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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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Dai Y, Zhang H, Fan X, Wei P, Shan Y, Zhao G. Optimized SEEG-guided three-dimensional radiofrequency thermocoagulation for insular epilepsy. Acta Neurochir (Wien) 2023; 165:249-258. [PMID: 36342542 DOI: 10.1007/s00701-022-05401-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 10/20/2022] [Indexed: 11/09/2022]
Abstract
PURPOSE The high risk of resection surgery for drug-resistant insular epilepsy has driven interest in new treatment techniques. Stereo-electroencephalography-guided three-dimensional radiofrequency thermocoagulation (SEEG-3D RFTC) offers an alternative option. Herein, we present the detailed protocol and investigation of the efficacy and safety of a preliminary observational study. METHODS From February 2017 to April 2021, ten patients diagnosed with insular epilepsy were enrolled in the study. They underwent implantation of a combination of SEEG electrodes to form a high-density focal stereo-array in insula, including oblique electrodes through the long axis of insula and orthogonal electrodes to widely cover the medial and lateral insula. SEEG-3D RFTC was performed between two contiguous contacts of the same electrode, or between two adjacent contacts of different electrodes. RESULTS Surgical procedures were well tolerated, with no related long-term complications. Seizure-free outcome was achieved in seven patients (70%), including ILAE I in four and ILAE II in three. Two other (20%) patients had rare seizures (ILAE III). One (10%) patient experienced an ILAE IV outcome (follow-up = 12--63 months). The responder rate (including ILAE I-IV) was 100%. CONCLUSION The optimized SEEG-3D RFTC is an effective and safe option for the treatment of drug-resistant insular epilepsy.
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Affiliation(s)
- Yang Dai
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45 Changchun St., Xicheng District, Beijing, 100053, China
- Clinical Research Center for Epilepsy, Capital Medical University, Beijing, 100053, China
| | - Huaqiang Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45 Changchun St., Xicheng District, Beijing, 100053, China
- Clinical Research Center for Epilepsy, Capital Medical University, Beijing, 100053, China
| | - Xiaotong Fan
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45 Changchun St., Xicheng District, Beijing, 100053, China
- Clinical Research Center for Epilepsy, Capital Medical University, Beijing, 100053, China
| | - Penghu Wei
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45 Changchun St., Xicheng District, Beijing, 100053, China
- Clinical Research Center for Epilepsy, Capital Medical University, Beijing, 100053, China
| | - Yongzhi Shan
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45 Changchun St., Xicheng District, Beijing, 100053, China.
- Clinical Research Center for Epilepsy, Capital Medical University, Beijing, 100053, China.
| | - Guoguang Zhao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45 Changchun St., Xicheng District, Beijing, 100053, China.
- Clinical Research Center for Epilepsy, Capital Medical University, Beijing, 100053, China.
- National Clinical Research Center for Geriatric Diseases, Beijing, 100053, China.
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Zhang D, Cui X, Zheng J, Zhang S, Wang M, Lu W, Sang L, Li W. Neurosurgical robot-assistant stereoelectroencephalography system: Operability and accuracy. Brain Behav 2021; 11:e2347. [PMID: 34520631 PMCID: PMC8553331 DOI: 10.1002/brb3.2347] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 07/18/2021] [Accepted: 08/18/2021] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Fine operation has been an eternal topic in neurosurgery. There were many problems in functional neurosurgery field with high precision requirements. Our study aims to explore the operability, accuracy and postoperative effect of robot-assisted stereoelectroencephalography (SEEG) in neurosurgery. METHODS We conducted a retrospective analysis of patients with epilepsy who underwent electrode implantation in our hospital. From 2016 to 2019, the epilepsy center of Hebei people's hospital implanted electrodes in neurosurgery on 24 patients, including 20 with SINO robot-assisted SEEG system and eight with frame-SEEG technology. RESULT Robot-assisted SEEG neurosurgery had higher accuracy, and the mean error of entry and target point was smaller than that of frame SEEG surgery. No bleeding or infection occurred postoperatively, and two patients who underwent robot-assisted SEEG neurosurgery had electrode displacement. Electrode displacement was observed in two patients, both the entry points were orbital frontal, one in the frame system and one in the robot assistant system. The average placement time of each electrode in robot assisted system surgery was less than that in frame system surgery. CONCLUSION The SINO SEEG electrode implantation assisted by surgical robot-assistant system manufactured in China is safe, accurate and mature.
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Affiliation(s)
- Di Zhang
- Neurosurgery Department of Epilepsy, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Xuehua Cui
- Neurosurgery Department of Epilepsy, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Jie Zheng
- Neurosurgery Department of Epilepsy, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Shunyao Zhang
- Neurosurgery Department of Epilepsy, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Meng Wang
- Neurosurgery Department of Epilepsy, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Wenpeng Lu
- Neurosurgery Department of Epilepsy, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Linxia Sang
- Neurosurgery Department of Epilepsy, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Wenling Li
- Neurosurgery Department of Epilepsy, The Second Hospital of Hebei Medical University, Shijiazhuang, China
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Bottan JS, Rubino PA, Lau JC, MacDougall KW, Parrent AG, Burneo JG, Steven DA. Robot-Assisted Insular Depth Electrode Implantation Through Oblique Trajectories: 3-Dimensional Anatomical Nuances, Technique, Accuracy, and Safety. Oper Neurosurg (Hagerstown) 2021; 18:278-283. [PMID: 31245818 DOI: 10.1093/ons/opz154] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 03/15/2019] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND The insula is a deep cortical structure that has renewed interest in epilepsy investigation. Invasive EEG recordings of this region have been challenging. Robot-assisted stereotactic electroencephalography has improved feasibility and safety of such procedures. OBJECTIVE To describe technical nuances of three-dimensional (3D) oblique trajectories for insular robot-assisted depth electrode implantation. METHODS Fifty patients who underwent robot-assisted depth electrode implantation between June 2017 and December 2018 were retrospectively analyzed. Insular electrodes were implanted through oblique, orthogonal, or parasagittal trajectories. Type of trajectories, accuracy, number of contacts within insular cortex, imaging, and complication rates were analyzed. Cadaveric and computerized tomography/magnetic resonance imaging 3D reconstructions were used to visualize insular anatomy and the technical implications of oblique trajectories. RESULTS Forty-one patients (98 insular electrodes) were included. Thirty (73.2%) patients had unilateral insular coverage. Average insular electrodes per patient was 2.4. The mean number of contacts was 7.1 (SD ± 2.91) for all trajectories and 8.3 (SD ± 1.51) for oblique insular trajectories. The most frequently used was the oblique trajectory (85 electrodes). Mean entry point error was 1.5 mm (0.2-2.8) and target error was 2.4 mm (0.8-4.0), 2.0 mm (1.1-2.9) for anterior oblique and 2.8 mm (0.8-4.9) for posterior oblique trajectories. There were no complications related to insular electrodes. CONCLUSION Oblique trajectories are the preferred method for insular investigation at our institution, maximizing the number of contacts within insular cortex without traversing through sulci or major CSF fissures. Robot-assisted procedures are safe and efficient. 3D understanding of the insula's unique anatomical features can help the surgeon to improve targeting of this structure.
