Operculoinsular cortectomy for refractory epilepsy. Part 1: Is it effective?

Restricted access

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.

ABBREVIATIONS EEG = electroencephalography; fMRI = functional MRI; MEG = magnetoencephalography; TTE = time to event.
Article Information

Contributor Notes

Correspondence Alain Bouthillier: University of Montreal Hospital Center, Montreal, QC, Canada. alain.bouthillier@umontreal.ca.INCLUDE WHEN CITING Published online September 20, 2019; DOI: 10.3171/2019.4.JNS1912.Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

Headings
References
  • 1

    Afif AChabardes SMinotti LKahane PHoffmann D: Safety and usefulness of insular depth electrodes implanted via an oblique approach in patients with epilepsy. Neurosurgery 62 (5 Suppl 2):ONS471ONS4802008

    • Search Google Scholar
    • Export Citation
  • 2

    Ahmed ROtsubo HSnead C IIIDonner EWidjaja EOchi A: Diagnostic evaluation and surgical management of pediatric insular epilepsy utilizing magnetoencephalography and invasive EEG monitoring. Epilepsy Res 140:72812018

    • Search Google Scholar
    • Export Citation
  • 3

    Ansari SFMaher COTubbs RSTerry CLCohen-Gadol AA: Surgery for extratemporal nonlesional epilepsy in children: a meta-analysis. Childs Nerv Syst 26:9459512010

    • Search Google Scholar
    • Export Citation
  • 4

    Ansari SFTubbs RSTerry CLCohen-Gadol AA: Surgery for extratemporal nonlesional epilepsy in adults: an outcome meta-analysis. Acta Neurochir (Wien) 152:129913052010

    • Search Google Scholar
    • Export Citation
  • 5

    Barba CRheims SMinotti LGuénot MHoffmann DChabardès S: Temporal plus epilepsy is a major determinant of temporal lobe surgery failures. Brain 139:4444512016

    • Search Google Scholar
    • Export Citation
  • 6

    Blauwblomme TDavid OMinotti LJob ASChassagnon SHoffman D: Prognostic value of insular lobe involvement in temporal lobe epilepsy: a stereoelectroencephalographic study. Epilepsia 54:165816672013

    • Search Google Scholar
    • Export Citation
  • 7

    Bouthillier ANguyen DK: Epilepsy surgeries requiring an operculoinsular cortectomy: Operative technique and results. Neurosurgery 81:6026122017

    • Search Google Scholar
    • Export Citation
  • 8

    Bouthillier ASurbeck WWeil AGTayah TNguyen DK: The hybrid operculo-insular electrode: a new electrode for intracranial investigation of perisylvian/insular refractory epilepsy. Neurosurgery 70:157415802012

    • Search Google Scholar
    • Export Citation
  • 9

    Bouthillier AWeil AGMartineau LLétourneau-Guillon LNguyen DK: Operculoinsular cortectomy for refractory epilepsy. Part 2: Is it safe? J Neurosurg [epub ahead of print September 20 2019. DOI: 10.3171/2019.6.JNS191126]

    • Search Google Scholar
    • Export Citation
  • 10

    Chevrier MCBard CGuilbert FNguyen DK: Structural abnormalities in patients with insular/peri-insular epilepsy: spectrum, frequency, and pharmacoresistance. AJNR Am J Neuroradiol 34:215221562013

    • Search Google Scholar
    • Export Citation
  • 11

    Desai AJobst BCThadani VMBujarski KAGilbert KDarcey TM: Stereotactic depth electrode investigation of the insula in the evaluation of medically intractable epilepsy. J Neurosurg 114:117611862011

    • Search Google Scholar
    • Export Citation
  • 12

    Ding HZhou JGuan YZhai FWang MWang J: Bipolar electro-coagulation with cortextomy in the treatment of insular and insulo-opercular epilepsy explored by stereoelectro-encephalography. Epilepsy Res 145:18262018

    • Search Google Scholar
    • Export Citation
  • 13

    Duffau HCapelle LLopes MBitar ASichez JPvan Effenterre R: Medically intractable epilepsy from insular low-grade gliomas: improvement after an extended lesionectomy. Acta Neurochir (Wien) 144:5635732002

