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Calley CS, Ho W, Babajani-Feremi A, Bodden C, Tyler-Kabara E, Clarke DF. A Proposed Stereoelectroencephalography Electrode Nomenclature and Call for Standardization. J Clin Neurophysiol 2024:00004691-990000000-00158. [PMID: 38935279 DOI: 10.1097/wnp.0000000000001103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2024] Open
Abstract
INTRODUCTION Between 20 and 40% of patients with epilepsy are considered pharmacoresistant. Stereoelectroencephalography (sEEG) is frequently used as an invasive method for localizing seizures in patients with pharmacoresistant epilepsy who are surgical candidates; however, electrode nomenclature varies widely across institutions. This lack of standardization can have many downstream consequences, including difficulty with intercenter or intracenter interpretation, communication, and reliability. METHODS The authors propose a novel sEEG nomenclature that is both intuitive and comprehensive. Considerations include clear/precise entry and target anatomical locations, laterality, distinction of superficial and deep structures, functional mapping, and relative labeling of electrodes in close proximity if needed. Special consideration was also given to electrodes approximating radiographically distinct lesions. The accuracy of electrode identification and the use of correct entry-target labels were assessed by neurosurgeons and epileptologists, not directly involved in each case. RESULTS The authors' nomenclature was used in 41 consecutive sEEG cases (497 electrodes total) within their institution. After reconstruction was complete, the accuracy of electrode identification was 100%, and the correct use of entry-target labels was 98%. The last 30 sEEG cases had 100% correct use of entry-target labels. CONCLUSIONS The proposed sEEG nomenclature demonstrated both high accuracy in electrode identification and consistent use of entry-target labeling. The authors submit this nomenclature as a model for standardization across epilepsy surgery centers. They intend to improve practicability, ease of use, and specificity of this nomenclature through collaboration with other surgical epilepsy centers.
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Affiliation(s)
- Clifford S Calley
- Department of Neurology, Dell Medical School, The University of Texas at Austin, Austin, Texas, U.S.A. Dr. A. Babajani-Feremi now with Department of Neurology, University of Florida, Gainesville, Florida, U.S.A
- Comprehensive Pediatric Epilepsy Center, Dell Children's Medical Center, Austin, Texas, U.S.A
- Department of Neurosurgery, Dell Medical School, The University of Texas at Austin, Austin, Texas, U.S.A
- Department of Pediatrics, Dell Medical School, The University of Texas at Austin, Austin, Texas, U.S.A
| | - Winson Ho
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, U.S.A
| | - Abbas Babajani-Feremi
- Department of Neurology, Dell Medical School, The University of Texas at Austin, Austin, Texas, U.S.A. Dr. A. Babajani-Feremi now with Department of Neurology, University of Florida, Gainesville, Florida, U.S.A
| | - Carla Bodden
- Department of Radiology, Dell Medical School, The University of Texas at Austin, Austin, Texas, U.S.A
| | - Elizabeth Tyler-Kabara
- Comprehensive Pediatric Epilepsy Center, Dell Children's Medical Center, Austin, Texas, U.S.A
- Department of Neurosurgery, Dell Medical School, The University of Texas at Austin, Austin, Texas, U.S.A
| | - Dave F Clarke
- Department of Neurology, Dell Medical School, The University of Texas at Austin, Austin, Texas, U.S.A. Dr. A. Babajani-Feremi now with Department of Neurology, University of Florida, Gainesville, Florida, U.S.A
- Comprehensive Pediatric Epilepsy Center, Dell Children's Medical Center, Austin, Texas, U.S.A
- Department of Neurosurgery, Dell Medical School, The University of Texas at Austin, Austin, Texas, U.S.A
- Department of Pediatrics, Dell Medical School, The University of Texas at Austin, Austin, Texas, U.S.A
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Dou Y, Xia J, Fu M, Cai Y, Meng X, Zhan Y. Identification of epileptic networks with graph convolutional network incorporating oscillatory activities and evoked synaptic responses. Neuroimage 2023; 284:120439. [PMID: 37939889 DOI: 10.1016/j.neuroimage.2023.120439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 10/01/2023] [Accepted: 10/31/2023] [Indexed: 11/10/2023] Open
Abstract
Stereoelectroencephalography (SEEG) offers unique neural data from in-depth brain structures with fine temporal resolutions to better investigate the origin of epileptic brain activities. Although oscillatory patterns from different frequency bands and functional connectivity computed from the SEEG datasets are employed to study the epileptic zones, direct electrical stimulation-evoked electrophysiological recordings of synaptic responses, namely cortical-cortical evoked potentials (CCEPs), from the same SEEG electrodes are not explored for the localization of epileptic zones. Here we proposed a two-stream model with unsupervised learning and graph convolutional network tailored to the SEEG and CCEP datasets in individual patients to perform localization of epileptic zones. We compared our localization results with the clinically marked electrode sites determined for surgical resections. Our model had good classification capability when compared to other state-of-the-art methods. Furthermore, based on our prediction results we performed group-level brain-area mapping analysis for temporal, frontal and parietal epilepsy patients and found that epileptic and non-epileptic brain networks were distinct in patients with different types of focal epilepsy. Our unsupervised data-driven model provides personalized localization analysis for the epileptic zones. The epileptic and non-epileptic brain areas disclosed by the prediction model provide novel insights into the network-level pathological characteristics of epilepsy.
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Affiliation(s)
- Yonglin Dou
- The Brain Cognition and Brain Disease Institute, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Jing Xia
- The Brain Cognition and Brain Disease Institute, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China; CAS Key Laboratory of Brain Connectome and Manipulation, The Brain Cognition and Brain Disease Institute, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Mengmeng Fu
- Department of Neurosurgery, Shenzhen University General Hospital, Shenzhen University, Shenzhen, China
| | - Yunpeng Cai
- Institute of Advanced Computing and Digital Engineering, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Xianghong Meng
- Department of Neurosurgery, Shenzhen University General Hospital, Shenzhen University, Shenzhen, China.
| | - Yang Zhan
- The Brain Cognition and Brain Disease Institute, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China; CAS Key Laboratory of Brain Connectome and Manipulation, The Brain Cognition and Brain Disease Institute, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China; Shenzhen-Hong Kong Institute of Brain Science-Shenzhen Fundamental Research Institutions, Shenzhen 518055, China.
