Medically resistant pediatric insular-opercular/perisylvian epilepsy. Part 2: outcome following resective surgery

Abstract

<jats:sec> <jats:title>OBJECTIVE</jats:title> <jats:p>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.</jats:p></jats:sec> <jats:sec> <jats:title>METHODS</jats:title> <jats:p>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.</jats:p></jats:sec> <jats:sec> <jats:title>RESULTS</jats:title> <jats:p>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.</jats:p></jats:sec> <jats:sec> <jats:title>CONCLUSIONS</jats:title> <jats:p>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.</jats:p></jats:sec>

Stereotactic thermocoagulation for insular epilepsy: Lessons from successes and failures

“…[2][3][4]33 However, the initial reports included mainly lesionectomies 34 or were limited to few patients and most often in nondominant hemispheres, 18,35 including pediatric cases. 7,36,37 Furthermore, series showed that favorable seizure outcome was obtained in the majority of the patients, with functional risks considered acceptable, despite ischemic lesions being observed in 60% of the cases. 19 The largest series (25 patients) reported that paresis, dysphasia, alteration of taste, smell, hearing, pain, and thermal perceptions were frequent (75%), but always transient except for one patient with persistent mild alteration of thermal and pain perception.…”

“…Indications for resective surgery have been recently revisited because of SEEG evidence of epilepsy originating within the insula . However, the initial reports included mainly lesionectomies or were limited to few patients and most often in nondominant hemispheres, including pediatric cases . Furthermore, series showed that favorable seizure outcome was obtained in the majority of the patients, with functional risks considered acceptable, despite ischemic lesions being observed in 60% of the cases .…”

Perisylvian, including insular, childhood epilepsy: Presurgical workup and surgical outcome

“…Insular lobe seizures are still poorly characterized particularly in children, 16,17,24,25 and most of the available evidences are based mainly on adult population studies. Insular lobe seizures are still poorly characterized particularly in children, 16,17,24,25 and most of the available evidences are based mainly on adult population studies.…”

“…[14][15][16][17] We report our experience with the presurgical workup, surgical procedures, and outcomes in a series of pediatric patients with drug-resistant epilepsy involving the perisylvian/insular regions. [14][15][16][17] We report our experience with the presurgical workup, surgical procedures, and outcomes in a series of pediatric patients with drug-resistant epilepsy involving the perisylvian/insular regions.…”

“…Literature data on electroclinical correlations of insular epilepsy are based mainly on adult populations, whereas only a few experiences in children are reported. [14][15][16][17] We report our experience with the presurgical workup, surgical procedures, and outcomes in a series of pediatric patients with drug-resistant epilepsy involving the perisylvian/insular regions.…”