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Temporal Lobe Epilepsy

Temporal Lobe Epilepsy Syndrome

Temporal lobe epilepsy is considered to be one of the most common types of epilepsy. Structures that constitute the mesial temporal lobe, primarily hippocampus, are hypothesized to be the origin of excitatory signals. Cognition, memory and functional ability are all impaired as a result of seizure activity. Imaging studies and EEG confirm the diagnosis, whereas treatment is primarily surgical, as this form of epilepsy is resistant to antiepileptics.


The clinical presentation of patients suffering from TLE starts with partial seizures and the appearance of an aura. Epigastric sensations, fear, deja vu or olfactory hallucinations are forms of aura that are encountered in these patients and are quite common [9]. In neonates and infants, however, these auras may be difficult to attain and recognize [9]. Seizures are characterized by arrest of motor behavior, blank stare, and automatisms [5]. At some point, symptoms that indicate memory loss, executive function, language deficits and various other impairments [11]. Both autobiographical and working memory loss has been observed [11], whereas significant disability may be seen as a result of slowed mental processing speed, mood and personality disorders, as well as extensive changes in emotional responses [5] [11]. Namely, failure to recognize fear, sadness and disgust have been observed, which may be used as indicative signs of temporal lobe involvement [12]. Interictal (the period between seizures) depression is diagnosed in up to one third of patients [5], suggesting that this condition carries a significant psychological burden.

