seizure relief following resection surgery for epilepsy, it was noted that only one of the four predictors of likely relief from seizures arising from this battery of tests were within a favorable range. While this is not a positive result, it should be noted that a full prognostic statement of likely relief from seizures following resection surgery must take into account other critical clinical and EEG data.” The results of the second presurgical neuropsychological evaluation indicated, “The patient is a 53-year-old right-handed female with moderate intellectual disability. This is conferred on the current IQ assessment. The majority of neuropsychological measures completed are consistent with her overall level of cognitive function. Interestingly, an area of particular strength was seen for repeat trials of verbal learning and memory…The patient interacts at a higher level than would be anticipated based on her IQ…Oral and cognitive presentation is reflective of generalized cortical dysfunction with preservation of left temporal lobe capacity. These findings are consistent with her history of bilateral seizures and significant illness during critical development.” It was concluded that improved seizure control would probably positively improve her life in terms of her personal safety and functional ability, with some risks to her verbal memory that would likely not be apparent in her day-to-day functional capacity.

Developmentally, B.R. and her husband lived with her parents. She was able to bathe and dress herself and do a few chores around the house, such as taking care of her cat, doing some of the cleaning, and folding the laundry, all of which she could do successfully with minimal supervision or guidance. She did not do the shopping or cooking, nor did she manage any finances. She was not able to manage her medications independently and relied on her mother to remind her to take her medication.

Postsurgically, B.R. was unable to provide subjective information about her cognitive difficulties. It had been well documented that she was mildly intellectually disabled and, per medical records, had limited insight into her cognitive limitations. Her mother reported that B.R.’s memory was poor prior to her undergoing the left anteromedial temporal resection but had seemed worse since the surgery. Additionally, she reported that B.R. had a tendency to confabulate and displayed some paranoid ideation. For example, 1 day B.R. could not find her cat and assumed someone had stolen it; in fact, the cat had simply wandered away for a short time. Another time, she found that money was gone from her husband’s wallet and assumed someone had stolen it, but he had just put the money in his pocket. Of note, medical records prior to surgery indicated that B.R. had a tendency to talk about memory for events that did not really happen even back then. Thus, it appeared that her tendency to confabulate was not new since the surgery. Further consistent with presurgical reports, B.R. had always been easily confused and forgetful about upcoming appointments and had often misplaced items. However, her mother felt that those problems had worsened since surgery. Her mother also reported that B.R. had begun to make literal paraphasic errors in conversation, such as saying that she wanted to go to the “feel good” store instead of the Goodwill store. This was reportedly new since she had undergone surgery. Her mother expressed concerns that these perceived cognitive changes were being caused by her long-term medication regimen of lamotrigine.

The postoperative neuropsychological test results are given in Table 13.2. Consistent with previous presurgical evaluations, the postsurgical neuropsychological evaluation measured B.R.’s overall level of intellectual functioning to be mildly intellectually disabled. On testing, B.R. performed in the impaired range on most tests of neuropsychological functioning, consistent with her performances on two previous presurgical evaluations. She once again demonstrated a relative strength in her verbal learning and memory abilities, as her performances were largely borderline to low average across those tasks. Compared with the most recent previous presurgical neuropsychological evaluation, however, she demonstrated a very mild decline in her verbal list learning capacity and retention, which was not surprising given that left mesial temporal structures that support verbal learning and memory were resected. Once again, her visual learning and memory was not as good as her verbal learning and memory. Interestingly, she also demonstrated a mild decline in her visual learning and memory abilities compared with presurgical performances. Overall, the findings of the postsurgical neuropsychological evaluation were consistent with a woman who suffered generalized cortical dysfunction and who, as a result, had mild intellectual disability and significant developmental delays. As had been demonstrated on previous presurgical neuropsychological evaluations, B.R. had a few areas of relative cognitive strength, including her verbal learning and memory ability and some aspects of social and executive skills. Her verbal learning and memory abilities continued to be a relative strength for her, despite showing a mild decline from presurgical levels. It was concluded that she was a woman who had clearly led a life that had been meaningful to her, and she continued to have the capacity to participate in her life at a level that gave her a sense of accomplishment and kept her feeling happy. Given that she was now seizure-free, she was leading a healthier life, and it was likely that she would continue to lead a happy and productive life for the foreseeable future, with very minimal to no change in her cognitive abilities since the surgery. Overall, it was felt that the neurosurgical resection to treat her refractory epilepsy was successful. Furthermore, there was no evidence to suggest that her antiepileptic medication regimen was negatively impacting her cognitive functioning or causing a significant change in her psychiatric or cognitive functioning.