PMC:6610377 / 11973-14618
Annnotations
{"target":"https://pubannotation.org/docs/sourcedb/PMC/sourceid/6610377","sourcedb":"PMC","sourceid":"6610377","source_url":"https://www.ncbi.nlm.nih.gov/pmc/6610377","text":"Seizure onset within the insula widely varies across patients. Seizure onset can be very restricted in space, and to differentiate insular from opercular seizure onset, extensive insulo-opercular coverage is necessary. The best approach is to combine a lateral orthogonal trajectory through the frontoparietal and temporal operculum27 with an oblique approach through the frontal or parietal cortices to allow a larger insular sampling28 (Figure 3A). Combined depth and subdural electrodes29,30 or hybrid operculo-insular electrodes31 can be also used to investigate the insulo-opercular complex. To better evaluate the extent of the future resection and to exclude any extrainsular onset, seizure spread must be examined, especially in MRI-negative cases. This includes appropriate sampling of extrainsular regions to which the insula is closely connected, taking into account the different patterns of connectivity that vary as a function of each insular gyrus32 with a rostrocaudal organization.33 The SEEG investigations of insular lobe seizures have shown the following: (1) Seizure onset patterns can be variable in the insula, but low-voltage fast discharge34 or high-frequency gamma activity7 are not uncommon (Figure 3B and C); (2) seizures often start very focally with a limited intrainsular spread before extrainsular propagation (Figure 3B-D), which therefore allows tailored limited resections (Figure 3E)35; (3) extrainsular spread explains clinical variability of insular lobe seizures; in particular, complex motor manifestations were shown to occur when the discharge spread over frontomesial and/or mesial and lateral temporal regions.16 This is in accordance with directed functional coupling analysis that reported a specific association between the insula and mesial frontal lobe during the propagation of insular seizures34; (4) corticocortical evoked potentials have showed that the 2 insulas are closely connected,36 with 8- to 24-milliseconds time to propagate from one to the other homotopic insular parcel37; therefore, insular seizures may propagate very quickly to the contralateral insula (Figure 3B) so that false lateralization may occur in insular or even temporo(-insular) epilepsy38; (5) typical insular signs can occur in seizures of extrainsular origin; in particular, insular spread is very common in seizures of temporal lobe origin22,39 and therefore may result in misleading seizure auras; and (6) the morbidity rate directly related to insular electrodes is low. In particular, none of the patients (including children) reported in 3 recent large studies experienced any hemorrhagic 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