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Cheval M, Rodrigo S, Taussig D, Caillé F, Petrescu AM, Bottlaender M, Tournier N, Besson FL, Leroy C, Bouilleret V. [ 18F]DPA-714 PET Imaging in the Presurgical Evaluation of Patients With Drug-Resistant Focal Epilepsy. Neurology 2023; 101:e1893-e1904. [PMID: 37748889 PMCID: PMC10663012 DOI: 10.1212/wnl.0000000000207811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 07/17/2023] [Indexed: 09/27/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Translocator protein 18 kDa (TSPO) PET imaging is used to monitor glial activation. Recent studies have proposed TSPO PET as a marker of the epileptogenic zone (EZ) in drug-resistant focal epilepsy (DRFE). This study aims to assess the contributions of TSPO imaging using [18F]DPA-714 PET and [18F]FDG PET for localizing the EZ during presurgical assessment of DRFE, when phase 1 presurgical assessment does not provide enough information. METHODS We compared [18F]FDG and [18F]DPA-714 PET images of 23 patients who had undergone a phase 1 presurgical assessment, using qualitative visual analysis and quantitative analysis, at both the voxel and the regional levels. PET abnormalities (increase in binding for [18F]DPA-714 vs decrease in binding for [18F]FDG) were compared with clinical hypotheses concerning the localization of the EZ based on phase 1 presurgical assessment. The additional value of [18F]DPA-714 PET imaging to [18F]FDG for refining the localization of the EZ was assessed. To strengthen the visual analysis, [18F]DPA-714 PET imaging was also reviewed by 2 experienced clinicians blind to the EZ location. RESULTS The study included 23 patients. Visual analysis of [18F]DPA-714 PET was significantly more accurate than [18F]FDG PET to both, show anomalies (95.7% vs 56.5%, p = 0.022), and provide additional information to refine the EZ localization (65.2% vs 17.4%, p = 0.019). All 10 patients with normal [18F]FDG PET had anomalies when using [18F]DPA-714 PET. The additional value of [18F]DPA-714 PET seemed to be greater in patients with normal brain MRI or with neocortical EZ (especially if insula is involved). Regional analysis of [18F]DPA-714 and [18F]FDG PET provided similar results. However, using voxel-wise analysis, [18F]DPA-714 was more effective than [18F]FDG for unveiling clusters whose localization was more often consistent with the EZ hypothesis (87.0% vs 39.1%, p = 0.019). Nonrelevant bindings were seen in 14 of 23 patients in visual analysis and 9 patients of 23 patients in voxel-wise analysis. DISCUSSION [18F]DPA-714 PET imaging provides valuable information for presurgical assessments of patients with DRFE. TSPO PET could become an additional tool to help to the localization of the EZ, especially in patients with negative [18F]FDG PET. TRIAL REGISTRATION INFORMATION Eudract 2017-003381-27. Inclusion of the first patient: September 24, 2018. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence on the utility of [18F]DPA-714 PET compared with [18F]FDG PET in identifying the epileptic zone in patients undergoing phase 1 presurgical evaluation for intractable epilepsy.
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Affiliation(s)
- Margaux Cheval
- From the Université Paris-Saclay (M.C., C.L., M.B., N.T.); BioMAPS (S.R., F.C., F.L.B.); Bicetre University Hospital (D.T., A.M.P.), Paris; and Imagerie Moléculaire In Vivo (V.B.), SHFJ, CEA, Orsay, France.
| | - Sebastian Rodrigo
- From the Université Paris-Saclay (M.C., C.L., M.B., N.T.); BioMAPS (S.R., F.C., F.L.B.); Bicetre University Hospital (D.T., A.M.P.), Paris; and Imagerie Moléculaire In Vivo (V.B.), SHFJ, CEA, Orsay, France
| | - Delphine Taussig
- From the Université Paris-Saclay (M.C., C.L., M.B., N.T.); BioMAPS (S.R., F.C., F.L.B.); Bicetre University Hospital (D.T., A.M.P.), Paris; and Imagerie Moléculaire In Vivo (V.B.), SHFJ, CEA, Orsay, France
| | - Fabien Caillé
- From the Université Paris-Saclay (M.C., C.L., M.B., N.T.); BioMAPS (S.R., F.C., F.L.B.); Bicetre University Hospital (D.T., A.M.P.), Paris; and Imagerie Moléculaire In Vivo (V.B.), SHFJ, CEA, Orsay, France
| | - Ana Maria Petrescu
- From the Université Paris-Saclay (M.C., C.L., M.B., N.T.); BioMAPS (S.R., F.C., F.L.B.); Bicetre University Hospital (D.T., A.M.P.), Paris; and Imagerie Moléculaire In Vivo (V.B.), SHFJ, CEA, Orsay, France
| | - Michel Bottlaender
- From the Université Paris-Saclay (M.C., C.L., M.B., N.T.); BioMAPS (S.R., F.C., F.L.B.); Bicetre University Hospital (D.T., A.M.P.), Paris; and Imagerie Moléculaire In Vivo (V.B.), SHFJ, CEA, Orsay, France
| | - Nicolas Tournier
- From the Université Paris-Saclay (M.C., C.L., M.B., N.T.); BioMAPS (S.R., F.C., F.L.B.); Bicetre University Hospital (D.T., A.M.P.), Paris; and Imagerie Moléculaire In Vivo (V.B.), SHFJ, CEA, Orsay, France
| | - Florent L Besson
- From the Université Paris-Saclay (M.C., C.L., M.B., N.T.); BioMAPS (S.R., F.C., F.L.B.); Bicetre University Hospital (D.T., A.M.P.), Paris; and Imagerie Moléculaire In Vivo (V.B.), SHFJ, CEA, Orsay, France
| | - Claire Leroy
- From the Université Paris-Saclay (M.C., C.L., M.B., N.T.); BioMAPS (S.R., F.C., F.L.B.); Bicetre University Hospital (D.T., A.M.P.), Paris; and Imagerie Moléculaire In Vivo (V.B.), SHFJ, CEA, Orsay, France
| | - Viviane Bouilleret
- From the Université Paris-Saclay (M.C., C.L., M.B., N.T.); BioMAPS (S.R., F.C., F.L.B.); Bicetre University Hospital (D.T., A.M.P.), Paris; and Imagerie Moléculaire In Vivo (V.B.), SHFJ, CEA, Orsay, France
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Filipescu C, Landré E, Turak B, Devaux B, Chassoux F. Towards a better identification of ictal semiology patterns in insular epilepsies: A stereo-EEG study. Clin Neurophysiol 2023; 155:32-43. [PMID: 37683325 DOI: 10.1016/j.clinph.2023.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 07/26/2023] [Accepted: 08/12/2023] [Indexed: 09/10/2023]
Abstract
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.
