Clinical Manifestations of Insular Lobe Seizures: A Stereo‐electroencephalographic Study

TLDR

The study reports clinical features of insular lobe seizures using video‑EEG, SEEG, and direct insular stimulation in patients evaluated for temporal lobe epilepsy. The authors implanted SEEG electrodes in the insular cortex of 50 consecutive TLE patients whose seizures were suspected to involve the perisylvian region. In six patients, a stereotyped ictal sequence—laryngeal constriction, widespread paresthesiae, dysarthria, and focal motor convulsions—occurred in full consciousness, reliably indicating insular origin and suggesting that insular recording should precede surgical decisions in TLE.

Abstract

Summary: Purpose: In this study, we report the clinical features of insular lobe seizures based on data from video and stereo‐electroencephalographic (SEEG) ictal recordings and direct electric insular stimulation of the insular cortex performed in patients referred for presurgical evaluation of temporal lobe epilepsy (TLE). Methods: Since our first recordings of insular seizures, the insular cortex has been included as one of the targets of stereo‐electroencephalographic (SEEG) electrode implantation in 50 consecutive patients with TLE whose seizures were suspected to originate from, or rapidly to propagate to, the perisylvian cortex. In six, a stereotyped sequence of ictal symptoms associated with intrainsular discharges could be identified. Results: This ictal sequence occurred in full consciousness, beginning with a sensation of laryngeal constriction and paresthesiae, often unpleasant, affecting large cutaneous territories, most often at the onset of a complex partial seizure (five of the six patients). It was eventually followed by dysarthric speech and focal motor convulsive symptoms. The insular origin of these symptoms was supported by the data from functional cortical mapping of the insula by using direct cortical stimulations. Conclusions: This sequence of ictal symptoms looks reliable enough to characterize insular lobe epileptic seizures (ILESs). Observation of this clinical sequence at the onset of seizures on video‐EEG recordings in TLE patients strongly suggests that the seizure‐onset zone is located not in the temporal but in the insular lobe; recording directly from the insular cortex should occur before making any decision regarding epilepsy surgery.