Temporal Lobe Epilepsy: Clinical

Semiology and Neurophysiological Studies

María Rosa Querol Pascual, MD

Most partial epilepsy crises originate in the temporal lobe. Two main syndromes have been
described in temporal lobe epilepsy (TLE): mesial temporal epilepsy and neocortical tem-
poral epilepsy. In recent years, the number and types of drugs used to control the crises
have significantly increased, but almost 30% of patients do not have complete control of
their epilepsy. In those cases, surgery is an efficient therapeutic option, especially in the
case of mesial temporal sclerosis. Before surgery, wide and complex neurophysiological
studies are needed to precisely delineate the epileptogenic area. The clinical and neuro-
physiological aspects of TLE that may be useful for understanding this pathologic entity are
reviewed.
Semin Ultrasound CT MRI 28:416-423 © 2007 Elsevier Inc. All rights reserved.

T emporal lobe epilepsy (TLE) is a partial form of epilepsy

that originates in one or several of the anatomic locations
of the temporal lobe, and which can spread through a net-
video-electroencephalography), neuroimaging studies, and
neuropsychological evaluation.

work of neuronal interconnections to the adjacent brain tis-

sue.1
Approximately 60% of all epilepsy patients suffer from
focal epilepsy; in a third of these cases, which are located
mostly in the temporal lobe,2 there is not sufficient control
following treatment with several antiepileptic drugs.3
According to the classification4 of epileptic syndromes,
TLE is divided into two main groups: the first and most
common is medial epilepsy, in which the crisis originates
principally in the temporal medial structures such as the
hippocampus, entorhinal cortex, amygdala, and parahip-
pocampal gyrus.5 The second type is lateral or neocortical
epilepsy, in which the crisis affects the temporal neocortex,
which includes the superior, medial, and inferior temporal
circumvolutions, the temporal-occipital and temporal-pari-
etal junctions, and the associative sensorial areas for hearing,
visual, and language functions.1,6,7
Epilepsy surgery is an alternative and effective treatment
for carefully selected patients who undergo a wide range of
presurgical studies, which include clinical history and careful
neurological exploration,8 complex neurophysiological stud-
ies (surface electroencephalogram, superficial, and invasive
Ethiology of
Temporal Lobe Epilepsy
Surgical treatment of epilepsy permits the realization of
anatomopathological studies of the cerebral cortex and iden-
tification of the lesions responsible for the epileptic seizures.
Sclerosis of the hippocampus is the most frequent cause of
pharmacoresistant epilepsy originating in the mesial struc-
tures, and is the histopathological finding that most fre-
quently occurs following partial temporal lobectomy.3,9,10
Other possible pathologies are: low-grade tumors, espe-
cially in ganglioglioma, malformations of cortical develop-
ment, traumatic, and infectious and vascular lesions3,9-11
(Table 1).
In 5% to 20% of the cases, temporal mesial sclerosis is
associated with other structural lesions, in this case known as
dual pathology, and in most patients the second lesion is
usually associated with congenital alterations such as dysgen-
esis or cortical heterotopia.9,10
From a clinical point of view a third type of temporal
epilepsy exists that does not show lesions in neuroimaging
studies and may be of a hereditary nature.12,13

Department of Neurology, Infanta Cristina Hospital, Complejo Hospitalario

Universitario de Badajoz (CHUB), Badajoz, Spain.
Address reprint requests to: María R. Querol Pascual, MD, Infanta Cristina
Hospital, Avda de Elvas s/n, 06080 Badajoz, Spain. E-mail: rquerolp@
hotmail.com
Clinical Semiology of
Temporal Lobe Epilepsy
Epileptic seizures are the main clinical characteristics of epi-
leptic syndromes. Their symptoms and signs are produced by

416 0887-2171/07/$-see front matter © 2007 Elsevier Inc. All rights reserved.
doi:10.1053/j.sult.2007.09.004
Clinical semiology and neurophysiological studies 417

