Temporal lobe, delineated above (dorsally) by a lateral
sulcus (sylvian fissure)
Occurs only in primates and is largest in...
The medial side with olfaction (the
uncus and nearby cortex)
semantic memory (the hippocampal
formation)
The nearby amygda...
Auditory areas
Brodmann’s
areas 41,42, and
22
Ventral Stream of
Visual Information -
Inferotemporal
cortex or TE
Brodmann’...
Hippocampal Formation
The components of the hippocampal formation are the hippocampus, an
enrolled gyrus adjacent to the p...
Amygdala
Amygdala located in the medial part of the temporal pole, anterior
to and partly overlapping the hippocampal head...
White Matter
Subcortical white matter comprises three populations of axons.
Association fibres connect cortical areas with...
Commissural fibres connect mainly but not exclusively symmetrical
cortical areas.
Largest group of commissural fibres is t...
Temporal Lobe Function
Processing auditory input
sends ventral and dorsal streams (object
identification and for movement ...
Sensory Processes
Identification and Categorization of
Stimuli
Cross-Modal Matching
Process of matching visual and
auditor...
Special face
processing pathway
Faces
Asymmetry of Temporal Lobe Function
Left temporal lobe
Verbal memory
Speech processing
Right temporal lobe
Nonverbal memor...
Symptoms of Temporal-Lobe Lesions
Clinical Neuropsychological Assessment of Temporal-
Lobe DamageTests do not assess all possible temporal-
lobe symptoms
Arterial Blood Supply and Venous Drainage
The temporal lobe receives blood from both the carotid and the
vertebrobasilar s...
The venous drainage of the temporal cortex
Into the superficial middle cerebral vein and also into the inferior
anastomoti...
Bilateral temporal lobe hyperintensity
Infective diseases (herpes simplex virus, congenital cytomegalovirus
infection)
Epi...
Diagnosis (n)
Percentage of total cases
(n=65)
Age or age range (years) Sex distribution
Infective diseases
Herpes encepha...
Bilateral temporal lobe hyperintensity Advanced MRI findings
S. no. Diagnosis
Clinical
features
Lobe GM WM Additional MRI ...
The clinical features, location and distribution of temporal lobe
hyperintensity, additional and advanced MRI findings wit...
8 CADASIL
Migraine,
hemisensory
loss
A, M − +
Lacunar infarcts,
subcortical WM,
external capsule and
insula
− − ND −
Non-
...
A 34-year-old male with herpes encephalitis. (a) Coronal T2weighted image shows
bilateral symmetric cortical swelling and ...
A 46-year-old male with herpes encephalitis. (a) Axial susceptibility-weighted image
demonstrates haemorrhages (black arro...
An 11-year-old female with cytomegalovirus infection. (a) Axial fluid-attenuated
inversion-recovery image shows bilateral ...
A 17-year-old male with complex partial seizure. (a) Oblique coronal fluid-attenuated
inversion-recovery image reveals bil...
A 64-year-old male with memory loss and personality changes. (a) Axial fluid-attenuated
inversion-recovery image shows hyp...
A 64-year-old female with frontotemporal dementia. (a) AxialT2 weighted image
shows hyperintensity with volume loss in bil...
A 34-year-old male with myotonic dystrophy Type 1. (a) Axial fluid-attenuated
inversion-recovery image shows bilateral ant...
A 61-year-old male with gliomatosis cerebri. (a) Axial T2weighted image
demonstrates cortical expansion and hyperintensity...
A 17-year-old male with mitochondrial encephalopathy, lactic acidosis and stroke-like
episodes (MELAS). (a) Axial fluid-at...
A 61-year-old female with hyperammonemic encephalopathy. Axial fluid-attenuated
inversion-recovery images show (a) bilater...
A 10-year-old male with Wilson's disease. (a) Axial T2weighted and (b) fluid-
attenuated inversion-recovery images demonst...
A 22-year-old male with megalencephalic leukoencephalopathy with subcortical cysts.
(a) Axial fluid-attenuated inversion-r...
A 35-year-old female with cerebral autosomal dominant arteriopathy with subcortical
infarcts and leukoencephalopathy. (a) ...
A 26-year-old male with paraneoplastic limbic encephalitis presenting with
progressive memory disturbance. (a) Initial cor...
Temporal and frontal lobe seizures differential semiological features.
