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Invasive Investigation of Insular Cortex Epilepsy

Ryvlin, Philippe*,†; Picard, Fabienne

Journal of Clinical Neurophysiology: July 2017 - Volume 34 - Issue 4 - p 328–332
doi: 10.1097/WNP.0000000000000395
Invited Review

Summary: Invasive long-term EEG investigations of the insula have been performed since the mid-nineties in an expanding range of focal epilepsies suspected to involve the insular cortex. The various clinical forms of insular epilepsies were delineated during the last 2 decades, and include the following presentations: perisylvian epilepsy, temporal plus epilepsy, sleep hypermotor epilepsy, MRI-negative frontal and parietal lobe epilepsies, and insular lesions. In fact, a majority of complex stereoelectroencephalography procedures will include at least one electrode targeting the insula. Stereoelectroencephalography is currently the preferred method to investigate the insula, using orthogonal, oblique, or a combination of both trajectories, with no evidence of higher risk of intracranial bleeding than in other brain regions. Orthogonal trajectories allow to sample the overlaying opercula, while oblique trajectories offer a better sampling of the insular cortex. Intrainsular ictal EEG pattern are often characterized by a prolonged focal discharge restricted to one of the five insular gyri, militating for a dense enough sampling of the insular cortex in suspected insular epilepsies. Stereoelectroencephalography offers the potential to perform thermolesion of insular epileptogenic zones which, together with MRI-guided laser ablation, represent a possibly safer alternative treatment to open-skull surgical resection of the insula.

*Department of Clinical Neurosciences, CHUV, Lausanne, Switzerland;

Institut Des EpilepsiEs (IDEE), Lyon, France; and

Department of Clinical Neurosciences, University Hospitals and Medical School of Geneva, Geneva, Switzerland.

Address correspondence and reprint requests to Philippe Ryvlin, BH10-137, Département des Neurosciences Cliniques, CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland; e-mail:

The authors have no funding or conflicts of interest to disclose.

© 2017 by the American Clinical Neurophysiology Society