Temporal Lobe Epilepsy (TLE)

By Dovy Paukstys, Founder, Komori Care

This article is educational and is not medical advice. It does not diagnose, treat, prevent, or cure any condition. Komori is not a medical device, is not FDA-cleared, does not detect seizures, and is not intended for people with epilepsy. Talk with a neurologist or epileptologist about personal medical decisions. Households living with epilepsy should use clinically validated seizure-detection devices as directed by their care team.

A lot of TLE does not look like a fall-down convulsion. It looks like a stare. A smell that isn't there. A wave of fear. Then a couple of minutes nobody can account for.

People get told they zoned out. They didn't.

I'm not a neurologist. I don't have epilepsy. I read the NINDS epilepsy page and the ILAE temporal-lobe and hippocampal sclerosis pages so this hub uses those words, not movie seizures.

What TLE is

NINDS: temporal lobe epilepsy is the most common epilepsy syndrome in people who get focal seizures. Focal seizures come from one part of the brain. About 60 percent of people with epilepsy have those.

TLE often starts in childhood or the teenage years. Auras of nausea, emotions such as déjà vu or fear, or an unusual smell or taste. Then a brief stretch of impaired awareness. Staring. A dream-like state. Repeated automatisms. Mouth movements. Fiddling with the hands. Walking in a circle.

NINDS also says repeated temporal lobe seizures are often tied to shrinkage and scarring of the hippocampus. Hippocampal sclerosis. The hippocampus matters for memory and learning. That is not a side note.

ILAE's 2017 classification paper calls out the same pairing. Mesial temporal lobe seizures with hippocampal sclerosis is a well-recognized structural association. If medicines fail, that pairing is one reason people get referred for surgery evaluation.

Mesial versus lateral. Same lobe, different opening act.

ILAE's temporal lobe seizure page splits the lobe.

Mesial, including the hippocampus. Onset can be a rising stomach sensation, abdominal discomfort, déjà vu or jamais vu, fear, or a bad smell or taste. Those can stay as focal aware seizures or roll into behavioral arrest, slowly fading awareness, chewing, lip-smacking, swallowing, and hand automatisms. Color change. Fast heart rate. Flushing or pallor. Seizures tend to last longer than lateral ones. Spread to a bilateral tonic-clonic seizure is less common.

Lateral, the outer temporal cortex. Opening can be a basic sound. Buzzing. Ringing. Not a full sentence. Or vertigo. Awareness drops earlier. Duration is shorter. Motor spread is more common. Face twitch. Head and eyes turning. Evolution to a bilateral tonic-clonic seizure is more common than on the mesial side.

Infants are sneakier. ILAE says temporal seizures in babies can be pallor, apnea, and a freeze. More motor stuff, even spasms, because a developing brain spreads differently.

What it can be mistaken for

ILAE's caution list is the one I would tape to a primary-care wall.

Temporal impaired-awareness seizures can look like frontal ones. Temporal onset is slower. Postictal confusion is heavier.

They can also look like absence. Both can have automatisms. Temporal seizures are typically longer than 30 seconds, come with pallor, and leave the person foggy after. Absence is shorter and cleaner on the way out.

NINDS says focal seizure symptoms get confused with narcolepsy, fainting, or mental illness. Strange feelings are still neurology until a clinician says they aren't.

Todd's paralysis, temporary weakness on one side after a seizure, can last 30 minutes to 36 hours and can look like a stroke. Let the ER sort a first-time event that looks like one.

Hippocampal sclerosis

ILAE: loss of pyramidal neurons, granule cell dispersion, gliosis in the hippocampus. Nearby structures can be involved. Then it's called mesial temporal sclerosis.

It's a common cause of temporal lobe seizures that do not respond to medicine. Acquired. Can follow seizures, especially prolonged febrile seizures.

About 25 percent of people with hippocampal sclerosis have a febrile seizure history, especially prolonged ones. Typical pattern: febrile seizures, a quiet stretch, then mesial temporal seizures later.

Memory can take a hit that matches the side. Verbal memory when the dominant hippocampus is scarred. Visual memory on the non-dominant side.