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Affiliation(s)
- Cristina Filipescu
- Surgical Epileptology Unit, Neurosurgery Department, GHU Paris Psychiatry and Neurosciences, Sainte-Anne Hospital, France; Neurophysiology and Epileptology Department, GHU Paris Psychiatry and Neurosciences, Sainte-Anne Hospital, France.
| | - Elisabeth Landré
- Surgical Epileptology Unit, Neurosurgery Department, GHU Paris Psychiatry and Neurosciences, Sainte-Anne Hospital, France.
| | - Baris Turak
- Surgical Epileptology Unit, Neurosurgery Department, GHU Paris Psychiatry and Neurosciences, Sainte-Anne Hospital, France.
| | - Bertrand Devaux
- Surgical Epileptology Unit, Neurosurgery Department, GHU Paris Psychiatry and Neurosciences, Sainte-Anne Hospital, France; Paris-Cité University, Paris, France.
| | - Francine Chassoux
- Surgical Epileptology Unit, Neurosurgery Department, GHU Paris Psychiatry and Neurosciences, Sainte-Anne Hospital, France.
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Cossette-Roberge H, Li J, Citherlet D, Nguyen DK. Localizing and lateralizing value of auditory phenomena in seizures. Epilepsy Behav 2023; 145:109327. [PMID: 37422934 DOI: 10.1016/j.yebeh.2023.109327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 06/11/2023] [Accepted: 06/15/2023] [Indexed: 07/11/2023]
Abstract
BACKGROUND Auditory seizures (AS) are a rare type of focal seizures. AS are classically thought to involve a seizure onset zone (SOZ) in the temporal lobe, but there remain uncertainties about their localizing and lateralizing value. We conducted a narrative literature review with the aim of providing an up-to-date description of the lateralizing and localizing value of AS. METHODS The databases PubMed, Scopus, and Google Scholar were searched for literature on AS in December 2022. All cortical stimulation studies, case reports, and case series were analyzed to assess for auditory phenomena that were suggestive of AS and to evaluate if the lateralization and/or localization of the SOZ could be determined. We classified AS according to their semiology (e.g., simple hallucination versus complex hallucination) and the level of evidence with which the SOZ could be predicted. RESULTS A total of 174 cases comprising 200 AS were analyzed from 70 articles. Across all studies, the SOZ of AS were more often in the left (62%) than in the right (38%) hemisphere. AS heard bilaterally followed this trend. Unilaterally heard AS were more often due to a SOZ in the contralateral hemisphere (74%), although they could also be ipsilateral (26%). The SOZ for AS was not limited to the auditory cortex, nor to the temporal lobe. The areas more frequently involved in the temporal lobe were the superior temporal gyrus (STG) and mesiotemporal structures. Extratemporal locations included parietal, frontal, insular, and rarely occipital structures. CONCLUSION Our review highlighted the complexity of AS and their importance in the identification of the SOZ. Due to the limited data and heterogeneous presentation of AS in the literature, the patterns associated with different AS semiologies warrant further research.
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Affiliation(s)
- Hélène Cossette-Roberge
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, QC, Canada; Neurology Division, Centre Hospitalier de l'Université de Sherbrooke (CHUS), Sherbrooke, QC, Canada.
| | - Jimmy Li
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, QC, Canada; Neurology Division, Centre Hospitalier de l'Université de Sherbrooke (CHUS), Sherbrooke, QC, Canada
| | - Daphné Citherlet
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, QC, Canada
| | - Dang Khoa Nguyen
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, QC, Canada; Department of Neurosciences, Université de Montréal, Montreal, QC, Canada; Neurology Division, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada
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Cameron N, Fry L, Kabangu JL, Schatmeyer BA, Miller C, Ulloa CM, Uysal U, Cheng JJ, Kinsman MJ, Rouse AG, Landazuri P. Using pre-surgical suspicion to guide insula implantation strategy. Heliyon 2023; 9:e18284. [PMID: 37539155 PMCID: PMC10395527 DOI: 10.1016/j.heliyon.2023.e18284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 06/27/2023] [Accepted: 07/13/2023] [Indexed: 08/05/2023] Open
Abstract
Rationale Insular epilepsy can be a challenging diagnosis due to overlapping semiology and scalp EEG findings with frontal, temporal, and parietal lobe epilepsies. Stereotactic electroencephalography (sEEG) provides an opportunity to better localize seizure onset. The possibility of improved localization is balanced by implantation risk in this vascularly rich anatomic region. We review both safety and pre-implantation factors involved in insular electrode placement across four years at an academic medical center. Methods Presurgical data, operative reports, and invasive EEG summaries were retrospectively reviewed for patients undergoing invasive epilepsy monitoring on the insula from 2016 through 2019. EEG reports were reviewed to record the presence of insula ictal and interictal involvement. We recorded which presurgical findings suggested insular involvement (insula lesion on MRI, insula changes on PET/SPECT/scalp EEG, characteristic semiology, or history of failed anterior temporal lobectomy). The likelihood of pre-sEEG insular onset was categorized as low suspicion if no presurgical findings were present ("rule out"), moderate suspicion if one finding was present, and high suspicion if two or more findings were present. Results 76 patients received 189 insular electrodes as part of their implantation strategy for 79 surgical cases. Seven patients (8.9%) had insular ictal onset. One clinically significant complication (left hemiparesis) occurred in a patient with moderate suspicion for insular onset. There were 38 low suspicion cases, 36 moderate suspicion cases, and 5 high suspicion cases for pre-sEEG insula ictal onset. Two low suspicion (5.3%), three moderate suspicion (8.6%), and two high suspicion (40%) cases had insular ictal onset. Conclusions The insula can safely receive sEEG. Having two or more presurgical factors indicating insular onset is a strong, albeit incomplete, predictor of insular seizure onset. Using pre-implantation clinical findings can offer clinicians predictive value for targeting the insula during invasive EEG monitoring.
