Ictal behavioral characteristics may provide clues in determining the nature of the epileptic focus. We defined ictal behavioral characteristics in patients with intractable temporal lobe epilepsy (TLE) who underwent anterior temporal lobectomy (ATL) and lived seizure-free for 2 years of follow-up. Video/EEG data on 282 seizures observed in 48 patients who suffered from TLE and underwent ATL were analyzed. All patients were seizure-free after surgery. We divided the patients into two groups on the basis of the pathological examination. Two hundred and two seizures in 35 patients with hippocampal sclerosis (Group 1) and eighty seizures in 13 patients with other pathological findings, such as tumors, cavernoma, and hamartoma (Group 2), were analyzed. Ictal behavior characteristics were evaluated for each of the seizures recorded in the two groups. Behavioral arrest, bilateral hand automatisms, oral and leg automatisms, and ictal aggression were significantly more frequent in Group 2 (P < 0.05), whereas contralateral dystonia of the upper extremity (P < 0.05), ipsilateral hand automatisms (P < 0.05), ipsilateral hand automatisms in the presence of contralateral dystonia of the upper extremity (P < 0.001), contralateral forced head deviation (P < 0.05), and secondary generalization (P < 0.05) were more significant in Group 1. There was no significant difference in vocalization and ipsilateral nonforced head deviation between the two groups (P > 0.05). The number of seizures observed during ictal speech, crying, and postictal nose wiping was not large enough, so differences could not be analyzed. It was concluded that although ictal behavioral characteristics differed between the two groups, certain behavioral patterns may be helpful in differentiating between hippocampal sclerosis and other pathology. (c) 2005 Elsevier Inc. All rights reserved.