Avoid falling into the depths of the insular trap

Area of Science:

• Neuroscience
• Epileptology
• Clinical Neurology

Background:

• Insular seizures can present with diverse semiologies, mimicking temporal lobe epilepsy (TLE) and nocturnal frontal lobe epilepsy (NFLE).
• Accurate localization of the ictal onset zone is critical for effective epilepsy management and surgical planning.

Observation:

• Two patients with suspected TLE and NFLE were found to have insular ictal onset zones.
• Patient 1 exhibited TLE-like seizures and sleep-related insular seizures, refractory to anterior temporal lobectomy.
• Patient 2 presented with nocturnal hypermotor seizures originating from the insula, despite initial suspicion of frontal lobe epilepsy.

Findings:

• Insular epilepsy can manifest with varied clinical presentations, challenging traditional epilepsy classifications.
• Invasive electroencephalography (EEG) monitoring is essential for precise localization of insular epileptogenic zones.
• Surgical outcomes for insular epilepsy depend on accurate localization and may require tailored approaches.

Implications:

• Recognizing insular seizure semiology is vital for accurate diagnosis and treatment of epilepsy.
• Advanced neuroimaging and invasive EEG techniques improve the identification of challenging epilepsy origins.
• Further research into insular epilepsy is needed to optimize surgical strategies and patient outcomes.