Surgical strategy to avoid ischemic complications of the pyramidal tract in resective epilepsy surgery of the insula: technical case report

2018 ◽  
Vol 128 (4) ◽  
pp. 1173-1177 ◽  
Author(s):  
Naoki Ikegaya ◽  
Akio Takahashi ◽  
Takanobu Kaido ◽  
Yuu Kaneko ◽  
Masaki Iwasaki ◽  
...  
Keyword(s):  
Seizure Control ◽  
Pyramidal Tract ◽  
Focal Cortical Dysplasia ◽  
Insular Cortex ◽  
Motor Deficits ◽  
Corona Radiata ◽  
Ischemic Complications ◽  
Posterior Insula ◽  
Functional Preservation ◽  
Perforating Arteries

Surgical treatment of the insula is notorious for its high probability of motor complications, particularly when resecting the superoposterior part. Ischemic damage to the pyramidal tract in the corona radiata has been regarded as the cause of these complications, resulting from occlusion of the perforating arteries to the pyramidal tract through the insular cortex. The authors describe a strategy in which a small piece of gray matter is spared at the bottom of the periinsular sulcus, where the perforating arteries pass en route to the pyramidal tract, in order to avoid these complications. This method was successfully applied in 3 patients harboring focal cortical dysplasia in the posterior insula and frontoparietal operculum surrounding the periinsular sulcus. None of the patients developed permanent postoperative motor deficits, and seizure control was achieved in all 3 cases. The method described in this paper can be adopted for functional preservation of the pyramidal tract in the corona radiata when resecting epileptogenic pathologies involving insular and opercular regions.

scholarly journals Cognitive and developmental outcomes after pediatric insular epilepsy surgery for focal cortical dysplasia

2020 ◽  
Vol 26 (5) ◽  
pp. 543-551
Author(s):  
Naoki Ikegaya ◽  
Masaki Iwasaki ◽  
Yuu Kaneko ◽  
Takanobu Kaido ◽  
Yuiko Kimura ◽  
...  
Keyword(s):  
Epilepsy Surgery ◽  
Repeated Measures ◽  
Seizure Control ◽  
Focal Cortical Dysplasia ◽  
Developmental Outcomes ◽  
Insular Cortex ◽  
Cortical Dysplasia ◽  
Motor Deficits ◽  
Seizure Outcome ◽  
Epileptogenic Zone

OBJECTIVECognitive risk associated with insular cortex resection is not well understood. The authors reviewed cognitive and developmental outcomes in pediatric patients who underwent resection of the epileptogenic zone involving the insula.METHODSA review was conducted of 15 patients who underwent resective epilepsy surgery involving the insular cortex for focal cortical dysplasia, with a minimum follow-up of 12 months. The median age at surgery was 5.6 years (range 0.3–13.6 years). Developmental/intelligence quotient (DQ/IQ) scores were evaluated before surgery, within 4 months after surgery, and at 12 months or more after surgery. Repeated measures multivariate ANOVA was used to evaluate the effects on outcomes of the within-subject factor (time) and between-subject factors (resection side, anterior insular resection, seizure control, and antiepileptic drug [AED] reduction).RESULTSThe mean preoperative DQ/IQ score was 60.7 ± 22.8. Left-side resection and anterior insular resection were performed in 9 patients each. Favorable seizure control (International League Against Epilepsy class 1–3) was achieved in 8 patients. Postoperative motor deficits were observed in 9 patients (permanent in 6, transient in 3). Within-subject changes in DQ/IQ were not significantly affected by insular resection (p = 0.13). Postoperative changes in DQ/IQ were not significantly affected by surgical side, anterior insular resection, AED reduction, or seizure outcome. Only verbal function showed no significant changes before and after surgery and no significant effects of within-subject factors.CONCLUSIONSResection involving the insula in children with impaired development or intelligence can be performed without significant reduction in DQ/IQ, but carries the risk of postoperative motor deficits.