Features Temporal Frontal
Sz frequancy Less frequen...
Feature Location
Automatism
Unilateral limb automatism Ipsilateral focus
Oral automatism (m)Temporal lobe
Unilateral eye b...
Autonomic
Ictal emeticus Temporal lobe focus (R)
Ictal urinary urge Temporal lobe focus (R)
Piloerection Temporal lobe foc...
Motor
Early nonforced head turn Ipsilateral focus
Late version Contralateral focus
Eye deviation Contralateral focus
Focal...
Approach to temporal lobe
Approach to temporal lobe
Approach to temporal lobe
Approach to temporal lobe
Approach to temporal lobe
Approach to temporal lobe
Approach to temporal lobe
Approach to temporal lobe
Approach to temporal lobe
Approach to temporal lobe
Approach to temporal lobe
Approach to temporal lobe
Approach to temporal lobe
Approach to temporal lobe
Approach to temporal lobe
Approach to temporal lobe
Approach to temporal lobe
Approach to temporal lobe
Approach to temporal lobe
Approach to temporal lobe
Approach to temporal lobe
Approach to temporal lobe
Approach to temporal lobe
Approach to temporal lobe
Approach to temporal lobe
Approach to temporal lobe
Approach to temporal lobe
Approach to temporal lobe
Approach to temporal lobe
Approach to temporal lobe
Approach to temporal lobe
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Approach to temporal lobe

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approach to temporal and limbic system brain lobe anatomy and function

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Approach to temporal lobe

  1. 1. Temporal lobe, delineated above (dorsally) by a lateral sulcus (sylvian fissure) Occurs only in primates and is largest in man Approximately 17% of the volume of the human cerebral cortex, 16% in the right and 17% in the left hemisphere Temporal cortex includes auditory, olfactory, vestibular, and visual senses Perception of spoken and written language. Addition to cortex, the temporal lobe contains white matter, part of the lateral ventricle, the tail of the caudate nucleus, the stria terminalis, the hippocampal formation, and the amygdala.
  2. 2. The medial side with olfaction (the uncus and nearby cortex) semantic memory (the hippocampal formation) The nearby amygdala generates responses to perceived sensory stimuli that have been partly analyzed elsewhere in the brain. Such responses include largely involuntary ones, mediated by the autonomic and somatic motor systems, and mental functions, especially those called feelings or emotions, that motivate decision and voluntary action
  3. 3. Auditory areas Brodmann’s areas 41,42, and 22 Ventral Stream of Visual Information - Inferotemporal cortex or TE Brodmann’s areas 20, 21,37, and 38
  4. 4. Hippocampal Formation The components of the hippocampal formation are the hippocampus, an enrolled gyrus adjacent to the parahippocampal gyrus Dentate gyrus, which represents the free edge of the pallium, and the associated white matter, the alveus, fimbria, and fornix. The cortex adjacent to the hippocampus is known as the entorhinal area; it is present along the whole length of the parahippocampal gyrus The hippocampal formation has indirect afferent connections from the whole of the cerebral cortex, funneled through the adjacent temporal cortex and the subiculum
  5. 5. Amygdala Amygdala located in the medial part of the temporal pole, anterior to and partly overlapping the hippocampal head Its receives fibres of the olfactory tract Two named gyri of the anterior end of the uncus, the ambient and semilunar gyri consist of periamygdaloid cortex that receives fibres from the olfactory tract The larger lateral part of the amygdala, like the hippocampal formation, receives direct and indirect input from most of the cerebral cortex
  6. 6. White Matter Subcortical white matter comprises three populations of axons. Association fibres connect cortical areas within the same cerebral hemisphere. The largest bundle is the arcuate fasciculus, whose anterior end is in the frontal lobe. Its above the insula and lentiform nucleus, two-way communication between frontal cortex, including Broca’s expressive speech area, and Wernicke’s receptive language area in the posterior part of the superior temporal gyrus. The condition of conduction aphasia is traditionally attributed to a destructive lesion that interrupts the arcuate fasciculus Another frontotemporal association bundle is the uncinate fasciculus hook like shape Visual association cortex extends from the occipital lobe to the middle and inferior temporal and fusiform gyri. The fornix and stria terminalis
  7. 7. Commissural fibres connect mainly but not exclusively symmetrical cortical areas. Largest group of commissural fibres is the corpus callosum. Projection fibres connect cortical areas with subcortical nuclei of grey matter. Its fibres afferent to the temporal cortex include medial geniculate body to the primary auditory area which is connected with the amygdala, hypothalamus, hippocampal formation, and parahippocampal gyrus Important thalamocortical pathway that passes through the temporal lobe is Meyer’s loop of the geniculocalcarine tract This loop carries signals derived from the upper quadrants of the contralateral visual fields to the corresponding primary visual cortex of the anterior half of the inferior bank of the calcarine sulcus.
