Rarely, laughter may be the most striking feature of a seizure (gelastic epilepsy). A particular combination of gelastic seizures and precocious puberty has been traced to a hamartoma of the hypothalamus. Crying, or dacrystic epilepsy, on the other hand, while demonstrated in children, is very infrequent and more often indicates a psychogenically induced episode.
The patient with temporal lobe seizures may exhibit only one of the foregoing manifestations of seizure activity or various combinations. In a series of 414 patients studied by Lennox, 43 percent displayed some of the motor changes; 32 percent, automatic behavior; and 25 percent, alterations in psychic function. Because of the frequent concurrence of these symptom complexes, he referred to them as the psycho-motor triad. Probably the clinical pattern varies with the precise locality of the lesion and the direction and extent of spread of the electrical discharge.
After the attack, the patient usually has no memory or only fragments of recall for what was said or done. Any type of complex partial seizures may proceed to other forms of secondary generalized seizures. The tendency to generalization holds true for all types of partial or focal epilepsy.
Temporal lobe seizures are not peculiar to any period of life, but they do show an increased incidence in adolescence and the adult years and have an uncertain relationship to childhood febrile seizures. The topic of febrile seizures is broader than this association suggests; it is taken up in a later section of the chapter. Neonatal convulsions, head trauma, and various other nonprogressive perinatal neurologic disorders are other antecedents that place a child at risk of developing complex partial seizures (Rocca et al). Two-thirds of patients with temporal lobe seizures also have generalized tonic-clonic seizures or have had them in early childhood, and it has been theorized that the generalized seizures may have led to secondary excitotoxic damage to the hippocampal portions of the temporal lobes. In the latter cases, carefully performed and quantitated MRI in the coronal plane may disclose a loss of volume and gliosis in the hippocampi and adjacent gyri on one or both sides—that is, medial (or mesial) temporal sclerosis, discussed later in the chapter (Fig. 15-4).
Temporal lobe seizures are highly variable in duration. Behavioral automatisms rarely last longer than a minute or two, although postictal confusion and amnesia may persist for a considerably longer time. Some consist only of a momentary change in facial expression and a blank spell, resembling an absence. Almost always, however, temporal lobe events are characterized by distinct ictal and postictal phases, whereas patients with absence attacks usually have an instantaneous return of full consciousness following the ictus.
Postictal behavior after temporal lobe seizures is often accompanied by widespread or focal slowing in the EEG. Prolonged disorientation for time and place suggests a right-sided source. Automatisms in the postictal period have no lateralizing connotation (Devinsky et al). However, postictal posturing and paresis of an arm (Todd’s paralysis) or an aphasic difficulty are helpful in determining the side of the lesion (Cascino). Postictal nose wiping, which is reported on video recording to occur in half of patients with temporal lobe seizures, is carried out by the hand ipsilateral to the seizure focus according to Leutzmezer and colleagues.