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Affiliation(s)
- Juan S Bottan
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Canada.,Division of Neurosurgery, Hospital General de Niños "Pedro De Elizalde," Ciudad Autónoma de Buenos Aires, Argentina
| | - Pablo A Rubino
- Hospital de Alta Complejidad en Red "El Cruce," Florencio Varela, Argentina
| | - Jonathan C Lau
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Canada
| | - Keith W MacDougall
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Canada
| | - Andrew G Parrent
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Canada
| | - Jorge G Burneo
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Canada.,Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, Canada
| | - David A Steven
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Canada.,Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, Canada
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Bouthillier A, Weil AG, Martineau L, Létourneau-Guillon L, Nguyen DK. Operculoinsular cortectomy for refractory epilepsy. Part 1: Is it effective? J Neurosurg 2020; 133:950-959. [PMID: 31629321 DOI: 10.3171/2019.4.jns1912] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 04/19/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Patients with refractory epilepsy of operculoinsular origin are often denied potentially effective surgical treatment with operculoinsular cortectomy (also termed operculoinsulectomy) because of feared complications and the paucity of surgical series with a significant number of cases documenting seizure control outcome. The goal of this study was to document seizure control outcome after operculoinsular cortectomy in a group of patients investigated and treated by an epilepsy team with 20 years of experience with this specific technique. METHODS Clinical, imaging, surgical, and seizure control outcome data of all patients who underwent surgery for refractory epilepsy requiring an operculoinsular cortectomy were retrospectively reviewed. Tumors and progressive encephalitis cases were excluded. Descriptive and uni- and multivariate analyses were done to determine seizure control outcome and predictors. RESULTS Forty-three patients with 44 operculoinsular cortectomies were studied. Kaplan-Meier estimates of complete seizure freedom (first seizure recurrence excluding auras) for years 0.5, 1, 2, and 5 were 70.2%, 70.2%, 65.0%, and 65.0%, respectively. With patients with more than 1 year of follow-up, seizure control outcome Engel class I was achieved in 76.9% (mean follow-up duration 5.8 years; range 1.25-20 years). With multivariate analysis, unfavorable seizure outcome predictors were frontal lobe-like seizure semiology, shorter duration of epilepsy, and the use of intracranial electrodes for invasive monitoring. Suspected causes of recurrent seizures were sparing of the language cortex part of the focus, subtotal resection of cortical dysplasia/polymicrogyria, bilateral epilepsy, and residual epileptic cortex with normal preoperative MRI studies (insula, frontal lobe, posterior parieto-temporal, orbitofrontal). CONCLUSIONS The surgical treatment of operculoinsular refractory epilepsy is as effective as epilepsy surgeries in other brain areas. These patients should be referred to centers with appropriate experience. A frontal lobe-like seizure semiology should command more sampling with invasive monitoring. Recordings with intracranial electrodes are not always required if the noninvasive investigation is conclusive. The complete resection of the epileptic zone is crucial to achieve good seizure control outcome.
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Affiliation(s)
| | - Alexander G Weil
- 1Divisions of Neurosurgery
- 4Division of Neurosurgery, Sainte-Justine University Hospital Center, Montreal, Quebec, Canada
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De Barros A, Zaldivar-Jolissaint JF, Hoffmann D, Job-Chapron AS, Minotti L, Kahane P, De Schlichting E, Chabardès S. Indications, Techniques, and Outcomes of Robot-Assisted Insular Stereo-Electro-Encephalography: A Review. Front Neurol 2020; 11:1033. [PMID: 33041978 PMCID: PMC7527495 DOI: 10.3389/fneur.2020.01033] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 08/07/2020] [Indexed: 01/04/2023] Open
Abstract
Stereo-electro-encephalography (SEEG) is an invasive, surgical, and electrophysiological method for three-dimensional registration and mapping of seizure activity in drug-resistant epilepsy. It allows the accurate analysis of spatio-temporal seizure activity by multiple intraparenchymal depth electrodes. The technique requires rigorous non-invasive pre-SEEG evaluation (clinical, video-EEG, and neuroimaging investigations) in order to plan the insertion of the SEEG electrodes with minimal risk and maximal recording accuracy. The resulting recordings are used to precisely define the surgical limits of resection of the epileptogenic zone in relation to adjacent eloquent structures. Since the initial description of the technique by Talairach and Bancaud in the 1950's, several techniques of electrode insertion have been used with accuracy and relatively few complications. In the last decade, robot-assisted surgery has emerged as a safe, accurate, and time-saving electrode insertion technique due to its unparalleled potential for orthogonal and oblique insertion trajectories, guided by rigorous computer-assisted planning. SEEG exploration of the insular cortex remains difficult due to its anatomical location, hidden by the temporal and frontoparietal opercula. Furthermore, the close vicinity of Sylvian vessels makes surgical electrode insertion challenging. Some epilepsy surgery teams remain cautious about insular exploration due to the potential of neurovascular injury. However, several authors have published encouraging results regarding the technique's accuracy and safety in both children and adults. We will review the indications, techniques, and outcomes of insular SEEG exploration with emphasis on robot-assisted implantation.
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Affiliation(s)
- Amaury De Barros
- Department of Neurosurgery, Toulouse University Hospital, Toulouse, France
| | | | - Dominique Hoffmann
- CHU Grenoble Alpes, Clinical University of Neurosurgery, Grenoble, France
| | | | - Lorella Minotti
- CHU Grenoble Alpes, Clinical University of Neurology, Grenoble, France
| | - Philippe Kahane
- CHU Grenoble Alpes, Clinical University of Neurology, Grenoble, France
| | | | - Stephan Chabardès
- CHU Grenoble Alpes, Clinical University of Neurosurgery, Grenoble, France
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Miyakoshi M, Jurgiel J, Dillon A, Chang S, Piacentini J, Makeig S, Loo SK. Modulation of Frontal Oscillatory Power during Blink Suppression in Children: Effects of Premonitory Urge and Reward. Cereb Cortex Commun 2020; 1:tgaa046. [PMID: 34296114 PMCID: PMC8153050 DOI: 10.1093/texcom/tgaa046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 07/23/2020] [Accepted: 07/27/2020] [Indexed: 01/14/2023] Open
Abstract
There is a dearth of studies examining the underlying mechanisms of blink suppression and the effects of urge and reward, particularly those measuring subsecond electroencephalogram (EEG) brain dynamics. To address these issues, we designed an EEG study to ask 3 questions: 1) How does urge develop? 2) What are EEG-correlates of blink suppression? 3) How does reward change brain dynamics related to urge suppression? This study examined healthy children (N = 26, age 8–12 years) during blink suppression under 3 conditions: blink freely (i.e., no suppression), blink suppressed, and blink suppressed for reward. During suppression conditions, children used a joystick to indicate their subjective urge to blink. Results showed that 1) half of the trials were associated with clearly defined urge time course of ~7 s, which was accompanied by EEG delta (1–4 Hz) power reduction localized at anterior cingulate cortex (ACC); 2) the EEG correlates of blink suppression were found in left prefrontal theta (4–8 Hz) power elevation; and 3) reward improved blink suppression performance while reducing the EEG delta power observed in ACC. We concluded that the empirically supported urge time course and underlying EEG modulations provide a subsecond chronospatial model of the brain dynamics during urge- and reward-mediated blink suppression.