    • Search Google Scholar
    • Export Citation
  • 14

    Engel J JrVan Ness PCRasmussen TBOjemann LM: Outcome with respect to epileptic seizures in Engel J Jr (ed): Surgical Treatment of the Epilepsies ed 2. New York: Raven Press1993 pp 609621

    • Search Google Scholar
    • Export Citation
  • 15

    Fei PSoucy JPObaid SBoucher OBouthillier ANguyen DK: The value of regional blood flow SPECT and FDG PET in operculoinsular epilepsy. Clin Nucl Med 43:e67e732018

    • Search Google Scholar
    • Export Citation
  • 16

    Finet PNguyen DKBouthillier A: Vascular consequences of operculoinsular corticectomy for refractory epilepsy. J Neurosurg 122:129312982015

    • Search Google Scholar
    • Export Citation
  • 17

    Freri EMatricardi SGozzo FCossu MGranata TTassi L: Perisylvian, including insular, childhood epilepsy: Presurgical workup and surgical outcome. Epilepsia 58:136013692017

    • Search Google Scholar
    • Export Citation
  • 18

    Gras-Combe GMinotti LHoffmann DKrainik AKahane PChabardes S: Surgery for nontumoral insular epilepsy explored by stereoelectroencephalography. Neurosurgery 79:5785882016

    • Search Google Scholar
    • Export Citation
  • 19

    Guillaume JMazars G: Technique de résection de l’insula dans les épilepsies insulaires. Rev Neurol (Paris) 81:900–9031949

  • 20

    Harroud ABouthillier AWeil AGNguyen DK: Temporal lobe epilepsy surgery failures: a review. Epilepsy Res Treat 2012:2016512012

  • 21

    Heers MRampp SStefan HUrbach HElger CEvon Lehe M: MEG-based identification of the epileptogenic zone in occult peri-insular epilepsy. Seizure 21:1281332012

    • Search Google Scholar
    • Export Citation
  • 22

    Irislimane MMathieu DBouthillier ADeacon CNguyen DK: Gamma knife surgery for refractory insular cortex epilepsy. Stereotact Funct Neurosurg 91:1701762013

    • Search Google Scholar
    • Export Citation
  • 23

    Isnard JGuénot MSindou MMauguière F: Clinical manifestations of insular lobe seizures: a stereo-electroencephalographic study. Epilepsia 45:107910902004

    • Search Google Scholar
    • Export Citation
  • 24

    Levitt MROjemann JGKuratani J: Insular epilepsy masquerading as multifocal cortical epilepsy as proven by depth electrode. J Neurosurg Pediatr 5:3653672010

    • Search Google Scholar
    • Export Citation
  • 25

    Levy AYen Tran TPBoucher OBouthillier ANguyen DK: Operculo-insular epilepsy: scalp and intracranial electroencephalographic findings. J Clin Neurophysiol 34:4384472017

    • Search Google Scholar
    • Export Citation
  • 26

    Malak RBouthillier ACarmant LCossette PGiard NSaint-Hilaire JM: Microsurgery of epileptic foci in the insular region. J Neurosurg 110:115311632009

    • Search Google Scholar
    • Export Citation
  • 27

    Mohamed ISGibbs SARobert MBouthillier ALeroux JMKhoa Nguyen D: The utility of magnetoencephalography in the presurgical evaluation of refractory insular epilepsy. Epilepsia 54:195019592013

    • Search Google Scholar
    • Export Citation
  • 28

    Montavont AMauguière FMazzola LGarcia-Larrea LCatenoix HRyvlin P: On the origin of painful somatosensory seizures. Neurology 84:5946012015

    • Search Google Scholar
    • Export Citation
  • 29

    Nguyen DKNguyen DBMalak RLeroux JMCarmant LSaint-Hilaire JM: Revisiting the role of the insula in refractory partial epilepsy. Epilepsia 50:5105202009

