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The role of the insular cortex in epilepsy has been largely neglected until very recently. With growing interest in insular epilepsies, this book provides unique, in-depth coverage of the condition from childhood to adulthood. Detailed description of the anatomy, vascularization, connectivity, and functions of the insula along with complete description of the semiology, neurophysiology, and neuroimaging of insular epilepsy helps clinicians better recognize the condition. Up-to-date treatment avenues are explored, guiding the management of patients, including drug-resistant cases suitable for neurosurgery. Authors come from a range of backgrounds, providing a multidisciplinary perspective essential to all health professionals involved in epilepsy diagnosis and treatment. A scratch-off code in the inside cover allow users access to an online equivalent of the book, featuring videos illustrating the semiology of the various forms of insular seizures. This authoritative overview provides clinicians with the necessary information to treat this under-recognized condition.
The role of the insula in temporal and temporal plus epilepsies has been poorly investigated. The insula is buried deep within the lateral sulcus and has dense connections with neighbored regions, thus limiting the usefulness of available non-invasive diagnostic tools, such as scalp EEG, SPECT, and 18FDG-PET. Also, clinical features related to the involvement of the insula might be misleading, thus making it mandatory to use invasive EEG recordings in most cases. In fact, only a primary involvement of the insula in the epileptogenic network may require to include this area in the resection to achieve seizure freedom. Using modern neurosurgical techniques, insular epilepsy surgery has proved to be safe and beneficial in carefully investigated cases; however, its efficacy remains to be fully elucidated.
Insular epilepsy has caught increasing attention in the presurgical evaluation of drug-resistant focal epilepsies, and it is evident that intracranial EEG recordings can be considered the best method to investigate such a deep-seated area of the brain, especially in non-lesional patients. Intracranial EEG recordings allow us to better understand the organization of epileptic EEG discharges involving the insular cortex and the complexity of the relationships between the insula and the different connected regions of the brain, particularly the opercular region. This peculiarity thus explains the heterogeneous clinical presentation of seizures arising from insular or insulo-opercular structures. While most patients have an epileptogenic zone extending beyond the insula, some have very focal ictal insular discharges, allowing the possibility of a restricted surgical resection. Consequently, only an appropriate sampling of the insula and of extra-insular connected structures can permit a precise identification of the epileptogenic zone and planning for a tailored resection.
Insular epilepsy has come into focus quite late in the field of epileptology. This entity was forgotten between the 1960s and 1980s by the last generation of epileptologists who were busy leading the fight for a localization approach and anatomo-electro-clinical correlations. This lengthy period is well documented in the first chapter of this work. This drift may be attributed to various restrictions, mostly technical: the insular cortex does not appear on the surface of the brain but is the seat of a plethoric vascularization that supplies blood to motor fibers in the centrum ovale through its network of perforating arteries. Therefore, it could not be operated without exposing the patient to unreasonable risks for the goal intended. It could not also be explored invasively without the risk of causing a hemorrhage due to the necessity of crossing a triple curtain of pial arteries. The condemnation was heard: “exploring the insula, at best, is useless, and at worst, dangerous.”