What is the most common symptom of temporal lobe (TL) epilepsy?

From the Guidelines

The most common symptom of temporal lobe epilepsy is a complex partial seizure, characterized by a loss of consciousness or awareness, often accompanied by automatisms such as lip smacking, chewing, or repetitive movements 1.

Key Characteristics of Complex Partial Seizures

• These seizures typically last between 30 seconds to 2 minutes and may be preceded by an aura, such as a strange sensation or smell 1.
• A typical aura consists of a rising sensation in the abdomen (epigastric aura) and/or an unusual unpleasant smell 1.
• Patients may be confused post-ictally for a long time, whereas in other conditions, clearheadedness is usually immediate 1.

Management of Temporal Lobe Epilepsy

• Medications like carbamazepine (200-400 mg twice daily) or levetiracetam (500-1000 mg twice daily) are often used as first-line treatments to control seizure frequency and severity.
• The development of molecular neuroimaging with interictal [18 F]fluorodeoxyglucose ([18 F] FDG) positron emission tomography (PET), ictal perfusion SPECT, or ictal subtraction perfusion SPECT has influenced and impacted the presurgical management of epilepsy patients, especially for the investigation of non-lesional epilepsy regarding postsurgical seizure outcome 1.
• In patients with drug-resistant focal epilepsy, epilepsy surgery is promising, depending on the epilepsy type, with approximately 65% of patients becoming seizure-free 1.
• The use of [11C]flumazenil ([11C]FMZ) PET has been explored for the detection of epileptogenic zones, particularly in temporal lobe epilepsy, with a reduced level of benzodiazepine receptors found in epileptogenic regions 1.

From the Research

Temporal Lobe Epilepsy Symptoms

The most common symptoms of temporal lobe (TL) epilepsy include:

• Aura, which can manifest as an epigastric sensation or other sensations 2, 3, 4
• Automatisms, such as hand or alimentary automatisms 5, 2, 4
• Behavioral arrest, which can lead to a complete loss of consciousness 6, 2, 4
• Ictal vomiting, which is more commonly associated with right temporal lobe seizures 4
• Unilateral dystonic posturing of an arm, mimetic automatisms, complex gestures, and ictal speech 4

Symptom Clusters and Sequences

Research has identified specific symptom clusters and sequences in temporal lobe epilepsy, including:

• A cluster of symptoms that includes epigastric aura, ictal vomiting, alimentary and hand automatisms 4
• A sequence of symptoms that begins with behavioral arrest, followed by alimentary and hand automatisms, looking around, and whole body movements 4
• A correlation between epigastric sensation and ictal vomiting in psychomotor seizures arising from the right temporal lobe 4

Lateralization of Seizure Activity

Some studies suggest that the lateralization of seizure activity to the left or right temporal lobe may influence the symptoms and severity of temporal lobe epilepsy 6, 5, 4

• Left temporal lobe seizures are more likely to be associated with postictal aphasia and secondarily generalized seizures 5
• Right temporal lobe seizures are more likely to be associated with automatisms and ictal vomiting 5, 4