  • Ictal tachycardia was documented with EEG-EKG recording in the latter patient, prior to right anterior temporal lobectomy and amygdalohippocampectomy.[ncbi.nlm.nih.gov]
  • Autonomic phenomena (pallor, flushing, tachycardia) are common. Upper limb automatisms may be unilateral and may lateralize the seizure to the ipsilateral hemisphere.[epilepsydiagnosis.org]
  • […] called focal aware) Auras/focal aware may be classified by symptom type, as follows: Sensory – auditory, gustatory, hot-cold sensations, olfactory, somatosensory, vestibular, visual Autonomic – Heart rate Change (asytole, bradycardia, palpitations, tachycardia[emedicine.medscape.com]
Panic Attacks
  • Given its often nonspecific neuropsychiatric manifestations and frequently negative electroencephalographic workup, TLE can be easily misdiagnosed as a psychiatric disorder, particularly panic attacks.[ncbi.nlm.nih.gov]
  • BACKGROUND: Panic attack semiology as a manifestation of epileptic seizures may lead to difficulties and delay in diagnosis.[ncbi.nlm.nih.gov]
  • Panic attacks . Occipital lobe epilepsy: may spread to the temporal lobe and be clinically indistinguishable from a temporal lobe seizure. Psychogenic seizures: patients with psychogenic seizures may also have epileptic seizures.[patient.info]
  • Auras can also be confused with sudden onset of panic, panic attacks or anxiety attacks creating difficulties in diagnosis.[en.m.wikipedia.org]
Visual Hallucination
  • Auditory and visual hallucinations may occur, that is the patient thinks they are hearing voices or see visions. Their need for sleep is greatly reduced. In it's most severe state it is a mental health emergency and may need inpatient care.[netdoctor.co.uk]
  • Less frequent are primitive visual hallucinations (figures, blobs of colors), speech arrest, vertigo, and smells. Seizures may be provoked by sleep.[doctorstrizhak.com]
  • These visual illusions differ from the visual hallucinations associated with occipital lobe seizure in that there is no formed visual image. Objects may appear smaller or larger than usual.[patient.info]
  • hallucinations linked to other qualities of perception such as voices, emotions, or time Any form of: Auditory perceptual abnormality; Olfactory hallucinations; Gustatory hallucinations; Rotation or disequilibrium feelings linked to other perceptual[pni.org]
  • They can also be characterised by irritating senses of smell or taste, autonomic symptoms (flushing, sweating, changes of heart rate), emotional changes (rising fear or anxiety, anger, depression, euphoria) or memory symptoms (déjà vu or jamais vu – a[epilepsyqueensland.com.au]
  • […] tachycardia), flushing, gastrorintestinal, pallor, piloerection, respiratory Cognitive/psychic – Déjà vu or jamais vu, dissociation, depersonalization or derealization, forced thinking, aphasia/dysphasia, memory Emotional/affective - agitation, aggression, anger[emedicine.medscape.com]
  • […] epilepsy who have psychiatric disorders or comparable physical disabilities. 10 Research done by Bear and Fedio 11 identified 18 personality characteristics in patients with TLE that differentiate them from normal controls: emotionality, elation, sadness, anger[consultant360.com]
  • Visual distortions such as macropsia and micropsia Dissociation or derealisation Synesthesia (stimulation of one sense experienced in a second sense) may transpire. [8] Dysphoric or euphoric feelings, fear, anger, and other emotions may also occur.[en.wikipedia.org]
  • […] symptomatology, and include: viscerosensory aura typically from lesions of the amygdala or insular cortex psychic (experienced) aura typically from limbic structures variable including dysmnesic phenomena, cognoscitive phenomena, emotional phenomena, delusions[radiopaedia.org]
  • At the time of discharge, 28 days after her admission, the patient’s delusions, irritability, and mood lability had resolved, but she continued to have hypergraphia and hyperreligiosity. Mrs.[consultant360.com]
  • ., delusion of lycanthropy, or misinterpreted as UFO abductions). Temporal lobe seizures may occur in anyone at any age, as a single episode, or as a chronic seizure disorder. Diagnosis Abnormal electrical activity on EEG.[medical-dictionary.thefreedictionary.com]
Olfactory Hallucination
  • While mesial temporal lobe epilepsy can be associated with olfactory hallucinations, deja vu and epigastric auras, temporal lobe seizures arising from the lateral cortex rather than the hippocampus may present with auditory hallucinations as the initial[epilepsygenetics.net]
  • I similarly studied olfactory hallucinations but a specific type of temporal lobe epilepsy olfactory hallucination could not be demonstrated although there were suggestive features.[pni.org]
