scholarly journals D.06 Insular involvement in intractable epilepsy: results of invasive EEG data

2016 ◽  
Vol 43 (S2) ◽  
pp. S14-S14
Author(s):  
M Ranjan ◽  
Y Starreveld ◽  
L Bello-Espinosa ◽  
S Wiebe ◽  
S Singh ◽  
...  
Keyword(s):  
Seizure Control ◽  
Refractory Epilepsy ◽  
Intractable Epilepsy ◽  
Insular Cortex ◽  
Electrode Placement ◽  
Secondary Spread ◽  
Depth Electrode ◽  
Eeg Data ◽  
Effective Adjunct ◽  
Good Seizure Control

Background: Exploration of the insular cortex is now commonly considered in patients with refractory epilepsy requiring invasive EEG investigations. The safety and yield of routine insular exploration is uncertain. Methods: All patients (pediatric and adult) who had invasive EEG (iEEG) with insular depth electrode placement, either through SEEG or open implantation, were reviewed. Ictal insular involvement was characterized as primary, secondary or not involved. Results of insular resections were recorded. Results: A total of 173 patients had iEEG of which 26 included insular electrodes (SEEG-18, Open - 8). No complications of placement were identified. Insular involvement was seen in 20 (76%) patients. Primary ictal involvement was identified in 9 (33 %) patients, while secondary spread was noted in 11 (42 %) patients. Six patients went on to have resections including the insular cortex of which 5 patients achieved good seizure control (Engle class I/II). Conclusions: Insular depth electrode placement is a safe and effective adjunct to invasive EEG investigations. Ictal involvement of the insular cortex was commonly identified in our series leading to inclusion of the insula in cortical resections with good seizure control, which may not have been considered without iEEG evidence.

Insular epilepsy masquerading as multifocal cortical epilepsy as proven by depth electrode

2010 ◽  
Vol 5 (4) ◽  
pp. 365-367 ◽  
Author(s):  
Michael R. Levitt ◽  
Jeffrey G. Ojemann ◽  
John Kuratani
Keyword(s):  
Seizure Control ◽  
Seizure Activity ◽  
Insular Cortex ◽  
Diagnosis And Treatment ◽  
Precise Localization ◽  
Partial Seizures ◽  
Complex Partial Seizures ◽  
Cortical Areas ◽  
Depth Electrodes ◽  
Depth Electrode

The insular cortex is an uncommon epileptogenic location from which complex partial seizures may arise. Seizure activity in insular epilepsy may mimic temporal, parietal, or other cortical areas. Semiology, electroencephalography, and even surface electrocorticography recordings may falsely localize other cortical foci, leading to inaccurate diagnosis and treatment. The use of insular depth electrodes allows more precise localization of seizure foci. The authors describe the case of a young girl with seizures falsely localized to the cortex, with foci arising from the insula, as proven by depth electrode recordings. Resection of the insula yielded seizure control.

The periinsular functional hemispherotomy

2012 ◽  
Vol 32 (3) ◽  
pp. E7 ◽  
Author(s):  
Leonardo Rangel-Castilla ◽  
Steven W. Hwang ◽  
George Al-Shamy ◽  
Andrew Jea ◽  
Daniel J. Curry
Keyword(s):  
Surgical Treatment ◽  
Operative Technique ◽  
Seizure Control ◽  
Refractory Epilepsy ◽  
Internal Capsule ◽  
Lateral Approach ◽  
Complication Rates ◽  
Central Sulcus ◽  
Functional Hemispherectomy ◽  
Good Seizure Control

The surgical treatment of refractory epilepsy has evolved as new innovations have been created. Disconnective procedures such as hemispherectomy have evolved. Presently, hemispherotomy has replaced hemispherectomy to reduce complication rates while maintaining good seizure control. Several disconnective techniques have been described including the Rasmussen, vertical, and lateral approaches. The lateral approach, or periinsular hemispherectomy, was derived from modifications on the functional hemispherectomy and involves removal of the temporal lobe mesial structures, exposure of the atrium via the circular sulcus, internal capsule transection under the central sulcus, intraventricular callosotomy, and frontobasal disconnection. The purpose of this article is to describe and illustrate in detail the anatomy and operative technique for periinsular hemispherotomy, as well as to discuss the nuances and issues involved with this procedure.