  8. 8. Temporal Lobe Function Processing auditory input sends ventral and dorsal streams (object identification and for movement planning) Visual object recognition Ventral visual stream Biological motion perception Superior Temporal Sulcus Long-term storage of information Memory (limbic system, hippocampus)
  9. 9. Sensory Processes Identification and Categorization of Stimuli Cross-Modal Matching Process of matching visual and auditory information Affective Responses Emotional response is associated with a particular stimulus Spatial Navigation Hippocampus – Spatial Memory Temporal Lobe Function
  10. 10. Special face processing pathway Faces
  11. 11. Asymmetry of Temporal Lobe Function Left temporal lobe Verbal memory Speech processing Right temporal lobe Nonverbal memory Musical processing Facial processing
  12. 12. Symptoms of Temporal-Lobe Lesions
  13. 13. Clinical Neuropsychological Assessment of Temporal- Lobe DamageTests do not assess all possible temporal- lobe symptoms
  14. 14. Arterial Blood Supply and Venous Drainage The temporal lobe receives blood from both the carotid and the vertebrobasilar systems. Anterior choroidal artery are the anterior end of the parahippocampal gyrus, the uncus, the amygdala, and the choroid plexus in the temporal horn of the lateral ventricle Middle cerebral artery giving off branches that supply the cortex of the superior and middle temporal gyri and the temporal pole. Posterior cerebral artery gives off two to four temporal branches, before it divides into the calcarine and parieto-occipital arteries, which supply the occipital lobe. The temporal branches of the posterior cerebral artery supply the inferior surface of most of the temporal lobe, but not the temporal pole.
  15. 15. The venous drainage of the temporal cortex Into the superficial middle cerebral vein and also into the inferior anastomotic vein (vein of Labbé) superficial middle cerebral vein with the transverse sinus Blood from interior of the lobe, including the amygdala, hippocampus, and fornix, flows into the posterior choroidal vein. The left and right internal cerebral veins joined by the basal veins and unite to form the great cerebral vein, a midline structure that continues into the straight sinus. The basal vein (vein of Rosenthal), which carries blood from the cortex and the interior of the frontal lobe, traverses the subarachnoid space in the cisterna ambiens, medial to the temporal lobe.
  16. 16. Bilateral temporal lobe hyperintensity Infective diseases (herpes simplex virus, congenital cytomegalovirus infection) Epileptic syndrome (mesial temporal sclerosis) Neurodegenerative disorders (Alzheimer's disease, frontotemporal dementia, Type 1 myotonic dystrophy) Neoplastic conditions (gliomatosis cerebri) Metabolic disorders (mitochondrial encephalopathy, lactic acidosis and stroke-like episodes, Wilson's disease, hyperammonemia) Dysmyelinating disease (megalencephalic leukoencephalopathy with subcortical cysts) Vascular (cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy) Paraneoplastic (limbic encephalitis) disorders.
  17. 17. Diagnosis (n) Percentage of total cases (n=65) Age or age range (years) Sex distribution Infective diseases Herpes encephalitis (15) 23 34–55 10M, 5F Congenital CMV infection (2) 3 8–11 1M, 1F Epileptic syndrome Mesial temporal sclerosis (10) 15.3 8–27 6M, 4F Neurodegenerative Alzheimer's disease (7) 10.7 58–65 5M, 2F Frontotemporal dementia (2) 3 61–64 2F Myotonic dystrophy (1) 1.5 27 1M Neoplastic Gliomatosis cerebri (9) 13.8 33–64 6M, 3F Metabolic MELAS (7) 10.7 10–22 5M, 2F Wilson's disease (1) 1.5 10 1M Hyperammonemia (1) 1.5 61 1F Dysmyelinating disease MLC (6) 9.2 6–20 5M, 1F Vascular CADASIL (2) 3 31–35 1M, 1F Paraneoplastic disorder Limbic encephalitis (2) 3 25–32 2M CADASIL, cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy; CMV, cytomegalovirus; F, female; M, male; MELAS, mitochondrial encephalopathy, lactic acidosis and stroke-like episodes; MLC, megalencephalic leukoencephalopathy with subcortical cysts.
