Insular seizures and epilepsies: Ictal semiology and minimal invasive surgery

Painful Todd's: Post-ictal painful hemiparesis as an identifier of insular epilepsy

The insula can generate seizures which mimic frontal, temporal and parietal epilepsies making electroclinical localization difficult. We report the case of a twenty-one-year-old woman who presented with seizure semiology of a left-sided painful somatosensory aura, progressing to bilateral tonic posturing and complex manual automatisms. She described a painful sensation and weakness affecting her left side following the offset of a seizure, with the pain consistenly outlasting the weakness. This would last from hours to days depending on the severity and duration of the seizure. Stereo-electroencephalography (SEEG) demonstrated seizure onset in the limen of the right insula. Extra-operative stimulation of the insula reproduced the clinical symptoms. She underwent radiofrequency thermocoagulation (RFTC) which has resulted in a significant reduction in seizure frequency. This case report describes a lateralized painful Todd's phenomenon as a feature of insular epilepsy confirmed by SEEG and extra-operative stimulation.

Neuropsychological and behavioural outcomes in epilepsy involving the insula: A scoping review

Objective: In patients with epilepsy, the insula has been increasingly recognized as a common site of seizures. There is growing interest in understanding the cognitive and psychological consequences of insular epilepsy to help provide clinical recommendations to support patient's cognitive and psychosocial functioning, and to help identify candidates for epilepsy resective surgery. The aim of this scoping review was to describe the cognitive and behavioural characteristics associated with insular epilepsy in children and adults. Method: A systematic search was completed according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis -Extension for Scoping Reviews guidelines. Eligible studies reported on a neuropsychological or behavioural outcome, using standardized or research-based psychological measures, in individuals with insular epilepsy, (i.e. the seizure focus and/or surgical resection included the insula), and a comparison group. After duplicates were removed, 2,423 citations were identified from the search, and 39 studies were included in the scoping review. Results: Across the included studies, intellectual/global cognitive functioning and language were most often evaluated. Lower functioning was found across multiple cognitive and behavioural processes in pediatric and adult patients with insular epilepsy. Following resective surgery involving the insula, behavioural and cognitive outcomes are general stable. Conclusions: The results of this scoping review further neuropsychologists' knowledge of the cognitive and behavioural outcomes of insular seizures prior to and following surgical treatment. These results can aid in counselling patients of the potential cognitive dysfunctions, and aid with treatment planning.

Innovative minimally invasive options to treat drug-resistant epilepsies

Despite the regular discovery of new molecules, one-third of epileptic patients are resistant to antiepileptic drugs. Only a few can benefit from resective surgery, the current gold standard. Although effective in 50-70% of cases, this therapy remains risky, costly, and can be associated with long-term cognitive or neurological side effects. In addition, patients are increasingly reluctant to have a craniotomy, emphasizing the need for new less invasive therapies for focal drug-resistant epilepsies. Here, we review different minimally invasive approaches already in use in the clinic or under preclinical development to treat drug-resistant epilepsies. Localized thermolesion of the epileptogenic zone has been developed in the clinic using high-frequency thermo-coagulations or magnetic resonance imaging-guided laser or ultrasounds. Although less invasive, they have not yet significantly improved the outcomes when compared with resective surgery. Radiosurgery techniques have been used in the clinic for the last 20years and have proven efficiency. However, their efficacy is not better than resective surgery, and various side effects have been reported as well as the potential risk of sudden unexpected death associated with epilepsy. Recently, a new strategy of radiosurgery has emerged using synchrotron-generated X-ray microbeams: microbeam radiation therapy (MRT). The low divergence and high-flux of the synchrotron beams and the unique tolerance to MRT by healthy brain tissues, allows a precise targeting of specific brain regions with minimal invasiveness and limited behavioral or functional consequences in animals. Antiepileptic effects over several months have been recorded in animal models, and histological and synaptic tracing analysis suggest a reduction of neuronal connectivity as a mechanism of action. The possibility of transferring this approach to epileptic patients is discussed in this review.

Resting-State Functional Connectivity Profile of Insular Subregions

The insula is often considered the fifth lobe of the brain and is increasingly recognized as one of the most connected regions in the brain, with widespread connections to cortical and subcortical structures. As a follow-up to our previous tractography work, we investigated the resting-state functional connectivity (rsFC) profiles of insular subregions and assessed their concordance with structural connectivity. We used the CONN toolbox to analyze the rsFC of the same 19 insular regions of interest (ROIs) we used in our prior tractography work and regrouped them into six subregions based on their connectivity pattern similarity. Our analysis of 50 healthy participants confirms the known broad connectivity of the insula and shows novel and specific whole-brain and intra-connectivity patterns of insular subregions. By examining such subregions, our findings provide a more detailed pattern of connectivity than prior studies that may prove useful for comparison between patients.

