Surgery for Nontumoral Insular Epilepsy Explored by Stereoelectroencephalography

Gras-Combe, Guillaume; Minotti, Lorella; Hoffmann, D.; Krainik, Alexandre; Kahane, Philippe; Chabardès, Stéphan

doi:10.1227/neu.0000000000001257

Cited by 52 publications

(55 citation statements)

References 43 publications

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“…Presurgical evaluation included video-electroencephalographic (EEG) recordings, high-resolution magnetic resonance imaging (MRI), functional MRI, and 18 F-fluorodeoxyglucose positron emission tomography ( 18 F-FDG-PET) scan coregistered with MRI for all patients. In addition, 16 patients underwent SEEG, five of them having two procedures.…”

Section: Presurgical Workupmentioning

confidence: 99%

“…MRI protocol included three-dimensional (3D) T1-weighted 1.2-mm-thick contiguous slices, and coronal T2-weighted and fluid-attenuated inversion recovery (FLAIR) sequences (1.5 T in six patients, 3 T in 13). 18…”

Section: Presurgical Workupmentioning

confidence: 99%

“…However, the insula lies deep in the sylvian fissure, covered by eloquent frontal, temporal, and parietal opercula with a dense network of vessels. This makes open surgical resection of the insula fraught with risk, despite some recent series reporting reasonable outcomes . Stereotactic thermocoagulation is a minimally invasive technique that has been used for half a century to create precise brain lesions and destroy deep epileptogenic structures, when resective surgery was not feasible .…”

Section: Introductionmentioning

confidence: 99%

“…This makes open surgical resection of the insula fraught with risk, despite some recent series reporting reasonable outcomes. [17][18][19][20] Stereotactic thermocoagulation is a minimally invasive technique that has been used for half a century to create precise brain lesions and destroy deep epileptogenic structures, when resective surgery was not feasible. 21 More recently, stereotactic radiofrequency thermocoagulation (RFTC) was performed in patients investigated for drug-resistant epilepsy, using the already implanted SEEG electrodes, as a treatment option for the disconnection of epileptic networks.…”

Section: Introductionmentioning

confidence: 99%

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Stereotactic thermocoagulation for insular epilepsy: Lessons from successes and failures

et al. 2019

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Objective To assess factors associated with favorable outcome in refractory insular epilepsy treated by volume‐based stereotactic radiofrequency thermocoagulation (RFTC). Methods We performed volume‐based RFTC in 19 patients (11 males, 7‐44 years old). The volume for thermocoagulation was identified by multimodal data including electroencephalography (EEG)‐video, magnetic resonance imaging (MRI), and fluorodeoxyglucose–positron emission tomography (PET) in all patients, and epileptogenic zone (EZ) was assessed by stereo‐electroencephalography (SEEG) in 16. MRI showed insular lesions in four patients (benign tumors, n = 2; focal cortical dysplasia [FCD], n = 1; polymicrogyria, n = 1). MRI was negative in 15 cases; however, PET was positive in 18, and FCD pattern was detected by SEEG in nine cases. The dominant hemisphere was involved in 12 cases. RFTC was performed as a separate procedure after SEEG, or as a single MRI‐guided procedure. The insular volume to be coagulated was determined by a tridimensional identification of the epileptogenic cortex using MRI, PET, and SEEG, and was destroyed with coalescent thermal lesions. Results Seizure‐free outcome was achieved in 10 patients (53%), including Engel class IA in three (follow‐up = 1‐12 years, mean = 5.4). The responder rate (including Engel classes I‐III) was 89%. Transient postoperative deficits (mild hemiparesia, dysarthria, hypoesthesia, dysgeusia) were observed in eight patients (42%), with rapid and total recovery in all but one with persistent mild dysarthria. Neurological deficits were related to higher number of RFTC procedures (P = .036) and greater volume of RFTC (P = .028). Neuropsychological status was unchanged or improved in all; however, psychiatric status transitorily worsened in three patients. Factors contributing to seizure‐free outcome were the detection of FCD pattern (P = .009), localized EZ (P = .038), low RFTC volume (P = .002), low number of RFTC procedures (P = .001), and low RFTC volume/number ratio (P = .012). Optimal volume of RFTC around 2 cm3 offered the best compromise between efficacy and safety. Significance RFTC may be curative in insular epilepsy after accurate localization of EZ with SEEG. Best outcome was associated with low volume of thermolesions.

