Abstract
Background: Epilepsy surgery failure is not uncommon, with several explanations having been proposed. In this series, we detail cases of epilepsy surgery failure subsequently attributed to insular involvement. Methods: We retrospectively identified patients investigated at the epilepsy monitoring units of two Canadian tertiary care centers (2004–2020). Included patients were adults who had undergone epilepsy surgeries with recurrence of seizures post-operatively and who were subsequently determined to have an insular epileptogenic focus. Clinical, electrophysiological, neuroimaging, and surgical data were synthesized. Results: We present 14 patients who demonstrated insular epileptic activity post-surgery-failure as detected by intracranial EEG, MEG, or seizure improvement after insular resection. Seven patients had manifestations evoking possible insular involvement prior to their first surgery. Most patients (8/14) had initial surgeries targeting the temporal lobe. Seizure recurrence ranged from the immediate post-operative period to one year. The main modality used to determine insular involvement was MEG (8/14). Nine patients underwent re-operations that included insular resection; seven achieved a favorable post-operative outcome (Engel I or II). Conclusions: Our series suggests that lowering the threshold for suspecting insular epilepsy may be necessary to improve epilepsy surgery outcomes. Detecting insular epilepsy post-surgery-failure may allow for re-operations which may lead to good outcomes.
Highlights
Introduction published maps and institutional affilEpilepsy surgery failure occurs in approximately 20–30% of temporal lobe surgeries and 30–50% of frontal lobe surgeries [1,2]
We reviewed cases of epilepsy surgery failure subsequently attributed to the contribution of the insular cortex to epilepsy genesis, with the hopes of improving the recognition of insular involvement in patients with refractory focal epilepsy
Though we aimed to only describe the cases of epilepsy surgery failure subsequently attributed to an insular focus in this series, a more ambitious study could have systematically gathered all cases of epilepsy surgery failure and offered comparisons between various subgroups
Summary
Introduction published maps and institutional affilEpilepsy surgery failure occurs in approximately 20–30% of temporal lobe surgeries and 30–50% of frontal lobe surgeries [1,2]. Surgery, which remains the most common surgical intervention for drug-resistant epilepsy, explanations that are classically put forward for failures include insufficient resection of epileptogenic tissue, dual pathology (the coexistence of mesial temporal sclerosis (MTS). Epilepsy surgery failure is not uncommon, with several explanations having been proposed. In this series, we detail cases of epilepsy surgery failure subsequently attributed to insular involvement. Included patients were adults who had undergone epilepsy surgeries with recurrence of seizures post-operatively and who were subsequently determined to have an insular epileptogenic focus. Results: We present 14 patients who demonstrated insular epileptic activity post-surgery-failure as detected by intracranial EEG, MEG, or seizure improvement after insular resection. Nine patients underwent re-operations that included insular resection; seven achieved a favorable post-operative outcome (Engel I or II). Detecting insular epilepsy postsurgery-failure may allow for re-operations which may lead to good outcomes
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