Ischemic complications associated with resection of opercular glioma

2007 ◽  
Vol 106 (2) ◽  
pp. 263-269 ◽  
Author(s):  
Toshihiro Kumabe ◽  
Shuichi Higano ◽  
Shoki Takahashi ◽  
Teiji Tominaga
Keyword(s):  
Mr Imaging ◽  
Tumor Resection ◽  
Wide Resection ◽  
Motor Deficits ◽  
Corona Radiata ◽  
Functional Brain Mapping ◽  
Sensorimotor Area ◽  
Ischemic Complications ◽  
Neuronavigation System ◽  
Mapping Techniques

Object Opercular glioma inferolateral to the hand/digit sensorimotor area can be resected safely using a neuronavigation system and functional brain mapping techniques. However, the surgery can still sometimes cause postoperative ischemic complications, the character of which remains unclear. The authors of this study investigated the occurrence of infarction associated with resection of opercular glioma and the arterial supply to this region. Methods The study involved 11 consecutive patients with gliomas located in the opercular region around the orofacial primary motor and somatosensory cortices but not involving either the hand/digit area or the insula, who had been treated in their department after 1997. Both pre- and postoperative diffusion-weighted magnetic resonance (MR) imaging was performed in the nine consecutive patients after 1998 to detect ischemic complications. All patients underwent open surgery for maximum tumor resection. Postoperative MR imaging identified infarction beneath the resection cavity in all patients. Permanent motor deficits associated with infarction involving the descending motor pathway developed in two patients. Cadaveric angiography showed that the distributing arteries to the corona radiata were the long insular arteries and/or medullary arteries from the opercular and cortical segments of the middle cerebral artery. Conclusions Subcortical resection around the upper limiting sulcus of the posterior region of the insula and wide resection in the anteroposterior and cephalocaudal directions of the opercular region were considered to be risk factors of the critical infarction. Surgeons should be aware that resection of opercular glioma can disrupt the blood supply of the corona radiata, and carries the risk of permanent motor deficits.

THE INSULA: ISLAND OF REIL

2015 ◽  
Vol 86 (11) ◽  
pp. e4.155-e4
Author(s):  
Ray Wynford-Thomas ◽  
Rob Powell
Keyword(s):  
Speech Processing ◽  
Brain Function ◽  
Insular Cortex ◽  
Normal Brain ◽  
Temporal Epilepsy ◽  
Normal Brain Function ◽  
Temporal Structures ◽  
Hypermotor Seizures ◽  
Posterior Insula ◽  
As Effects

Just as ‘no man is an island’, despite its misleading name, the insula is not an island. Sitting deeply within the cerebrum, the insular cortex and its connections play an important role in both normal brain function and seizure generation. Stimulating specific areas of the insula can produce somatosensory, viscerosensory, somatomotor and visceroautonomic symptoms, as well as effects on speech processing and pain. Insular onset seizures are rare, but may mimic both temporal and extra-temporal epilepsy and if not recognised, may lead to failure of epilepsy surgery. We therefore highlight the semiology of insular epilepsy by discussing three cases with different auras. Insular onset seizures can broadly be divided into three main types both anatomically and according to seizure semiology:1. Seizures originating in the antero-inferior insula present with laryngeal constriction, along with visceral and gustatory auras (similar to those originating in medial temporal structures).2. Antero-superior onset seizures can have a silent onset, but tend to propagate rapidly to motor areas causing focal motor or hypermotor seizures.3. Seizures originating in the posterior insula present with contralateral sensory symptoms.

scholarly journals Intractable Childhood Epilepsy and Maternal Fatigue

2006 ◽  
Vol 33 (3) ◽  
pp. 306-310 ◽  
Author(s):  
Mohammed M.S. Jan
Keyword(s):  
Mental Retardation ◽  
Seizure Control ◽  
Intractable Epilepsy ◽  
Motor Deficits ◽  
Regular Exercise ◽  
Childhood Epilepsy ◽  
Contributing Factors ◽  
Physical Handicap ◽  
Factors Associated ◽  
Maternal Fatigue

