bioRxiv2026
BACKGROUND AND OBJECTIVESPatients with epilepsy (PWE), especially temporal lobe epilepsy (TLE), experience impaired memory for personally experienced events. However, current assessments of episodic memory are limited in their ecological validity with a potential to miss detection of subtle cognitive decline. We conducted an exploratory study to determine whether a naturalistic film-viewing task with open-ended spoken recall could detect memory differences between TLE patients and healthy controls (HCs). METHODSTLE patients (ages 18-60, fluent in English, not legally blind) were recruited from a Level 4 Epilepsy Center (2018-2024). TLE diagnosis was based on seizure semiology, MRI Brain, and EEG. TLE patients scored [≥]22/30 on the Montreal Cognitive Assessment (MOCA); HCs scored [≥]26/30. Subjects watched 6 short films and then freely recalled film details. Spoken responses were recorded, transcribed, segmented, and scored for film- and event-level recall. Recall order was assessed using the Damerau-Levenshtein distance. Semantic and causal centrality were quantified using sentence embeddings and rater-identified causal links, respectively. Beta regression with cluster-robust standard errors assessed group and centrality effects on recall probability. Beta regression evaluated the influence of age, MOCA, and testing platform on sequence recall error. RESULTSWe recruited 51 subjects (27 TLEs; 24 HCs, 70.1% F, mean 29.9 {+/-}8.3 years). TLE patients and HCs showed similar recall of films (HC 89% {+/-}11% vs TLE 88% {+/-}18%, p = 0.54), coarse events (HC 50% {+/-}16% vs TLE 44% {+/-}18%, p = 0.19) and fine events (HC 25%{+/-}10% vs. TLE 22%{+/-}12%, p=0.17). Both groups recalled high causal centrality events better. For coarse event sequence recall, TLE patients showed a numerical trend toward greater sequence errors compared to HCs (HC 10.8% {+/-} 10.5% vs. TLE 19.5% {+/-} 18%, p = 0.06), although this difference did not reach statistical significance. However, TLE patients showed significantly greater fine event sequence errors at recall than HCs (HC 15% {+/-}13% vs 23% {+/-}18%, p = 0.02, Hedges g = 0.85, Cliffs {delta} = 0.51), with RTLE demonstrating more sequence errors than HCs (15%{+/-}13 vs. 29%{+/-}21% p = 0.021) Age, education, MOCA, and performance on standard verbal and visual memory tasks were unrelated to film, event, and sequence recall performance. DISCUSSIONWe demonstrate that a short film task with spontaneous spoken recall can identify sequence memory impairment in TLE patients despite intact film- and event-level recall. Sequence memory may represent a subtle manifestation of memory impairment that is not detected by standard cognitive testing. Key PointsO_LIWe asked whether a naturalistic film recall task could detect episodic memory impairment in a temporal lobe epilepsy cohort. C_LIO_LIPatients with temporal lobe epilepsy showed comparable film and event recall compared to healthy controls but were found to have impaired sequence memory. C_LIO_LISequential memory for temporal order is an overlooked aspect of episodic memory that may detect subtle memory decline. C_LI