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Affiliation(s)
- Makoto Miyakoshi
- Swartz Center for Computational Neuroscience, Institute for Neural Computation, University of California San Diego, La Jolla, CA 92093-0559, USA
| | - Joseph Jurgiel
- Semel Institute for Neuroscience and Human Behavior, University of California Los Angeles, Los Angeles, CA 90095, USA
| | - Andrea Dillon
- Semel Institute for Neuroscience and Human Behavior, University of California Los Angeles, Los Angeles, CA 90095, USA
| | - Susanna Chang
- Semel Institute for Neuroscience and Human Behavior, University of California Los Angeles, Los Angeles, CA 90095, USA
| | - John Piacentini
- Semel Institute for Neuroscience and Human Behavior, University of California Los Angeles, Los Angeles, CA 90095, USA
| | - Scott Makeig
- Swartz Center for Computational Neuroscience, Institute for Neural Computation, University of California San Diego, La Jolla, CA 92093-0559, USA
| | - Sandra K Loo
- Semel Institute for Neuroscience and Human Behavior, University of California Los Angeles, Los Angeles, CA 90095, USA
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Taussig D, Chipaux M, Fohlen M, Dorison N, Bekaert O, Ferrand-Sorbets S, Dorfmüller G. Invasive evaluation in children (SEEG vs subdural grids). Seizure 2020; 77:43-51. [DOI: 10.1016/j.seizure.2018.11.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 11/09/2018] [Accepted: 11/14/2018] [Indexed: 10/27/2022] Open
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Kappen P, Eltze C, Tisdall M, Cross JH, Thornton R, Moeller F. Stereo-EEG exploration in the insula/operculum in paediatric patients with refractory epilepsy. Seizure 2020; 78:63-70. [PMID: 32203882 DOI: 10.1016/j.seizure.2020.02.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 02/09/2020] [Accepted: 02/12/2020] [Indexed: 11/27/2022] Open
Abstract
PURPOSE Failure to recognise involvement of the insula / opercula (I/O) region is associated with poor outcome in epilepsy surgery. Recognition is challenging due to high connectivity with adjacent structures resulting in variable and misleading semiology, often subjective and therefore likely to be underreported by children. In this study we explored prevalence and characteristics of I/O involvement in paediatric patients undergoing sEEG exploration. METHOD We retrospectively included all consecutive patients undergoing sEEG at our centre between 11/2014 and 01/2018 with at least three contacts within I/O and excluded those with undetermined seizure onset zone (SOZ) by sEEG. We divided patients into three groups: 1) SOZ in I/O, 2) spread to I/O and 3) no I/O involvement. We compared pre-invasive characteristics, sEEG results, surgery and outcome for each group. RESULTS 29 of all 53 consecutive patients had an identified SOZ by sEEG and at least three contacts within the I/O and were included. 41% had I/O SOZ, 38% had I/O spread and 21% had no I/O involvement. Insula associated symptoms described in adult literature were not statistically different between the three groups. Complications due to sEEG were low (2 of 53 patients). Following I/O surgery, 63% were seizure free while an additional 26% of patients achieved seizure reduction. Postoperative deficits were seen in 75% of the patients but completely resolved in all but one patient. CONCLUSIONS Our data suggest an important role of the I/O region with frequent onset or propagation to the I/O region (at least 64% of all 53 sEEG cases). Semiology appears less specific than in adults. Insula depth electrode insertion is safe with subsequent good surgical outcomes albeit common transient deficits.
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Affiliation(s)
- Pablo Kappen
- Department of Neurophysiology, Great Ormond Street Hospital for Children, London, United Kingdom; Department of (Child) Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands.
| | - Christin Eltze
- Department of Neurophysiology, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Martin Tisdall
- Department of Neurophysiology, Great Ormond Street Hospital for Children, London, United Kingdom
| | - J Helen Cross
- Department of Neurophysiology, Great Ormond Street Hospital for Children, London, United Kingdom; University College London Institute of Child Health, London, United Kingdom
| | - Rachel Thornton
- Department of Neurophysiology, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Friederike Moeller
- Department of Neurophysiology, Great Ormond Street Hospital for Children, London, United Kingdom
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Feng AY, Ho AL, Kim LH, Sussman ES, Pendharkar AV, Iv M, Yeom KW, Halpern CH, Grant GA. Utilization of Novel High-Resolution, MRI-Based Vascular Imaging Modality for Preoperative Stereoelectroencephalography Planning in Children: A Technical Note. Stereotact Funct Neurosurg 2020; 98:1-7. [PMID: 32062664 DOI: 10.1159/000503693] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 09/25/2019] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Stereoelectroencephalography (SEEG) is a powerful intracranial diagnostic tool that requires accurate imaging for proper electrode trajectory planning to ensure efficacy and maximize patient safety. Computed tomography (CT) angiography and digital subtraction angiography are commonly used, but recent developments in magnetic resonance angiography allow for high-resolution vascular visualization without added risks of radiation. We report on the accuracy of electrode placement under robotic assistance planning utilizing a novel high-resolution magnetic resonance imaging (MRI)-based imaging modality. METHODS Sixteen pediatric patients between February 2014 and October 2017 underwent SEEG exploration for epileptogenic zone localization. A gadolinium-enhanced 3D T1-weighted spoiled gradient recalled echo sequence with minimum echo time and repetition time was applied for background parenchymal suppression and vascular enhancement. Electrode placement accuracy was determined by analyzing postoperative CT scans laid over preoperative virtual electrode trajectory paths. Entry point, target point, and closest vessel intersection were measured. RESULTS For any intersection along the trajectory path, 57 intersected vessels were measured. The mean diameter of an intersected vessel was 1.0343 ± 0.1721 mm, and 21.05% of intersections involved superficial vessels. There were 157 overall intersection + near-miss events. The mean diameter for an involved vessel was 1.0236 ± 0.0928 mm, and superficial vessels were involved in 20.13%. Looking only at final electrode target, 3 intersection events were observed. The mean diameter of an intersected vessel was 1.0125 ± 0.2227 mm. For intersection + near-miss events, 24 were measured. An involved vessel's mean diameter was 1.1028 ± 0.2634 mm. For non-entry point intersections, 45 intersected vessels were measured. The mean diameter for intersected vessels was 0.9526 ± 0.0689 mm. For non-entry point intersections + near misses, 126 events were observed. The mean diameter for involved vessels was 0.9826 ± 0.1008 mm. CONCLUSION We believe this novel sequence allows better identification of superficial and deeper subcortical vessels compared to conventional T1-weighted gadolinium-enhanced MRI.
