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Original article
Epileptic peri-ictal psychosis, a reversible cause of psychosis
Psicosis epiléptica periictal, una causa de psicosis reversible
C. González Mingota,
Corresponding author
crismingot@hotmail.com

Corresponding author.
, M.P. Gil Villara, D. Calvo Medelb, T. Corbalán Sevillaa, L. Martínez Martíneza, C. Iñiguez Martíneza, S. Santos Lasaosaa, J.A. Mauri Llerdaa
a Servicio de Neurología, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
b Servicio de Psiquiatría, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
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between 19&#37; and 80&#37; of all epileptic patients experience a psychotic episode at some point during the course of the disease&#46; Some studies have shown that the type of epileptic syndrome&#44; treatment response&#44; and the patient&#39;s psychosocial conditions affect an epileptic patient&#39;s probability of developing psychosis&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Epileptic psychoses often manifest as visions&#44; auditory or visual hallucinations&#44; and affective changes&#44; such as agitation&#44; fear&#44; or paranoia&#46; They may be described as peri-ictal or interictal psychoses depending on the moment in which they appear&#46; Peri-ictal psychoses have a close temporal relationship with epileptic seizures&#44; and may occur before &#40;pre-ictal&#41;&#44; during &#40;ictal&#41;&#44; or after &#40;postictal&#41; seizures&#46; They are generally characterised by abrupt onset and resolution&#44; short duration&#44; and full remission with risk of recurrence&#46; The relationship between interictal or chronic psychoses and epileptic seizures is not based on proximity in time&#46; Based on the link between psychosis and type of seizure treatment&#44; we can distinguish between epileptic psychosis due to forced normalisation and alternative psychosis&#44; which includes epileptic psychosis secondary to epilepsy surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">A combination of antiepileptic and neuroleptic drugs is frequently used in treating epileptic psychoses&#44; despite the interactions caused by the hepatic metabolism of most of these drugs&#46; Nevertheless&#44; there is no consensus on the optimal antiepileptic drug for this pathology and no standard guidelines for treating this type of psychosis&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Patients and methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">We present a descriptive study of 5 cases of peri-ictal epileptic psychosis that respond to treatment with antiepileptic drugs associated with an antipsychotic during the acute phase &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; We highlight the safety of and good response to treatment with levetiracetam and low doses of neuroleptic drugs in these cases&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Pre-ictal psychosis</span><p id="par0025" class="elsevierStylePara elsevierViewall">Case 1 was a female patient aged 32 years who was diagnosed in 1997 with relapsing-remitting multiple sclerosis that progressed rapidly&#46; She therefore was treated consecutively with interferon &#946;-1a&#44; azathioprine&#44; and mitoxantrone&#46; The condition stabilised over the 2 following years &#40;EDSS 3&#46;5&#41; with glatiramer acetate&#44; amantine&#44; and oxybutynin&#46; The patient visited the emergency department and stated that she was hearing voices&#46; She was diagnosed with obsessive intrusive thoughts&#44; with judgement and sense of reality remaining intact&#59; the patient was discharged under treatment with oxcarbazepine&#46; After 48<span class="elsevierStyleHsp" style=""></span>hours&#44; she returned to the emergency department with symptoms of disorientation&#44; distress&#44; and paranoia&#46; Clinical progression was changeable and she was even conscious of her agitation at times&#46; She was able to speak coherently&#44; exhibiting spontaneous&#44; fluent&#44; and occasionally verbose language&#46; She also expressed self-obsessed damaging delusional thinking &#40;&#8220;I&#8217;m going to go mute&#8221;&#44; &#8220;I&#8217;m going to die&#8221;&#41; and auditory hallucinations&#46; She was admitted into the psychiatry department and treated with quetiapine &#40;100<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41;&#46; Forty-eight hours later&#44; she suffered a tonic-clonic seizure preceded by bending of the torso and head to the right for a few minutes&#44; with no tongue biting or sphincter dilation&#44; followed by post-ictal stupor&#46; A few minutes later&#44; a similar new seizure occurred&#46; The brain MRI showed no new lesions or contrast uptake in pre-existing lesions&#46; Waking EEG showed a deep irritative temporal left focus with normal recorded baseline reading &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; In light of the above&#44; she was diagnosed with pre-ictal epileptic psychosis and treated with levetiracetam &#40;2000<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41; and quetiapine &#40;100<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41;&#46; The patient has not experienced any new epileptic seizures or psychotic episodes during the last 4 years&#46; Therefore&#44; quetiapine was progressively discontinued and she remains under treatment with levetiracetam &#40;1000<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Case 2 was a male patient aged 42 years with antisocial personality traits&#44; impulsive behaviour&#44; and low self-esteem&#46; The patient had suffered from idiopathic focal epilepsy of the temporal lobe since childhood&#46; He was being treated with carbamazepine &#40;800<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41; and topiramate &#40;300<span class="elsevierStyleHsp" style=""></span>mg&#41; which failed to achieve correct epilepsy control &#40;2 seizures per month&#41;&#46; The patient experienced symptoms of paranoia and distressing auditory hallucinations &#40;in the second and third person&#41; with spiritual and religious content&#46; He was therefore admitted to the psychiatry unit&#46; The patient had delusional and megalomaniac thoughts that were related to his auditory hallucinations and notions of thought extraction&#46; Twenty-four hours after he was admitted&#44; he suffered partial epileptic seizure with secondary generalisation&#46; CT and waking EEG were performed during the episode&#44; but revealed no abnormalities&#46; The condition was brought under control with neuroleptic drugs &#40;60<span class="elsevierStyleHsp" style=""></span>mg of olanzapine every 24<span class="elsevierStyleHsp" style=""></span>hours&#41; during the acute phase&#46; Upon discharge&#44; he was asymptomatic&#46; Nevertheless&#44; the patient still experienced frequent epileptic seizures &#40;2&#8211;3 per month&#41;&#44; occasionally preceded by psychotic episodes&#46; During the course of the disease&#44; he also suffered from psychotic episodes which were not seizure-related&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Postictal psychosis</span><p id="par0035" class="elsevierStylePara elsevierViewall">Case 3 was a male who had suffered from temporal epilepsy secondary to left mesial temporal sclerosis since childhood&#46; Beginning at the age of 7 months&#44; the patient experienced frequent complex focal epileptic seizures &#40;15 seizures per month&#41;&#44; which were refractory to treatment with multiple combinations of antiepileptic drugs including valproic acid&#44; carbamazepine&#44; oxcarbazepine&#44; topiramate&#44; zonisamide&#44; lamotrigine&#44; and benzodiazepines&#46; At the age of 29&#44; 36<span class="elsevierStyleHsp" style=""></span>hours after a focal seizure with secondary generalisation&#44; the patient presented hallucinations with spiritual delusions lasting 72<span class="elsevierStyleHsp" style=""></span>hours and attempted to attack a member of his family while in a confusional state&#46; Results from the urine test for toxic substances were negative&#46; Waking EEG showed an irregular activity of 2 to 4<span class="elsevierStyleHsp" style=""></span>Hz in the left temporal region and acute waves in the left medial temporal region which were moderately persistent during the intercritical period &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Despite treatment with neuroleptic drugs &#40;olanzapine 20<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41; and antiepileptic polytherapy &#40;rivotril 3<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#44; lamotrigine 600<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#44; zonisamide 400<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41;&#44; he continued having epileptic seizures and occasional postictal psychotic episodes with similar characteristics lasting between 1 and 5 days&#46; When the patient was 32&#44; a preoperative study ruled out bitemporal irritative activity&#46; Doctors decided to perform left temporal lobectomy to treat the drug-resistant epilepsy&#46; After surgery&#44; seizures persisted &#40;6 per month&#41; and frequency of the post-critical psychotic episodes increased despite maintenance of the patient&#39;s antiepileptic treatment&#46; After levetiracetam &#40;3000<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41; was associated with olanzapine &#40;5<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41;&#44; the patient attained acceptable seizure control&#44; with 1 seizure per month and no new episodes of postictal psychosis after the seizure&#46; Neuroleptic drugs could therefore be gradually discontinued&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Case 4 was a 41-year-old woman diagnosed in 1991 with relapsing-remitting multiple sclerosis&#46; She had experienced multiple sensory&#44; motor&#44; and cerebellar exacerbations despite successive courses of treatment with interferon&#44; azathioprine&#44; and mitoxantrone &#40;EDSS 4&#46;5&#41;&#46; In 2002 she suffered a first-ever generalised tonic-clonic seizure&#46; A day later&#44; she suffered a psychotic episode with delusional thoughts and hallucinations of voices criticising her behaviour&#44; which caused distress&#46; The patient reported having experienced olfactory hallucinations and frequent d&#233;j&#224; vu phenomena&#46; Brain MRI showed no acute lesions&#46; The intercritical waking EEG revealed a slightly slow and unstable record with some generalised slower bursts &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; Doctors began treatment with quetiapine &#40;100<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41; and lamotrigine &#40;400<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41;&#46; Despite the treatment&#44; epileptic seizures persisted on a bimonthly