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Affiliation(s)
- Nathaniel Cameron
- Dept. of Neurosurgery, University of Kansas Medical Center, United States
| | - Lane Fry
- Dept. of Neurosurgery, University of Kansas Medical Center, United States
| | - Jean-Luc Kabangu
- Dept. of Neurosurgery, University of Kansas Medical Center, United States
| | | | - Christopher Miller
- Dept. of Neurosurgery, University of Kansas Medical Center, United States
| | - Carol M. Ulloa
- Dept. of Neurology, University of Kansas Medical Center, United States
| | - Utku Uysal
- Dept. of Neurology, University of Kansas Medical Center, United States
| | - Jennifer J. Cheng
- Dept. of Neurosurgery, University of Kansas Medical Center, United States
| | - Michael J. Kinsman
- Dept. of Neurosurgery, University of Kansas Medical Center, United States
| | - Adam G. Rouse
- Dept. of Neurosurgery, University of Kansas Medical Center, United States
- Dept. of Cell Biology & Physiology, University of Kansas Medical Center, United States
- Dept. of Electrical Engineering and Computer Science, University of Kansas, United States
| | - Patrick Landazuri
- Dept. of Neurology, University of Kansas Medical Center, United States
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Smith KM, Starnes DK, Brinkmann BH, So E, Cox BC, Marsh WR, Van Gompel JJ, Wirrell E, Britton JW, Burkholder DB, Wong-Kisiel LC. Stereo-EEG localization of midline onset seizures on scalp EEG. Epilepsy Res 2023; 193:107162. [PMID: 37172404 DOI: 10.1016/j.eplepsyres.2023.107162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 04/06/2023] [Accepted: 05/01/2023] [Indexed: 05/15/2023]
Abstract
PURPOSE The objective of this study was to describe the sEEG-defined seizure onset zone (SOZ), seizure semiology, presurgical evaluations, surgical intervention and outcome in patients with midline onset noninvasive phase I monitoring. METHODS A single center sEEG database was reviewed to identify patients with seizures onset predominantly involving midline electrodes (FZ, CZ, PZ, OZ) on scalp EEG. Data abstracted included clinical factors, seizure semiology graded into lobar segmentation, imaging and electrographic findings, sEEG plan, interventions, and outcome. RESULTS Twelve patients were identified (8 males, median age of sEEG 28 years) out of 100 cases of sEEG performed from January 2015-September 2019. "Frontal lobe" seizure semiology was the most common. sEEG-defined SOZ were frontal (5), diffuse (1), multifocal (1), frontal and insular (1), frontal and cingulate (1), insular (1), cingulate (1), and mesial temporal (1). CZ and/or FZ scalp EEG changes were present for all patients with SOZ involving the frontal, cingulate, and insular regions. PZ/OZ scalp involvement was present in one patient with mesial temporal SOZ. Four patients underwent a definitive resective or ablative surgery, and the remaining patients underwent a palliative intervention. Of those with follow-up information available, 8/11 had seizure reduction by ≥ 50%, including 4 with an Engel I outcome. No clinical factors were associated with outcome. CONCLUSIONS SOZ for midline onset seizures from noninvasive phase I monitoring was most commonly in the frontal, cingulate, and insular regions. A complex cortical network between these regions may explain overlap in semiology and scalp EEG findings. While the number rendered seizure-free was limited, a significant proportion experienced a reasonably favorable outcome justifying use of sEEG to identify surgical options in these patients.
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Affiliation(s)
- Kelsey M Smith
- Department of Neurology, Mayo Clinic, 200 1st St. SW, Rochester, MN 55906, United States.