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Affiliation(s)
- Austin Y Feng
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Allen L Ho
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Lily H Kim
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Eric S Sussman
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Arjun V Pendharkar
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Michael Iv
- Department of Radiology, Stanford University Medical Center, Stanford, California, USA
| | - Kristen W Yeom
- Department of Radiology, Pediatric Radiology, Lucile Packard Children's Hospital at Stanford, Stanford, California, USA
| | - Casey H Halpern
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Gerald A Grant
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA, .,Division of Pediatric Neurosurgery, Lucile Packard Children's Hospital Stanford, Stanford, California, USA,
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11
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Sala-Padro J, Fong M, Rahman Z, Bartley M, Gill D, Dexter M, Bleasel A, Wong C. A study of perfusion changes with Insula Epilepsy using SPECT. Seizure 2019; 69:44-50. [PMID: 30974406 DOI: 10.1016/j.seizure.2019.03.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 03/12/2019] [Accepted: 03/27/2019] [Indexed: 11/28/2022] Open
Abstract
PURPOSE The non-invasive localisation of insular lobe epilepsy is a challenge. We aimed to determine if ictal SPECT is a reliable adjunctive test in insular cases and to explore its role in the tailoring of intracranial strategies. METHOD From a dataset of patients who underwent SEEG between December 2012 and December 2016, we collected patients with focal insular onset epilepsy. We examined semiology, EEG, PET and SPECT hyperperfusion pattern with SISCOM. We also reviewed relevant literature. RESULTS 5 patients were identified, 4 females, from a dataset of 51 patients. Median age of seizure onset was 8 years old (8 months to 10 years). All patients had an ictal SPECT during pre-surgical work-up: median injection time was 7 s (3-17 sec) from clinical onset, and median seizure duration was 42 s (11-85 sec). Insula cortex showed focal hyperaemia in four patients, all bilateral, with the greatest hyperperfusion contralateral to the ictal onset in two cases, using SISCOM threshold at 1.5 standard deviation. Other sites with hyperaemia included basal ganglia and middle temporal gyrus. The SEEG confirmed insular onset seizures in all the cases. All patients had epilepsy surgery and were seizure free at 21 to 50 months follow up. The results from the literature review showed frequent hyperperfusion in structures outside insula and frequently over the contralateral hemisphere. CONCLUSIONS This study highlights the technical limitations of SPECT when attempting to assess seizures arising from the insula. Our findings and the literature show ictal SPECT can be localising but falsely lateralising in seizures arising from the insula.
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Affiliation(s)
- Jacint Sala-Padro
- Epilepsy Unit, Department of Neurology, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain.
| | - Michael Fong
- Epilepsy Unit, Department of Neurology, Westmead Hospital and Children's Hospital at Westmead, Hawkesbury Rd, Westmead, NSW, 2145, Australia
| | - Zebunnessa Rahman
- Epilepsy Unit, Department of Neurology, Westmead Hospital and Children's Hospital at Westmead, Hawkesbury Rd, Westmead, NSW, 2145, Australia; Westmead Clinical School, University of Sydney, Hawkesbury Rd, Westmead, NSW, 2145, Australia
| | - Melissa Bartley
- Epilepsy Unit, Department of Neurology, Westmead Hospital and Children's Hospital at Westmead, Hawkesbury Rd, Westmead, NSW, 2145, Australia
| | - Deepak Gill
- Epilepsy Unit, Department of Neurology, Westmead Hospital and Children's Hospital at Westmead, Hawkesbury Rd, Westmead, NSW, 2145, Australia; Westmead Clinical School, University of Sydney, Hawkesbury Rd, Westmead, NSW, 2145, Australia
| | - Mark Dexter
- Epilepsy Unit, Department of Neurology, Westmead Hospital and Children's Hospital at Westmead, Hawkesbury Rd, Westmead, NSW, 2145, Australia
| | - Andrew Bleasel
- Epilepsy Unit, Department of Neurology, Westmead Hospital and Children's Hospital at Westmead, Hawkesbury Rd, Westmead, NSW, 2145, Australia; Westmead Clinical School, University of Sydney, Hawkesbury Rd, Westmead, NSW, 2145, Australia
| | - Chong Wong
- Epilepsy Unit, Department of Neurology, Westmead Hospital and Children's Hospital at Westmead, Hawkesbury Rd, Westmead, NSW, 2145, Australia; Westmead Clinical School, University of Sydney, Hawkesbury Rd, Westmead, NSW, 2145, Australia
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Roland JL, Smyth MD. Recent advances in the neurosurgical treatment of pediatric epilepsy: JNSPG 75th Anniversary Invited Review Article. J Neurosurg Pediatr 2019; 23:411-421. [PMID: 30970205 DOI: 10.3171/2018.12.peds18350] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The field of epilepsy surgery has seen tremendous growth in recent years. Innovative new devices have driven much of this growth, but some has been driven by revisions of existing products. Devices have also helped to rejuvenate existing procedures, as in the case of robotic assistance for electrode placement for stereo-electroencephalography, and these devices have brought significant attention along with their introduction. Other devices, such as responsive neurostimulators or laser interstitial thermal therapy systems, have introduced novel treatment modalities and broadened the surgical indications. Collectively, these advances are rapidly changing much of the landscape in the world of pediatric neurosurgery for medically refractory epilepsy. The foundations for indications for neurosurgical intervention are well supported in strong research data, which has also been expanded in recent years. In this article, the authors review advances in the neurosurgical treatment of pediatric epilepsy, beginning with trials that have repeatedly demonstrated the value of neurosurgical procedures for medically refractory epilepsy and following with several recent advances that are largely focused on less-invasive intervention. ABBREVIATIONS AED = antiepileptic drug; ANT = anterior nucleus of the thalamus; BOLD = blood oxygen level dependent; CCEP = cortico-cortical evoked potential; DBS = deep brain stimulation; ECoG = electrocorticography; ERSET = Early Randomized Surgical Epilepsy Trial; FCD = focal cortical dysplasia; HH = hypothalamic hamartoma; LITT = laser interstitial thermal therapy; RCT = randomized controlled trial; r-fMRI = resting-state functional MRI; RNS = responsive neurostimulation; SEEG = stereo-electroencephalography; VNS = vagus nerve stimulation.