basis and were sometimes followed by psychotic episodes&#46; Doctors decided to add a second antiepileptic drug&#44; and since the patient did not respond to oxcarbazepine&#44; they opted for levetiracetam &#40;1500<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41;&#46; The patient continued taking levetiracetam in monotherapy since her response to that treatment was optimal&#46; Her quetiapine dose has been reduced to 50<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Psychosis secondary to epilepsy surgery due to forced normalisation</span><p id="par0045" class="elsevierStylePara elsevierViewall">Case 5 was a woman with a mild intellectual disability who had suffered from complex focal epilepsy since the age of 8 months&#46; The patient showed a poor response to several combinations of antiepileptic drugs with a mean of 8 seizures per month while awake and daily during sleep&#46; During video-EEG monitoring&#44; she presented 30 simple focal seizures and 7 complex focal seizures&#46; The waking EEG performed during the intercritical period showed high-voltage spikes and polyspikes in the left posterior temporal region which were very frequent during the REM sleep phase &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; Brain MRI revealed a left temporal mass compatible with ganglioglioma&#44; which was confirmed in the anatomical pathology study&#46; Anterior resection of the left temporal lobe was performed when the patient was 15&#46; Forty-five days later&#44; she had not experienced any additional epileptic seizures and the waking EEG showed no sign of irritative activity&#46; However&#44; she suffered an acute episode of delusional thoughts with visual hallucinations&#44; inability to recognise people&#44; and extreme agitation&#44; which required neuroleptic drugs &#40;haloperidol&#41; to treat the symptoms&#46; Four months later&#44; less intense epileptic seizures reappeared and the patient resumed treatment with levetiracetam &#40;2000<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41;&#46; Seizure intensity and number decreased &#40;3 to 4 seizures per month&#41; with no new psychotic episodes&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0050" class="elsevierStylePara elsevierViewall">Pre-ictal psychotic episodes begin during the prodromal phase of epileptic seizures &#40;hours or days&#41;&#46; The chronological sequence in these psychoses are a matter of debate&#46; According to some theories&#44; episodes are really seizures induced by a psychotic substrate rather than disorders predicting a new epileptic seizure&#46; Other authors believe them to be interictal phenomena&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> The main distinguishing feature of our cases is that psychotic episodes were acute and self-limiting&#46; In the long term&#44; however&#44; they entail a higher risk of developing interictal psychosis&#46; The second case shows that if there is inadequate control over seizures&#44; and therefore over associated psychosis&#44; patients may experience episode recurrence and interictal psychosis&#46; However&#44; use of levetiracetam in the first case provided seizure control and prevented new psychotic episodes&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Ictal psychoses are uncommon&#46; These phenomena are typically localised in the temporal lobe and elicit activation of the limbic system and neocortical temporal areas&#46; Prolonged ictal psychotic states are even more infrequent&#46; They usually occur in non-convulsive status epilepticus with simple or complex focal seizures and petit mal seizures&#46; Transient ictal psychoses may be secondary to continuous epileptic discharges that cause no other epileptic symptoms&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Postictal psychosis is the most well-known type of epileptic psychosis and occurs in 2&#37; to 7&#37; of patients with epilepsy&#46; It is defined as a psychotic episode lasting more than 15<span class="elsevierStyleHsp" style=""></span>hours and less than 3 months which appears within a week of an epileptic seizure&#46; The patient presents a confusional state which may appear psychotic&#44; possibly accompanied by hallucinations and delusional thoughts&#46; Affective disorders &#40;depression&#44; mania&#44; aggressiveness&#41; are more common than hallucinations&#46; Negative symptoms are not remarkable&#46; A lucid period lasting 2&#46;5 to 48<span class="elsevierStyleHsp" style=""></span>hours typically presents between the epileptic seizure and the onset of psychotic symptoms&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Risk factors are as follows&#58; age above 30 years&#44; bilateral seizures or intercritical focus&#44; cluster seizures&#44; secondary generalisation&#44; and family history of affective disorders&#46; Postictal psychosis usually appears a minimum of 10 years after onset of epilepsy &#40;although it has been described after only 5 years&#41; and it is equally frequent in right and left temporal seizures&#46; As the frequency of postictal psychotic episodes increases&#44; so does the risk of developing chronic interictal psychosis&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Postictal psychosis is related to the presence of bilateral epileptic activity&#44; whether interictal<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> or ictal&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> The