  • Often, the patient cannot describe the sensations. [9] Olfactory hallucinations often seem indescribable to patients beyond "pleasant" or "unpleasant". [10] Focal aware seizures are often called " auras " when they serve as a warning sign of a subsequent[en.wikipedia.org]
  • 60% of patients reoperated in the ipsilateral temporal lobe for persistent seizures became seizure free.[ncbi.nlm.nih.gov]
  • Seizure frequency and lateralization are 2 important clinical factors that characterize epileptic seizures.[ncbi.nlm.nih.gov]
  • Instead of focal seizures, prolonged absence seizures were validated by video-EEG monitoring and she became seizure-free after a change to broad-spectrum antiepileptic drugs.[ncbi.nlm.nih.gov]
  • Anticonvulsive medication previously controlled secondary generalized seizures over a period of years but focal seizures continued at a lower rate.[ncbi.nlm.nih.gov]
  • The phase-amplitude coupling strength (modulation index) increased significantly in the mid-seizure epoch and decrease significantly in seizure termination and post-seizure epochs (p 0.001).[ncbi.nlm.nih.gov]
  • The uncommon, isolated psychic symptoms associated with it suggests that ADLTE encompasses a wider range of auras of temporal origin than hitherto reported.[ncbi.nlm.nih.gov]
  • Neocortical temporal lobe epilepsy (NTLE) comprises a heterogeneous group of epilepsies with focal seizures characterized by auditory, somatosensory, or psychic auras followed by motionless staring, early contralateral clonic activity often secondarily[ncbi.nlm.nih.gov]
  • Auras are variable in symptomatology, and include: viscerosensory aura typically from lesions of the amygdala or insular cortex psychic (experienced) aura typically from limbic structures variable including dysmnesic phenomena, cognoscitive phenomena,[radiopaedia.org]
  • We reviewed at least three seizures from each patient and analyzed the following clinical data: presence of aura, duration of aura, ictal and post-ictal period, clinical semiology of aura, ictal and post-ictal period.[ncbi.nlm.nih.gov]
  • Our findings demonstrate the diagnostic value of a nonvisual fMRI task to lateralize MTLE despite congenital blindness and may therefore contribute to the risk assessment for postsurgical amnesia in rare cases with refractory MTLE and accompanying congenital[ncbi.nlm.nih.gov]
  • One of the patients received the diagnosis of transient epileptic amnesia (TEA). All patients underwent a standardized clinical protocol for diagnosis including a comprehensive neuropsychological assessment.[ncbi.nlm.nih.gov]
  • The second patient showed a sudden fearful expression, followed by oral automatisms, staring, and amnesia for the event. Both patients had left mesial temporal lobe epilepsy.[ncbi.nlm.nih.gov]
  • Multiple habitual events were recorded for each patient, characterized by staring, oral automatisms and amnesia. In addition, partial preservation of responsiveness and speech were seen during seizures in all three patients.[ncbi.nlm.nih.gov]
  • Accelerated long-term forgetting (ALF) refers to a slowly developing anterograde amnesia in which material is retained normally over short delays but then forgotten at an abnormally fast rate over days to weeks.[ncbi.nlm.nih.gov]
Jamais Vu
  • Symptoms Hallucinations: hearing of sounds, vertigo, visual hallucinations and illusions, déjà vu, jamais vu Motor seizures: hand automatisms, grimacing, clonic movements in the face, arm posturing, vocalizations, whole body rotation, speech disturbance[doctorstrizhak.com]
  • They can also be characterised by irritating senses of smell or taste, autonomic symptoms (flushing, sweating, changes of heart rate), emotional changes (rising fear or anxiety, anger, depression, euphoria) or memory symptoms (déjà vu or jamais vu – a[epilepsyqueensland.com.au]
  • Psychic phenomena: Feeling of déjà vu (familiarity) or jamais vu (unfamiliarity). Depersonalisation (ie feeling of detachment from oneself) or derealisation (surroundings appear unreal). Fear or anxiety.[patient.info]
  • As I reached the top step, I suddenly became aware of an intense jamais-vu … I had stepped up into a parallel universe, vaguely familiar but with something terribly wrong about it.[assap.ac.uk]
Deja Vu
  • vu (a sense of familiarity) or recalled memories or emotions A sudden, intense emotion not related to anything happening at the time During the seizure, a person may experience motor disturbances, sensory symptoms, or autonomic symptoms.[webmd.com]
  • While mesial temporal lobe epilepsy can be associated with olfactory hallucinations, deja vu and epigastric auras, temporal lobe seizures arising from the lateral cortex rather than the hippocampus may present with auditory hallucinations as the initial[epilepsygenetics.net]
  • vu extreme happiness a rising sensation in the abdomen anxiety These early signs are called auras or warnings, and they may last for a few seconds up to a few minutes before the seizure occurs.[healthline.com]