Focused ultrasounds: What is their future in epileptology? A critical review

High intensity focused ultrasounds (HIFU) are being increasingly advocated as a useful tool in the management of focal drug-resistant epilepsy. Our aim was to review current literature on the topic and perform an inventory of open trials assessing HIFU effectiveness and safety in epilepsy management. To do so, a review was conducted and yielded one prospective clinical trials, two case reports and one safety study were retrieved, indicating that HIFU is still in its infancy when it comes to focal drug-resistant epilepsy therapy. Efforts should be made to develop this technology using multicentric prospective data with larger cohorts and prolonged follow-up.

Neurological morbidity of surgery for suprasylvian operculoinsular epilepsy

OBJECTIVE

The objective of this study was to identify risk factors associated with surgery-related neurological morbidity in patients with drug-resistant epilepsy undergoing suprasylvian operculoinsular resections. As secondary outcomes, we also analyzed the risk factors for ischemic lesion (IL) of corona radiata and seizure recurrence.

METHODS

A retrospective analysis was conducted on a cohort of patients who underwent suprasylvian operculoinsular resections for drug-resistant epilepsy. The association of several presurgical, surgical, and postsurgical factors with both primary (persistent neurological deficits) and secondary (structural abnormalities on postoperative magnetic resonance imaging [MRI] and seizure recurrence) postoperative outcomes was investigated with univariate and multivariate statistical analysis.

RESULTS

The study included a total of 65 patients; 46.2% of patients exhibited postoperative neurological deficits, but only 12.3% experienced persistent deficits. On postoperative MRI, IL in the corona radiata and corticospinal tract Wallerian degeneration (CSTWd) were seen in 68% and 29% of cases, respectively. Only CSTWd was significantly associated with persistent neurological deficits (relative risk [RR] = 2.6). Combined operculoinsular resection (RR = 3.62) and surgery performed on the left hemisphere (RR = .37) were independently associated with IL in the corona radiata. Variables independently associated with CSTWd were the presence of malacic components in the IL (RR = 1.96), right central operculum resection (RR = 1.79), and increasing age at surgery (RR = 1.03). Sixty-two patients had a postoperative follow-up > 12 months (median = 56, interquartile range = 30.75-73.5), and 62.9% were in Engel class I at last outpatient control. The risk of seizure recurrence was reduced by selective opercular resection (RR = .25) and increased by the histological diagnosis of aspecific gliosis (RR = 1.39).

SIGNIFICANCE

This study provides insights into the risk factors associated with surgery-related neurological morbidity, as well as further evidence on the postoperative occurrence of subcortical injury and seizure recurrence in epileptic patients undergoing suprasylvian operculoinsular resections. The findings highlighted in this study may be useful to better understand the processes supporting the increased surgical risk in the operculoinsular region.

Current state of the art of traditional and minimal invasive epilepsy surgery approaches

Introduction

Open resective surgery remains the main treatment modality for refractory epilepsy, but is often considered a last resort option due to its invasiveness.

Research question

This manuscript aims to provide an overview on traditional as well as minimally invasive surgical approaches in modern state of the art epilepsy surgery.

Materials and methods

This narrative review addresses both historical and contemporary as well as minimal invasive surgical approaches in epilepsy surgery. Peer-reviewed published articles were retrieved from PubMed and Scopus. Only articles written in English were considered for this work. A range of traditional and minimally invasive surgical approaches in epilepsy surgery were examined, and their respective advantages and disadvantages have been summarized.

Results

The following approaches and techniques are discussed: minimally invasive diagnostics in epilepsy surgery, anterior temporal lobectomy, functional temporal lobectomy, selective amygdalohippocampectomy through a transsylvian, transcortical, or subtemporal approach, insulo-opercular corticectomies compared to laser interstitial thermal therapy, radiofrequency thermocoagulation, stereotactic radiosurgery, neuromodulation, high intensity focused ultrasound, and disconnection surgery including callosotomy, hemispherotomy, and subpial transections.

Discussion and conclusion

Understanding the benefits and disadvantages of different surgical approaches and strategies in traditional and minimal invasive epilepsy surgery might improve the surgical decision tree, as not all procedures are appropriate for all patients.

Towards a better identification of ictal semiology patterns in insular epilepsies: A stereo-EEG study

OBJECTIVE

To describe pure insular ictal semiology and patterns of extra-insular spread demonstrated by stereoelectroencephalography (SEEG) according to a classification based on the insular cytoarchitecture.