| | - Donnie K Starnes
- Department of Neurology, Mayo Clinic, 200 1st St. SW, Rochester, MN 55906, United States
| | - Benjamin H Brinkmann
- Department of Neurology, Mayo Clinic, 200 1st St. SW, Rochester, MN 55906, United States
| | - Elson So
- Department of Neurology, Mayo Clinic, 200 1st St. SW, Rochester, MN 55906, United States
| | - Benjamin C Cox
- Department of Neurology, Mayo Clinic, 200 1st St. SW, Rochester, MN 55906, United States
| | - W Richard Marsh
- Department of Neurosurgery, Mayo Clinic, 200 1st St. SW, Rochester, MN 55906, United States
| | - Jamie J Van Gompel
- Department of Neurosurgery, Mayo Clinic, 200 1st St. SW, Rochester, MN 55906, United States
| | - Elaine Wirrell
- Department of Neurology, Mayo Clinic, 200 1st St. SW, Rochester, MN 55906, United States
| | - Jeffrey W Britton
- Department of Neurology, Mayo Clinic, 200 1st St. SW, Rochester, MN 55906, United States
| | - David B Burkholder
- Department of Neurology, Mayo Clinic, 200 1st St. SW, Rochester, MN 55906, United States
| | - Lily C Wong-Kisiel
- Department of Neurology, Mayo Clinic, 200 1st St. SW, Rochester, MN 55906, United States
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Obaid S, Chen JS, Ibrahim GM, Bouthillier A, Dimentberg E, Surbeck W, Guadagno E, Brunette-Clément T, Shlobin NA, Shulkin A, Hale AT, Tomycz LD, Von Lehe M, Perry MS, Chassoux F, Bouilleret V, Taussig D, Fohlen M, Dorfmuller G, Hagiwara K, Isnard J, Oluigbo CO, Ikegaya N, Nguyen DK, Fallah A, Weil AG. Predictors of outcomes after surgery for medically intractable insular epilepsy: A systematic review and individual participant data meta-analysis. Epilepsia Open 2023; 8:12-31. [PMID: 36263454 PMCID: PMC9978079 DOI: 10.1002/epi4.12663] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 09/28/2022] [Indexed: 11/11/2022] Open
Abstract
Insular epilepsy (IE) is an increasingly recognized cause of drug-resistant epilepsy amenable to surgery. However, concerns of suboptimal seizure control and permanent neurological morbidity hamper widespread adoption of surgery for IE. We performed a systematic review and individual participant data meta-analysis to determine the efficacy and safety profile of surgery for IE and identify predictors of outcomes. Of 2483 unique citations, 24 retrospective studies reporting on 312 participants were eligible for inclusion. The median follow-up duration was 2.58 years (range, 0-17 years), and 206 (66.7%) patients were seizure-free at last follow-up. Younger age at surgery (≤18 years; HR = 1.70, 95% CI = 1.09-2.66, P = .022) and invasive EEG monitoring (HR = 1.97, 95% CI = 1.04-3.74, P = .039) were significantly associated with shorter time to seizure recurrence. Performing MR-guided laser ablation or radiofrequency ablation instead of open resection (OR = 2.05, 95% CI = 1.08-3.89, P = .028) was independently associated with suboptimal or poor seizure outcome (Engel II-IV) at last follow-up. Postoperative neurological complications occurred in 42.5% of patients, most commonly motor deficits (29.9%). Permanent neurological complications occurred in 7.8% of surgeries, including 5% and 1.4% rate of permanent motor deficits and dysphasia, respectively. Resection of the frontal operculum was independently associated with greater odds of motor deficits (OR = 2.75, 95% CI = 1.46-5.15, P = .002). Dominant-hemisphere resections were independently associated with dysphasia (OR = 13.09, 95% CI = 2.22-77.14, P = .005) albeit none of the observed language deficits were permanent. Surgery for IE is associated with a good efficacy/safety profile. Most patients experience seizure freedom, and neurological deficits are predominantly transient. Pediatric patients and those requiring invasive monitoring or undergoing stereotactic ablation procedures experience lower rates of seizure freedom. Transgression of the frontal operculum should be avoided if it is not deemed part of the epileptogenic zone. Well-selected candidates undergoing dominant-hemisphere resection are more likely to exhibit transient language deficits; however, the risk of permanent deficit is very low.
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Affiliation(s)
- Sami Obaid
- Division of Pediatric Neurosurgery, Department of Surgery, Sainte Justine Hospital, University of Montreal, Quebec, Montreal, Canada.,Division of Neurosurgery, University of Montreal Hospital Center, Montreal, Quebec, Canada
| | - Jia-Shu Chen
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - George M Ibrahim
- Division of Neurosurgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Alain Bouthillier
- Division of Neurosurgery, University of Montreal Hospital Center, Montreal, Quebec, Canada
| | - Evan Dimentberg
- Division of Pediatric Neurosurgery, Department of Surgery, Sainte Justine Hospital, University of Montreal, Quebec, Montreal, Canada.,Faculty of Medicine, Université Laval, Quebec City, Quebec, Canada
| | - Werner Surbeck
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital of the University of Zurich, Zurich, Switzerland
| | - Elena Guadagno
- Harvey E. Beardmore Division of Pediatric Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Tristan Brunette-Clément
- Division of Pediatric Neurosurgery, Department of Surgery, Sainte Justine Hospital, University of Montreal, Quebec, Montreal, Canada.,Division of Neurosurgery, University of Montreal Hospital Center, Montreal, Quebec, Canada
| | - Nathan A Shlobin
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Aidan Shulkin
- Division of Pediatric Neurosurgery, Department of Surgery, Sainte Justine Hospital, University of Montreal, Quebec, Montreal, Canada
| | - Andrew T Hale
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Luke D Tomycz
- The Epilepsy Institute of New Jersey, Jersey City, New Jersey, USA
| | - Marec Von Lehe
- Department of Neurosurgery, Brandenburg Medical School, Neuruppin, Germany
| | - Michael Scott Perry
- Comprehensive Epilepsy Program, Jane and John Justin Neuroscience Center, Cook Children's Medical Center, Fort Worth, Texas, USA
| | - Francine Chassoux
- Service de Neurochirurgie, GHU Paris Psychiatrie et Neurosciences, Université Paris-Descartes Paris, Paris, France
| | - Viviane Bouilleret
- Université Paris Saclay-APHP, Unité de Neurophysiologie Clinique et d'Épileptologie(UNCE), Le Kremlin Bicêtre, France
| | - Delphine Taussig
- Université Paris Saclay-APHP, Unité de Neurophysiologie Clinique et d'Épileptologie(UNCE), Le Kremlin Bicêtre, France.,Pediatric Neurosurgery Department, Rothschild Foundation Hospital, Paris, France
| | - Martine Fohlen
- Pediatric Neurosurgery Department, Rothschild Foundation Hospital, Paris, France
| | - Georg Dorfmuller
- Pediatric Neurosurgery Department, Rothschild Foundation Hospital, Paris, France
| | - Koichi Hagiwara
- Epilepsy and Sleep Center, Fukuoka Sanno Hospital, Fukuoka, Japan
| | - Jean Isnard
- Department of Functional Neurology and Epileptology, Hospices Civils de Lyon, Hospital for Neurology and Neurosurgery, Lyon, France
| | - Chima O Oluigbo
- Department of Neurosurgery, Children's National Medical Center, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Naoki Ikegaya
- Departments of Neurosurgery, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Dang K Nguyen
- Division of Neurology, University of Montreal Hospital Center, Montreal, Quebec, Canada
| | - Aria Fallah
- Department of Neurosurgery and Pediatrics, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California, USA
| | - Alexander G Weil
- Division of Pediatric Neurosurgery, Department of Surgery, Sainte Justine Hospital, University of Montreal, Quebec, Montreal, Canada.,Division of Neurosurgery, University of Montreal Hospital Center, Montreal, Quebec, Canada.,Department of Neuroscience, University of Montreal, Montreal, Quebec, Canada
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9
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Solanki C, Williams J, Andrews C, Fayed I, Wu C. Insula in epilepsy - "untying the gordian knot": A systematic review. Seizure 2023; 106:148-161. [PMID: 36878050 DOI: 10.1016/j.seizure.2023.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 02/23/2023] [Accepted: 02/25/2023] [Indexed: 03/02/2023] Open
Abstract
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.