  18. 18. Bilateral temporal lobe hyperintensity Advanced MRI findings S. no. Diagnosis Clinical features Lobe GM WM Additional MRI findings DWI SWI MRS Gd-enhancement Laboratory result 1 Herpes encephalitis Fever, seizure, altered sensorium A, M + − Orbital gyri involvement, gyriform haemorrhages R + ND Gyriform HSV antibodies in CSF 2 Mesial temporal sclerosis Complex partial seizure M + + Hippocampal, mamillary body, fornix and collateral WM atrophy − − ND ND Temporal lobe localisation on EEG 3 Gliomatosis cerebri Headache, recurrent seizures A, M + + Expansion of parenchyma, multilobar involvement − − ↑ML Absent / patchy Non- contributory 4 MELAS Episodes of LOC, seizure P, M + + Fleeting hyperintensity, basal ganglia involvement R − ↑lac Patchy ↑Serum and CSF lactate 5 Alzheimer's disease Personality changes, memory loss A, M − + Hippocampal atrophy, enlarged parahippocampal fissures − − ↑ML − Non-contributory 6 MLC Development al delay, seizure Whole − + Temporal lobe cysts, subcortical WM, external capsule − − ↓NAA ↑cho − Non-contributory 7 Congenital CMV Seizure P − + Periventricular cysts, pachygyria-agyria complex − − ND − Non-contributory
  19. 19. The clinical features, location and distribution of temporal lobe hyperintensity, additional and advanced MRI findings with relevant laboratory results ↓, decreased; ↑, elevated; −, negative; +, positive; A, anterior; CADASIL, cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy; Cho, choline; CMV, cytomegalovirus; CPS, complex partial seizure; CSF, cerebrospinal fluid; DWI, diffusion-weighted imaging; EC, external capsule; EEG, electroencephalogram; Gd, gadolinium; GM, grey matter; HSV, herpes simplex virus; L, lateral; Lac, lactate; LOC, loss of consciousness; M, medial; MELAS, mitochondrial encephalopathy, lactic acidosis and stroke-like episodes; ML, myoinositol; MLC, megalencephalic leukoencephalopathy with subcortical cysts; MRS, MR spectroscopy; NA, not applicable; NAA, N-acetylaspartate; ND, not done; P, posterior; R, restriction; S. no., serial number; SWI, susceptibility- weighted imaging; WM, white matter; VR, Virchow–Robin spaces.
  20. 20. 8 CADASIL Migraine, hemisensory loss A, M − + Lacunar infarcts, subcortical WM, external capsule and insula − − ND − Non- contributory 9 Frontotemporal dementia Dementia A,M − + Fronto-temporal atrophy − − ↓NAA ↑cho − Non- contributory 10 Limbic encephalitis Memory disturbance M + − Cingulate gyrus, subfrontal cortex and inferior frontal WM − − ND − Pleocytosis, lymphoma antibodies in CSF 11 Hyperammonemia Confusion, altered sensorium A + − Posterior cingulate gyrus R − ND ND ↑Blood ammonia 12 Wilson's disease Weakness, extrapyrami dal symptoms A, P, L + + Fronto-parietal lobes, dorsal midbrain, deep grey nuclei R − ND − ↑Serum and urine copper, ↓ceruloplasmin 13 Myotonic dystrophy Development al delay, facial and distal limb weakness A − + Periventricular and deep WM, prominent VR spaces − − ND ND Myotonic discharges in electromyograph y
  21. 21. A 34-year-old male with herpes encephalitis. (a) Coronal T2weighted image shows bilateral symmetric cortical swelling and hyperintensity involving the anteromedial temporal lobes including the insular cortex (white arrows) with characteristic sparing of basal ganglia (open arrows). (b) AxialT2 weighted image shows additional involvement of orbital gyri (black arrows). (c) Axial diffusion-weighted image depicts restricted diffusion in the involved areas (white arrows).
