PMC:6610377 / 24278-28339 JSONTXT

{"target":"https://pubannotation.org/docs/sourcedb/PMC/sourceid/6610377","sourcedb":"PMC","sourceid":"6610377","source_url":"https://www.ncbi.nlm.nih.gov/pmc/6610377","text":"Con: Diagnosis and Treatment of Medically Refractory Insula Epilepsy: Challenges and Pitfalls\nJorge Gonzalez-Martinez, MD, PhD\nInsular epilepsy is a particularly challenging topic in medically refractory epilepsies. The clinical and surgical challenges are intrinsically related to the heterogeneous semiological features of seizures arising from the insula and adjacent structures, the difficult access to the insular cortex, and the relative high morbidity associated with insula and perisylvian resections.\nRegarding the technique of insular implantation, several series have addressed the technique and safety of insular exploration by the SEEG methodology.40, 41 The SEEG is arguably the most common and appropriate surgical method to explore the insula cortex among other invasive techniques. Since its inception by Talairach and Bancaud,57 the SEEG methodology, and in particular its technique, evolved over the years. Nevertheless, the common denominator among different techniques is accurate vascular imaging, particularly important for insula explorations. Even in the highly vascular insular cortex, SEEG can still be performed safely if planning and technique are performed carefully.\nThe most common SEEG depth electrode implantation technique is the transopercular approach,27 in which orientation of electrodes is perpendicular to the sagittal plane, as defined by the anterior commissure–posterior commissure line. The advantages of this approach include its common and widespread clinical application, its safety and efficacy for accessing the insula cortex and adjacent areas, and its ability to sample medial and lateral portions of the insula, as well as the adjacent frontal and temporal opercula.\nOnce localization methods confirm that seizures are in fact arising from the insula cortex, and the extent of the epileptogenic zone is defined, the surgical treatment strategies become the main challenge. Several published manuscripts reported the outcome and morbidity related to insula epilepsy surgeries.11,35, 48, 58 Alomar et al40 reported the results of 17 patients with nonlesional imaging who were surgically treated for medically intractable epilepsy (15 resection and 2 laser ablations). Overall, 11 of 15 patients with insular resection had favorable outcome (Engel I and Engel II), of whom 5 (33.3%) had an Engel I outcome and 6 (40%) an Engel II outcome. The remaining patients had either an Engel III (n = 3, 20%) or an Engel IV outcome (n = 1, 6.7%). In this cohort, 3 patients developed permanent neurological deficits related to hemiparesis (17.6%), with an additional 4 patients developing transient deficits and mild complications. Therefore, the total complication rate in this series was approximately 41%. Interestingly, all permanent motor deficits were related to the resection of the caudal dorsal insula and adjacent parietal operculum, possibly due to damage of the small caliber performant arteries originating from the MCA, which exclusively provide vascular supply to the more caudal aspect of the corona radiata, harboring motor, and sensory fibers (Figure 7).\nFigure 7. Postoperative T2 MRI image (coronal orientation) after right caudal rostral insula resection in a 22-year-old female, resulting in symptomatic infarct in the ipsilateral corona radiata (red arrow). The procedure resulted in seizure freedom, but with a only partially recovered left side hemiparesis. MRI indicates magnetic resonance imaging. In conclusion, the authors highlighted the dangers related to the dorsal caudal insula resections. Because of the relatively high morbidity associated with open resections in the most caudal–rostral aspect of the insular cortex, preoperative discussion should include alternative treatment approaches including RNS and focal laser ablation. In order to overcome the potential high morbidity related to this area, 2 patients at our center underwent MRI-guided stereotactic laser ablation targeting the dorsal–caudal insula cortex, resulting in no complications and good control of focal 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