Hemispherotomy and other disconnective techniques

2008 ◽  
Vol 25 (3) ◽  
pp. E14 ◽  
Author(s):  
Sandrine De Ribaupierre ◽  
Olivier Delalande
Keyword(s):  
Surgical Treatment ◽  
Seizure Control ◽  
Intractable Epilepsy ◽  
Historical Background ◽  
Epileptogenic Zone ◽  
Complication Rates ◽  
Hypothalamic Hamartomas ◽  
Posterior Quadrant ◽  
Technical Innovations ◽  
Good Seizure Control

The surgical treatment of intractable epilepsy has evolved as new technical innovations have been made. Hemispherotomy techniques have been developed to replace hemispherectomy in order to reduce the complication rates while maintaining good seizure control. Disconnective procedures are based on the interruption of the epileptic network rather than the removal of the epileptogenic zone. They can be applied to hemispheric pathologies, leading to hemispherotomy, but they can also be applied to posterior quadrant epilepsies, or hypothalamic hamartomas. In this paper, the authors review the literature, present an overview of the historical background, and discuss the different techniques along with their outcomes and complications.

Surgery for Nontumoral Insular Epilepsy Explored by Stereoelectroencephalography

Neurosurgery ◽  
2016 ◽  
Vol 79 (4) ◽  
pp. 578-588 ◽  
Author(s):  
Guillaume Gras-Combe ◽  
Lorella Minotti ◽  
Dominique Hoffmann ◽  
Alexandre Krainik ◽  
Philippe Kahane ◽  
...  
Keyword(s):  
Focal Cortical Dysplasia ◽  
Intractable Epilepsy ◽  
Insular Cortex ◽  
Cavernous Angioma ◽  
Cortical Dysplasia ◽  
Electrode Placement ◽  
Seizure Freedom ◽  
Epileptogenic Zone ◽  
Pharmacoresistant Epilepsy ◽  
The Right

Abstract BACKGROUND Hidden by the perisylvian operculi, insular cortex has long been underexplored in the context of epilepsy surgery. Recent studies advocated stereoelectroencephalography (SEEG) as a reliable tool to explore insular cortex and its involvement in intractable epilepsy and suggested that insular seizures could be an underestimated entity. However, the results of insular resection to treat pharmacoresistant epilepsy are rarely reported. OBJECTIVE We report 6 consecutive cases of right insular resection performed based on anatomoelectroclinical correlations provided by SEEG. METHODS Six right-handed patients (3 male, 3 female) with drug-resistant epilepsy underwent comprehensive presurgical evaluation. Based on video electroencephalographic recordings, they all underwent SEEG evaluation with bilateral (n = 4) or unilateral right (n = 2) insular depth electrode placement. All patients had both orthogonal and oblique (1 anterior, 1 posterior) insular electrodes (n = 4-6 electrodes). Preoperative magnetic resonance imaging findings were normal in 4 patients, 1 patient had right insular focal cortical dysplasia, and 1 patient had a right opercular postoperative scar (cavernous angioma). All patients underwent right partial insular corticectomy via the subpial transopercular approach. RESULTS Intracerebral recordings demonstrated an epileptogenic zone confined to the right insula in all patients. After selective insular resection, 5 of 6 patients were seizure free (Engel class I) with a mean follow-up of 36.2 months (range, 18-68 months). Histological findings revealed focal cortical dysplasia in 5 patients and a gliosis scar in 1 patient. All patients had minor transient neurological deficit (eg, facial paresis, dysarthria). CONCLUSION Insular resection based on SEEG findings can be performed safely with a significant chance of seizure freedom.

Anatomic hemispherectomy for intractable epilepsy in a patient with unilateral schizencephaly

2008 ◽  
Vol 2 (2) ◽  
pp. 146-149 ◽  
Author(s):  
Gregory G. Heuer ◽  
Douglas A. Hardesty ◽  
Kareem A. Zaghloul ◽  
Erin M. Simon Schwartz ◽  
A. Reghan Foley ◽  
...  
Keyword(s):  
Ventriculoperitoneal Shunt ◽  
Seizure Control ◽  
Refractory Epilepsy ◽  
Intractable Epilepsy ◽  
Cerebral Hemispheres ◽  
Communicating Hydrocephalus ◽  
Brain Shift ◽  
Brain Malformation ◽  
Viable Option ◽  
Medically Refractory Epilepsy

Schizencephaly is a rare congenital cortical brain malformation defined by unilateral or bilateral clefts of the cerebral hemispheres. These malformations are often associated with medically intractable epilepsy. Surgical solutions include lesionectomy, lobectomy, or hemispherectomy. The authors describe the case of an anatomic hemispherectomy for medically intractable epilepsy in an 8-year-old boy with a large schizencephalic cleft. Seven years prior to his epilepsy surgery, the patient underwent placement of a ventriculoperitoneal shunt for communicating hydrocephalus that resulted in severe left-to-right shift. Subsequently, medically refractory epilepsy developed and the patient underwent an anatomic hemispherectomy for seizure control. The preoperative brain shift remained after the surgery, although the patient tolerated the procedure well and was seizure free postoperatively. Anatomic hemispherectomy is a viable option for treating medically intractable epilepsy in a schizencephalic pediatric patient—even one with considerable brain shift.