Table 1 Etiology of Temporal Epilepsies Of the types of auras that have been described in TLE, the
A. Temporal mesial sclerosis following are the most important.
B. Neocortical epilepsy Visceral-Sensory or Autonomous Auras
1. Defects of neuronal migration
These originate in the insular cortex and amygdala regions
a. Lamination alterations
b. Heterotopic neurons
that have wide interneuronal connections with other cerebral
c. Focal cortical dysplasia zones.17-19
2. Infections The most characteristic of the somatosensory auras, and
a. Bacterial meningitis probably the most frequent due to its high incidence in TLE,
b. Encephalitis is the abdominal sensation or epigastric rising sensa-
c. Cerebral abscess tion.7,14,16,20,21 This epigastric aura is more frequent in the
d. Parasitary infections subtype of temporal medial epilepsy than in temporal lateral
3. Cranial traumatisms epilepsy, although it is not exclusive of the temporal lobe.7,22
4. Tumors In all patients with abdominal aura followed by automatisms
a. Oligodendroglioma the epilepsy is located in the temporal regions.23
b. Astrocytoma
Other autonomous phenomena are: pallor, flushing, cya-
c. Meningioma
d. Glioblastoma
nosis, alterations in cardiac frequency and rhythm, vomiting,
e. Gangliocytoma urinary urgency, piloerection or pupillary alterations.16,21,24
f. Dysembryoplastic neuroepithelial tumor (DNT) Ictal vomiting may be the only manifestation of a partial
5. Vascular malformations simple seizure; it has been related with temporal crises of the
a. Cavernous angioma nondominant hemisphere25-27 and according to other au-
b. Artero-venous malformation thors with crises of the left dominant hemisphere.28,29
6. Cerebral infarction/Stroke Of the alterations of cardiac rhythm, sinus tachycardia is
7. Congenital malformations the most frequently associated with epileptic crises.14,18,21
a. Porencephalic cyst Bradycardia, which can become asystolic, is an uncommon
b. Arachnoid cyst phenomenon.30
c. Temporal encephalocele
C. Familiar temporal epilepsies Psychic or Experienced Auras
1. Dominant autonomous epilepsy with auditory This type of aura is characteristic of TLE and reflects the point
symptoms or lateral temporal dominant epilepsy of junction established between specific cerebral areas and
2. Medial familiar temporal epilepsy important neuropsychological aspects such as memory, re-
Reprinted from “Tratado de epilepsia” (“Treatise on Epilepsy”) by call, or lived experiences.21 In recent years, studies with deep
Asconapé and Gil-Nagel, McGraw-Hill-Interamericana, with per- electrodes have related the limbic structures of the temporal
mission from the publishers.49
lobe with this type of phenomenon.
In these auras the following are included:

the activation of determined cortical regions responsible for
generating or propagating these. Thus, through a detailed
clinical description of the seizure in anamnesis, and studies
with ictal and interictal electroencephalography (EEG) regis-
ters, different clinical patterns have been identified as char-
acteristic of each type of syndrome, and these offer lateraliz-
ing and even localizing information in many patients.6,14,15
TLE is characterized mainly by recurrent complex partial
seizures (with loss of consciousness) preceded in a variable
percentage of cases by epileptic auras that represent simple
partial seizures.16
We now present a description of the most frequent features
of both clinical types.
Epileptic Auras or Simple Partial Seizures
According to the Classification and Terminology Commis-
sion of the International League Against Epilepsy (ILAE), the
epileptic aura is a set of symptoms and signs that occur before
loss of consciousness, of brief duration (between 5 and 30
seconds), and for which memory is retained.4 It is a common
phenomenon in temporal epilepsy, often of important local-
izing value, and may be the only comitial manifestation or
previous symptom to a complex partial seizure.
Dysmnesic phenomena. These consist of distortions of
memory. The most characteristic is déjà vu, which is the
sensation of having previously lived a determined situation,
and has been assigned a localizing value at the level of the
anterior nondominant temporal lobe.16,31 Jamais vu is the
inverse phenomenon, which consists in the inability to rec-
ognize familiar surroundings.
The feeling of presentiment is a very infrequent manifesta-
tion of temporal aura, and according to Sadler and Rathey it
may have lateralizing value.32
Cognoscitive phenomena. These are situations in which per-
ception of internal or external reality is altered. The main
ones are: distortion of appreciation of time, sensation of un-
reality, of depersonalization, changes in body image, and
what is known as forced thought, which consists of imposed
and intrusive thoughts at the onset of crises.14,21,33
Emotional phenomena. With regard to affective alterations,
the most frequent aura is fear associated with a rising epigas-
tric sensation indicating a mesolimbic localization,7,14,17 and
in some cases is related with amygdalar atrophy.34 Panic at-
tacks with autonomic and behavioral changes (agitation, pa-
ralysis through terror, calls for help) have been described,
418
and deep EEG recordings have shown that the areas involved
are situated in orbital-prefrontal regions, in the anterior cin-
gular gyrus and temporal limbic cortex, and most frequently
in the nondominant hemisphere.35 Other less frequent
symptoms include sadness, pleasure, sexual emotions,
and anguish.33
Illusions and hallucinations. Illusions or auditive, visual, or
vestibular hallucinations most often have lateral temporal
localization.7
The most frequent of these are visual hallucinations, which
represent up to 20% of patients with temporal lobe crises.
They consist of deformations of size, shape, color, move-
ment, or distance, and in general the right temporal lobe is
most affected.21,31
Auditive auras have been described as a buzzing, whis-
tling, or whining noise, and reflect the activation of Heschl’s
gyrus7,21; they are common symptoms of hereditary temporal
epilepsy.12,13
Olfactory auras are usually unpleasant sensations associ-
ated, or not, with taste, and are known as uncinated crises.
Their origin would seem to be in the temporal mesial region
near the amygdala, or in orbital-frontal regions.36 The most
frequent subjacent pathology consists of localized tumors in
temporal regions.14,37
Complex Partial Crises
In 70% of cases, after the aura there exists a loss of conscious-
ness associated with a variable neurological symptomatology
with or without secondary generalization, which is followed
by a period of postictal confusion.7 It is therefore possible to
distinguish in the epileptic crisis an ictal period and a postic-
tal period.
Ictal Period
Automatisms. Between 40% and 80% of patients with tem-
poral epilepsy have stereotyped automatisms, especially oral
alimentary and manual automatisms,7,14,16,38 during crisis.
The oral alimentary automatisms most frequently originate in
the amygdala and anterior temporal region.7
Automatisms are involuntary motor activities that in most
cases occur with alterations of consciousness, although in 10%
of cases of attacks originating in the right hemisphere the patient
remains reactive, usually with subsequent amnesia.38
Language alterations. These vary greatly in both the critical
and the postcritical period. The presence during a crisis of
intelligible, well-articulated, linguistically correct language,
also known as ictal speech, is related to the onset of a crisis
lateralized to the nondominant temporal lobe, in the supra-
marginal and angular circumvolutions.7,26,39
Ictal aphasia and verbal automatisms are more frequent in
the dominant hemisphere26 in relation to limbic neocortical
structures.7,39
Unilateral dystonic posturing. This is a forced, unnatural
posturing of a limb, maintained for more than 10 seconds, in
either flexion or extension, with rotation. Its localizing value
is very high especially when accompanied by automatisms of
M.R. Querol Pascual
the other extremity, which always indicates contralaterality
to ictal discharge.25,40
Its origin has been attributed to propagation of the dis-
charge toward the basal ganglia.40-42
Versive head-turning. The localizing and lateralizing value of
this is controversial. It is very frequent in temporal seizures, but
not exclusive to them.
There exists a general consensus on its localizing value
when a clearly forced deviation occurs, with sustained and
unnatural posturing of the eyes and head, for at least 10
seconds, followed by a generalized tonic-clonic convulsion.
Origin is contralateral to the movement in more than 90% of
cases.5,15,20,26 The phenomenon appears when epileptic activ-
ity extends to supra-Sylvian structures and involves the fron-
tal lobe.5
Postictal Period
Focal findings during the postictal period reflect the area of
origin of the crisis, are independent of the region affected
during the propagation of the attack,14,43 and therefore have
great localizing value.
The postictal period is clearly related with a confusional
state that can last several minutes. It is shorter if the epileptic
focus is located in the right hemisphere.26
Postictal aphasia is more frequent when the epileptic dis-
charge is involved in the dominant hemisphere.5,7,26
Less known are the psychiatric symptoms following an
epileptic seizure, which include depression, anxiety and irri-
tability, and even psychotic symptoms.5
Neurophysiological Diagnostic
Tests in Temporal Lobe Epilepsy
Detailed clinical history and neurological explorations are
essential for the initial study of the epileptic patient. Neuro-
physiological and neuroimaging diagnostic tests are used to
confirm the pathology by attempting to identify the area of
the cortex where the epileptic discharge originates, known as
the irritative zone, and to determine the presence or not of
subjacent lesion.
Surgical treatment in pharmacoresistant epilepsy of the
temporal lobe requires an extensive presurgical study includ-
ing studies of classic electroencephalography with surface
EEG, video-electroencephalography (VEEG) studies, and the
use of more invasive methods with oval foramen, sphenoidal,
or subdural electrodes, or, in very selected cases, intracranial
electrodes.
The presurgical study is completed with neuropsycholog-
ical evaluation, and imaging tests such as magnetic resonance
and cerebral single-photon emission computed tomography
(SPECT) and positron emission tomography (PET).
Electroencephalography
Despite technological advances, EEG continues to be essential in
the study of the epileptic patient. EEG records electrical activity
of the brain using different types of electrodes. Cerebral electri-
Clinical semiology and neurophysiological studies 419