  22. 22. A 46-year-old male with herpes encephalitis. (a) Axial susceptibility-weighted image demonstrates haemorrhages (black arrows) in both temporal lobes. (b) Axial T1weighted post-gadolinium image shows gyriform enhancement (white arrows) in the involved temporal lobes.
  23. 23. An 11-year-old female with cytomegalovirus infection. (a) Axial fluid-attenuated inversion-recovery image shows bilateral periventricular cysts with gliosis of white matter (white arrows) in both temporal lobes. (b) Axial T2weighted image demonstrates gyral abnormality in the form of pachygyria–agyria complex (open arrows) bilaterally involving the temporo-occipital lobes in addition to the periventricular cysts (white arrows). Combination of these imaging findings along with periventricular calcifications are in favour of congenital cytomegalovirus infection
  24. 24. A 17-year-old male with complex partial seizure. (a) Oblique coronal fluid-attenuated inversion-recovery image reveals bilateral hippocampal atrophy, hyperintensity indicating gliosis (white arrows) with loss of internal architecture consistent with a diagnosis of bilateral mesial temporal sclerosis. (b) Oblique coronalT1 weighted image demonstrates bilateral mamillary body atrophy (white arrows).
  25. 25. A 64-year-old male with memory loss and personality changes. (a) Axial fluid-attenuated inversion-recovery image shows hyperintensity in both anteromedial temporal lobes (white arrows). (b) Axial T2weighted and (c) coronal T1weighted images depict marked atrophy of temporal lobes with preferential volume loss of hippocampi and parahippocampi gyri and corresponding enlargement of parahippocampal fissures including choroidal (downwards arrows on c) and hippocampal fissures (black arrows), and temporal horns (white arrow). Temporal lobe hyperintensity indicates non-specific gliosis because of marked atrophy; however, the selective mesial temporal atrophy with enlarged parahippocampal fissures are diagnostic of Alzheimer's disease.
  26. 26. A 64-year-old female with frontotemporal dementia. (a) AxialT2 weighted image shows hyperintensity with volume loss in bilateral temporal lobes (black arrows). (b) Axial fluid-attenuated inversion-recovery image demonstrates predominate volume loss in both frontal and temporal lobes with associated increased signal in white matter indicating underlying gliosis (white arrows)
  27. 27. A 34-year-old male with myotonic dystrophy Type 1. (a) Axial fluid-attenuated inversion-recovery image shows bilateral anterior temporal white matter hyperintensity (black arrows). (b) Coronal T2weighted image shows hyperintensity in periventricular white matter (white arrow) and prominent perivascular spaces (open arrows) disproportionate to the age.
  28. 28. A 61-year-old male with gliomatosis cerebri. (a) Axial T2weighted image demonstrates cortical expansion and hyperintensity (white arrows) in both medial temporal lobes. (b) Axial T2 weighted image shows multifocal brain parenchymal involvement with expansion and relative preservation of architecture. Involvement of frontotemporal lobes (white arrows), basal ganglia (open arrows) and thalami (black arrows) are seen. (c) MR spectroscopy shows markedly elevated myoinositol peak at 3.45 parts per million.
  29. 29. A 17-year-old male with mitochondrial encephalopathy, lactic acidosis and stroke-like episodes (MELAS). (a) Axial fluid-attenuated inversion-recovery (FLAIR) image shows bilateral asymmetric cortical and subcortical temporal lobe hyperintensity (white arrows), right more than the left and (b) axial FLAIR image 4 months later shows resolution of previous hyperintensity and new area of involvement on left side (white arrow) indicating the fleeting nature of the lesions. (c) MR spectroscopy demonstrates elevated lactate peak at 1.3 parts per million. These findings are consistent with a diagnosis of MELAS.
  30. 30. A 61-year-old female with hyperammonemic encephalopathy. Axial fluid-attenuated inversion-recovery images show (a) bilateral peripheral cortical temporal lobe (white arrows) and (b) right posterior cingulate gyrus (open arrow) hyperintensity. Diffusion- weighted images show corresponding restricted diffusion (white arrows) in (c) the bilateral peripheral cortical temporal lobe and (d) the right posterior cingulate gyrus. The typical distribution of lesions with elevated blood ammonia level suggests this diagnosis.
  31. 31. A 10-year-old male with Wilson's disease. (a) Axial T2weighted and (b) fluid- attenuated inversion-recovery images demonstrate bilateral extensive cortical and subcortical temporal lobe hyperintensity (white arrows), dorsal midbrain involvement (open arrow), bilateral symmetric basal ganglia (yellow arrows) and anterolateral thalamic (black arrows) hyperintensity. Extensive grey and white matter lesions are less frequently in Wilson's disease however concomitant basal ganglia, thalamic and dorsal brainstem abnormalities point to the diagnosis.
  32. 32. A 22-year-old male with megalencephalic leukoencephalopathy with subcortical cysts. (a) Axial fluid-attenuated inversion-recovery and (b) axial T2weighted images reveal bilateral anterior temporal lobe cysts (white arrows), deep (black arrow) and subcortical (open arrow) white matter hyperintensity. Temporal lobe cysts with extensive white matter lesions involving the deep and subcortical white matter, and external capsule with sparing of basal ganglia, thalami and internal capsules are typical for this subtype of van der Knaap leukoencephalopathy.
  33. 33. A 35-year-old female with cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy. (a) Axial T2weighted image shows confluent hyperintense lesions in both anterior temporal lobes (open arrows). (b) Axial fluid- attenuated inversion-recovery image shows patchy subcortical hyperintense areas (white arrows) and multiple lacunar infarcts (thin white arrow). (c) AxialT2 weighted image shows multiple patchy hyperintense areas involving the external capsule (open arrow), insular cortex (thin arrow) and basal ganglia (asterisk).
  34. 34. A 26-year-old male with paraneoplastic limbic encephalitis presenting with progressive memory disturbance. (a) Initial coronal T2weighted image demonstrates swelling and increase signal in both mesial temporal lobes (white arrows). (b) Follow-up coronal T2weighted image after 1 year shows significant decrease in the swelling and abnormal signal intensity (white arrows). (c) Axial contrast-enhanced CT section through the mid-abdomen shows ileocolic intussusception (black arrow) with marked concentric wall thickening of ascending colon (white arrows). Biopsy proven Burkitt's lymphoma of ascending colon is also shown.
  35. 35. Temporal and frontal lobe seizures differential semiological features. Features Temporal Frontal Sz frequancy Less frequent Often daily Sz onset Slower Abrupt, explosive Sleep activation Less common Characteristic Progression Slower Rapid Automatisms Common-longer Less common Initial motionless stare Common Less common Complex postures Late, less frequent, less prominent Frequent, prominent, and early Hypermotor Rare Common Bipedal automatisms Rare Characteristic Somatosensory Sx Rare Common Vocalization Speech (nondominant) Loud, nonspeech (grunt, scream, moan) Seizure duration Longer Brief Secondary generalization Less common Common Postictal confusion More prominent-longer Less prominent, Short Postictal aphasia Common in dominant hemisphere Rare unless spreads to temporal lobe
  36. 36. Feature Location Automatism Unilateral limb automatism Ipsilateral focus Oral automatism (m)Temporal lobe Unilateral eye blinks Ipsilateral to focus Postictal cough Temporal lobe Postictal nose wiping Ipsilateral temporal lobe Ictal spitting or drinking Temporal lobe focus (R) Gelastic seizures (m)Temporal, hypothalamic, frontal (cingulate) Dacrystic seizures (m)Temporal, hypothalamic Unilateral limb automatisms Ipsilateral focus Whistling Temporal lobe Semiological Features (TLE) - Lateralizing or Localizing Value.
  37. 37. Autonomic Ictal emeticus Temporal lobe focus (R) Ictal urinary urge Temporal lobe focus (R) Piloerection Temporal lobe focus (L) Speech Ictal speech arrest Temporal lobe (usually dominant hemisphere) Ictal speech preservation Temporal lobe (usually nondominant) Postictal aphasia Temporal lobe (dominant hemisphere)
  38. 38. Motor Early nonforced head turn Ipsilateral focus Late version Contralateral focus Eye deviation Contralateral focus Focal clonic jerking Contralateral perirolandic focus Asymmetrical clonic ending Ipsilateral focus Fencing (M2E) Contralateral (supplementary motor) Figure  4 Contralateral to the extended limb (temporal) Tonic limb posturing Contralateral focus Dystonic limb posturing Contralateral focus Unilateral ictal paresis Contralateral focus Postictal Todd’s paresis Contralateral focus
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