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Affiliation(s)
- Chirag Solanki
- Consultant Neurosurgeon, Department of Neurosurgery, Sterling Hospital, Ahmedabad, Gujarat, India.
| | - Justin Williams
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, United States.
| | - Carrie Andrews
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, United States.
| | - Islam Fayed
- Stereotactic and Functional Neurosurgery, Vickie and Jack Farber Institute for Neuroscience, Thomas Jefferson University, Philadelphia, United States.
| | - Chengyuan Wu
- Associate Professor of Neurosurgery and Radiology, Vickie and Jack Farber Institute for Neuroscience, Thomas Jefferson University, Philadelphia, United States.
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You L, Zhang Y, Zhang D, Wang L, Liu X, Peng C, Qi Y, Qian R. Stereoelectroencephalography-based research on the value of drug-resistant temporal lobe epilepsy auras: A retrospective single-center study. Epilepsy Behav 2023; 138:108981. [PMID: 36470058 DOI: 10.1016/j.yebeh.2022.108981] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 09/25/2022] [Accepted: 10/27/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE To explore the localization value of drug-resistant temporal lobe epilepsy (TLE) aura for preoperative evaluation, based on stereoelectroencephalography (SEEG), and its prognostic value on the surgical outcome. METHODS The data of patients with drug-resistant TLE who had SEEG electrodes implanted during preoperative evaluation at the First Affiliated Hospital of the University of Science and Technology of China (Hefei, China) were retrospectively analyzed. The patients were divided into aura-positive and aura-negative groups according to the presence of aura in seizures. To explore the clinical features of aura, we evaluated the localizing and prognostic values of aura for the outcome of anterior temporal lobectomy based on SEEG. RESULTS Among forty patients, twenty-seven patients were in the aura-positive group and ten (25.0%) patients had multiple auras. The most common TLE aura was abdominal aura [thirteen (34.2%) patients]. The postoperative seizure frequency was significantly reduced in the preoperative aura-positive patients compared to the preoperative aura-negative patients (P = 0.011). Patients with abdominal (P = 0.029) and single (P = 0.036) auras had better surgical prognoses than aura-negative patients. In the preoperative evaluation, aura-positive patients had a better surgical outcome if the laterality of positron emission tomography-computed tomography (PET-CT) hypometabolism was concordant with the epileptogenic focus identified with SEEG (P = 0.031). A good postoperative epileptic outcome in aura-positive patients was observed among those with hippocampal sclerotic medial temporal lobe epilepsy (P = 0.025). CONCLUSION Epileptic aura is valuable for the localization of the epileptogenic focus. Abdominal aura and single aura were good predictors of better surgical outcomes. Among patients with a preoperative diagnosis of hippocampal sclerosis or with laterality of PET-CT hypometabolism concordant with the epileptogenic focus identified using SEEG, those with aura are likely to benefit from surgery.
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Affiliation(s)
- Longfei You
- Department of Neurosurgery, Anhui Provincial Hospital, WanNan Medical College, Wuhu, PR China
| | - Yiming Zhang
- Department of Neurosurgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei 230001, PR China
| | - Dong Zhang
- Department of Neurosurgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei 230001, PR China
| | - Lanlan Wang
- Department of Nerve Electrophysiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui 230001, PR China
| | - Xiang Liu
- Department of Nerve Electrophysiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui 230001, PR China; Anhui Provincial Institute of Stereotactic Neurosurgery, 9 Lujiang Road, Hefei, Anhui Province 230001, PR China
| | - Chang Peng
- Department of Neurosurgery, Anhui Provincial Hospital, WanNan Medical College, Wuhu, PR China
| | - Yinbao Qi
- Department of Neurosurgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei 230001, PR China
| | - Ruobing Qian
- Department of Neurosurgery, Anhui Provincial Hospital, WanNan Medical College, Wuhu, PR China; Department of Neurosurgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei 230001, PR China; Anhui Provincial Institute of Stereotactic Neurosurgery, 9 Lujiang Road, Hefei, Anhui Province 230001, PR China.
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11
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Li D, Podkorytova I, Dieppa M, Perven G. Pearls & Oy-sters: Two Cases of Stereotactic EEG-Proven Insular Epilepsy With Non-localizing Scalp EEG and Interesting Semiologies. Neurology 2022; 99:437-441. [PMID: 35764400 DOI: 10.1212/wnl.0000000000200993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 06/03/2022] [Indexed: 11/15/2022] Open
Abstract
Insular epilepsy is a great mimicker and can be mistaken for seizures originating from other areas of the brain or as non-epileptic spells. The semiology of insular epilepsy can include, but is not limited to, auditory illusions, paresthesias, gastric rising, laryngeal constriction, and hyperkinetic movements. These arise from both the functions of the insula itself and its extensive connections with other regions of the brain. Noninvasive workup can be negative or non-localizing due to the insula's location deep within the lateral sulcus. Stereotactic EEG can therefore be an important tool in cases of insular epilepsy so that patients may be appropriately diagnosed and evaluated for potential surgical treatment. We present two cases of epilepsy with non-localizing scalp EEG and challenging semiologies, the workup undertaken to identify them as cases of insular epilepsy, and subsequent surgical treatment and outcomes.