Table 2 Electroencephalographic Findings in TLE

Electroencephalograph
(EEG) Temporal Medial Epilepsy
Ictal EEG Focal rhythmic activity in the theta range (5–9 Hz)
with maximum amplitude in the basal temporal
electrodes, preceded or not by bilateral
hypersynchronic slowdown.
Interictal EEG Spike-wave interictal paroxystic alterations,
normally located in the anterior temporal
region. Unilateral or bilateral in 40% of cases.
Temporal Lateral Epilepsy
Onset of seizure may have a wider
distribution and has typical presence of
irregular activity, polymorphic at 2–5 Hz
in inferior-temporal regions.
Interictal paroxystic discharges in medium
or posterior-temporal derivations.

cal activity has its origin in the ionic currents derived from the
biochemical processes occurring on the cellular level.44
Surface Electroencephalography
Surface EEG is a recording of 20-30 minutes made by applying
the electrodes directly on the scalp. During recordings certain
maneuvers are carried out to provoke critical events such as
hyperventilation or intermittent luminous stimulation. Routine
EEG studies on temporal epilepsy should be performed with the
usual electrodes plus additional anterotemporal electrodes (T1,
T2), or temporal-basal electrodes, and should include record-
ings made during wakefulness and sleep to facilitate reg-
ister of intercritical epileptiform activity.45,46
The main indications for EEG to be performed are:
1. Contribution to the identification of paroxystic events
with clinical suspicion of epileptic crisis.
2. Classification of the different types of epilepsy and ep-
ileptic syndromes.
3. Prognostic usefulness in recurrence of crisis.
Interictal activity registered in EEG studies has a lateraliz-
ing capacity in 80% of cases, but low localizing capacity due
partly to the relative distance from the irritative zone, and
also to the fact that other anatomic structures are interposed
between this zone and the electrodes.8,16 It is, however, a first
step in the assessment of epileptic patients and can guide
subsequent studies.47
Table 2 shows the principal electroencephalographic fea-
tures of the two main subtypes of TLE: mesial3,16,22,48-51 and
neocortical or lateral.3,22,45
Video-electroencephalography
Video-electroencephalography (VEEG) monitoring consists
of simultaneous EEG recording and video recording of the
patient’s behavior during a paroxystic event for a prolonged
period (Fig. 1).
The usefulness of VEEG recordings can be summarized in
the following points:
1. They are helpful in the differential diagnosis of epileptic
crises. VEEG recordings have shown that in 20% to
30% of patients the crisis was not epileptic.8,20,52