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Jobst BC, Gonzalez-Martinez J, Isnard J, Kahane P, Lacuey N, Lahtoo SD, Nguyen DK, Wu C, Lado F. The Insula and Its Epilepsies. Epilepsy Curr 2019; 19:11-21. [PMID: 30838920 PMCID: PMC6610377 DOI: 10.1177/1535759718822847] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Insular seizures are great mimickers of seizures originating elsewhere in the
brain. The insula is a highly connected brain structure. Seizures may only
become clinically evident after ictal activity propagates out of the insula with
semiology that reflects the propagation pattern. Insular seizures with
perisylvian spread, for example, manifest first as throat constriction, followed
next by perioral and hemisensory symptoms, and then by unilateral motor
symptoms. On the other hand, insular seizures may spread instead to the temporal
and frontal lobes and present like seizures originating from these regions. Due
to the location of the insula deep in the brain, interictal and ictal scalp
electroencephalogram (EEG) changes can be variable and misleading. Magnetic
resonance imaging, magnetic resonance spectroscopy, magnetoencephalography,
positron emission tomography, and single-photon computed tomography imaging may
assist in establishing a diagnosis of insular epilepsy. Intracranial EEG
recordings from within the insula, using stereo-EEG or depth electrode
techniques, can prove insular seizure origin. Seizure onset, most commonly seen
as low-voltage, fast gamma activity, however, can be highly localized and easily
missed if the insula is only sparsely sampled. Moreover, seizure spread to the
contralateral insula and other brain regions may occur rapidly. Extensive
sampling of the insula with multiple electrode trajectories is necessary to
avoid these pitfalls. Understanding the functional organization of the insula is
helpful when interpreting the semiology produced by insular seizures. Electrical
stimulation mapping around the central sulcus of the insula results in
paresthesias, while stimulation of the posterior insula typically produces
painful sensations. Visceral sensations are the next most common result of
insular stimulation. Treatment of insular epilepsy is evolving, but poses
challenges. Surgical resections of the insula are effective but risk significant
morbidity if not carefully planned. Neurostimulation is an emerging option for
treatment, especially for seizures with onset in the posterior insula. The close
association of the insula with marked autonomic changes has led to interest in
the role of the insula in sudden unexpected death in epilepsy and warrants
additional study with larger patient cohorts.
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Affiliation(s)
| | | | - Jean Isnard
- 3 Hospices Civils de Lyon, Hospital for Neurology and Neurosurgery, Lyon, France
| | | | - Nuria Lacuey
- 5 University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Samden D Lahtoo
- 5 University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | | | - Chengyuan Wu
- 7 Thomas Jefferson University, Philadelphia, PA, USA
| | - Fred Lado
- 8 Northwell Health, Great Neck, NY, USA
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14
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Abstract
Focal epilepsy originating from the insular cortex is rare. One reason is the small amount of cortical tissue compared with other lobes of the brain. However, the incidence of insular epilepsy might be underestimated because of diagnostic difficulties. The semiology and the surface EEG are often not meaningful or even misleading, and elaborated imaging might be necessary. The close connections of the insular cortex with other potentially epileptogenic areas, such as the temporal lobe or frontal/central cortex, is increasingly recognized as possible reason for failure of epilepsy surgery for temporal or extratemporal seizures. Therefore, some centers consider invasive EEG recording of the insular cortex not only in case of insular epilepsy but also in other focal epilepsies with nonconclusive results from the presurgical work-up. The surgical approach to and resection of insular cortex is challenging because of its deep location and proximity to highly eloquent brain structures. Over the last decades, technical adjuncts like navigation tools, electrophysiological monitoring and intraoperative imaging have improved the outcome after surgery. Nevertheless, there is still a considerable rate of postoperative transient or permanent deficits, in some cases as unavoidable and calculated deficits. In most of the recent series, seizure outcome was favorable and comparable with extratemporal epilepsy surgery or even better. Up to now, the data volume concerning long-term follow-up is limited. This review focusses on the surgical challenges of resections to treat insular epilepsy, on prognostic factors concerning seizure outcome, on postoperative deficits and complications. Moreover, less invasive surgical techniques to treat epilepsy in this highly eloquent area are summarized.
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Garcia-Lorenzo B, del Pino-Sedeño T, Rocamora R, López JE, Serrano-Aguilar P, Trujillo-Martín MM. Stereoelectroencephalography for Refractory Epileptic Patients Considered for Surgery: Systematic Review, Meta-Analysis, and Economic Evaluation. Neurosurgery 2018; 84:326-338. [DOI: 10.1093/neuros/nyy261] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 05/16/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- Borja Garcia-Lorenzo
- Bordeaux Population Health, Team EMOS, Université de Bordeaux, Inserm U1219, Bordeaux, France
- Fundación Canaria de Investigación Sanitaria (FUNCANIS), Santa Cruz de Tenerife, Spain
- Universitat Internacional de Catalunya (UIC), Barcelona, Spain
| | - Tasmania del Pino-Sedeño
- Fundación Canaria de Investigación Sanitaria (FUNCANIS), Santa Cruz de Tenerife, Spain
- Departamento de Psicología Clínica, Psicobiología y Metodología, Universidad de La Laguna, Santa Cruz de Tenerife, Spain
| | - Rodrigo Rocamora
- Epilepsy Unit, Department of Neurology, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain
- Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
- Department of Experimental and Health Sciences, Pompeu Fabra University (UPF), Barcelona, Spain
| | - Juan Erviti López
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Madrid, Spain
- Servicio de Prestaciones Farmacéuticas, Dirección Atención Primaria, Servicio Navarro de Salud, Pamplona, Spain
| | - Pedro Serrano-Aguilar
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Madrid, Spain
- Servicio de Evaluación y Planificación (SESCS), Servicio Canario de la Salud, Santa Cruz de Tenerife, Spain
| | - María M Trujillo-Martín
- Fundación Canaria de Investigación Sanitaria (FUNCANIS), Santa Cruz de Tenerife, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Madrid, Spain
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Bouthillier A, Nguyen DK. Epilepsy Surgeries Requiring an Operculoinsular Cortectomy: Operative Technique and Results. Neurosurgery 2018; 81:602-612. [PMID: 28419327 DOI: 10.1093/neuros/nyx080] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Accepted: 02/04/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Epilepsy surgeries requiring an operculoinsulectomy pose significant difficulties because the perisylvian area is highly vascular, deep, and functional. OBJECTIVE To report the operative technique and results of epilepsy surgeries requiring an operculoinsular cortectomy at our institution. METHODS The data of all consecutive patients who had undergone an epilepsy surgery requiring an operculoinsular cortectomy with a minimum follow-up of 1 yr were reviewed. Tumor and vascular malformation cases were excluded. Surgical techniques are described based on findings during surgery. RESULTS Twenty-five patients underwent an epilepsy surgery requiring an operculoinsular cortectomy: mean age at surgery was 35 y (9-51), mean duration of epilepsy was 19 y (5-36), 14 were female, and mean duration of follow-up was 4.7 y (1-16). Magnetic resonance imaging of the operculoinsular area was normal or revealed questionable nonspecific findings in 72% of cases. Investigation with intracranial EEG electrodes was done in 17 patients. Surgery was performed on the dominant side for language in 7 patients. An opercular resection was performed in all but 2 patients who only had an insulectomy. Engel class I seizure control was achieved in 80% of patients. Postoperative neurological deficits (paresis, dysphasia, alteration of taste, smell, hearing, pain, and thermal perceptions) were frequent (75%) but always transient except for 1 patient with persistent mild alteration of thermal and pain perception. CONCLUSION Surgical treatment of operculoinsular epilepsy is effective in achieving seizure control and is associated with an acceptable long-term complication rate.