METHODS

We investigated the ictal semiology in 17 patients undergoing SEEG for insular epilepsy. The insular cortex was divided into three regions roughly overlapping with the agranular, dysgranular and granular regions. Ictal semiology was described accordingly: anterior insula (AI, short anterior and middle gyri), middle insula (MI, short posterior and long anterior gyri) and posterior insula (PI, long posterior gyrus).

RESULTS

Awareness impairment occurred secondarily to extra-insular ictal spread. Subjective manifestations were constant. AI seizures (n = 3) presented with autonomic (increased heart rate [HR], respiratory changes), oropharyngeal (mainly throat sensations), emotional (fear, anguish) semiology and the "hand-to-throat" sign followed by frontal-like semiology. MI seizures (n = 8) presented with mainly non-painful paresthesia, some autonomic (respiratory, increased HR), oropharyngeal or thermic symptoms and early motor features with spread to the opercular cortex. PI seizures (n = 6) were characterized by somatosensory semiology, mainly paresthesia potentially painful, and cephalic sensations.

CONCLUSIONS

Cytoarchitectonic-based classification and the corresponding ictal features support the antero-posterior grading of insular seizures and highlight specific ictal symptoms.

SIGNIFICANCE

This refinement of insular semiology can help optimize the planning of SEEG for presumed insular epilepsy.

Insula in epilepsy - "untying the gordian knot": A systematic review

PURPOSE

Despite significant advances in epileptology, there are still many uncertainties about the role of the insula in epilepsy. Until recently, most insular onset seizures were wrongly attributed to the temporal lobe. Further, there are no standardised approaches to the diagnosis and treatment of insular onset seizures. This systematic review gathers the available information about insular epilepsy and synthesizes current knowledge as a basis for future research.

METHOD

Adhering to the PRISMA guidelines, studies were meticulously extracted from the PubMed database. The empirical data pertaining to the semiology of insular seizures, insular networks in epilepsy, techniques of mapping the insula, and the surgical intricacies of non-lesional insular epilepsy were reviewed from published studies. The corpus of information available was then subjected to a process of concise summarization and astute synthesis.

RESULTS

Out of 235 studies identified for full-text review, 86 studies were included in the systematic review. The insula emerges as a brain region with a number of functional subdivisions. The semiology of insular seizures is diverse and depends on the involvement of particular subdivisions. The semiological heterogeneity of insular seizures is explained by the extensive connectivity of the insula and its subdivisions with all four lobes of the brain, deep grey matter structures, and remote brainstem areas. The mainstay of the diagnosis of seizure onset in the insula is stereoelectroencephalography (SEEG). The surgical resection of the insular epileptogenic zone (when possible) is the most effective treatment. Open surgery on the insula is challenging but magnetic resonance-guided laser interstitial thermal therapy (MRgLITT) also holds promise.

CONCLUSION

The physiological and functional roles of the insula in epilepsy have remained obfuscated. The dearth of precisely defined diagnostic and therapeutic protocols acts as an impediment to scientific advancement. This review could potentially facilitate forthcoming research endeavours by establishing a foundational framework for uniform data collection protocols, thereby enhancing the feasibility of comparing findings across future studies and promoting progress in this domain.

Laser interstitial thermal therapy for the treatment of insular lesions: A systematic review

Background

The surgical treatment of insular lesions has been historically associated with high morbidity. Laser interstitial thermal therapy (LITT) has been increasingly used in the treatment of insular lesions, commonly neoplastic or epileptogenic. Stereotaxis is used to guide laser probes to the insula where real-time magnetic resonance thermometry defines lesion creation. There is an absence of previously published reviews on insular LITT, despite a rapid uptake in use, making further study imperative.

Methods

Here we present a systematic review of the PubMed and Scopus databases, examining the reported clinical indications, outcomes, and adverse effects of insular LITT.

Results

A review of the literature revealed 10 retrospective studies reporting on 53 patients (43 pediatric and 10 adults) that were treated with insular LITT. 87% of cases were for the treatment of epilepsy, with 89% of patients achieving seizure outcomes of Engle I-III following treatment. The other 13% of cases reported on insular tumors and radiological improvement was seen in all cases following treatment. All but one study reported adverse events following LITT with a rate of 37%. The most common adverse events were transient hemiparesis (29%) and transient aphasia (6%). One patient experienced an intracerebral hemorrhage, which required a decompressive hemicraniectomy, with subsequent full recovery.