Figure 1 VEEG: image showing simultaneous video recording with EEG. The vertical line shows real time in EEG and
synchronizes both activities. (Color version of figure is available online.)
420
2. They classify and characterize the type of crisis.8,14,20,48
3. They quantify the crisis and assess triggering factors,
thus amplifying the interictal information obtained
through conventional EEG.48
4. They identify subtle crises that may go unnoticed by the
patient and those around him or her.
5. They provide presurgical assessment.11
VEEG monitoring should be of sufficient duration to cap-
ture a suitable number of crises similar to those habitually
experienced by the patient; to achieve this, it may be neces-
sary to reduce partially or totally anticomitial treatment.8,11,14
These prolonged VEEG studies require patients to be hos-
pitalized in specialized units. Some authors, however, pro-
pose the use of VEEG in outpatient clinics with a duration of
30 minutes, or several hours in cases where patients have
very frequent crises, or when the crises can be reproduced
by other triggering factors; in these cases the time used is
considered sufficient to obtain a critical recording.8,53,54
In these VEEG studies surface or noninvasive electrodes
may be used in addition to the conventional ones of the
International 10-20 System55 such as nasopharyngeal, sphe-
noidal, nasoethmoidal, and supraorbital electrodes, or inva-
sisve or intracranial electrodes for the assessment of surgical
candidates.56,57 Of this latter type the most frequently used
Figure 2 Recording during ictal episode. (A) Before seizure. (B) Patient begins to notice epigastric sensation. (C) Patient
also notices tachycardia. Bioelectric manifestations start with beta rhythm in right mesial temporal region (graphic),
and turn into a spike pattern. (Color version of figure is available online.)
M.R. Querol Pascual
are electrodes placed in the oval foramen, in the epidural,
subdural, or intraparenchymatous space.8,47
Foramen Ovale Electrodes
This technique, considered semi-invasive, was designed by
Wieser and coworkers58 using flexible cylindrical electrodes
of between 4 and 8 contacts, which are introduced with
radioscopic control by puncturing the Gasser’s ganglion
through an oval hole to the ambiens cistern, below and at the
level of the hippocampal gyrus. These studies provide infor-
mation on bilateral electric activity originating in the hip-
pocampal formation and in the circumvolution of the para-
hippocampus, and reduce the artifacts that are produced
during the crisis with EEG recording47,58 (Fig. 2).
Foramen ovale electrodes have two main indications:
first, to determine whether the origin of the crisis is medial
basal or not, and second, to determine the laterality in
cases of dubious bilateral medial epilepsy, or with normal
cerebral magnetic resonance imaging (MRI).59,60
Few side effects exist; 9% have pain or transitory sensitive
alterations in the trigeminus area, or infectious complica-
tions, and in less than 1% of cases subarachnoid or intrapa-
renchymatous hemorrhage may exist.46,60
Clinical semiology and neurophysiological studies
Figure 3 Blanket of 64 subdural electrodes. (Color version of figure
is available online.)
Study with Deep Electrodes
Intracranial electrodes are used exclusively in presurgical
studies for assessing patients with pharmacoresistant epi-
lepsy, as they are invasive and require the use of a complex
and costly stereotaxic technique. The electrodes are placed
on or near the zone where the epilepsy is theoretically pro-
duced.
The main indications for the use of intracranial electrodes are:
1. In patients presenting with clinical semiology, neu-
roimaging studies (cerebral MRI, SPECT, PET), non-
invasive neuropsychological and neurophysiological
studies with insufficient or incongruous informa-
tion.11,57,59,61,62
2. In cases of dual pathology or possible neocortical tem-
poral epilepsy.61
3. In epileptogenic lesions close to the eloquent cortex
(motor zone, language area) in which it is necessary to
Figure 4 Deep electrodes.
421
make a cartography by means of electric stimulation
before surgical resection.11
4. In other types of pharmacoresistant extratemporal
epilepsy.63
Subdural Electrodes
Subdural electrodes are the most frequently used. There are
two types: grids or strips, of varying size and configuration
(Fig. 3).
They must be placed by means of craniotomy or trepana-
tion depending on whether grids or strips, respectively, are
used, and are placed on the theoretically epileptogenic
zone.11,61,63 At least 4% of the patients implanted with these
electrodes presented important complications, such as men-
ingitis, bone infections, intracranial hypertension syndrome,
and subdural or intraparenchymatous hematoma.57
Intracerebral Electrodes
A variable number of these electrodes (between 5 and 15)
with various contacts are implanted orthogonally to the ce-
rebral cortex in the three axes of the space following the
stereotaxic Talairach atlas.64 The most frequent hemorrhage
and infection complications affect 3% of the patients im-
planted61 (Fig. 4).
Intracranial recordings should not be considered as an
initial diagnostic technique, but rather should be seen as a
complement to the other tests, because they are not exempt
from morbidity.
In summary, a detailed clinical history combined with
neurophysiological, neuroimaging (specific protocols) and
functional (PET and SPECT) studies must be carried out
prior to considering the surgical treatment of pharmacologi-
cal-resistant epilepsy.
422
Acknowledgment
We would like to thank Dr A. Gil-Nagel Rein (Epilepsy Unit,
Ruber International Hospital, Madrid) for his kind collabo-
ration in providing the iconographic material.
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