The initial diagnosis of epilepsy can be made based on clinical criteria, whereas a confirmation of TLE can be made through the following methods [2] [13]:

  • Imaging studies - MRI is considered as a very good first-line imaging procedure that identifies hippocampal atrophy with great specificity [2]. Additional studies include positron emission tomography (PET) and single photon emission computed tomography (SPECT), methods that are valuable in detecting extra-temporal sources of excitatory signals, especially in patients in whom MRI findings are inconclusive, or in those who already had surgery [3]. The role of SPECT is not as significant unless it is performed during an attack [3]. MRI spectroscopy has also been listed as one of the possible methods, due to its even higher specificity.
  • EEG - Evaluation of brain signaling, in combination with imaging studies, is considered as the optimal diagnostic approach in patients suffering from epilepsy of any type. Both invasive and noninvasive EEG studies may be performed, but video EEG is recommended in all patients [5]. Invasive methods include intracranial depth electrodes and subdural grids (also known as iEEG), whereas epidural, scalp and foramen ovale electrodes are non-invasive forms of EEG [3]. In addition to evaluating brain signals at the location where imaging studies have determined the presumable focus, a thorough evaluation of the entire brain should be conducted, as bilateral changes may be observed, which may substantially complicate treatment.
Seizure Activity
  • However, intracranial EEG data and [(18)F] FDG-PET suggested that these symptoms were related to seizure activity, highlighting the difficulties in differentiating ictal symptoms from psychiatric episodes in some patients with epilepsy and comorbid psychiatric[ncbi.nlm.nih.gov]
  • Video/EEG monitoring showed no evidence of ongoing seizure activity. She was treated with high-dose benzodiazepines for presumed catatonia, but the behavioral pattern did not resolve.[ncbi.nlm.nih.gov]
  • This latter observation has led some in the field to speculate that sustained seizure activity is driven by reverberating activity of these local circuits within the dentate gyrus.[sites.google.com]
  • Because of the dangers inherent in the surgery, this mode of therapy is reserved for those patients who do not respond to medical management and in whom the focus of seizure activity is accessible.[medical-dictionary.thefreedictionary.com]
  • In turn, these toxins may act as a trigger for seizure activity. Eat plenty of fiber by including fiber-rich fruits and vegetables in your diet. You should also stay hydrated in order to maintain good bowel health. 3 Stop smoking.[wikihow.com]
Epileptiform Activity
  • However, little is currently known about the modulation of these networks by epileptiform activity, such as interictal spikes and seizures.[ncbi.nlm.nih.gov]
  • Neurophysiologic findings in NTLE are typically a predominance of lateral temporal interictal epileptiform activity (IEA) and an ictal onset pattern consisting of irregular, hemispheric delta slowing.[ncbi.nlm.nih.gov]
  • These observations have led to the development of innovative assessment techniques, and prompted a new domain of investigation focused on the relationships between interictal epileptiform activities and the integrity of anatomo-functional systems.[ncbi.nlm.nih.gov]
  • Our study focused on lateralization and extent of epileptiform activity regarding postoperative seizure persistence and the effect of reoperation. This study comprises 426 consecutive patients operated for intractable mTLE.[ncbi.nlm.nih.gov]
  • However, these methods lack the spatiotemporal resolution to allow precise localization of epileptiform activity.[ncbi.nlm.nih.gov]
Temporal Epileptiform Discharges
  • The electroencephalogram ( EEG ) of mesial TLE contains interictal features often associated with anterior temporal epileptiform discharges with a maximal voltage over the basal temporal electrodes.[journals.lww.com]
  • The particular sensitivity of the anterior hippocampus (probably the amygdala) to hypocapnia might be an important factor contributing to seizures.[ncbi.nlm.nih.gov]
Sinus Arrest
  • We report a case of a previously healthy man presenting with syncope in whom telemetry revealed sinus arrest.[ncbi.nlm.nih.gov]


Temporal lobe epilepsy is not responsive to pharmacotherapy, which shifts the focus of management to surgery. The goal is to completely excise and remove the zone in which the epileptic signal originates [3], and procedures such as anterior temporal lobectomy (ATL) or selective amygdalohippocampectomy (SAH) are indicated [10]. With successfully resected regions, many patients become seizure-free, but a small percentage is left with some form of disability, as neurosurgery carries a minor, but significant risk of brain injury. For resection to be complete and successful, a thorough preoperative assessment guided by EEG and imaging studies is detrimental [13]. In the case of bilateral hippocampal involvement, the risks and benefits of surgery should be discussed.


The prognosis of patients with successful surgical therapy is very good [10], and marked reduction or even disappearance of seizure activity can be achieved. The diagnosis of TLE, however, is often delayed for a considerable amount of time, which correlates with a poorer prognosis. TLE is practically nonresponsive to pharmacological therapy and precious time is often used on attempting to find the appropriate antiepileptic regimen. In fact, studies have identified that it takes up to 9 or even 10 years for surgical therapy to be instated [6], while some reports suggest that more than 20 years elapse prior to confirming TLE [6]. The importance of choosing the optimal surgical approach also has important prognostic factors in long-term management of patients, due to the fact that neurosurgical procedures are quite sensitive and may result in further damage. For these reasons, a careful and detailed pre-operative assessment through imaging modalities and EEG is necessary.