Background:Mothers of children with intractable epilepsy are generally stressed and experience more emotional problems. Fatigue may affect their productivity, social interactions, and their ability to adequately take care of their children. The objectives were to examine the relationship between intractable childhood epilepsy and maternal fatigue, and explore possible contributing factors.Methods:Sixty-four consecutive mothers of children with intractable epilepsy were identified prospectively. Exclusion criteria included degenerative/metabolic disorders or life threatening illness, such as brain tumors. Fatigue was measured using a standardized 11-item questionnaire, which has been revalidated in an Arabic speaking population.Results:Mothers' ages were 24-45 years (mean 34) and ages of their epileptic children were 1-15 years (mean 6.7). Most children (64%) had epilepsy for >2 years, were on >1 antiepileptic drug (AED) (72%), and had daily seizures (47%). Thirty-four (54%) of the children had motor deficits and 83% had mental retardation (severe in 41%). Twenty-eight (44%) mothers were fatigued. Factors associated with increased maternal fatigue included child's age <2 years (p=0.01), cryptogenic epilepsy (p=0.03), and severe motor deficits (p=0.04). Factors associated with lowered fatigue included performing regular exercise (p=0.006), lack of mental retardation (p=0.01), seizure control (p=0.05), using one AED (p=0.002), infrequent ER visits (p=0.005), and lack of recent hospitalization (p=0.005).Conclusion:Mothers of children with intractable epilepsy are increasingly fatigued. Several correlating factors were identified, mostly related to seizure control, mental and physical handicap. Strategies to manage the problem include proper education, seizure control, participation in regular exercise, social support, and psychological counseling.

scholarly journals Repeat surgery for focal cortical dysplasias in children: indications and outcomes

2017 ◽  
Vol 19 (2) ◽  
pp. 174-181 ◽  
Author(s):  
Matthew F. Sacino ◽  
Cheng-Ying Ho ◽  
Matthew T. Whitehead ◽  
Amy Kao ◽  
Dewi Depositario-Cabacar ◽  
...  
Keyword(s):  
Seizure Control ◽  
Focal Cortical Dysplasia ◽  
Univariate Analysis ◽  
National Health System ◽  
Intractable Epilepsy ◽  
Complete Resection ◽  
Seizure Freedom ◽  
Mri Findings ◽  
Repeat Surgery ◽  
Quality Control Mechanism

OBJECTIVE Focal cortical dysplasia (FCD) is a common cause of medically intractable epilepsy that often may be treated by surgery. Following resection, many patients continue to experience seizures, necessitating a decision for further surgery to achieve the desired seizure outcomes. Few studies exist on the efficacy of reoperation for intractable epilepsy due to FCD in pediatric cohorts, including the definition of prognostic factors correlated with clinical benefit from further resection. METHODS The authors retrospectively analyzed the medical records and MR images of 22 consecutive pediatric patients who underwent repeat FCD resection after unsuccessful first surgery at the Children's National Health System between March 2005 and April 2015. RESULTS Accounting for all reoperations, 13 (59%) of the 22 patients achieved complete seizure freedom and another 5 patients (23%) achieved significant improvement in seizure control. Univariate analysis demonstrated that concordance in electrocorticography (ECoG) and MRI localization (p = 0.005), and completeness of resection (p = 0.0001), were associated with seizure freedom after the first reoperation. Patients with discordant ECoG and MRI findings ultimately benefited from aggressive multilobe lobectomy or hemispherectomy. Repeat lesionectomies utilizing intraoperative MRI (iMRI; n = 9) achieved complete resection and seizure freedom in all cases. CONCLUSIONS Reoperation may be clinically beneficial in patients with intractable epilepsy due to FCD. Patients with concordant intraoperative ECoG and MRI localization may benefit from extended resection of residual dysplasia at the margins of the previous lesional cavity, and iMRI may offer benefits as a quality control mechanism to ensure that a complete resection has been accomplished. Patients with discordant findings may benefit from more aggressive resections at earlier stages to achieve better seizure control and ensure functional plasticity.

scholarly journals The parieto-insular vestibular cortex in humans: more than a single area?

