Temporal lobe epilepsy is characterized by seizures originating in the temporal lobe. It is the most common localization-related epilepsy, accounting for around 60% of such cases. Mesial temporal lobe epilepsy is the most frequent form, often caused by hippocampal sclerosis. Auras are common and can include epigastric sensations, cephalic sensations, anxiety, hallucinations and more. Automatisms like lip smacking or gesturing often occur during seizures. Around 60% of temporal lobe epilepsy patients respond well to antiepileptic drug treatment, while the remaining 40% have drug-resistant epilepsy and may require surgery.

1. TEMPORAL LOBE EPILEPSY
Presenter-Dr.syed.zainab 1st yr pg
Moderator-Dr.Meghana 3rd yr pg
Department of psychiatry
Kmch,guntur

2. INTRODUCTION
• Epilepsy-a condition characterized by 2/more
recurrent epileptic seizures over a period longer
than 24hrs,unprovoked by any immediate
identified cause .
• Temporal lobe epilepsy (TLE)-condition
characterised by recurrent unprovoked seizures
originating from the antero medial aspect of
temporal lobe (hippocampus,parahippocampal
gyrus,Amygdala)

3. • It is the most common of the anatomically
defined syndromes, accounting for around
60% of all patients with localisation-related
epilepsy.
• They represent approximately two thirds of
the intractable seizure population
requiring surgical treatment

4. • TYPES OF TLE-
• MESIAL TEMPORAL LOBE EPILEPSY (Most
frequent)-most common form of partial
epilepsy in adolscent and adults
• Lateral or neocortical temporal epilepsy (NTE)-
teen age

5. Causes
• The most frequent cause of TLE is Hippocampal
sclerosis, also known as mesial temporal sclerosis or
Ammon’s horn sclerosis, accounting for 50–70% of
cases in temporal lobectomy series.
• Other causes of TLE include
1. dysembryoplastic
2. neuroepithelial tumours
3. cavernous angiomas
4. gliomas,
5. cortical dysplasia
6. gliosis secondary to encephalitis or meningitis.

6. • Temporal lobe seizures may take the form of simple and
complex partial seizures, with both occurring in some 70% of
Patients
• seizures, those arising in the temporal lobes characteristically
have a gradual onset, usually feature a conspicuous
motionless stare and are relatively prolonged, with
automatisms often continuing for 2 minutes, occasionally
even longer. A wide variety of auras occur in TLE and many are
highly characteristic.

7. Auras of temporal lobe epilepsy
• Aura are usually subjective symptoms without
objective signs
• Aura itself simple partial or focal aware seizure
• The epigastric aura is the most common, being
reported by up to 50% of patients with TLE.
• It consists of ill-defined sensations rising from the
epigastrium towards the throat, typically described
as churning, ‘butterflies’ or a feeling of nervousness.
• Also frequent are inexplicable odd sensations in the
head (cephalic aura),although these have less
specificity for TLE.

8. Auras of partial seizures.
Symptom Frequency in TLE Temporal Frontal Parietal Occipital
 Epigastric aura 30–53 +++ – – –
 Cephalic aura 23–30 ++ ++ – –
 Anxiety/fear 14–24 ++ + – –
 Hallucinations/illusions
 Visual 16–18 + – + +++
Elementary 5–7 + – + +++
Complex 3 ++ – ++ –
 Auditory 8–16 +++ – + –
Elementary 1–12 +++ – – –
Complex 3–4 +++ – – –
 Olfactory 8–12 +++ + – –
 Gustatory 3–11 +++ + – –
 Somatosensory 2–19 + ++ +++ –
 Dysmnesic/déjà vu 7–18 +++ – – –
 No aura 10–51

9. • Affective experiences are a feature of
approximately one-quarter of temporal lobe
auras.
• The most common is anxiety, which is often
intense (ictal fear) and wells up suddenly
without provocation.
• Ictal emotional experiences may be very
intense and tend to have a unique, though
often difficult-to-describe,

10. Cognitive abnormalities
• Cognitive abnormalities include -disturbances of
speech,memory and thought.
• Vocalisation is seen in approximately 50% of temporal
lobe seizures. It is usually non-verbal, in which case it
may be associated with either dominant or non-
dominant foci and has no lateralising value.
• However, speech automatisms (recurrent, irrelevant or
emotionally toned utterances), which can be thought
of as evidence of preserved speech during the seizure
discharge, are strongly related to a non-dominant
temporal lobe focus

11. • Disturbances of memory (dysmnestic aura) range
from sudden difficulty with recall to compulsive
reminiscence on topics, scenes or events from
the past.
The essential quality of recognition may change,
with strong feelings of familiarity or unfamiliarity
leading to déjà vu and jamais vu.
• Disorders of thought-thought blocking,forced
thinking,incoherent tqlk are are rare and less
specific for TLE

12. • Hallucinations of taste (gustatory) and smell
(olfactory) derive from medial temporal lobe
structures, particularly the amygdala, and are of
considerable signifi ance for the diagnosis of TLE.
• uncommon, accounting for less than 10% of
temporal lobe auras, and may also be seen in
frontal lobe seizures.
• The smells and tastes are usually described as
unpleasant.
• Uncinate fits are typically unpleasant smells

13. • Visual illusions may include objects appearing
larger (macropsia) or smaller (micropsia), inclined
at an angle (plagiopsia), elongated or flattened
(dysplatopsia), drained of colour (achromatopsia)
or infused with a specific colour (erythropsia, red;
xanthopsia, blue).
• complex visual hallucinations of scenes,faces or
visions of past experiences have been described
with both medial temporal lobe foci and lateral
temporal lobe foci

14. • Auditory hallucinations, associated with foci in
the superior lateral temporal gyrus, may be
simple or complex, ranging from ringing and
buzzing noises to organised experiences such
as music or voices.

15. • These varied aspects of the auras can occur in
any combination. There is often a characteristic
‘march’, passing- for example from an initial
epigastric sensation to gustatory hallucinations
to forced thinking, or from intense déjà vu to an
overwhelming sense of fear. Sometimes various
aspects of the aura appear to occur
simultaneously, or the content is so rich and
strange that the patient lacks the vocabulary to
describe the experiences.

16. ictal semiology in TLE.
• Dystonic posturing, most commonly of the
hand or arm, occurs in up to 70% of temporal
lobe seizures and strongly suggests a
contralateral focus.
• Slow gradual recovery with postictal delirium
extending over several minutes is characteristic
and headache is common.

17. • Clinical features of temporal lobe seizures with lateralising value.
• Lateralising value Semiological feature
• Ipsilateral - Unilateral gestural automatisms
Postictal nose rubbing
• Contralateral - Dystonic posturing
Late versive movement
(preceding secondary generalisation)
Unilateral clonic activity (uncommon)
Todd’s paresis (uncommon)
• Dominant hemisphere - Postictal dysphasia
• Non-dominant hemisphere - Ictal speech
• Note that the aura of temporal lobe epilepsy have little lateralising value
with the possible exception of ictal fear, which may suggest a focus in the
non-dominant hemisphere.

18. automatisms in TLE
• Repetitive involuntary purposeless movements that are
usually inappropriate but occassionally simulate
relatively normal events
• The most frequent automatisms are oro-alimentary
(lipsmacking,chewing, swallowing) and gestural
(fumbling,picking, rubbing movements).
• Unilateral gestural automatisms are suggestive of an
ipsilateral focus.
• Other common automatisms are ictal speech,
grimacing, wandering and searching behaviour.
• Prolonged nature of automatisms is feature of TLE

19. • Automatisms involving the lower limbs in
pedalling or kicking movements are rare in TLE
and more often associated with frontal lobe
seizures
• Seizures may prsent as -
Automatisms,illusions,hallucinations,
pilomotor erections

20. • Studies found a highly significant relationship
between personality disorder and epileptic aura.
• No patient who did not experience an aura had a
personality disorder. There were no associations
with type of epilepsy or laterality, and no
relationship with age at onset, duration of
epilepsy or seizure frequency.
• Avoidant or dependent traits might develop as a
reaction to frightening and unwanted
experiences.

21. SEQUELE OF TLE
1. POST ICTAL PSYCHOSIS-brief self limiting
episodes of psychosis that are of abrupt onset
following seizure
• Mixed psychotic and affective features most
notably agitation following brief lucid interval
after seizures
• Most common form of psychosis in pts with
epilepsy
• Minor pts may develop chronic ictal psychosis

22. • 2 INTER ICTAL PSYCHIATRIC ILLNESS-
• Depression-common in people with epilepsy
,especially those with poorly controlled
seizures esp TLE
• Anxiety
• Suicide
• Schizophrenia like psychosis

23. Diagnosis
• MRI
• Video EEG
• Functional imaging –PET,SPECT
• Invasive eeg

24. Clinical finding- Reduced
hippocampal volume-
hippocampal atrophy
(95%)

28. TREATMENT
• MEDICAL TREATMENT-
• Antiepileptic drugs
• About 60% TLE respond to AED and 40% have
DRE (drug resistnt epilrepsy )
• Drug of choice for the First line monotherapy
in TLE is Carbamazepine or Oxcarbazepine
• Others –lamotrigine,levetiracetam,valproate

29. • SURGICAL TREATMENT –
• Temporal lobe resection
• Procedures more practiced are anterior
temporal resection and amygdala
hippocampectomy
• Seziure freedom will be between 60;70%

30. Neuropsychological (NP)testing
• Mandatory part of presurgical evaluation
• TLE-memory and language
• Dominant TLE –verbal memory deficits
• NON Dominant TLE-visuospatisl memory
deficits
• MEMORY DECLINE –MOST COMMON deficit
after TLE surgery

31. References
• Lishmans Organic psychiatry 4th edition
• Kaplan saddocks synopsis of psychiatry 11th
edition
• Google images of brain neuroimaging