presence of postictal psychosis is considered to be a poor surgical prognostic factor in mesial temporal epilepsy&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> given that postictal psychosis is associated with bitemporal dysfunction&#46; On the other hand&#44; some authors have achieved good seizure control with no recurrence of postictal psychosis&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> In the third case&#44; a preoperative study showed no evidence of bilateral ictal and interictal activity&#44; but the patient did not respond well to surgical treatment&#46; As in the fourth case&#44; epilepsy and postictal psychosis were controlled using the combination of levetiracetam and low doses of a new neuroleptic drug&#46; We were able to reduce the dose in once case and discontinue the antipsychotic drug in the other&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Several studies have highlighted the relationship between seizures&#44; psychosis&#44; and the phenomenon of forced normalisation&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> This phenomenon is quite uncommon in patients with partial drug-resistant epilepsy whose seizures have been controlled or reduced through treatment&#46; Forced normalisation usually occurs after administration of an effective antiepileptic drug or performance of epilepsy surgery that normalises a previously aberrant EEG &#40;forced normalisation or alternative psychosis&#41;&#46; The first 6 months after surgery constitute a high-risk period&#46; The prevalence of developing psychosis as a complication of epilepsy surgery&#44; after resection of the temporal focus&#44; ranges between 3&#37; and 28&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> The underlying pathophysiological mechanisms remain unclear&#46; It is believed that the high number of temporal lobe discharges could have an inhibitory effect on the limbic structures&#46; Therefore&#44; once seizures have abated&#44; limbic disinhibition responsible for behaviour disorders will appear&#46; Risk factors for psychosis as a neurosurgical complication are as follows&#58; the presence of a right-sided focus&#44; anomalous tissue suggesting an alteration in cell differentiation&#44; hamartomas&#44; and gangliogliomas&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Our female patient presented symptomatic epilepsy caused by a left cerebral ganglioglioma&#46; In this case&#44; the appearance of de novo epileptic psychoses would be determined by both processes&#58; the surgery itself and the phenomena of forced normalisation&#44; since treatment resulted in a considerable decrease in seizure number and intensity&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Although there are no standard guidelines for treating epileptic psychoses&#44; associating antiepileptic and neuroleptic drugs is frequent&#46; Numerous antiepileptic drugs have been proposed in these cases &#40;carbamazepine&#44; valproic acid&#44; lamotrigine&#44; etc&#46;&#41;&#44; but there is no standard treatment at present&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> Most antiepileptic drugs increase hepatic metabolism&#44; which decreases the effective levels of neuroleptic drugs&#46; Patients with epileptic psychoses therefore require higher doses of neuroleptic drugs than do patients with isolated psychosis&#44; which increases the probability of drug interactions&#46; This is why in these cases we suggest using renally metabolised antiepileptic drugs&#44; such as levetiracetam&#44; in association with neuroleptics&#46; There are no controlled trials with levetiracetam for epileptic psychosis&#46; Whereas 2&#37; of the patients on long-term treatment with levetiracetam have experienced behavioural disorders&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> this drug has been confirmed as a safe treatment for mania and bipolar psychosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;19</span></a> According to our experience&#44; levetiracetam is an ideal drug for use with neuroleptics both during the acute phase of peri-ictal psychosis and on a long-term basis in cases of interictal psychosis&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Differentiating between mental disorders associated with epilepsy according to their temporal relationship with epileptic seizures is clinically and prognostically useful&#44; since it provides important data regarding the treatment and course of the disease&#46; The treatment of peri-ictal or acute mental disorders is oriented towards rigorous control over epileptic seizures&#44; whereas treatment of interictal or chronic disorders resembles that of true psychiatric disorders&#46; Controlled trials are needed to study this condition given that strict seizure control may prevent interictal psychosis&#44; improve quality of life&#44; and decrease level of disability&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p id="par0080" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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              "titulo" => "Pre-ictal psychosis"
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              "identificador" => "sec0020"
              "titulo" => "Postictal psychosis"
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            2 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Psychosis secondary to epilepsy surgery due to forced normalisation"