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Section: Presurgical Workupmentioning

confidence: 99%

Section: Presurgical Workupmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Stereotactic thermocoagulation for insular epilepsy: Lessons from successes and failures

et al. 2019

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“…However, this explanation is somewhat unsatisfactory as recent studies indicate that subtle focal cortical dysplasias may be the most common histopathological finding in nonlesional refractory insular patients who are operated. In a small recently published series of six refractory insular epilepsy cases, all four patients with normal MRI were found to have a subtle focal cortical dysplasia following histopathological analysis of the resected epileptogenic insula . Baulac et al also identified on histopathology a subtle insular focal dysplasia in a patient with normal MRI and DEPDC5 mutation .…”

Section: Discussionmentioning

confidence: 97%

Proton MR Spectroscopy in Patients with Nonlesional Insular Cortex Epilepsy Confirmed by Invasive EEG Recordings

Aitouche

Gibbs

Gilbert

et al. 2017

Journal of Neuroimaging

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Electroclinical features of insulo‐opercular epilepsy: an SEEG and PET study

Wang

McGonigal

et al. 2019

Ann Clin Transl Neurol

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Objective To report clinical experience with presurgical evaluation in patients with insulo‐opercular epilepsy. Quantitative analysis on PET imaging and stereoelectroencephalography (SEEG) signals was used to summarize their electroclinical features. Methods Twenty‐two patients with focal epilepsy arising from the insular and/or opercular cortex according to SEEG were retrospectively analyzed. Presurgical noninvasive data were analyzed in detail. Interictal PET data of patients were then statistically compared with those of healthy controls to identify the interictal hypometabolic network. The epileptogenicity index (EI) of ictal SEEG signal was computed to identify areas of spread at the beginning of seizure onset. Results Focal tonic seizures of the face and/or neck (16/22, 73%) were the most prevalent early objective signs. Epileptic discharges in the interictal and ictal scalp‐EEG mostly showed an ipsilateral perisylvian distribution. Statistical analysis of interictal PET showed significant hypometabolism in the insular lobe, central operculum, supplementary motor area, middle cingulate cortex, bilateral caudate nuclei, and putamen. According to the EI analysis, insulo‐opercular epilepsy could be classified as insulo‐opercular epilepsy (50%), opercular epilepsy (41%), and insular cortex epilepsy (9%). Significance Clinical diagnosis of insulo‐opercular epilepsy is challenging because of its complex seizure semiology and nonlocalizing discharges on scalp‐EEG. A common hypometabolic network involving the insulo‐opercular cortex, mesial frontal cortex and subcortical nuclei may be involved in the organization of the insulo‐opercular epilepsy network. Furthermore, quantified SEEG analysis suggested that pure insular epilepsy is rare, and the close connection between insular and opercular cortex necessitates SEEG implantation to define the epileptogenic zone.

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Surgery for Nontumoral Insular Epilepsy Explored by Stereoelectroencephalography

Abstract: EEG, electroencephalographyEZ, epileptic zoneFCD, focal cortical dysplasiaILE, insular lobe epilepsySEEG, stereoelectroencephalography.

Cited by 52 publications

References 43 publications

Stereotactic thermocoagulation for insular epilepsy: Lessons from successes and failures

Stereotactic thermocoagulation for insular epilepsy: Lessons from successes and failures

Proton MR Spectroscopy in Patients with Nonlesional Insular Cortex Epilepsy Confirmed by Invasive EEG Recordings

Electroclinical features of insulo‐opercular epilepsy: an SEEG and PET study

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