Summary Epilepsy due to encephaloceles of the temporal pole may be an under recognized, treatable cause of refractory temporal lobe epilepsy (TLE). We describe three adult patients initially labeled “lesion negative” TLE. In all, video–electroencephalography (EEG) revealed ictal theta in the left temporal region and positron emission tomography (PET) showed temporal lobe hypometabolism, but neuropsychology revealed preserved verbal memory. Close inspection of structural magnetic resonance imaging (MRI) suggested subtle abnormalities at the tip of the left temporal lobe. High resolution computed tomography (CT) confirmed bony defects in the inner table of the skull. 3T MRI with fine coronal and sagittal slices indicated cerebrospinal fluid (CSF) and brain tissue protruding into the defects. All proceeded to resection of the temporal tip and became seizure free. Patients with “lesion negative” TLE should have careful review of images covering the temporal pole. If encephalocele is suspected, further imaging with high‐resolution CT and MRI can be helpful. Temporal polar resection, sparing mesial structures, appears to be curative.

An immobile or fasciculating tongue is an unusual finding in isolation. Its presence generally indicates a problem with the hypoglossal nerve which controls all the intrinsic and extrinsic muscles of the tongue except the palatoglossus and has five segments; the medullary, cisternal, skull base, carotid space and sublingual. This case series discusses five patients who initially presented with isolated hypoglossal nerve palsies. In each patient the lesion localised to a different segment of the nerve with clear imaging confirmation to support their respective causes. The cases (in anatomical order) include hypoglossal nerve damage as a complication of over-shunting in a patient with idiopathic intracranial hypertension, hypoglossal chronic inflammatory demyelinating polyneuropathy, hypoglossal canal fracture, glomus tumour and tongue malignancy. These cases highlight the broad range of differential diagnoses that should come to mind when assessing a patient with poor tongue movement, wasting and or fasciculation. A structured, anatomical approach to lesions of the hypoglossal nerve is fundamental to accurate diagnosis.