    • Search Google Scholar
    • Export Citation
  • 30

    Obaid SZerouali YNguyen DK: Insular epilepsy: semiology and noninvasive investigations. J Clin Neurophysiol 34:3153232017

  • 31

    Park YSLee YHShim KWLee YJKim HDLee JS: Insular epilepsy surgery under neuronavigation guidance using depth electrode. Childs Nerv Syst 25:5915972009

    • Search Google Scholar
    • Export Citation
  • 32

    Penfield WFaulk ME Jr: The insula; further observations on its function. Brain 78:4454701955

  • 33

    Perry MSDonahue DJMalik SIKeator CGHernandez AReddy RK: Magnetic resonance imaging-guided laser interstitial thermal therapy as treatment for intractable insular epilepsy in children. J Neurosurg Pediatr 20:5755822017

    • Search Google Scholar
    • Export Citation
  • 34

    Ryvlin PMinotti LDemarquay GHirsch EArzimanoglou AHoffman D: Nocturnal hypermotor seizures, suggesting frontal lobe epilepsy, can originate in the insula. Epilepsia 47:7557652006

    • Search Google Scholar
    • Export Citation
  • 35

    Silfvenius HGloor PRasmussen T: Evaluation of insular ablation in surgical treatment of temporal lobe epilepsy. Epilepsia 5:307–3201964

    • Search Google Scholar
    • Export Citation
  • 36

    Surbeck WBouthillier AWeil AGCrevier LCarmant LLortie A: The combination of subdural and depth electrodes for intracranial EEG investigation of suspected insular (perisylvian) epilepsy. Epilepsia 52:4584662011

    • Search Google Scholar
    • Export Citation
  • 37

    Téllez-Zenteno JFDhar RWiebe S: Long-term seizure outcomes following epilepsy surgery: a systematic review and meta-analysis. Brain 128:118811982005

    • Search Google Scholar
    • Export Citation
  • 38

    Tirakotai WSure UBenes LKrischek BBien SBertalanffy H: Image-guided transsylvian, transinsular approach for insular cavernous angiomas. Neurosurgery 53:129913052003

    • Search Google Scholar
    • Export Citation
  • 39

    Türe UYaşargil DCAl-Mefty OYaşargil MG: Topographic anatomy of the insular region. J Neurosurg 90:7207331999

  • 40

    von Lehe MWellmer JUrbach HSchramm JElger CEClusmann H: Insular lesionectomy for refractory epilepsy: management and outcome. Brain 132:104810562009

    • Search Google Scholar
    • Export Citation
  • 41

    Weil AGFallah ALewis ECBhatia S: Medically resistant pediatric insular-opercular/perisylvian epilepsy. Part 1: invasive monitoring using the parasagittal transinsular apex depth electrode. J Neurosurg Pediatr 18:5115222016

    • Search Google Scholar
    • Export Citation
  • 42

    Weil AGLe NMJayakar PResnick TMiller IFallah A: Medically resistant pediatric insular-opercular/perisylvian epilepsy. Part 2: outcome following resective surgery. J Neurosurg Pediatr 18:5235352016

    • Search Google Scholar
    • Export Citation
  • 43

    Weil AGSurbeck WRahme RBouthillier AHarroud ANguyen DK: Somatosensory and pharyngolaryngeal auras in temporal lobe epilepsy surgeries. ISRN Neurol 2013:1485192013

    • Search Google Scholar
    • Export Citation
  • 44

    Wiebe SBlume WTGirvin JPEliasziw M: A randomized, controlled trial of surgery for temporal-lobe epilepsy. N Engl J Med 345:3113182001

    • Search Google Scholar
    • Export Citation
  • 45

    Zerouali YPouliot PRobert MMohamed IBouthillier ALesage F: Magnetoencephalographic signatures of insular epileptic spikes based on functional connectivity. Hum Brain Mapp 37:325032612016

    • Search Google Scholar
    • Export Citation
TrendMD
Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 75 75 75
Full Text Views 13 13 13
PDF Downloads 9 9 9
EPUB Downloads 0 0 0
PubMed
Google Scholar