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M. Scott Perry, David J. Donahue, Saleem I. Malik, Cynthia G. Keator, Angel Hernandez, Rohit K. Reddy, Freedom F. Perkins Jr., Mark R. Lee, and Dave F. Clarke

. In 1964, Silfvenius et al. reviewed the history of insular resection and noted the “considerably higher” rate of complications (20.6% vs 2.8%) when temporal lobectomy included insular resection. 14 As a result, methods of surgical therapy for intractable insular epilepsy that avoid these potential dangers are worthwhile. MRI-guided laser interstitial thermal therapy (LiTT) is a minimally invasive stereotactic surgical technique that can be employed to apply laser-induced heat to ablate epileptogenic foci. Application of LiTT for the surgical treatment of epilepsy

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Michael R. Levitt, Jeffrey G. Ojemann, and John Kuratani

cortex may be falsely localized to the cortical surface by scalp EEG and even ECoG, leading to persistence of seizures after topectomy. Lobar corticography alone would have incorrectly localized these seizures and incorrectly classified the seizures as multifocal. Only by interpretation of depth electrode data can insular epilepsy be localized and treated. Insular electrode implantation is a safe method of determining primary versus secondary insular involvement prior to surgery. 1 , 5 Previous work has shown that, although combining conventional temporal lobectomy

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Naoki Ikegaya, Masaki Iwasaki, Yuu Kaneko, Takanobu Kaido, Yuiko Kimura, Tetsuya Yamamoto, Noriko Sumitomo, Takashi Saito, Eiji Nakagawa, Kenji Sugai, Masayuki Sasaki, Akio Takahashi, and Taisuke Otsuki

results in cognitive changes must be clarified. Knowledge of the impact of insular epilepsy surgery on cognitive function is limited. Evaluation with multiple neuropsychological batteries before and after surgery found that mild impairment of oromotor speed can occur despite the absence of major neuropsychological effects. 17 However, postoperative cognitive function was also found to remain unchanged or was improved. 2 , 18 Cognitive function disturbance in pediatric epilepsy is often related to the underlying etiology, seizures, age at onset, and potentially

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Kathrin Machetanz, Florian Grimm, Thomas V. Wuttke, Josua Kegele, Holger Lerche, Marcos Tatagiba, Sabine Rona, Alireza Gharabaghi, Jürgen Honegger, and Georgios Naros

%) of 15 patients had a multifocal seizure onset, 1 (50%) of whom was treated with vagus nerve stimulation and had a poor outcome (Engel grade III). The clinical outcome of subsequent resective surgery is summarized in Table 3 . TABLE 3. Outcome of patients with insular epilepsy-related SEEG activity Epilepsy-Related Insular SEEG Activity (n = 15) No. of Patients (%) 2nd-Stage Surgery Outcome Mean FU, mos (range) Purely insular 7 (47.0) Lesionectomy: 5 (71.4) * Engel grade I: 5 (100) 33.8 ± 16.3 (11

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Alexander G. Weil, Ngoc Minh D. Le, Prasanna Jayakar, Trevor Resnick, Ian Miller, Aria Fallah, Michael Duchowny, and Sanjiv Bhatia

features on EEG often mimic frontal, temporal, and/or parietal lobe patterns. 12 , 13 , 26 , 27 Progress in understanding the physiological relationships and vascular anatomy of the insula together with the introduction of more sophisticated stereotactic and microsurgical techniques have improved the outcomes of insular epilepsy surgery. 23 Recent reports, mostly in adult patients, have shown that insular-opercular invasive investigation and resection are both feasible and effective. 1 , 13 , 21 , 29 However, surgical experience with insular epilepsy surgery

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Atman Desai, Kimon Bekelis, Terrance M. Darcey, and David W. Roberts

role of intracranial insular recording in the effective surgical treatment of insular epilepsy. Furthermore, they have used a number of techniques and trajectories to place recording electrodes into the insula. Insular seizures confirmed by stereo-EEG are usually simple partial in nature, with common features being laryngeal discomfort, dysphonia, paresthesias, and somatomotor symptoms. They may additionally include hypermotor features mimicking frontal lobe seizures, visceral symptoms, or dysphasia mimicking temporal lobe seizures, and early somatosensory symptoms

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Timothy J. Kaufmann, Vance T. Lehman, Lily C. Wong-Kisiel, Panagiotis Kerezoudis, and Kai J. Miller

Insular epilepsy can be difficult to identify because the insula connects extensively with other cortical structures, resulting in nonheterogeneous seizure presentations. 1 The deep-seated location and extensive neural network can result in misleading scalp electroencephalography (EEG) seizure onset patterns. In the surgical evaluation for medically refractory insular epilepsy, stereo EEG (sEEG) is often preferred over grid-and-strip invasive monitoring to target this deep-seated structure and sample distant cortical surfaces to reveal accurate insular

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Soha Alomar, Jeffrey P. Mullin, Saksith Smithason, and Jorge Gonzalez-Martinez

A lthough the insula was first described by Johann Christian Reil in the 18th century, ‘‘surgical’’ interest in the insula only arose in the 1940s and 1950s with Guillaume and colleagues 21 , 22 and Penfield and Faulk. 29 Semiology of seizures generated by insular lesions is often described as similar to that for temporal 24 and frontal seizures, 32 but given the complex physiology and extensive connections between the insula and other brain regions, patients with insular epilepsy could present with many other semiological features, such as vegetative

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Elakkat D. Gireesh, Kihyeong Lee, Holly Skinner, Joohee Seo, Po-Ching Chen, Michael Westerveld, Richard D. Beegle, Eduardo Castillo, and James Baumgartner

thermocoagulation (RFTC) 11 and laser interstitial thermal therapy (LITT) have been used as a surgical strategy for managing epilepsy arising from the insula. RFTC performed to treat lesional insular epilepsy resulted in a seizure-free outcome in 53% of patients, with a responder rate of 89% (described as Engel class I–III). Of the patients treated with insular RFTC, 42% experienced perioperative neurological deficits. In a recent study comparing LITT to open surgery for insular seizure foci, favorable outcomes were reported in 71% (Engel class I and II) in the LITT group and 75

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Alain Bouthillier, Alexander G. Weil, Laurence Martineau, Laurent Létourneau-Guillon, and Dang Khoa Nguyen

R efractory epilepsy of operculoinsular origin is being increasingly recognized as a type of extratemporal epilepsy. 1 , 11 , 23 , 24 , 29 , 34 , 41 The description of classical seizure semiology 23 , 29 and the development of adapted intracerebral electrode schemes for invasive monitoring 1 , 8 , 11 , 12 , 31 , 36 , 41 have led to an increase in the detection and surgical treatment of insular epilepsy around the world. Furthermore, an increased index of suspicion of insular involvement when interpreting noninvasive imaging for seizure foci localization has