What are the symptoms and treatment options for temporal lobe seizures?

Temporal Lobe Seizure Symptoms and Treatment

Temporal lobe seizures present with distinctive symptoms including auras, automatisms, and post-ictal confusion, and are effectively treated with antiepileptic medications as first-line therapy, with surgery considered for medication-resistant cases. 1

Clinical Presentation

Characteristic Auras

• Rising epigastric sensations, unusual smells, or other recurring phenomena specific to the individual patient commonly occur as warning signs before temporal lobe seizures 1
• Emotional or psychic symptoms including fear, anxiety, or déjà vu experiences may precede the seizure 1
• Olfactory dysfunction can manifest as parosmia (distorted perception of odors) that may be most severe in the week following a seizure 2

Seizure Manifestations

• Automatisms such as chewing, lip smacking, or repetitive blinking are hallmark features of temporal lobe epilepsy 1, 3
• Motor arrest with blank stare followed by impaired consciousness is typical 3
• Hemilateral clonic movements may occur during the seizure 1
• Tongue biting, typically on the lateral side, is common 1
• Prolonged post-ictal confusion distinguishes temporal lobe seizures from other seizure types 1

Cognitive and Psychiatric Symptoms

• Patients often exhibit impairments in attention, memory, mental processing speed, and executive functions 3
• Interictal depression occurs in approximately one-third of temporal lobe epilepsy patients 3, 4
• Anxiety and interictal dysphoria are common psychiatric comorbidities 4
• Mood, personality, and drive-related behaviors may be affected 3

Diagnostic Approach

Neuroimaging

• MRI is the preferred imaging modality with high-resolution protocols including coronal T1-weighted imaging, high-resolution volume T1-weighted gradient echo, and coronal T2 and fluid-attenuated inversion recovery sequences 1
• FDG-PET can detect hypometabolism in the epileptogenic zone with 79-95% sensitivity and specificity, particularly valuable when MRI is negative 5
• PET can identify subtle cortical dysplasia or other lesions missed on initial MRI evaluation 5

Electroencephalography

• Diagnosis is confirmed by capturing a typical episode during an EEG or video-EEG, with epileptiform activity over one or both temporal regions 3
• Video-EEG monitoring has revolutionized diagnosis and should be considered in patients with uncertain diagnosis 3

Differential Diagnosis

• Temporal lobe seizures can be confused with syncope but can be differentiated by the presence of prodromal symptoms, duration of unconsciousness, and post-event recovery 1
• Psychogenic non-epileptic seizures can be distinguished by eye fluttering, pelvic thrusting, and prolonged duration 1
• Frontal lobe epilepsy may present with similar symptoms but typically has shorter seizures with less post-ictal confusion 5
• Limbic encephalitis can mimic temporal lobe epilepsy symptoms and should be considered, especially with new-onset seizures in adults 5

Treatment Options

Pharmacological Management

• Antiepileptic drugs are the first-line treatment for temporal lobe epilepsy 3
• Medication selection should be based on seizure type, side effect profile, and patient characteristics 1
• Monotherapy is preferred initially, with combination therapy considered for refractory cases 1

Surgical Intervention

• Epilepsy surgery should be considered in all patients with refractory partial epilepsy 3
• Resection of the epileptogenic zone in the temporal lobe can lead to a high rate of seizure control 6
• FDG-PET can help identify the epileptogenic zone for surgical planning, especially when MRI is negative 5
• Surgical outcomes are better when there is concordance between different diagnostic modalities such as PET, ictal SPECT, and ictal EEG 5

Alternative Therapies

• Vagus nerve stimulation is an option for patients who are not candidates for resective surgery 3
• Stress reduction techniques may be beneficial as psychological stress is a common trigger for temporal lobe seizures 7

Clinical Considerations and Pitfalls

• Temporal lobe hypometabolic regions on PET often extend beyond the presumed epileptogenic zone, reflecting broader cerebral dysfunction 5
• Cognitive impairment correlates with extratemporal hypometabolism, involving the mesial frontoparietal networks 5
• Inappropriate use of EEG in cases of clear syncope may lead to misdiagnosis 1
• Psychiatric comorbidities considerably reduce quality of life and should be addressed alongside seizure management 4
• The seizure focus may extend beyond the hippocampus and amygdala in some cases, which may explain incomplete seizure control after standard resection 6