Although the exact cause of epilepsy in general remains incompletely understood, the principal source of aberrant signaling in the case of TLE is the hippocampus [7], which undergoes sclerosis, atrophy and neuronal loss, with similar effects seen in the amygdala and parahippocampal gyri. As a result, diffuse pathological changes are observed in the morphology and structure [8]. TLE has shown to be strongly associated with several conditions [3] [9]:

  • Cortical dysplasia, a congenital condition that is also a recognized cause of epilepsy, has shown to be present in up to 20% of patients suffering from TLE.
  • Various brain tumors, including astrocytomas, gangliomas, oligodendrogliomas and neuroepithelial tumors have been diagnosed in up to 60% of patients undergoing brain surgery.
  • Vascular changes, such as cavernous hemangiomas and arteriovenous malformation are also brought into connection with TLE, although the exact mechanism remains unknown.
  • Several forms of brain trauma are considered as potential triggers of epilepsy. Namely, trauma that results in loss of consciousness for more than 30 minutes, causes penetrating injuries or linear skull fractures, but also scarring that is visible on MRI are able to provoke excitatory signaling from the temporal lobe [3].

In addition to these conditions, a hypothesis that some previous condition in early childhood triggered the pathological sequence has been suggested as well. Febrile seizures, birth injuries and status epilepticus have shown to be present in a substantial amount of patients who developed TLE, suggesting that other factors may also play a role in etiology [8].


Global estimations suggest that the prevalence of all forms of epilepsy combined reach up to 1% of the population [6], with significant variations across the world. In developed countries, prevalence rates are approximately 1 per 1000 individuals, whereas developing countries have shown rates of up to 50 per 1000 individuals [1]. In general, epilepsy is most frequently encountered in young children and the elderly [1], but early childhood and adolescence is considered to be the principal age of onset [9]. TLE is the most common form of partial seizures, which comprise almost 60% of all cases of epilepsy, with estimations that of 1,200,000 Americans who suffer from epilepsy, 400,000 are affected by TLE [5]. Exact prevalence and incidence rates of TLE, however, are unknown at this moment [1]. In addition to diseases that are mentioned as potential causes of TLE, such as cortical dysplasia, tumors and vascular malformations [3], febrile seizures during infancy and birth injuries have also been identified as potential risk factors for later development of TLE [8].

Sex distribution
Age distribution


The most common and most important pathological finding in patients with TLE is atrophy and sclerosis of the hippocampus [2], one of the constitutive parts of the mesial temporal lobe, together with the amygdala, uncus, parahippocampal and dentate gyri. Presumably, hippocampal sclerosis and atrophy are a result of neuronal loss that occurs in the temporal lobe and cause disruption of signaling, causing enhanced excitation and hypersynchronnous discharge of neurons in that area that eventually lead to epilepsy [7]. In addition, various pathophysiological processes have been described - loss of interneurons, impaired neurogenesis and mossy fiber sprouting (branching of additional neurons) [8]. The exact mechanism of epilepsy, however, is still not completely understood.


Current prevention strategies do not exist, as the exact pathophysiological mechanism of TLE remains unknown. Given the fact that recent evidence about the involvement of inflammatory changes in seizures have been published, anti-inflammatory drugs, but also growth hormone secretagogues have been proposed as potentially preventing agents [8]. Further studies, however, need to be conducted in order to determine the exact role of inflammation and other pathophysiological events in the development of TLE.