Dual pathology is a thing. Hippocampal sclerosis plus another structural problem. Malformation of cortical development. A vascular malformation. ILAE's imaging page says up to one third have dual pathology. Hunt both.

Imaging they want for this: thin-slice volumetric T1, axial and coronal T2 and FLAIR. Atrophy plus high T2/FLAIR signal in the hippocampus. A casual MRI can miss it.

Diagnosis is a history plus tests

NINDS still says the history is one of the best tools. People often don't remember the event. Witnesses matter. What they felt first. How long it lasted. What their hands did.

EEG looks for focal epileptiform discharges. Video-EEG when the events are unclear. MRI, sometimes PET or SPECT, when a surgeon is in the conversation. SEEG if they need electrodes in the brain to find the start point.

None of that is a blog activity.

CDC: about 2.9 million US adults had active epilepsy in 2021, and an estimated 456,000 children 17 or younger in 2022. TLE is a big slice of the focal group. I don't have a fetched TLE-only census, so I'm not inventing one.

Treatment, in general terms

NINDS: medicines first. More than 40 antiseizure drugs exist. One drug when possible. Combinations when one isn't enough. I'm not naming a "best" TLE drug and I'm not dosing anything.

If two appropriate medicines fail, or if there's a clear lesion, surgery enters the chat. NINDS says assess that at a center that actually does this work. Temporal resection is the common operation when the focus is in one removable area. Laser interstitial thermal therapy is the less open option they list. Risks are real. Memory and language sit in this neighborhood.

Vagus nerve stimulation, responsive stimulation, and deep brain stimulation are device options NINDS lists for people who are not surgical candidates or who need another tool. Those are implanted medical devices prescribed by a care team. Not a consumer wearable. Not a nighttime wellness gadget.

SUDEP and TLE, without a product sentence

NINDS: SUDEP is sudden death in someone with epilepsy not explained by injury, drowning, or another known cause. People with seizures that are hard to control have a higher incidence. Taking antiseizure medicine as prescribed is the risk-reduction sentence they use.

Households living with epilepsy should use clinically validated seizure-detection devices as directed by their care team. I will not say a consumer monitor prevents SUDEP. It doesn't, and nobody fetched a page that says it does.

FAQ

What is temporal lobe epilepsy?

The most common epilepsy syndrome among people with focal seizures, per NINDS. Seizures start in one or both temporal lobes. Auras, impaired awareness, automatisms. Often tied to hippocampal sclerosis.

What is an aura in TLE?

A focal aware seizure that can warn a bigger event is coming. NINDS lists nausea, déjà vu, fear, unusual smell or taste. ILAE adds rising epigastric sensation for mesial onset and buzzing or ringing for lateral onset. Same every time, usually.

Is TLE the same as hippocampal sclerosis?

No. Sclerosis is a structural cause. TLE is the epilepsy. You can have temporal lobe seizures without that scar. You can have the scar and a second lesion. ILAE calls that dual pathology.

Who diagnoses TLE?

A physician. Neurologist or epileptologist. History, witness account, EEG, usually MRI. Surgery talk belongs at an epilepsy center. No app diagnoses this from a "funny feeling."

Sources

• NINDS, Epilepsy and Seizures: https://www.ninds.nih.gov/health-information/disorders/epilepsy-and-seizures
• ILAE / epilepsydiagnosis.org, Temporal lobe seizure: https://www.epilepsydiagnosis.org/seizure/temporal-overview.html
• ILAE / epilepsydiagnosis.org, Hippocampal sclerosis: https://www.epilepsydiagnosis.org/aetiology/hippocampal-sclerosis-overview.html
• ILAE / epilepsydiagnosis.org, Hippocampal sclerosis imaging: https://www.epilepsydiagnosis.org/aetiology/hippocampal-sclerosis-imaging.html
• Scheffer et al., ILAE classification of the epilepsies, Epilepsia (2017): https://www.ilae.org/files/dmfile/ClassificationOfEpilepsies_Scheffer_et_al-2017-Epilepsia.pdf
• CDC, Epilepsy Basics: https://www.cdc.gov/epilepsy/about/index.html
• CDC, First Aid for Seizures: https://www.cdc.gov/epilepsy/first-aid-for-seizures/index.html