Temporal lobe seizures are characterized by behavioral arrest with loss of awareness (dyscognitive features). Automatisms are common and include oro-alimentary and/or gestural automatisms. Seizures often commence with an aura which can be experiential such as fear or déjà vu. Epigastric and auditory aura also occur. Autonomic features are common including pallor and palpitations. Postictal confusion typically occurs.

Specific features suggest seizure onset in the dominant or non-dominant temporal lobe (see hemispheric lateralization). Ictal speech, spitting, vomiting, drinking, urge to urinate and automatisms with preserved consciousness suggest seizure onset in the non-dominant temporal lobe. Postictal speech disturbance suggests a dominant temporal lobe seizure. Upper limb dystonia is a useful lateralizing feature, lateralizing the seizure to the contralateral hemisphere. Conversely, manual automatisms usually occur on the ipsilateral side.

In infants, temporal seizures may be subtle and manifest with pallor, apnoea and behavioral arrest. There may be earlier and more marked motor manifestations including tonic events and epileptic spasms, which may reflect different patterns of spread in the developing brain.

CAUTION Temporal focal dyscognitive seizures can have similar features to frontal seizures, however dyscognitive seizures of temporal origin tend to have a slower onset and progression, and postictal confusion is more pronounced.

CAUTION Temporal focal dyscognitive seizures need to be distinguished from absence seizures. While both may have automatisms, temporal lobe seizures are typically longer (> 30 seconds), associated with pallor, and followed by postictal confusion.

Subtypes of temporal lobe seizures

  1. Mesial temporal lobe including hippocampus

    Seizures that arise in the mesial temporal lobe may be characterized by distinctive auras such as a rising epigastric sensation or abdominal discomfort and experiential features such as déjà vu, jamais vu and fear. Unpleasant olfactory and gustatory auras may also occur. Auras may occur in isolation or may be followed by the onset of behavioral arrest with slowly progressive impairment of awareness and oro-alimentary (chewing, lip-smacking, swallowing, tongue movements) and manual automatisms. Autonomic phenomena (pallor, flushing, tachycardia) are common. Upper limb automatisms may be unilateral and may lateralize the seizure to the ipsilateral hemisphere. Unilateral pupillary dilatation can occur, and can also lateralize the seizure to the ipsilateral hemisphere. Contralateral upper limb dystonia may develop and head and eye version to the contralateral side can occur. Whilst seizures tend to have a longer duration than for lateral temporal lobe seizures, evolution to a bilateral convulsion is uncommon.

  2. Lateral / neocortical temporal lobe

    Lateral temporal lobe seizures may have an initial aura with auditory, complex visual, illusionary or vertiginous features. The auditory aura is usually a basic sound such as buzzing or ringing (rather than formed speech). If the aura is heard in only one ear it suggests the seizure is in the contralateral hemisphere. In comparison to mesial temporal lobe seizures, seizures are of shorter duration, and the onset of altered awareness is an earlier feature (the initial aura is not as prolonged). Lateral temporal lobe seizures may spread and motor features such as contralateral upper limb dystonia, facial twitching or grimacing, and head and eye version may occur. Evolution to a bilateral convulsion is more common than in mesial temporal lobe seizures.

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