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Although TLE is classified as a focal epilepsy, it has traditionally been defined by hippocampal and extra-hippocampal atrophy. However, several studies also report regions of increased cortical thickness, or cortical hypertrophy, in TLE, challenging the notion that structural change in epilepsy is unidirectional. In this narrative review, we synthesize evidence for cortical hypertrophy in TLE and place these findings in a broader neurobiological context. We provide an overview of cortical thickness and MRI approaches used to measure it, highlighting differences between surface-based, volume-based and voxel-based methods. We then review MRI studies reporting cortical hypertrophy in TLE, noting variability in affected regions, patient populations and analytical techniques. We discuss potential mechanisms that may underlie cortical hypertrophy, including seizure-related structural remodelling, glial or inflammatory processes, compensatory neuroplasticity, network effects and methodological limitations. Finally, we outline key gaps and controversies regarding the biological validity, temporal dynamics and clinical relevance of cortical hypertrophy in TLE. We conclude that consideration of both cortical atrophy and hypertrophy may improve broader understanding of TLE as a disorder involving brain remodelling rather than isolated regional atrophy.<\/jats:p>","DOI":"10.1093\/brain\/awag214","type":"journal-article","created":{"date-parts":[[2026,6,19]],"date-time":"2026-06-19T11:52:40Z","timestamp":1781869960000},"page":"3379-3386","source":"Crossref","is-referenced-by-count":0,"title":["Rethinking cortical hypertrophy in temporal lobe epilepsy"],"prefix":"10.1093","volume":"149","author":[{"given":"H\u00e9l\u00e8ne","family":"Cossette-Roberge","sequence":"first","affiliation":[{"name":"Department of Medicine, Universit\u00e9 de Sherbrooke , Sherbrooke, Qu\u00e9bec J1H 5N4 ,","place":["Canada"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Binh Thanh","family":"Nguyen","sequence":"additional","affiliation":[{"name":"Department of Medical Imaging and Radiation Sciences, Centre de Recherche du CHUS, Universit\u00e9 de Sherbrooke , Sherbrooke, Qu\u00e9bec J1H 5N4 ,","place":["Canada"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Fatemeh","family":"Fadaie","sequence":"additional","affiliation":[{"name":"Department of Neurology and Neurosurgery, Montreal Neurological Institute and Hospital, McGill University , Montr\u00e9al, Qu\u00e9bec H3A 2B4 ,","place":["Canada"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Charles","family":"Deacon","sequence":"additional","affiliation":[{"name":"Department of Medicine, Universit\u00e9 de Sherbrooke , Sherbrooke, Qu\u00e9bec J1H 5N4 ,","place":["Canada"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Boris C","family":"Bernhardt","sequence":"additional","affiliation":[{"name":"Department of Neurology and Neurosurgery, Montreal Neurological Institute and Hospital, McGill University , Montr\u00e9al, Qu\u00e9bec H3A 2B4 ,","place":["Canada"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5487-0923","authenticated-orcid":false,"given":"Fr\u00e9d\u00e9ric L W V J","family":"Schaper","sequence":"additional","affiliation":[{"name":"Center for Brain Circuit Therapeutics, Brigham and Women\u2019s Hospital, Harvard University , Boston, MA 02115 ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3849-4168","authenticated-orcid":false,"given":"Davide","family":"Giampiccolo","sequence":"additional","affiliation":[{"name":"Department of Epilepsy, UCL Queen Square Institute of Neurology, University College London , London WC1N 3BG ,","place":["UK"]},{"name":"Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery , London WC1N 3BG ,","place":["UK"]},{"name":"Institute of Neuroscience, Cleveland Clinic London , London SW1X 7HY ,","place":["UK"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sara","family":"Larivi\u00e8re","sequence":"additional","affiliation":[{"name":"Department of Medical Imaging and Radiation Sciences, Centre de Recherche du CHUS, Universit\u00e9 de Sherbrooke , Sherbrooke, Qu\u00e9bec J1H 5N4 ,","place":["Canada"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2026,6,22]]},"reference":[{"key":"2026100419581980200_awag214-B1","doi-asserted-by":"crossref","first-page":"141","DOI":"10.1016\/S0920-1211(96)00043-5","article-title":"Introduction to temporal lobe epilepsy","volume":"26","author":"Engel","year":"1996","journal-title":"Epilepsy Res."},{"key":"2026100419581980200_awag214-B2","doi-asserted-by":"crossref","first-page":"223","DOI":"10.1212\/01.wnl.0000169066.46912.fa","article-title":"Progression in temporal lobe epilepsy: Differential atrophy in mesial temporal 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