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Affiliation(s)
- Alain Bouthillier
- Division of Neurosurgery, Hôpital Notre-Dame (CHUM), Université de Montréal, Quebec, Canada
| | - Dang Khoa Nguyen
- Division of Neurology, Hôpital Notre-Dame (CHUM), Université de Montréal, Quebec, Canada
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Tomycz LD, Hale AT, Haider AS, Clarke DF, Lee MR. Invasive Insular Sampling in Pediatric Epilepsy: A Single-Institution Experience. Oper Neurosurg (Hagerstown) 2017; 15:310-317. [DOI: 10.1093/ons/opx253] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND
It has been increasingly recognized that the insular cortex plays an important role in frontotemporal-parietal epilepsy in children. The insula, however, cannot be properly interrogated with conventional subdural grids, and its anatomy makes it difficult to implicate the insula with semiology or noninvasive modalities. Frame-based, stereotactic placement of insular depth electrodes for direct extraoperative monitoring is a relatively low-risk maneuver that allows for conclusive interrogation of this region, and, in select cases, can easily be replaced with a laser applicator for minimally invasive treatment via thermoablation.
OBJECTIVE
To describe the largest reported series of pediatric patients with refractory epilepsy undergoing insular depth electrode placement.
METHODS
We used current procedural terminology billing records to identify cases of depth electrode insertion performed at our institution. Clinical information from patients undergoing invasive insular sampling was then retrospectively collected.
RESULTS
Seventy-four insular depth electrodes were placed in 49 patients for extraoperative, inpatient monitoring. The decision to place insular depth electrodes was determined by a multidisciplinary epilepsy team. In 65.3% of cases, direct invasive sampling implicated the insula in seizure onset and prompted either thermoablation or surgical resection of some portion of the insula. There were no serious adverse effects or complications associated with the placement of insular depth electrodes.
CONCLUSION
Given the low morbidity of insular depth electrode insertion and the high proportion of patients who exhibited insular involvement, it is worth considering whether insular depth electrodes should be part of the standard presurgical evaluation in children with treatment-refractory frontotemporal-parietal epilepsy.
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Affiliation(s)
- Luke D Tomycz
- Department of Neurological Surgery, Dell Children's Medical Center, Austin, Texas
| | - Andrew T Hale
- Medical Scientist Training Program, Vanderbilt University School of Medicine, Nashville, Tennessee
| | | | - Dave F Clarke
- Department of Pediatric Neurology, Dell Children's Medical Center, Austin, Texas
| | - Mark R Lee
- Department of Neurological Surgery, Dell Children's Medical Center, Austin, Texas
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Laoprasert P, Ojemann JG, Handler MH. Insular epilepsy surgery. Epilepsia 2017; 58 Suppl 1:35-45. [PMID: 28386920 DOI: 10.1111/epi.13682] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2016] [Indexed: 11/29/2022]
Abstract
Since it was originally described nearly 70 years ago, insular epilepsy has been increasingly recognized and may explain failures after apparently well-planned operations. We review the history of awareness of the phenomenon, techniques for its assessment, and its surgical management. Insular epilepsy can mimic features of frontal, parietal, or temporal seizures. It should be considered when a combination of somatosensory, visceral, and motor symptoms is observed early in a seizure. Extraoperative intracranial recordings are required to accurately diagnose insular seizures. Stereo-electroencephalography (EEG) or craniotomy with implantation of surface and depth electrodes have been used successfully to identify insular onset of seizures. Surgical resection of an insular focus may be performed with good success and acceptable risk.
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Affiliation(s)
- Pramote Laoprasert
- Division of Neurology, Department of Pediatrics, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, Colorado, U.S.A
| | - Jeffrey G Ojemann
- Department of Neurosurgery, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - Michael H Handler
- Department of Neurosurgery, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, Colorado, U.S.A
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Abstract
Stereoelectroencephalography (SEEG) is a method for invasive study of patients with refractory epilepsy. Localization of the epileptogenic zone in SEEG relied on the hypothesis of anatomo-electro-clinical analysis limited by X-ray, analog electroencephalography (EEG), and seizure semiology in the 1950s. Modern neuroimaging studies and digital video-EEG have developed the hypothesis aiming at more precise localization of the epileptic network. Certain clinical scenarios favor SEEG over subdural EEG (SDEEG). SEEG can cover extensive areas of bilateral hemispheres with highly accurate sampling from sulcal areas and deep brain structures. A hybrid technique of SEEG and subdural strip electrode placement has been reported to overcome the SEEG limitations of poor functional mapping. Technological advances including acquisition of three-dimensional angiography and magnetic resonance image (MRI) in frameless conditions, advanced multimodal planning, and robot-assisted implantation have contributed to the accuracy and safety of electrode implantation in a simplified fashion. A recent meta-analysis of the safety of SEEG concluded the low value of the pooled prevalence for all complications. The complications of SEEG were significantly less than those of SDEEG. The removal of electrodes for SEEG was much simpler than for SDEEG and allowed sufficient time for data analysis, discussion, and consensus for both patients and physicians before the proceeding treatment. Furthermore, SEEG is applicable as a therapeutic alternative for deep-seated lesions, e.g., nodular heterotopia, in nonoperative epilepsies using SEEG-guided radiofrequency thermocoagulation. We review the SEEG method with technological advances for planning and implantation of electrodes. We highlight the indication and efficacy, advantages and disadvantages of SEEG compared with SDEEG.