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Affiliation(s)
- Denise Li
- Adult Neurology Residency Program, University of Texas Southwestern Medical Center
| | - Irina Podkorytova
- Department of Neurology, University of Texas Southwestern Medical Center
| | - Marisara Dieppa
- Department of Neurology, University of Texas Southwestern Medical Center
| | - Ghazala Perven
- Department of Neurology, University of Texas Southwestern Medical Center
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12
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Okadome T, Takeuchi H, Yamaguchi T, Mukaino T, Ogata H, Masaki K, Shigeto H, Isobe N. Shadowboxing-induced reflex seizures in a patient with focal epilepsy. Epilepsy Behav Rep 2022; 19:100543. [PMID: 35520950 PMCID: PMC9062418 DOI: 10.1016/j.ebr.2022.100543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 04/11/2022] [Accepted: 04/13/2022] [Indexed: 11/22/2022] Open
Abstract
We describe a focal epilepsy patient with shadowboxing-induced reflex seizures. We identified a precipitative motion within the shadowboxing by video-EEG. Avoiding the motion enabled him to continue boxing free from reflex seizures.
Exercise-induced reflex seizures are a rare form of reflex seizures that are exclusively induced by a specific type of exercise. Many patients with exercise-induced reflex seizures exhibit drug-resistance, and are therefore advised to avoid the triggering exercise. Here, we describe a focal epilepsy patient with shadowboxing-induced reflex seizures. His semiology included focal aware seizures with speech and behavioral arrest that evolved to head version to the right, preceded by cephalic aura. We identified a specific motion that induced these seizures during shadowboxing using video-electroencephalographic recording, and the patient was able to continue boxing by avoiding this motion. We speculate that a broad brain network may be the pathological substrate of his exercise-induced reflex seizures. Identification of the specific motion that induces exercise-induced reflex seizures is useful for not only understanding the underlying pathophysiology, but also for minimizing the therapeutic restriction of the exercise.
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Affiliation(s)
- Toshiki Okadome
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Hajime Takeuchi
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Takahiro Yamaguchi
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Takahiko Mukaino
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Hidenori Ogata
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Katsuhisa Masaki
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Hiroshi Shigeto
- Division of Medical Technology, Department of Health Sciences, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Noriko Isobe
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
- Corresponding author.
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13
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Martinez-Lizana E, Brandt A, Foit NA, Urbach H, Schulze-Bonhage A. Ictal semiology of epileptic seizures with insulo-opercular genesis. J Neurol 2021; 269:3119-3128. [PMID: 34812940 PMCID: PMC9120119 DOI: 10.1007/s00415-021-10911-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 10/15/2021] [Accepted: 11/15/2021] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- Eva Martinez-Lizana
- Epilepsy Center, Medical Center, University of Freiburg, Breisacher Str. 64, 79106, Freiburg im Breisgau, Germany.
| | - Armin Brandt
- Epilepsy Center, Medical Center, University of Freiburg, Breisacher Str. 64, 79106, Freiburg im Breisgau, Germany
| | - Niels A Foit
- Department of Neurosurgery, Medical Center, University of Freiburg, Freiburg im Breisgau, Germany
| | - Horst Urbach
- Department of Neuroradiology, Medical Center, University of Freiburg, Freiburg im Breisgau, Germany
| | - Andreas Schulze-Bonhage
- Epilepsy Center, Medical Center, University of Freiburg, Breisacher Str. 64, 79106, Freiburg im Breisgau, Germany
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14
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Rachidi I, Minotti L, Martin G, Hoffmann D, Bastin J, David O, Kahane P. The Insula: A Stimulating Island of the Brain. Brain Sci 2021; 11:1533. [PMID: 34827532 PMCID: PMC8615692 DOI: 10.3390/brainsci11111533] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 11/07/2021] [Accepted: 11/12/2021] [Indexed: 11/16/2022] Open
Abstract
Direct cortical stimulation (DCS) in epilepsy surgery patients has a long history of functional brain mapping and seizure triggering. Here, we review its findings when applied to the insula in order to map the insular functions, evaluate its local and distant connections, and trigger seizures. Clinical responses to insular DCS are frequent and diverse, showing a partial segregation with spatial overlap, including a posterior somatosensory, auditory, and vestibular part, a central olfactory-gustatory region, and an anterior visceral and cognitive-emotional portion. The study of cortico-cortical evoked potentials (CCEPs) has shown that the anterior (resp. posterior) insula has a higher connectivity rate with itself than with the posterior (resp. anterior) insula, and that both the anterior and posterior insula are closely connected, notably between the homologous insular subdivisions. All insular gyri show extensive and complex ipsilateral and contralateral extra-insular connections, more anteriorly for the anterior insula and more posteriorly for the posterior insula. As a rule, CCEPs propagate first and with a higher probability around the insular DCS site, then to the homologous region, and later to more distal regions with fast cortico-cortical axonal conduction delays. Seizures elicited by insular DCS have rarely been specifically studied, but their rate does not seem to differ from those of other DCS studies. They are mainly provoked from the insular seizure onset zone but can also be triggered by stimulating intra- and extra-insular early propagation zones. Overall, in line with the neuroimaging studies, insular DCS studies converge on the view that the insula is a multimodal functional hub with a fast propagation of information, whose organization helps understand where insular seizures start and how they propagate.
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Affiliation(s)
- Inès Rachidi
- CHU Grenoble Alpes, 38000 Grenoble, France; (L.M.); (G.M.); (D.H.); (P.K.)
| | - Lorella Minotti
- CHU Grenoble Alpes, 38000 Grenoble, France; (L.M.); (G.M.); (D.H.); (P.K.)
- Univ. Grenoble Alpes, Inserm, U1216, Grenoble Institut Neurosciences, 38000 Grenoble, France; (J.B.); (O.D.)
| | - Guillaume Martin
- CHU Grenoble Alpes, 38000 Grenoble, France; (L.M.); (G.M.); (D.H.); (P.K.)
- Univ. Grenoble Alpes, Inserm, U1216, Grenoble Institut Neurosciences, 38000 Grenoble, France; (J.B.); (O.D.)
| | - Dominique Hoffmann
- CHU Grenoble Alpes, 38000 Grenoble, France; (L.M.); (G.M.); (D.H.); (P.K.)
| | - Julien Bastin
- Univ. Grenoble Alpes, Inserm, U1216, Grenoble Institut Neurosciences, 38000 Grenoble, France; (J.B.); (O.D.)
| | - Olivier David
- Univ. Grenoble Alpes, Inserm, U1216, Grenoble Institut Neurosciences, 38000 Grenoble, France; (J.B.); (O.D.)
| | - Philippe Kahane
- CHU Grenoble Alpes, 38000 Grenoble, France; (L.M.); (G.M.); (D.H.); (P.K.)