209 Surgical Outcomes with Insular and Insular-Plus Pediatric Epilepsy: A Single-Institution Experience

Neurosurgery ◽  
2017 ◽  
Vol 64 (CN_suppl_1) ◽  
pp. 256-256
Author(s):  
Andrew T Hale ◽  
Luke Tomycz ◽  
Ali S Haider ◽  
Dave Clarke ◽  
Mark R Lee
Keyword(s):  
Surgical Resection ◽  
Surgical Outcomes ◽  
Insular Cortex ◽  
Clinical Information ◽  
Primary Brain Tumor ◽  
Cortical Dysplasia ◽  
Electrode Placement ◽  
Pediatric Epilepsy ◽  
Depth Electrode ◽  
Operative Care

Abstract INTRODUCTION It has been increasingly recognized that the insular cortex plays an important role in frontotemporal-parietal epilepsy (FTPE) 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 non-invasive modalities. At last year's meeting, we reported on the safety and utility of insular-depth electrode placement for interrogation of the insula. Here, we report post-surgical outcomes on 31 patients with insular-depth electrode confirmed refractory epilepsy. METHODS We used Current Procedural Terminology (CPT) billing records to identify cases of depth electrode insertion performed at our institution. Clinical information, operative reports, and pathology data from patients undergoing operative intervention was then retrospectively collected. RESULTS >Thirty-one patients underwent direct invasive sampling implicating the insula in seizure onset and prompted either thermoablation or surgical resection of some portion of the insula. Fourteen patients had biopsy-proven cortical dysplasia, Fourteen patients had suspected cortical dysplasia, two patients had tuberous sclerosis and one patient had a primary brain tumor. Fourteen patients had prior intracranial operations. Fourteen patients underwent thermoablation of the insula and seventeen underwent resection of some portion of the insula. 31% of patients who underwent thermoablation of the insular had an Engel Class outcome of I compared to 63% of patients who underwent open insular resection. Thus, in our cohort, insular resection was superior to thermoablation in achieving superior functional outcomes as measured by Engel Class. CONCLUSION Surgical resection and thermoablation of the insula are both acceptable treatments for insular and insular-plus epilepsy. In our cohort, outcomes with surgical resection were improved, although the reasons for this are unclear. Further study is required to delineate optimal operative care in patients with insular and insular-plus epilepsy.

Robotic image-guided depth electrode implantation in the evaluation of medically intractable epilepsy

2008 ◽  
Vol 25 (3) ◽  
pp. E19 ◽  
Author(s):  
William J. Spire ◽  
Barbara C. Jobst ◽  
Vijay M. Thadani ◽  
Peter D. Williamson ◽  
Terrance M. Darcey ◽  
...  
Keyword(s):  
Intractable Epilepsy ◽  
Robotic System ◽  
Electrode Placement ◽  
Seizure Onset ◽  
Electrode Implantation ◽  
Grid Electrode ◽  
Image Guided ◽  
Depth Electrodes ◽  
Depth Electrode ◽  
Time Period

Object The authors describe their experience with a technique for robotic implantation of depth electrodes in patients concurrently undergoing craniotomy and placement of subdural monitoring electrodes for the evaluation of intractable epilepsy. Methods Patients included in this study underwent evaluation in the Dartmouth Surgical Epilepsy Program and were recommended for invasive seizure monitoring with depth electrodes between 2006 and the present. In all cases an image-guided robotic system was used during craniotomy for concurrent subdural grid electrode placement. A total of 7 electrodes were placed in 4 patients within the time period. Results Three of 4 patients had successful localization of seizure onset, and 2 underwent subsequent resection. Of the patients who underwent resection, 1 is now seizure free, and the second has only auras. There was 1 complication after subpial grid placement but no complications related to the depth electrodes. Conclusions Robotic image-guided placement of depth electrodes with concurrent craniotomy is feasible, and the technique is safe, accurate, and efficient.