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Affiliation(s)
- Koji Iida
- Department of Neurosurgery, Hiroshima University Hospital.,Epilepsy Center, Hiroshima University Hospital
| | - Hiroshi Otsubo
- Neurophysiology Laboratory, Division of Neurology, The Hospital for Sick Children
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20
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Weil AG, Fallah A, Lewis EC, Bhatia S. Medically resistant pediatric insular-opercular/perisylvian epilepsy. Part 1: invasive monitoring using the parasagittal transinsular apex depth electrode. J Neurosurg Pediatr 2016; 18:511-522. [PMID: 27472667 DOI: 10.3171/2016.4.peds15636] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE Insular lobe epilepsy (ILE) is an under-recognized cause of extratemporal epilepsy and explains some epilepsy surgery failures in children with drug-resistant epilepsy. The diagnosis of ILE usually requires invasive investigation with insular sampling; however, the location of the insula below the opercula and the dense middle cerebral artery vasculature renders its sampling challenging. Several techniques have been described, ranging from open direct placement of orthogonal subpial depth and strip electrodes through a craniotomy to frame-based stereotactic placement of orthogonal or oblique electrodes using stereo-electroencephalography principles. The authors describe an alternative method for sampling the insula, which involves placing insular depth electrodes along the long axis of the insula through the insular apex following dissection of the sylvian fissure in conjunction with subdural electrodes over the lateral hemispheric/opercular region. The authors report the feasibility, advantages, disadvantages, and role of this approach in investigating pediatric insular-opercular refractory epilepsy. METHODS The authors performed a retrospective analysis of all children (< 18 years old) who underwent invasive intracranial studies involving the insula between 2002 and 2015. RESULTS Eleven patients were included in the study (5 boys). The mean age at surgery was 7.6 years (range 0.5-16 years). All patients had drug-resistant epilepsy as defined by the International League Against Epilepsy and underwent comprehensive noninvasive epilepsy surgery workup. Intracranial monitoring was performed in all patients using 1 parasagittal insular electrode (1 patient had 2 electrodes) in addition to subdural grids and strips tailored to the suspected epileptogenic zone. In 10 patients, extraoperative monitoring was used; in 1 patient, intraoperative electrocorticography was used alone without extraoperative monitoring. The mean number of insular contacts was 6.8 (range 4-8), and the mean number of fronto-parieto-temporal hemispheric contacts was 61.7 (range 40-92). There were no complications related to placement of these depth electrodes. All 11 patients underwent subsequent resective surgery involving the insula. CONCLUSIONS Parasagittal transinsular apex depth electrode placement is a feasible alternative to orthogonally placed open or oblique-placed stereotactic methodologies. This method is safe and best suited for suspected unilateral cases with a possible extensive insular-opercular epileptogenic zone.
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Affiliation(s)
| | | | - Evan C Lewis
- Pediatric Neurology, Miami (Nicklaus) Children's Hospital, Miami, Florida
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21
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Weil AG, Le NMD, Jayakar P, Resnick T, Miller I, Fallah A, Duchowny M, Bhatia S. Medically resistant pediatric insular-opercular/perisylvian epilepsy. Part 2: outcome following resective surgery. J Neurosurg Pediatr 2016; 18:523-535. [PMID: 27472665 DOI: 10.3171/2016.4.peds15618] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Seizure onset in the insular cortex as a cause of refractory epilepsy is underrepresented in the pediatric population, possibly due to difficulties localizing seizure onset in deep anatomical structures and limited surgical access to the insula, a complex anatomical structure with a rich overlying vascular network. Insular seizure semiology may mimic frontal, temporal, or parietal lobe semiology, resulting in false localization, incomplete resection, and poor outcome. METHODS The authors retrospectively reviewed the records of all pediatric patients who underwent insular cortical resections for intractable epilepsy at Miami Children's Hospital from 2009 to 2015. Presurgical evaluation included video electroencephalography monitoring and anatomical/functional neuroimaging. All patients underwent excisional procedures utilizing intraoperative electrocorticography or extraoperative subdural/depth electrode recording. RESULTS Thirteen children (age range 6 months-16 years) with intractable focal epilepsy underwent insular-opercular resection. Seven children described symptoms that were suggestive of insular seizure origin. Discharges on scalp EEG revealed wide fields. Four patients were MRI negative (i.e., there were no insular or brain abnormalities on MRI), 4 demonstrated insular signal abnormalities, and 5 had extrainsular abnormalities. Ten patients had insular involvement on PET/SPECT. All patients underwent invasive investigation with insular sampling; in 2 patients resection was based on intraoperative electrocorticography, whereas 11 underwent surgery after invasive EEG monitoring with extraoperative monitoring. Four patients required an extended insular resection after a failed initial surgery. Postoperatively, 2 patients had transient hemiplegia. No patients had new permanent neurological deficits. At the most recent follow-up (mean 43.8 months), 9 (69%) children were seizure free and 1 had greater than 90% seizure reduction. CONCLUSIONS Primary insular seizure origin should be considered in children with treatment-resistant focal seizures that are believed to arise within the perisylvian region based on semiology, widespread electrical field on scalp EEG, or insular abnormality on anatomical/functional neuroimaging. There is a reasonable chance of seizure freedom in this group of patients, and the surgical risks are low.
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Affiliation(s)
- Alexander G Weil
- Pediatric Neurosurgery, Miami (Nicklaus) Children's Hospital, Miami, Florida
| | | | | | | | - Ian Miller
- Departments of 1 Pediatric Neurology and
| | - Aria Fallah
- Pediatric Neurosurgery, Miami (Nicklaus) Children's Hospital, Miami, Florida
| | | | - Sanjiv Bhatia
- Pediatric Neurosurgery, Miami (Nicklaus) Children's Hospital, Miami, Florida
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Finet P, Nguyen DK, Bouthillier A. Vascular consequences of operculoinsular corticectomy for refractory epilepsy. J Neurosurg 2015; 122:1293-8. [DOI: 10.3171/2014.10.jns141246] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
Surgery in the insular region is considered challenging because of its vascular relationships, the proximity of functional structures, and its deep location in the sylvian fissure. The authors report the incidence and consequences of ischemic lesions after operculoinsular corticectomy for refractory epilepsy.
METHODS
The authors retrospectively reviewed the data of all patients who underwent an insular resection with or without an opercular resection for refractory epilepsy at their center. All patients underwent postoperative MRI, enabling a radiological analysis of the ischemic lesions as a result of the corticectomies. The resections were classified according to the location and extent of the insular corticectomy and the type of operculectomy. Each patient underwent clinical follow-up.
RESULTS
Twenty patients underwent surgery. All patients underwent insular corticectomy with or without an operculectomy. Ischemic lesions were identified in 12 patients (60%). In these patients, 11 ischemic lesions (55%) were related to the insular corticectomy, and 1 was related to the associated periinsular resection. The ischemic lesions associated with the insulectomies were typically located in the corona radiata running from the insula to the periventricular region. Nine patients (45%) developed a postoperative neurological deficit, among whom 6 (67%) had an insular corticectomy–related ischemic lesion. All reported neurological deficits were transient. Five patients (25%) had ischemic lesions without neurological deficit.
CONCLUSIONS
Operculoinsular corticectomies are associated with ischemic lesions in approximately 60% of patients. However, given that no patient had a definitive postoperative deficit, these ischemic lesions have few clinical consequences. Therefore, this surgical procedure can be considered reasonably safe for the treatment of refractory epilepsy.