Partial-onset seizures comprise almost 60% of all epilepsies and temporal lobe epilepsy (TLE) is the most common form of partial seizures worldwide [1]. Of approximately 1,200,000 people suffering from partial seizures in the United States, TLE is the cause in more than 400,000, indicating its importance in clinical practice [2]. Theories regarding its etiology are numerous, but various studies have established that in up to a third of patients, some preexisting condition is thought to be the trigger for abnormal excitatory signaling in the mesial temporal lobe [3] [4]. Tumors, cortical dysplasia, vascular malformations, head trauma and encephalomalacia have all been discovered in a significant amount of patients who developed TLS [3]. Hence, these conditions present as significant risk factors for its appearance, but the exact pathophysiological mechanisms remain to be fully disclosed. The principal pathological findings are hippocampal sclerosis, neuronal damage and atrophy, which leaves a detrimental effect on various processes, including memory, cognition and motor function [2]. Additional structures that constitute the mesial temporal lobe - the amygdala, uncus, dentate gyrus and parahippocampal gyrus, have all shown similar pathological degradation and are also considered as potential sources of epileptic signaling [2]. The clinical presentation somewhat varies across different age groups (partly due to a varying etiology between the pediatric, adolescent and adult population), but universally includes partial seizures and the presence of auras (olfactory, epigastric or gustatory sensations). Memory and attention impairments, as well as reduced speed of mental function, mood changes and emotional abnormalities appear at some point and can be severely debilitating [5]. The initial diagnosis of epilepsy is made based on clinical findings, but imaging and electroencephalographic (EEG) studies are necessary to identify the exact origin of aberrant signals. Magnetic resonance imaging (MRI) is an effective diagnostic method, whereas single photon emission computed tomography (SPECT) and positron emission tomography (PET) may be considered when MRI findings are inconclusive [3]. Both invasive and noninvasive EEG studies, including video EEG are equally necessary as imaging studies and the combination of findings is imperative in determining the exact site of epileptic signals [4]. Because TLE is resistant to antiepileptic drugs (AEDs) in virtually all cases, a surgical approach as early as possible is advocated to assure a good quality of life and reduce functional impairment [6]. With either complete resection or removal of the structures in the mesial temporal lobe, much better outcomes have been encountered [6], which is why a prompt definite diagnosis by using all available tools and surgery can significantly reduce the burden of this condition in daily life.

Patient Information

Epilepsy is considered to be a major issue in clinical practice, as estimates suggest that 1% of the world population suffers from any of the recognized forms. Temporal lobe epilepsy (TLE) one of the most common causes, with more than 400,000 people who live in the United States are presumed to suffer from TLE. This form of epilepsy is established to be one of the most severe, since it does not respond to antiepileptic drugs and requires other therapeutic modalities. The exact cause of TLE remains to be discovered, but in up to 30% of patients, an accompanying structural abnormality such as brain tumors or cortical dysplasia has been identified. Studies have observed loss of neuronal function and atrophy of the hippocampus, one of the most important parts of the brain when it comes to memory, whereas the amygdala (principally responsible for emotions such as fear) may be affected as well. TLE may appear at any age, but it's onset is primarily seen in young children. The first and most important symptom is seizures that involve only one brain hemisphere (partial seizures) and the arrest of motor activity with a blank stare during the onset of seizures. They may be followed or preceded by auras (strange sensations in the stomach, deja-vu or visual and auditory hallucinations), together with various neurological complaints. Patients with TLE may suffer from memory loss, inability to perform daily functions, language difficulties and severe cognitive disability. The diagnosis is made through the use of imaging studies such as magnetic resonance imaging (MRI) and positron emission tomography (PET scan), together with eletroencephalography (EEG). These methods are used to visualize and map the exact location where abnormal signaling occurs, which is necessary for treatment. In the case of TLE, surgery is the recommended therapeutic method. In general, removal of parts of the brain that are determined to be the source of epileptic signals is necessary and early surgery has shown drastic success in reducing or completely abolishing the appearance of seizures. Despite the advantages of surgery, the diagnosis is delayed in many patients due to attempts to handle seizures with antiepileptic drugs, which is why a detailed diagnostic workup is essential.



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Last updated: 2018-06-22 01:03