Invasive Insular Sampling in Pediatric Epilepsy: A Single-Institution Experience

2017 ◽  
Vol 15 (3) ◽  
pp. 310-317 ◽  
Author(s):  
Luke D Tomycz ◽  
Andrew T Hale ◽  
Ali S Haider ◽  
Dave F Clarke ◽  
Mark R Lee
Keyword(s):  
Insular Cortex ◽  
Clinical Information ◽  
Electrode Placement ◽  
Pediatric Epilepsy ◽  
Seizure Onset ◽  
Single Institution ◽  
Invasive Treatment ◽  
Depth Electrodes ◽  
Depth Electrode ◽  
Electrode Insertion

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.

scholarly journals Tailored suprainsular partial hemispherotomy: a new functional disconnection technique for stroke-induced refractory epilepsy

2018 ◽  
Vol 22 (6) ◽  
pp. 601-609 ◽  
Author(s):  
Didier Scavarda ◽  
Tiago Cavalcante ◽  
Agnès Trébuchon ◽  
Anne Lépine ◽  
Nathalie Villeneuve ◽  
...  
Keyword(s):  
Motor Cortex ◽  
Seizure Control ◽  
Refractory Epilepsy ◽  
Favorable Outcome ◽  
Functional Consequences ◽  
Severe Epilepsy ◽  
Ischemic Events ◽  
Good Seizure Control ◽  
Surgical Option

OBJECTIVEHemispherotomy is currently the most frequently performed surgical option for refractory epilepsy associated with large perinatal or childhood ischemic events. Such an approach may lead to good seizure control, but it has inherent functional consequences linked to the disconnection of functional cortices. The authors report on 6 consecutive patients who presented with severe epilepsy associated with hemiplegia due to stroke and who benefitted from a new, stereoelectroencephalography-guided partial disconnection technique.METHODSThe authors developed a new disconnection technique termed “tailored suprainsular partial hemispherotomy” (TSIPH). Disconnection always included premotor and motor cortex with variable anterior and posterior extent.RESULTSAt a mean follow-up of 28 months, there were no deaths and no patient had hydrocephalus. Motor degradation was observed in all patients in the 2 weeks after surgery, but all patients completely recovered. The 6 patients were seizure free (Engel class IA) at the last follow-up. No neuropsychological aggravation was observed.CONCLUSIONSTSIPH appears to be a conservative alternative to classic hemispherotomy, leading to favorable outcome in this series.

Intractable epilepsy in paralimbic World Health Organization Grade II gliomas: should the hippocampus be resected when not invaded by the tumor?

2012 ◽  
Vol 116 (6) ◽  
pp. 1226-1234 ◽  
Author(s):  
Fadi Ghareeb ◽  
Hugues Duffau
Keyword(s):  
Seizure Control ◽  
Refractory Epilepsy ◽  
Intractable Epilepsy ◽  
World Health ◽  
Full Time ◽  
Group A ◽  
Grade Ii ◽  
Group B ◽  
The Impact ◽  
Preoperative Score

Object Beyond its oncological benefit, surgery could improve seizure control in paralimbic frontotemporoinsular or temporoinsular WHO Grade II gliomas generating intractable seizures. However, no studies have examined the impact of hippocampal resection on chronic epilepsy when the hippocampus is not invaded by Grade II gliomas. Here, the authors compared the epileptological outcomes and return to work in 2 groups of patients who underwent surgery with or without hippocampectomy for paralimbic Grade II gliomas eliciting intractable epilepsy despite no tumoral involvement of the hippocampus. Methods Surgery was performed in 15 consecutive patients who were unable to work (median Karnofsky Performance Scale [KPS] Score 70) because of refractory epilepsy due to paralimbic Grade II gliomas that were not invading the hippocampus. In Group A (8 patients), the hippocampus was preserved. In Group B (7 patients), glioma removal was associated with hippocampectomy. Results No patient died or suffered a permanent deficit after surgery. Postoperatively, in Group A, no patients were seizure free (4 patients were in Engel Class II and 4 were in Class III). In Group B, all 7 patients were seizure free (Class I) (p = 0.02). Only 62.5% of patients returned to work in Group A, whereas all patients are working full time in Group B. The postsurgical median KPS score was 85 in Group A, that is, not significantly improved in comparison with the preoperative score, while the postsurgical median KPS was 95 in Group B, that is, significantly improved in comparison with the preoperative score (p = 0.03). Conclusions The authors' data support, for the first time, the significant impact of hippocampectomy in patients with intractable epilepsy generated by a paralimbic Grade II glioma, even if it does not invade the hippocampus. Hippocampal resection allowed seizure control in all patients, with an improvement in KPS scores, since all patients resumed their social and professional activities. Thus, the authors suggest performing a resection of the nontumoral hippocampus in addition to resection of the tumor in patients with refractory epilepsy due to paralimbic Grade II gliomas.

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