            ]
          ]
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          "titulo" => "Discussion"
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            0 => "Epilepsy"
            1 => "Seizure"
            2 => "Levetiracetam"
            3 => "Peri-ictal"
            4 => "Psychosis"
            5 => "Epileptic psychosis"
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            0 => "Epilepsia"
            1 => "Crisis"
            2 => "Levetiracetam"
            3 => "Periictal"
            4 => "Psicosis"
            5 => "Psicosis epil&#233;ptica"
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        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Epileptic psychoses are categorised as peri-ictal and interictal according to their relationship with the occurrence of seizures&#46; There is a close temporal relationship between peri-ictal psychosis and seizures&#44; and psychosis may present before &#40;preictal&#41;&#44; during &#40;ictal&#41; or after seizures &#40;postictal&#41;&#46; Epileptic psychoses usually have acute initial and final phases&#44; with a short symptom duration and complete remission with a risk of recurrence&#46; There is no temporal relationship between interictal or chronic psychosis and epileptic seizures&#46; Another type of epileptic psychosis is related to the response to epilepsy treatment&#58; epileptic psychosis caused by the phenomenon of forced normalisation &#40;alternative psychosis&#41;&#44; which includes epileptic psychosis secondary to epilepsy surgery&#46; Although combination treatment with antiepileptic and neuroleptic drugs is now widely used to manage this condition&#44; there are no standard treatment guidelines for epileptic psychosis&#46;</p> <span class="elsevierStyleSectionTitle">Clinical cases</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We present 5 cases of peri-ictal epileptic psychosis in which we observed an excellent response to treatment with levetiracetam&#46; Good control was achieved over both seizures and psychotic episodes&#46; Levetiracetam was used in association with neuroleptic drugs with no adverse effects&#44; and our patients did not require high doses of the latter&#46;</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Categorising psychotic states associated with epilepsy according to their temporal relationship with seizures is clinically and prognostically useful because it provides important information regarding disease treatment and progression&#46; The treatment of peri-ictal or acute mental disorders is based on epileptic seizure control&#44; while the treatment of interictal or chronic disorders has more in common with managing disorders which are purely psychiatric in origin&#46; In addition to improving the patient&#39;s quality of life and reducing disability&#44; achieving strict control over seizures may also prevent the development of interictal psychosis&#46; For this reason&#44; we believe that establishing a treatment protocol for such cases is necessary&#46;</p>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle">Introducci&#243;n</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Las psicosis epil&#233;pticas se dividen respecto de su relaci&#243;n con las crisis en periictales e interictales&#46; Las psicosis periictales tienen una estrecha relaci&#243;n temporal con las crisis epil&#233;pticas y ocurren antes &#40;preictales&#41;&#44; durante &#40;ictales&#41; o despu&#233;s de las mismas &#40;postictales&#41;&#46; Generalmente&#44; tienen un inicio y final agudo&#44; corta duraci&#243;n y una remisi&#243;n completa&#44; con riesgo de recurrencia&#46; Las psicosis interictales o cr&#243;nicas no guardan relaci&#243;n temporal con las crisis epil&#233;pticas&#46; Existe otro tipo de psicosis epil&#233;pticas que se relaciona con la respuesta al tratamiento de la epilepsia&#58; psicosis epil&#233;ptica por fen&#243;meno de normalizaci&#243;n forzada &#40;psicosis alternativa&#41; y dentro de esta se encuentra la psicosis epil&#233;ptica secundaria a cirug&#237;a de la epilepsia&#46; Aunque se ha generalizado la combinaci&#243;n de antiepil&#233;pticos y neurol&#233;pticos para su manejo&#44; no existen unas pautas estandarizadas de tratamiento en las psicosis epil&#233;pticas&#46;</p> <span class="elsevierStyleSectionTitle">Casos cl&#237;nicos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Presentamos 5 casos de psicosis epil&#233;pticas periictales y remarcamos la excelente respuesta al tratamiento con levetiracetam&#46; Consiguiendo un buen control tanto de las crisis como de los episodios psic&#243;ticos&#46; Este f&#225;rmaco result&#243; inocuo al asociarlo con neurol&#233;pticos en nuestros pacientes y no se precisaron dosis elevadas de estos &#250;ltimos&#46;</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La diferenciaci&#243;n de los estados psic&#243;ticos asociados con la epilepsia seg&#250;n la relaci&#243;n temporal con las crisis epil&#233;pticas tiene utilidad cl&#237;nica y pron&#243;stica&#44; dado que aporta aspectos importantes respecto al tratamiento y a la evoluci&#243;n de la enfermedad&#46; El tratamiento de los trastornos mentales periictales o agudos se basa en el control de las crisis epil&#233;pticas&#44; mientras que el tratamiento de los interictales o cr&#243;nicos guarda m&#225;s similitud con el de los trastornos de origen puramente psiqui&#225;trico&#46; El control estricto de las crisis puede&#44; adem&#225;s de mejorar la calidad de vida del paciente y su discapacidad&#44; prevenir el desarrollo de una psicosis interictal&#44; por lo que consideramos que ser&#237;a necesario establecer un protocolo de tratamiento para estos casos&#46;</p>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; Gonz&#225;lez Mingot C&#44; et al&#46; Psicosis epil&#233;ptica periictal&#44; una causa de psicosis reversible&#46; Neurolog&#237;a&#46; 2013&#59;28&#58;81&#8211;7&#46;</p>"
