Amygdala enlargement in pediatric epilepsy: A clinically meaningful finding?

Amygdala enlargement (AE) is an increasingly recognized finding in temporal lobe epilepsy (TLE), particularly in patients without clear magnetic resonance imaging (MRI) lesions. While AE has been associated with later seizure onset, mood symptoms, and immune-mediated mechanisms, its role in epilepsy remains unclear. AE is not consistently epileptogenic and may be present in other epilepsy syndromes and even in healthy individuals. Most studies focus on adults; little is known about AE in pediatric TLE. We present a pediatric case series examining clinical, neuroimaging, and outcome data to clarify the significance of AE in this population.

A retrospective chart review was conducted at Children's Medical Center Dallas and Plano. Pediatric patients with AE identified on MRI between January 1, 2000, and May 1, 2025 were included. Collected variables included seizure characteristics, epilepsy etiology and workup, prognosis, treatment details, and psychiatric comorbidities.

Thirty-nine patients were included in this study. Median age at seizure onset was eight. Eleven patients had right side AE, 19 had left side AE and nine had bilateral AE. AE was concordant to epilepsy laterality in 22 patients. Intractable epilepsy was present in 19 patients. Developmental delay/intellectual disability was present in 18 patients and five patients had mention of a mood disorder. Autoimmune testing was done in 13 patients with one positive result.

AE is associated with epilepsy, with a high prevalence of intractability in pediatric patients. There was low correlation of identified, autoimmune-mediated disease with AE.