- Univ. Grenoble Alpes, Inserm, U1216, Grenoble Institut Neurosciences, 38000 Grenoble, France; (J.B.); (O.D.)
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15
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McGonigal A, Bartolomei F, Chauvel P. On seizure semiology. Epilepsia 2021; 62:2019-2035. [PMID: 34247399 DOI: 10.1111/epi.16994] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 06/23/2021] [Accepted: 06/23/2021] [Indexed: 12/30/2022]
Abstract
The clinical expression of seizures represents the main symptomatic burden of epilepsy. Neural mechanisms of semiologic production in epilepsy, especially for complex behaviors, remain poorly known. In a framework of epilepsy as a network rather than as a focal disorder, we can think of semiology as being dynamically produced by a set of interconnected structures, in which specific rhythmic interactions, and not just anatomical localization, are likely to play an important part in clinical expression. This requires a paradigm shift in how we think about seizure organization, including from a presurgical evaluation perspective. Semiology is a key data source, albeit with significant methodological challenges for its use in research, including observer bias and choice of semiologic categories. Better understanding of semiologic categorization and pathophysiological correlates is relevant to seizure classification systems. Advances in knowledge of neural mechanisms as well as anatomic correlates of different semiologic patterns could help improve knowledge of epilepsy networks and potentially contribute to therapeutic innovations.
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Affiliation(s)
- Aileen McGonigal
- Inserm, INS, Institut de Neurosciences des Systèmes, Aix Marseille Univ, Marseille, France.,Clinical Neurophysiology, APHM, Timone Hospital, Marseille, France
| | - Fabrice Bartolomei
- Inserm, INS, Institut de Neurosciences des Systèmes, Aix Marseille Univ, Marseille, France.,Clinical Neurophysiology, APHM, Timone Hospital, Marseille, France
| | - Patrick Chauvel
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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16
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Shih JJ. Deciphering the Great Mimicker. Epilepsy Curr 2021; 21:93-95. [PMID: 34025283 PMCID: PMC8010865 DOI: 10.1177/1535759720988540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Mapping the Insula With Stereo-Electroencephalography: The Emergence of Semiology in Insula Lobe Seizures Singh R, Principe A, Tadel F, et al. Ann Neurol. 2020;88(3):477-488. PMID: 32542728. doi:10.1002/ana.25817 Objective: Insula epilepsy is rare and can be evaluated effectively by stereotactic intracerebral electroencephalography. Many previous studies of insulo-opercular seizures have been unable to separate insular and opercular onset. With adequate sampling of the insula, this study shows this is possible. Methods: We analyzed intrainsular dynamics and extrainsular propagation in 12 patients with “pure” insula epilepsy (n = 9) or insular and only deepest opercular involvement (n = 3) at seizure onset. Review of semiology defined clinical groups, agglomerative cluster, and principal component analysis of semiological features were performed. Quantitative epileptogenicity and intrainsular and extrainsular propagation were computed via time frequency analysis and epileptogenicity mapping. Results: Seizure-onset patterns were heterogeneous; the seizure-onset zone was focal. Seizure-onset and first ictal change within insula functional subdivision correlated with aura and reflex component. No paninsular spread occurred; contralateral insular spread was very early. While the discharge was intrainsular, clinical signs were related to aura or vegetative signs. Extrainsular propagation was early and related to the emergence of the majority of clinical signs. Cluster analysis found an anterior, intermediate, and posterior insula seizure-onset group. The largest principal component separated anterior insula manifestations, including early hypermotor signs, early recovery, and no aura from posterior insula features of early dystonia, early tonic motor features, and sensorimotor aura. Interpretation: Aura is vital to identifying seizure onset and relates to insula functional subdivision. Seizures are heterogenous; extrainsular propagation occurs early, accounting for most of the semiology. With adequate sampling, “pure” insula epilepsy can be identified and focal curative resection is possible.
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Abstract
PURPOSE OF REVIEW The increased identification of seizures with insular ictal onset, promoted by the international development of stereo-electroencephalography (SEEG), has led to the recent description of larger cohorts of patients with insular or insulo-opercular epilepsies than those previously available. These new series have consolidated and extended our knowledge of the rich ictal semiology and diverse anatomo-clinical correlations that characterized insular seizures. In parallel, some experiences have been gained in the surgical treatment of insular epilepsies using minimal invasive procedures. RECENT FINDINGS The large majority of patients present with auras (mostly somatosensory and laryngeal) and motor signs (predominantly elementary and orofacial), an underlying focal cortical dysplasia, and an excellent postoperative seizure outcome. Many other subjective and objective ictal signs, known to occur in other forms of epilepsies, are also observed and clustered in five patterns, reflecting the functional anatomy of the insula and its overlying opercula, as well as preferential propagation pathways to frontal or temporal brain regions. A nocturnal predominance of seizure is frequently reported, whereas secondary generalization is infrequent. Some rare ictal signs are highly suggestive of an insular origin, including somatic pain, reflex seizures, choking spells, and vomiting. Minimal invasive surgical techniques have been applied to the treatment of insular epilepsies, including Magnetic Resonance Imaging-guided laser ablation (laser interstitial thermal therapy (LITT)), radiofrequency thermocoagulation (RFTC), gamma knife radiosurgery, and responsive neurostimulation. Rates of seizure freedom (about 50%) appear lower than that reported with open-surgery (about 80%) with yet a significant proportion of transient neurological deficit for LITT and RFTC. SUMMARY Significant progress has been made in the identification and surgical treatment of insular and insulo-opercular epilepsies, including more precise anatomo-clinical correlations to optimally plan SEEG investigations, and experience in using minimal invasive surgery to reduce peri-operative morbidity.
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