      ]
    ]
    "multimedia" => array:5 [
      0 => array:7 [
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        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
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        "descripcion" => array:1 [
          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Waking EEG shows an irritative temporal left focus with a normal baseline readout in a patient with pre-ictal psychosis&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
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          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Waking EEG shows irregular activity of 2 to 4<span class="elsevierStyleHsp" style=""></span>Hz in the left temporal region and acute waves in the left medial temporal region in patient with postictal psychosis&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
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        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Intercritical waking EEG shows a somewhat slow unstable trace with slower generalised bursts in a patient with postictal psychosis&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "fig0020"
        "etiqueta" => "Figure 4"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Waking EEG readout showing high-voltage spikes and polyspikes in the left posterior temporal region in a patient with cerebral ganglioglioma&#44; prior to surgery and development of psychosis due to forced normalisation&#46;</p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Case&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Type&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Age at onset of epilepsy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Age at onset of psychosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Clinical history&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Interictal EEG&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Treatment in acute phase&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Treatment in chronic phase&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Course of disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pre-ictal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">32 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">32 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Multiple sclerosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Left temporal focus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Quetiapine Levetiracetam&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Levetiracetam&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No seizures&#44; no psychosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pre-ictal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">42 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Antisocial personality&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">OlanzapineTopiramateCarbamazepine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">OlanzapineTopiramateCarbamazepine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Seizures persistPsychotic episodes persist&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Postictal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">29 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mesial temporal sclerosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Left temporal focusl&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">OlanzapineLevetiracetam&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Olanzapine &#40;progressively decreasing doses&#41;Levetiracetam&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Fewer seizuresNo psychosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Postictal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">41 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">41 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Multiple sclerosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Slow generalised bursts&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">QuetiapineLevetiracetam&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">QuetiapineLevetiracetam&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No seizuresNo psychosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Due to forced normalisation after epilepsy surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Surgery on cerebral ganglioglioma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Left temporal focus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">HaloperidolLevetiracetam&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Levetiracetam&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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Article information
ISSN: 21735808
Original language: English
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos