Temporal Lobe Epilepsy in Early Childhood

To explore the electroclinical features of temporal lobe epilepsy (TLE) in early childhood, we studied results of video-EEG and other tests of 14 children aged 16 months to 12 years selected by seizure-free outcome after temporal lobectomy. Four children had mesiotemporal sclerosis, 1 had cortical dysplasia, and 9 had low-grade temporal neoplasms. The children had complex partial seizures (CPS) with symptomatology similar to that of adults with TLE, including decreased responsiveness and automatisms. Automatisms tended to be simpler in the younger children, typically limited to lip smacking and fumbling hand gestures. Scalp/sphenoidal EEC showed anterior/inferior temporal interictal sharp waves and unilateral temporal seizure onset in the 4 children with mesiotemporal sclerosis and in the child with cortical dysplasia, but EEG findings in 9 children with low-grade temporal tumors were complex, including multifo-cal interictal sharp waves or poorly localized or falsely lateralized EEG seizure onset. In children without tumors, video-EEG was critical to localization of the epi-leptogenic zone for resection, but in patients with tumors video-EEG was less localizing and its main value was to confirm that the reported behaviors were epileptic seizures with semiology typical of temporal lobe onset.     

Hyperkinetic seizures in patients with temporal lobe epilepsy: clinical features and outcome after temporal lobe resection

Purpose: Temporal lobe epilepsy (TLE) is usually associated with automatisms. Hyperkinetic seizures are supposed to be unusual. Because we witnessed several patients with TLE and ictal hyperkinetic symptoms, we retrospectively assessed the number, clinical findings, and seizure outcome in such patients who had undergone temporal lobe resection. Methods: We reviewed medical history, video–electroencephalography (EEG) recording and neuroimaging of adult patients who underwent epilepsy surgery for TLE at the Kork Epilepsy Center over the last 20 years with a minimum postoperative follow‐up of 12 months. Key Findings: Among 294 patients who were resected exclusively in the temporal region, we identified 17 (6%) who presented with hyperkinetic semiology such as violent vocalization, complex movements of the proximal segments of the limbs, rotation of the trunk, pelvic thrusting, or early tonic or dystonic posturing. Most of the patients had a preceding aura. Ictal EEG activity was located in the corresponding temporal region, usually with a wide distribution over temporal electrodes with fast spread to unilateral frontal electrodes and to the contralateral side. Neuroimaging revealed extended lesions in the temporal lobe involving mesial and neocortical structures. Most of the patients underwent classical anterior temporal lobe resection including amygdalo‐hippocampectomy. Fourteen patients (82%) became completely seizure‐free (Engel class Ia). Histopathology showed mainly focal cortical dysplasia plus hippocampal sclerosis. Significance: Hyperkinetic seizure semiology may occasionally occur in patients with TLE and is, therefore, no contradiction to the hypothesis of TLE if scalp EEG patterns and neuroimaging findings correspond. The postoperative seizure outcome is favorable in such patients and not different from outcome data in classical TLE.     

Semiology of Temporal Lobe Seizures: Value in Lateralizing the Seizure Focus

Summary: Purpose: To determine the lateralizing value of the clinical manifestations of seizures in patients with temporal lobe epilepsy (TLE), we made a retrospective videotape analysis of complex partial seizures (CPS) in 55 patients who underwent temporal lobectomy and were seizure-free postopera-tively for >2 years. Methods: Blinded to clinical details, we reviewed videotapes from video-EEG telemetry monitoring with attention paid to seizure semiology. Results: Useful lateralizing features included unilateral clonic activity (with the seizure focus contralateral in all patients), unilateral dystonic or tonic posturing (with the seizure focus contralateral in 90 and 86%, respectively), unilateral automatisms (with the seizure focus ipsilateral in 80%), and ictal speech preservation (with the seizure focus contralateral to the language-dominant hemisphere in 80%). Versive head rotation occurring ≤10 s before seizures secondarily generalized consistently predicted a contralateral focus. Seizure manifestations less predictive but suggestive of lateralization included ictal speech arrest and postictal speech status, with predictive values of 67%. Seizure manifestations not providing reliable lateralizing information included eye deviation, type of aura, and versive head movements occurring at times other than immediately before seizures secondarily generalized. Conclusions: In TLE, several clinical seizure manifestations are useful in lateralizing the seizure focus, although some provide no reliable information. Therefore, ictal semiology can assist in the evaluation of patients for seizure surgery, providing additional information in the lateralization of TLE.     

Nichtinvasives Video-EEG-Monitoring in der Diagnostik fokaler Epilepsien und als Prädiktor für das postoperative Ergebnis

Video-documented seizure semiology and non-invasive EEG are mandatory elements of presurgical epilepsy diagnosis. Non-invasive interictal and ictal EEG invaluably contribute to the diagnosis and prognosis of non-tumoral mesial temporal lobe epilepsy (TLE) and frontal lobe epilepsy (FLE). The semiology of auras and seizures help to lateralize FLE and TLE, and add to the consistency of various methods. In posterior epilepsy, the semiology of auras and seizures provides important information on localization and prognosis as opposed to non-invasive EEG.¶???During the first two years after surgery, routine EEG helps to predict the long-term seizure outcome. Further studies about long-term seizure outcome over more than five years are necessary.¶ ???Beyond the scope of this review about non-invasive video/ EEG monitoring, a multitude of other non-invasive methods are used which would deserve seperate consideration.     

Outcomes of resective surgery in children and adolescents with focal lesional epilepsy: The experience of a tertiary epilepsy center

ObjectiveThis study aimed to investigate the efficacy of resective surgery in children with focal lesional epilepsy by evaluating the predictive value of pre- and postsurgical factors in terms of seizure freedom.MethodsThis study included 61 children aged between 2 and 18 years who were admitted to the pediatric video-EEG unit for presurgical workup. Each patient was evaluated with a detailed history, video-EEG, neuroimaging, and postsurgical outcomes according to Engel classification to predict postsurgical seizure freedom. All the possible factors including history, etiology, presurgical evaluation, surgical procedures, and postsurgical results were analyzed for their predictive value for postoperative seizure freedom.ResultsOf the 61 patients, 75% were diagnosed as having temporal lobe epilepsy (TLE), and 25% were diagnosed with extra-TLE. Two years after the surgery, 78.6% were seizure-free, of which 89% had TLE, and 50% had extra-TLE (p < 0.05). Patients were more likely to have a favorable outcome for seizure freedom if they had rare seizure frequency, focal EEG findings, and focal seizures; had a temporal epileptogenic zone; or had TLE and hippocampal sclerosis. On the other hand, patients were more likely to have unfavorable results for seizure freedom if they had younger age of seizure onset, frequent seizures before the surgery, a frontal or multilobar epileptogenic zone, secondarily generalized seizures, extra-TLE with frontal lobe surgery, or focal cortical dysplasia.SignificanceResective surgery is one of the most effective treatment methods in children with intractable epilepsy. A history of young age of seizure onset, frequent seizures before surgery, secondarily generalized seizures, a multilobar epileptogenic zone, frontal lobe surgery, and focal cortical dysplasia (FCD) are the most important predictive factors indicating that a patient would continue having seizures after surgery. On the other hand, focal seizure semiologies, temporal lobe localization, and hippocampal sclerosis indicate that a patient would have better results in terms of seizure freedom.     

Somatosensory auras in refractory temporal lobe epilepsy

PURPOSE: To determine the prevalence, manifestations, lateralizing value, and surgical prognostic value of somatosensory auras (SSAs) in patients with refractory temporal lobe epilepsy (TLE). METHODS: Eighty-one consecutive patients undergoing temporal lobectomy for refractory complex-partial seizures were screened for SSAs. The characteristics of the somatosensory phenomena, occurrence of other aura types, seizure semiology, findings of EEG and imaging studies, temporal lobe neuropathology, and postoperative seizure outcome were determined in each patient with SSAs. RESULTS: Nine (11%) of 81 patients with refractory temporal lobe seizures reported distinct SSAs as part of their habitual seizures. The most common manifestation of SSAs was tingling (eight of nine, 89%), but sensory loss (one of nine, 11%) and pain (one of nine, 11%) also were reported. Five patients had unilateral somatosensory symptoms, and four patients had bilateral somatosensory symptoms. Seizure origin was in the contralateral temporal lobe in four (80%) of five patients with unilateral SSAs, including all patients with unilateral SSAs affecting a limb. Partial temporal lobe resection produced complete seizure remission in all nine (100%) patients 1 year after surgery and in seven (78%) of nine patients 2 years after surgery. CONCLUSIONS: SSAs occur more frequently than previously appreciated in patients with refractory temporal lobe seizures and usually manifest as either unilateral or bilateral tingling. In patients with temporal lobe seizures, unilateral SSAs involving a limb suggest a seizure origin in the contralateral temporal lobe. The surgical outcome of TLE patients with SSAs is favorable. Thus the presence of SSAs should not serve as a deterrent to temporal lobe resection in patients with clearly defined TLE.     

Nonmanipulative proximal upper extremity automatisms lateralize contralaterally in temporal lobe epilepsy

Purpose : Upper extremity automatisms are considered to be an ipsilateral seizure lateralizing sign in temporal lobe epilepsy (TLE). Herein we describe different types of contralateral upper extremity automatisms (CUEAs). Methods : One hundred ninety‐three video–(electroencephalography) EEG recordings of 59 patients were reviewed. Other than two patients who refused surgery, all patients underwent standardized temporal lobectomy with favorable postoperative outcome. Fifty‐seven seizures of 21 patients were selected with CUEAs. We evaluated their electroclinical characteristics and their relation to other lateralizing motor symptoms. Results : Two types of CUEAs were observed. Nonmanipulative, proximal upper extremity automatisms were seen unilaterally and contralaterally to the operated side. These automatisms were rhythmic; repetitive; and often occurred with a circulatory component resembling waving, flaunting, circling, or stirring movements. They occurred in 29 seizures (15%) of 11 patients (19%), in most seizures in the first half of the seizure, and never postictally, in various time sequences and combined with dystonic/tonic posturing or limb immobility. Manipulative/distal type of CUEAs occurred in 11 seizures (6%) of 7 patients (12%) on the unexpected contralateral side. These CUEAs were seen in all phases of the seizures, including in the postictal state. Discussion : Nonmanipulative unilateral proximal upper extremity automatism is a reliable lateralizing sign to the contralateral hemisphere in TLE. This sign may be pathophysiologically related to dystonic/tonic posturing. Manipulative distal automatisms have less lateralizing value.     

Seizure outcome after anterior temporal lobectomy and its predictors in patients with apparent temporal lobe epilepsy and normal MRI

PURPOSE: Very little reliable information is available regarding the role of anterior temporal lobectomy (ATL), optimal presurgical evaluation strategy, post-ATL seizure outcome, and the factors that predict the outcome in patients with medically refractory temporal lobe epilepsy (TLE) and normal high-resolution magnetic resonance imaging (MRI). To be cost-effective, epilepsy surgery centers in developing countries will have to select candidates for epilepsy surgery by using the locally available technology and expertise. METHODS: We reviewed the electroclinical and pathological characteristics and seizure outcome of 17 patients who underwent ATL for medically refractory TLE after being selected for ATL based on a noninvasive selection protocol without the aid of positron emission tomography (PET) or single-photon emission computed tomography (SPECT), despite a normal preoperative high-resolution MRI. RESULTS: Seven (41%) patients achieved an excellent seizure outcome; five of them were totally seizure free. An additional five (29%) patients had >75% reduction in seizure frequency. The following pre-ATL factors predicted an excellent outcome: antecedent history of febrile seizures, strictly unilateral anterior temporal interictal epileptiform discharges (IEDs), and concordant type 1 ictal EEG pattern. All the five patients with pathologically verified hippocampal formation neuronal loss were seizure free. The presence of posterior temporal, bilateral temporal, and generalized IEDs portended unfavorable post-ATL seizure outcome. CONCLUSIONS: A subgroup of patients destined to have an excellent post-ATL outcome can be selected from MRI-negative TLE patients by using history and scalp-recorded interictal and ictal EEG data. The attributes of these patients are antecedent history of febrile seizures, strictly unilateral anterior IEDs, and concordant type 1 ictal EEG pattern.     

The effect of age on seizure semiology in childhood temporal lobe epilepsy

PURPOSE: Complex partial seizure is the characteristic seizure type observed in epilepsy arising from temporal lobe structures. The seizure evolution in adult patients is quite stereotyped and well characterized, manifesting initially with an aura, behavioral arrest, and oroalimentary and gestural automatism. A greater variability of semiology including motor features with tonic or myoclonic components, as well as a paucity of automatism, has been reported in young children with temporal lobe epilepsy. The aim of our study was to examine in more detail the effects of age on individual ictal features to be able to determine the critical age when lesional temporal lobe seizure semiology undergoes transition from the pediatric to the more adult-type clinical pattern. METHODS: We performed a video analysis of 83 seizures from 15 children (aged 11-70 months) selected by post-temporal lobectomy seizure-free outcome, looking specifically at the motor and behavioral (nonmotor) manifestations in relation to age of the children. RESULTS: All of the children younger than 42 months had seizures with early and marked motor features, which included tonic and myoclonic components and epileptic spasms. Parallel with age, the frequency of these motor components decreased, and in five of 11 children older than 3 years, motor features were totally absent. Analyzed quantitatively, we saw a linear and inverse correlation of the ratio of motor components with age at monitoring. CONCLUSIONS: These findings support the hypothesis that events in brain maturation significantly affect clinical seizure semiology and may override the more typical localizing features seen in adult-type temporal lobe epilepsy. These findings are important to consider in the early diagnosis of childhood temporal lobe epilepsy.     

Complex Partial Seizures of Temporal Lobe Origin in Children of Different Age Groups

Summary: The semiology of complex partial seizures(CPS) of temporal lobe origin in adults is well known and is important in establishing seizure localization in patients considered for epilepsy surgery. In contrast, the behavioral features of temporal lobe seizures (TLS) in children described in the literature have not been consistent. In the present study, we investigated children with TLS to compare their attacks to TLS occurring in adults. The study was based on video recordings of 29 children with TLS aged 18 months to 16 years. Children were included, if they became seizure-free after temporal lobectomy (except 4 children with a marked reduction in seizure frequency and 1 with isolated auras), and if clear unitemporal seizure onset in ictal EEG-recordings, unilateral radiological lesions, and corresponding histopathological findings were detected. Children aged >6 years had TLS with features similar to those of adults. In younger children, typical semiology included symmetric motor phenomena of the limbs, postures similar to frontal lobe seizures in adults, and head nodding as in infantile spasms. We concluded that the clinical features of TLS in younger children can be misleading and should therefore be considered with caution in selecting patients for surgical procedures on the temporal lobe.     

Semiology of hyperkinetic seizures of frontal versus temporal lobe origin

Aims. Hyperkinetic seizures are usually associated with frontal lobe epilepsy. However, some patients have hyperkinetic seizures of temporal lobe origin. The semiological differences in hyperkinetic seizures between frontal and temporal lobe epilepsy have not been well studied. Here, we retrospectively assessed ictal semiology in order to distinguish between hyperkinetic seizures of frontal lobe origin and those of temporal lobe origin. Methods. We retrospectively reviewed data on patients who had undergone surgery for hyperkinetic seizures of temporal or frontal lobe origin and achieved favourable seizure outcomes (Engel Class I) with a minimum postoperative follow‐up of 24 months. We reviewed seizure histories, imaging reports, video‐EEG monitoring data, operative records, and pathological findings. We analysed and compared the hyperkinetic semiology of video‐recorded seizures of temporal lobe origin and those of frontal lobe origin. Results. Forty hyperkinetic seizures in eight patients (seven adult patients and one 12‐year‐old patient) with temporal lobe epilepsy and 45 hyperkinetic seizures in nine patients (eight adult patients and one 16‐year‐old patient) with frontal lobe epilepsy were analysed. Emotional facial expressions (such as fear, laughing, or anger), bilateral forceful elbow flexion, bilateral forceful grasping, facial flushing, and bilateral facial contraction were observed significantly more frequently in seizures of frontal lobe origin. Oroalimentary automatisms, seizures during wakefulness, salivation, and bilateral drop of the corners of the mouth were observed significantly more frequently in seizures of temporal lobe origin. Conclusions. Observation of a number of signs during hyperkinetic manifestations may help to predict whether a seizure originates from the frontal lobe or the temporal lobe.     

Lateralizing value of behavioral arrest in patients with temporal lobe epilepsy

Analysis of ictal semiology is essential to presurgical evaluation of patients with epilepsy. To assess the localizing value of behavioral arrest in temporal lobe epilepsy (TLE), we analyzed 107 video/EEG monitoring-documented seizures of 107 adult patients with TLE for a set of defined seizure phenomena with respect to frequency and sequence of occurrence in relation to epileptogenic (mesial vs extramesial, left vs right) origin. Behavioral arrest was observed more frequently in left-sided temporal seizures: 25.7% of left-sided mesial seizures and 25.0% of left-sided extramesial seizures exhibited behavioral arrest, whereas only 3.4% of right-sided mesial seizures and 10.5% of right-sided extramesial seizures were associated with behavioral arrest. In addition, occurence of behavioral arrest within the sequence of seizure phenomena was remarkably consistent, being observed mainly as the first apparent feature of seizure onset. Thus, behavioral arrest is a valuable early indicator of a left-sided temporal epileptogenic focus in adult patients with TLE.     

Foramen ovale electrodes in the preoperative evaluation of temporal lobe epilepsy in children

Purpose:  Foramen ovale electrodes (FOEs) can localize the epileptogenic zone in adults with mesial temporal lobe epilepsy (TLE). Our aim was to investigate the feasibility and safety of using FOEs to investigate refractory TLE in children.
Methods:  Thirty-eight children with seizure semiology and video-EEG (electroencephalography) consistent with medically refractory TLE, and/or the presence of a lesion in the temporal lobe, had FOEs inserted. Complications occurring during the monitoring and up to 3 months after surgery and the long-term seizure outcome were registered.
Results:  Forty electrodes were placed in 38 patients. The mean age of the patients was 9.8 years (range 2.3–15.4 years). FOEs confirmed a unilateral mesial temporal lobe seizure onset in 14 patients, onset in both FOEs and lateral electrodes in two patients, and onset in the anterior temporal electrodes in only one patient. Six patients had seizures recorded but were not considered surgical candidates; four patients had no seizures recorded, and 11 patients were further investigated with depth electrodes. One patient (2.6%) developed a hematoma in the cheek, and in two patients the electrodes were extracranial but could still be used for recording. Twenty-eight children had a temporal resection; 25 were Engel class I at follow-up.
Discussion:  FOEs are safe to use in children and provide valuable information on the mesial temporal lobe structures in the preoperative investigation of pediatric TLE. Patient selection for FOE investigation is, however, essential for a conclusive result.     

Ictal spitting in left temporal lobe epilepsy: report of three cases.

PURPOSE: Ictal spitting is rarely reported in patients with epilepsy. More often it is observed in patients with temporal lobe epilepsy (TLE) and is presumed to be a lateralizing sign to language nondominant hemisphere. We report three patients with left TLE who had ictal spitting registered during prolonged video-EEG monitoring. METHODS: Medical charts of all patients with medically refractory partial epilepsy submitted to prolonged video-EEG monitoring in the Epilepsy Unit at UNIFESP during a 3-year period were reviewed, in search of reports of ictal spitting. The clinical, neurophysiological and neuroimaging data of the identified patients were reviewed. RESULTS: Among 136 patients evaluated with prolonged video-EEG monitoring, three (2.2%) presented spitting automatisms during complex partial seizures. All of them were right-handed, and had clear signs of left hippocampal sclerosis on MRI. In two patients, in all seizures in which ictal spitting was observed, EEG seizure onset was seen in the left temporal lobe. In the third patient, ictal onset with scalp electrodes was observed in the right temporal lobe, but semi-invasive monitoring with foramen ovale electrodes revealed ictal onset in the left temporal lobe, confirming false lateralization in surface records. The three patients became seizure-free following left anterior temporal lobectomy. CONCLUSIONS: Ictal spitting is a rare finding in patients with epilepsy, and may be considered a localizing sign of seizure onset in the temporal lobe. It may be observed in seizures originating from the left temporal lobe, and thus should not be considered a lateralizing sign of nondominant TLE.     

Hypermotor seizures in patients with temporal pole lesions

Hypermotor seizures are considered to be characteristic of frontal lobe epilepsy, with only rare occurrence in temporal lobe epilepsy. After noting hypermotor seizures in several patients with lesions involving the pole of the temporal lobe, we investigated whether temporal pole lesions were associated with hypermotor seizures. We systematically reviewed medical records, MRI images and pathological findings in consecutive patients who underwent epilepsy surgery over the preceding 10 years in our institution and identified eight patients with temporal pole lesions and intractable complex partial seizures. We analyzed all recorded seizures for semiology, classifying seizures as hypermotor or typical "psychomotor." Four patients exhibited hypermotor seizure semiology and four patients manifested typical psychomotor seizure characteristics. In patients with hypermotor seizures, scalp EEG tended to demonstrate lateral anterior temporal ictal onset, with lesser involvement of the sphenoidal electrode, while the patients with psychomotor seizures had initial inferomesial temporal rhythmic theta activity. Two patients with hypermotor seizures had implanted frontal and temporal subdural grids demonstrating orbitofrontal spread before hypermotor behavior. Patients underwent either anterior temporal lobectomy or lesionectomy. All improved considerably, with six patients seizure-free since surgery. We conclude that hypermotor seizures occur frequently in patients with temporal pole lesions. A search for temporal pole pathology is recommended for patients with hypermotor seizures and temporal epileptiform discharges. Modification of the surgical approach to include this region should be considered in patients who exhibit hypermotor seizures.     

The localizing value of the abdominal aura and its evolution: a study in focal epilepsies.

OBJECTIVE: To evaluate the localizing value of abdominal aura and its evolution into other seizure types. METHODS: The seizures of 491 consecutive patients with focal epilepsies were prospectively classified according to a recently introduced semiologic seizure classification. All patients underwent prolonged EEG video monitoring and MRI scan. Two hundred twenty-three patients (45%) had temporal lobe epilepsies (TLE); 113 patients (23%) had extratemporal epilepsies; and for 155 (32%) patients, the epilepsy could not be localized to one lobe. RESULTS: Abdominal auras were more frequent with TLE (117 of 223 patients, 52%) than in extratemporal epilepsy (13 of 113 patients, 12%, p < 0.0001) and more frequent in mesial TLE (70 of 110 patients, 64%) than in neocortical TLE (16 of 41 patients, 39%, p = 0.007). No preponderance to one side existed. Abdominal auras were followed by ictal oral and manual automatisms (automotor seizure) in at least one seizure evolution in all patients with TLE (117 patients, 100%). In contrast, only two patients with extratemporal epilepsy (2 of 13 patients, 15%, p < 0.0001) had abdominal auras evolving into automotor seizures. An abdominal aura is associated with TLE with a probability of 73.6%. The evolution of an abdominal aura into an automotor seizure, however, increases the probability of TLE to 98.3%. CONCLUSIONS: These results demonstrate that evolution of abdominal aura into automotor seizure permits differentiation between temporal lobe epilepsy and extratemporal epilepsy, showing that analysis of seizure evolution provides more localizing information than does the frequency of particular seizure types.     

Diagnosis and treatment of temporal lobe epilepsy

Of the 1,200,000 Americans with partial epilepsy, temporal lobe epilepsy (TLE) occurs in more than 400,000. Temporal lobe seizures are usually stereotypic in their symptoms and duration. A typical sequence is an aura followed by arrest of motor behavior, blank stare, and automatisms. Patients with TLE often show impairments in attention, memory, mental processing speed, executive functions, mood, personality, and drive-related behaviors. Interictal depression occurs in approximately one third of TLE patients. TLE is diagnosed by a history of characteristic partial seizure symptoms. The diagnosis is confirmed by the capture of a typical episode during an electroencephalogram (EEG) or video-EEG, with epileptiform activity over one or both temporal regions. Video-EEG monitoring has revolutionized diagnosis and should be considered in patients in whom diagnosis is uncertain. TLE is treated with medications, resective surgery, and vagus nerve stimulation. Epilepsy surgery should be considered in all patients with refractory partial epilepsy.     

An evaluation of lateralizing signs in patients with temporal lobe epilepsy

Resective epilepsy surgery has been accepted as an effective treatment for patients with medically intractable temporal lobe epilepsy (TLE) to control the seizures and to limit cognitive dysfunction. Complete resection of the epileptic zone, and therefore the success of the surgery, depends on the identification of the seizure focus. Reliable lateralizing semiologic signs, together with other presurgical assessments, are of great importance for an accurate identification of the seizure focus. In this respect, this study evaluated the frequency of semiologic signs in medically intractable temporal lobe epilepsy (TLE) together with the lateralizing values and variations according to the age and gender groups. Two hundred seventy-three seizures of 55 patients of the Adult Epilepsy Monitoring Unit of Gazi University Faculty of Medicine with the diagnosis of medically intractable TLE, whose epileptic foci were detected through noninvasive presurgical procedures and seizures were controlled successfully after anterior temporal lobectomy (ATL), were analyzed retrospectively. Seizure semiologies of the patients were evaluated in terms of lateralizing values, and it was inquired whether age/gender causes any variation. Versive head rotation, unilateral dystonic limb posturing, asymmetric tonic limb posturing, and the combination of unilateral hand automatisms and dystonic posturing were determined as the semiologic signs with the highest lateralizing values (90–100%). While hand automatisms were observed frequently in the group with early seizure-onset age (onset age ≤ 2), asymmetric tonic limb posturing was detected as more frequent in the group with later seizure-onset age (onset age > 2; p < .005). In addition to this, semiologic signs were noted to be different between male and female groups; psychic and autonomic auras and ictal emotional signs were associated with women (p < .005).     

Parahippocampal epilepsy with subtle dysplasia: A cause of “imaging negative” partial epilepsy

Purpose: Lesion‐negative refractory partial epilepsy is a major challenge in the assessment of patients for potential surgery. Finding a potential epileptogenic lesion simplifies assessment and is associated with good outcome. Here we describe imaging features of subtle parahippocampal dysplasia in five cases that were initially assessed as having imaging‐negative frontal or temporal lobe epilepsy. Methods: We analyzed the clinical and imaging features of five patients with seizures from the parahippocampal region. Results: Five patients had subtle but distinctive magnetic resonance imaging (MRI) abnormalities in the parahippocampal gyrus. This was a unilateral signal abnormality in the parahippocampal white matter extending into gray matter on heavily T₁‐ and T₂‐weighted images with relative preservation of the gray–white matter boundary on T₁‐weighted volume sequences. Only one of these patients had typical electroclinical unilateral temporal lobe epilepsy (TLE); one mimicked frontal lobe epilepsy, two showed bitemporal seizures, and one had unlocalized partial seizures. All have had surgery; four are seizure‐free (one has occasional auras only, follow‐up 6 months to 10 years), and one has a >50% seizure reduction. Histopathologic evaluation suggested dysplastic features in the surgical specimens in all. Discussion: In patients with lesion‐negative partial epilepsy with frontal or temporal semiology, or in cases with apparent bitemporal seizures, subtle parahippocampal abnormalities should be carefully excluded. Recognizing the MRI findings of an abnormal parahippocampal gyrus can lead to successful surgery without invasive monitoring, despite apparently incongruent electroclinical features.     

Lateralizing value of postictal automatisms in temporal lobe epilepsy

PURPOSE: To describe clinical characteristics and lateralizing value of postictal automatisms in patients with temporal lobe epilepsy (TLE). METHODS: One hundred and ninety-three videotaped seizures of 55 consecutive patients with refractory TLE and postoperatively seizure-free outcome were analyzed. Ictal as well as postictal (manual, oral and speech) automatisms were monitored. RESULTS: Thirty-four (62%) of the 55 patients showed PA at least once during their seizures. Postictal automatism was observed in 70 (36%) attacks as manual (21%), oral (13%) or speech (9%) automatisms. Fifteen seizures contained a combination of two different postictal automatisms. The presence of postictal oral automatisms did not lateralize the seizure onset zone (p=0.834). Speech automatisms (repetitive verbal behavior) occurred more frequently after left-sided seizures (p=0.002). Postictal unilateral manual automatism showed no lateralizing value occurring by the ipsilateral hand in 10 and the contralateral upper limb in 6 seizures (p=0.454). CONCLUSION: : Postictal automatism is a relatively frequent phenomenon in TLE. Postictal speech automatism lateralizes the seizure onset zone to the left hemisphere. Our observation can help the presurgical evaluation of TLE because verbal perseveration frequently occurs spontaneously, even in seizures without appropriate postictal language testing.