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Affiliation(s)
| | - Dang Khoa Nguyen
- 2Neurology, University of Montreal Medical Center (CHUM), Montreal, Quebec, Canada
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Princich JP, Wassermann D, Latini F, Oddo S, Blenkmann AO, Seifer G, Kochen S. Rapid and efficient localization of depth electrodes and cortical labeling using free and open source medical software in epilepsy surgery candidates. Front Neurosci 2013; 7:260. [PMID: 24427112 PMCID: PMC3876273 DOI: 10.3389/fnins.2013.00260] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2013] [Accepted: 12/11/2013] [Indexed: 11/23/2022] Open
Abstract
Depth intracranial electrodes (IEs) placement is one of the most used procedures to identify the epileptogenic zone (EZ) in surgical treatment of drug resistant epilepsy patients, about 20–30% of this population. IEs localization is therefore a critical issue defining the EZ and its relation with eloquent functional areas. That information is then used to target the resective surgery and has great potential to affect outcome. We designed a methodological procedure intended to avoid the need for highly specialized medical resources and reduce time to identify the anatomical location of IEs, during the first instances of intracranial EEG recordings. This workflow is based on established open source software; 3D Slicer and Freesurfer that uses MRI and Post-implant CT fusion for the localization of IEs and its relation with automatic labeled surrounding cortex. To test this hypothesis we assessed the time elapsed between the surgical implantation process and the final anatomical localization of IEs by means of our proposed method compared against traditional visual analysis of raw post-implant imaging in two groups of patients. All IEs were identified in the first 24 H (6–24 H) of implantation using our method in 4 patients of the first group. For the control group; all IEs were identified by experts with an overall time range of 36 h to 3 days using traditional visual analysis. It included (7 patients), 3 patients implanted with IEs and the same 4 patients from the first group. Time to localization was restrained in this group by the specialized personnel and the image quality available. To validate our method; we trained two inexperienced operators to assess the position of IEs contacts on four patients (5 IEs) using the proposed method. We quantified the discrepancies between operators and we also assessed the efficiency of our method to define the EZ comparing the findings against the results of traditional analysis.
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Affiliation(s)
- Juan Pablo Princich
- Epilepsy Section, Neurosciences Clinic and Applicated Center, Hospital Ramos Mejia, Universidad de Buenos Aires Buenos Aires, Argentina ; Fundación Favaloro, Resonancia Magnética, Neuroimágenes Buenos Aires, Argentina ; Imágenes Médicas -Neuroimágenes, Resonancia Magnética, Hospital de Pediatría SAMIC Prof. Dr. Juan Pedro Garrahan Buenos Aires, Argentina
| | - Demian Wassermann
- Department of Radiology, Harvard Medical School, Brigham and Women's Hospital Boston, MA, USA
| | - Facundo Latini
- Epilepsy Section, Neurosciences Clinic and Applicated Center, Hospital Ramos Mejia, Universidad de Buenos Aires Buenos Aires, Argentina
| | - Silvia Oddo
- Epilepsy Section, Neurosciences Clinic and Applicated Center, Hospital Ramos Mejia, Universidad de Buenos Aires Buenos Aires, Argentina
| | - Alejandro Omar Blenkmann
- Epilepsy Section, Neurosciences Clinic and Applicated Center, Hospital Ramos Mejia, Universidad de Buenos Aires Buenos Aires, Argentina
| | - Gustavo Seifer
- Epilepsy Section, Neurosciences Clinic and Applicated Center, Hospital Ramos Mejia, Universidad de Buenos Aires Buenos Aires, Argentina
| | - Silvia Kochen
- Epilepsy Section, Neurosciences Clinic and Applicated Center, Hospital Ramos Mejia, Universidad de Buenos Aires Buenos Aires, Argentina
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Somatosensory and pharyngolaryngeal auras in temporal lobe epilepsy surgeries. ISRN NEUROLOGY 2013; 2013:148519. [PMID: 23862072 PMCID: PMC3686131 DOI: 10.1155/2013/148519] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Accepted: 05/08/2013] [Indexed: 12/04/2022]
Abstract
Purpose. Somatosensory (SSA) and pharyngolaryngeal auras (PLA) may suggest an extratemporal onset (e.g., insula, second somatosensory area). We sought to determine the prognostic significance of SSA and PLA in temporal lobe epilepsy (TLE) patients undergoing epilepsy surgery. Methods. Retrospective review of all patients operated for refractory TLE at our institution between January 1980 and July 2007 comparing outcome between patients with SSA/PLA to those without. Results. 158 patients underwent surgery for pharmacoresistant TLE in our institution. Eleven (7%) experienced SSA/PLA as part of their seizures. All but one had lesional (including hippocampal atrophy/sclerosis) TLE. Compared to patients without SSA or PLA, these patients were older (P = 0.049), had a higher prevalence of early ictal motor symptoms (P = 0.022) and prior CNS infection (P = 0.022), and were less likely to have a localizing SPECT study (P = 0.025). A favorable outcome was achieved in 81.8% of patients with SSA and/or PLA and 90.4% of those without SSA or PLA (P > 0.05). Conclusion. Most patients with pharmacoresistant lesional TLE appear to have a favorable outcome following temporal lobectomy, even in the presence of SSA and PLA.
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Irislimane M, Mathieu D, Bouthillier A, Deacon C, Nguyen DK. Gamma Knife Surgery for Refractory Insular Cortex Epilepsy. Stereotact Funct Neurosurg 2013; 91:170-6. [DOI: 10.1159/000343205] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Accepted: 09/04/2012] [Indexed: 01/22/2023]
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Intracranial electrodes in the presurgical evaluation of epilepsy. Neurol Sci 2012; 33:723-9. [PMID: 22460695 DOI: 10.1007/s10072-012-1020-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2011] [Accepted: 03/13/2012] [Indexed: 10/28/2022]
Abstract
The resection of the epileptogenic area of brain is very important and useful for the treatment of uncontrolled epilepsy, especially for the patients with stereotyped partial seizures. The critical point for successful epilepsy surgery is the precise identification of epileptogenic zone. Actually, we cannot precisely localize the epileptogenic zone in about 25 % of patient with refractory seizures based on the noninvasive examination; thus for these patients, we mainly use the intracranial EEG to localize the epileptogenic zone which could be useful in 10-15 % of surgical candidates. The intracranial electrodes which are most used currently are depth electrodes, subdural strip electrodes, and subdural grid electrodes. The subject of this paper is to discuss and compare the indications, construction, insertion, interpretation, limitations, risks and accuracy of each of these methods.
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Desai A, Bekelis K, Darcey TM, Roberts DW. Surgical techniques for investigating the role of the insula in epilepsy: a review. Neurosurg Focus 2012; 32:E6. [DOI: 10.3171/2012.1.focus11325] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Intracranial electroencephalography monitoring of the insula is an important tool in the investigation of the insula in medically intractable epilepsy and has been shown to be safe and reliable. Several methods of placing electrodes for insular coverage have been reported and include open craniotomy as well as stereotactic orthogonal and stereotactic anterior and posterior oblique trajectories. The authors review each of these techniques with respect to current concepts in insular epilepsy.
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