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led to secondary ischemic 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 in the hippocampi and adjacent gyri on one or both sides ie, medial temporal sclerosis (Fig 16-2) Complex partial seizures are notably 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 complex partial seizures consist only of a momentary change in facial expression and a blank spell, resembling an absence Almost always, however, the former 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 partial complex seizures is often accompanied by widespread slowing in the EEG With seizures of left-sided origin there is likely to be global and non uent aphasia 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 dif culty are helpful in determining the side of the lesion (Cascino) Also, postictal nose wiping is carried out by the hand ipsilateral to the seizure focus in 97 percent of patients, according to Leutzmezer and colleagues, but we are in no position to con rm this Amnesic Seizures Rarely, brief, recurrent attacks of transient amnesia are the only manifestations of temporal lobe epilepsy, although it is unclear whether the amnesia in such patients represents an ictal or postictal phenomenon These attacks of pure amnesia have been referred to as transient epileptic amnesia, or TEA (Palmini et al; Zeman et al) If the patient functions at a fairly high level during the attack, as may happen, there is some resemblance to transient global amnesia (page 379) However, the brevity and frequency of the TEA spells, their tendency to occur on awakening, the impaired performance on complex cognitive tasks, and, of course, a history of epilepsy and associated seizure discharges in the EEG help to make the distinction Behavioral and Psychiatric Disorders Some comments are in order concerning the issues of personality, behavioral, and psychiatric disorders in patients with complex partial seizures Data as to prevalence of these disorders are limited and have been derived mainly from studies of selected groups of patients attending university hospitals and other specialty clinics that tend to treat the most dif cult and complicated cases In one such study (Victoroff), about one-third of the patients had a history of major depressive illness, and an equal number had symptoms of anxiety disorder; psychotic symptoms were found in 10 percent Similar gures, also from a university-based epilepsy center, have been reported by Blumer et al It must be emphasized that these remarkable rates of psychiatric morbidity do not re ect the prevalence in the entire population of epileptics The postictal state in patients with temporal lobe epilepsy sometimes takes the form of a protracted paranoid-delusional or amnesic psychosis lasting for days or weeks The EEG during this period may show no seizure discharge, though this does not exclude repeated or sustained seizure activity in the amygdala and other deep temporal lobe structures This disorder, virtually indistinguishable from schizophrenia in form (but not in temporal evolution), may also present in the interictal period An excess of psy-.

Figure 16-2 Medial temporal sclerosis A Thin-slice volumetric MRI in the coronal plane, showing shrinkage of the right hippocampus (shown by arrow) and secondary enlargement of the temporal horn of the lateral ventricle B T2-weighted image showing signal change in the hippocampi (shown by arrow) (Courtesy of Dr Peter Williamson)

chosis has been reported only in studies emanating from specialized centers; epidemiologic studies provide only limited evidence of an association with psychosis in the overall population of epileptics (see Trimble and Schmitz and the review by Trimble for a critical discussion of this subject) Again, the frequency of this association with temporal lobe epilepsy is uncertain Epileptic Personality Disorder It has long been observed that some patients with temporal lobe seizures may exhibit a number of abnormalities of behavior and personality during the interictal period Often they are slow and rigid in their thinking, verbose, circumstantial and tedious in conversation, inclined to mysticism, and preoccupied with rather naive religious and philosophical ideas Also, they are often subject to outbursts of bad temper and aggressiveness Obsessionalism, humorless sobriety, emotionality (mood swings, sadness and anger), and a tendency to paranoia are other frequently described traits Diminished sexual interest and potency in men and menstrual problems in women, not readily attributable to anticonvulsant drugs, are common among patients with complex partial seizures of temporal lobe origin Geschwind proposed that a triad of behavioral abnormalities hyposexuality, hypergraphia, and hyperreligiosity constitute a characteristic syndrome in such patients Bear and Fedio have suggested that certain of these traits (obsessionalism, elation, sadness, and emotionality) are more common with right temporal lesions and that anger, paranoia, and cosmologic or religious conceptualizing are more characteristic of left temporal lesions However, Rodin and Schmaltz, who administered the Bear-Fedio inventory to patients with both primary generalized and temporal lobe epilepsy, found no features that would distinguish patients with right-sided temporal foci from those with leftsided ones Moreoever, they found no behavioral changes that

would distinguish patients with temporal lobe epilepsy from other groups of epileptics The problem of personality disturbances in epilepsy remains to be clari ed (see review by Trimble)

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There remain to be considered several epileptic syndromes and other seizure states that cannot be readily classi ed with the usual types of generalized or partial seizures These special types are described below

Benign Childhood Epilepsy with Centrotemporal Spikes (Rolandic Epilepsy, Sylvian Epilepsy) and Epilepsy with Occipital Spikes