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walking, running), and sometimes prolonged. Manual automatisms may occur only or
predominantly on one side; this is ipsilateral to the side of ictal onset, particularly if
contralateral dystonic posturing is present. Vocalisation is also common, and other motor
automatisms can occur. If speech with identifiable words occurs during a seizure (ictal
speech) this suggests a non-dominant seizure focus (see Loddenkemper and Kotagal9 for a
review of lateralising signs).

Post-ictal confusion and headache are common after focal seizures with loss of awareness
arising from the temporal lobe, and if dysphasia occurs this is a useful lateralising sign
indicating seizure origin in the speech-dominant temporal lobe10. Post-ictal nose-rubbing is
commonly seen in temporal lobe epilepsy, and in 90% of cases is ipsilateral to the focus11.
Amnesia is the rule for the blank spell and the automatism. Secondary generalisation is much
less common than in extra-temporal lobe epilepsy. Patients often complain of poor memory
for recent events, and this may get worse as the epilepsy continues.

The inter-ictal EEG in mediobasal temporal lobe epilepsy usually shows anterior or mid-
temporal spikes. Sphenoidal electrodes may occasionally be necessary for their detection.
Other changes include intermittent or persisting slow activity over the temporal lobes. The
EEG signs can be unilateral or bilateral. Modern MRI will frequently reveal the abnormality
underlying the epilepsy (see Chapter 21).

Epilepsy arising in the lateral temporal neocortex (Table 2)

There is considerable overlap between the clinical and EEG features of mediobasal and lateral
temporal lobe epilepsy12,13. There is often a detectable underlying structural pathology, the
commonest being a glioma, cavernous angioma, hamartoma, dysembryoplastic
neuroepithelial tumour, other benign tumour, malformation of cortical development, and
damage following trauma. There is no association with a history of febrile convulsions.
Consciousness may be preserved for longer than in a typical medial temporal seizure.

The typical aura includes hallucinations which are often structured and of visual, auditory,
gustatory, or olfactory forms (which can be crude or elaborate) or illusions of size (macropsia,
micropsia), shape, distance, or sound. Affective, visceral or psychic auras occur but are less
common than in mediobasal temporal lobe epilepsy. The automatisms can be unilateral and
have more prominent motor manifestations than in mediobasal temporal lobe epilepsy. Post-
ictal phenomena, amnesia for the attack and psychiatric comorbidity are as common in this
form of temporal lobe epilepsy as in the mediobasal form.

The inter-ictal EEG often shows spikes over the temporal region, maximal over the lateral
convexity rather than inferomedial electrodes. Hippocampal volumes and T2 measures on
MRI scanning are usually normal, in contrast to medial temporal epilepsy, and MRI will
reliably demonstrate the other structural lesions responsible for the epilepsy (although in
some patients, imaging studies are normal) (see Chapter 21). Cortical stimulation may elicit
the symptoms of seizures15.

Pharmacological options for temporal lobe epilepsy are the same as for other focal epilepsies,
and surgical treatment may be an option if medication is unsuccessful14 (Section Nine). Class
1 evidence comparing continued medical treatment against temporal lobectomy supports that
surgery is superior to prolonged medical therapy16. Even if scalp EEG suggests bitemporal
lobe epilepsy, intracranial EEG recordings may reveal unilateral seizure onset, and,
particularly in the context of unilateral hippocampal sclerosis or non-lesional temporal lobe
epilepsy, surgical outcomes can still be favourable17.