Conclusion

This systematic review highlights the suitability of LITT for the treatment of both insular seizure foci and insular tumors. Despite the growing use of this technique, prospective studies remain absent in the literature. Future work should directly evaluate the efficacy of LITT with randomized and controlled trials.

Insular Involvement in Cases of Epilepsy Surgery Failure

Background: Epilepsy surgery failure is not uncommon, with several explanations having been proposed. In this series, we detail cases of epilepsy surgery failure subsequently attributed to insular involvement. Methods: We retrospectively identified patients investigated at the epilepsy monitoring units of two Canadian tertiary care centers (2004–2020). Included patients were adults who had undergone epilepsy surgeries with recurrence of seizures post-operatively and who were subsequently determined to have an insular epileptogenic focus. Clinical, electrophysiological, neuroimaging, and surgical data were synthesized. Results: We present 14 patients who demonstrated insular epileptic activity post-surgery-failure as detected by intracranial EEG, MEG, or seizure improvement after insular resection. Seven patients had manifestations evoking possible insular involvement prior to their first surgery. Most patients (8/14) had initial surgeries targeting the temporal lobe. Seizure recurrence ranged from the immediate post-operative period to one year. The main modality used to determine insular involvement was MEG (8/14). Nine patients underwent re-operations that included insular resection; seven achieved a favorable post-operative outcome (Engel I or II). Conclusions: Our series suggests that lowering the threshold for suspecting insular epilepsy may be necessary to improve epilepsy surgery outcomes. Detecting insular epilepsy post-surgery-failure may allow for re-operations which may lead to good outcomes.

Knowledge Atlas of Insular Epilepsy: A Bibliometric Analysis

OBJECTIVE

In order to determine research hotspots and prospective directions, this work used VOSviewer and CiteSpace to assess the current state of insular epilepsy research.

METHODS

We looked for pertinent research about insular epilepsy published between the first of January 2000 and the thirtieth of April 2022 in the Web of Science Core Collection (WoSCC) database. CiteSpace and VOSviewer were used to build a knowledge atlas by analyzing authors, institutions, countries, keywords with citation bursts, keyword clustering, keyword co-occurrence, publishing journals, reference co-citation patterns, and other factors.

RESULTS

A total of 305 publications on insular epilepsy were found. Nguyen DK had the most articles published (37), whereas Mauguière F and Isnard J had the highest average number of citations/publications (39.37 and 38.09, respectively). The leading countries and institutions in this field were the United States (82 papers) and Université de Montréal (40 papers). Authors, countries, and institutions appear to be actively collaborating. Hot topics and research frontiers included surgical treatment, functional network connectivity, and the application of neuroimaging methods to study insular epilepsy.

CONCLUSION

In summary, the most influential articles, authors, journals, organizations, and countries on the subject of insular epilepsy were determined by this analysis. This study investigated the area of insular epilepsy research and forecasted upcoming trends using co-occurrence and evolution methods.

Ictal semiology of epileptic seizures with insulo-opercular genesis

Objective

Epileptic seizures with insular genesis are often difficult to distinguish from those originating in the temporal lobe due to their complex and variable semiology. Here, we analyzed differentiating characteristics in the clinical spectrum of insulo-opercular seizures.

Methods

Ictal semiology in patients with a diagnosis of insulo-opercular epilepsy (IOE) based on imaging of epileptogenic lesions or electrophysiological evidence of an insulo-opercular seizure origin was retrospectively analyzed and compared to age-matched controls with mesial temporal lobe epilepsy (MTE).

Results

Forty-six IOE and 46 matched MTE patients were included. The most prominent ictal features in IOE were focal motor phenomena in 80.4% of these patients. Somatosensory sensations, version, tonic and clonic features, when present, were more frequent contralateral to the SOZ in MTE patients, while they occurred about equally often ipsilateral and contralateral to the SOZ in IOE patients. Ipsilateral manual automatisms were significantly more frequent in MTE patients than in IOE (p = 0.010). Multivariate analysis correctly identified IOE in 78.3% and MTE in 84.8% using five semiologic features (Chi-square = 53.79 with 5 degrees of freedom, p < 0.0001). A subanalysis comparing patients with purely insular lesions with MTE patients using only the earliest ictal signs showed that somatosensory sensations are significantly more frequent in insular epilepsy (p = 0.010), while automatisms were significantly more frequent in MTE patients (p = 0.06).

Significance

Our study represents the first in-depth analysis of ictal semiology in IOE compared to MTE. Use of these differentiating characteristics can serve for a correct syndrome classification and to steer appropriate diagnostic and local therapeutic procedures.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00415-021-10911-0.