2018 ◽  
Vol 120 (3) ◽  
pp. 1438-1450 ◽  
Author(s):  
Sebastian M. Frank ◽  
Mark W. Greenlee
Keyword(s):  
Nonhuman Primate ◽  
Visual Motion ◽  
Insular Cortex ◽  
Vestibular Cortex ◽  
Anatomical Structures ◽  
The Core ◽  
Primate Brain ◽  
Cortex Area ◽  
Posterior Insula ◽  
And Function

Here, we review the structure and function of a core region in the vestibular cortex of humans that is located in the midposterior Sylvian fissure and referred to as the parieto-insular vestibular cortex (PIVC). Previous studies have investigated PIVC by using vestibular or visual motion stimuli and have observed activations that were distributed across multiple anatomical structures, including the temporo-parietal junction, retroinsula, parietal operculum, and posterior insula. However, it has remained unclear whether all of these anatomical areas correspond to PIVC and whether PIVC responds to both vestibular and visual stimuli. Recent results suggest that the region that has been referred to as PIVC in previous studies consists of multiple areas with different anatomical correlates and different functional specializations. Specifically, a vestibular but not visual area is located in the parietal operculum, close to the posterior insula, and likely corresponds to the nonhuman primate PIVC, while a visual-vestibular area is located in the retroinsular cortex and is referred to, for historical reasons, as the posterior insular cortex area (PIC). In this article, we review the anatomy, connectivity, and function of PIVC and PIC and propose that the core of the human vestibular cortex consists of at least two separate areas, which we refer to together as PIVC+. We also review the organization in the nonhuman primate brain and show that there are parallels to the proposed organization in humans.

Insular epilepsy masquerading as multifocal cortical epilepsy as proven by depth electrode

2010 ◽  
Vol 5 (4) ◽  
pp. 365-367 ◽  
Author(s):  
Michael R. Levitt ◽  
Jeffrey G. Ojemann ◽  
John Kuratani
Keyword(s):  
Seizure Control ◽  
Seizure Activity ◽  
Insular Cortex ◽  
Diagnosis And Treatment ◽  
Precise Localization ◽  
Partial Seizures ◽  
Complex Partial Seizures ◽  
Cortical Areas ◽  
Depth Electrodes ◽  
Depth Electrode

The insular cortex is an uncommon epileptogenic location from which complex partial seizures may arise. Seizure activity in insular epilepsy may mimic temporal, parietal, or other cortical areas. Semiology, electroencephalography, and even surface electrocorticography recordings may falsely localize other cortical foci, leading to inaccurate diagnosis and treatment. The use of insular depth electrodes allows more precise localization of seizure foci. The authors describe the case of a young girl with seizures falsely localized to the cortex, with foci arising from the insula, as proven by depth electrode recordings. Resection of the insula yielded seizure control.

scholarly journals Dysmorphic neuron density underlies intrinsic epileptogenicity of the centre of cortical tubers

2019 ◽  
Author(s):  
Sarah EM. Stephenson ◽  
Harley G. Owens ◽  
Kay L. Richards ◽  
Wei Shern Lee ◽  
Colleen D’Arcy ◽  
...  
Keyword(s):  
Seizure Control ◽  
Focal Cortical Dysplasia ◽  
Epileptic Activity ◽  
Neurological Deficits ◽  
Unbiased Stereology ◽  
Neuron Density ◽  
Mri Studies ◽  
Cortical Tubers ◽  
Eloquent Cortex ◽  
Dysmorphic Neurons

AbstractCortical tubers are benign lesions that develop in patients with tuberous sclerosis complex (TSC), often resulting in drug-resistant epilepsy. Surgical resection may be required for seizure control, but the extent of the resection required is unclear. Many centres include resection of perituberal cortex, which may be associated with neurological deficits. Also, patients with tubers in eloquent cortex may be excluded from epilepsy surgery.Our electrophysiological and MRI studies indicate that the tuber centre is the source of seizures, suggesting that smaller resections may be sufficient for seizure control. Here we report five epilepsy surgeries in four children with TSC and focal motor seizures from solitary epileptogenic tubers in the sensorimotor cortex in whom the resection was limited to the tuber centre, leaving the tuber rim and surrounding perituberal cortex intact. Seizures were eliminated in all cases, and no functional deficits were observed. On routine histopathology we observed an apparent increase in density of dysmorphic neurons at the tuber centre, which we confirmed using unbiased stereology which demonstrated a significantly greater density of dysmorphic neurons within the resected tuber centre (1951 ± 215 cells/mm3) compared to the biopsied tuber rim (531 ± 189 cells/mm3, n = 4, p = 0.008).Taken together with our previous electrophysiological and MRI studies implicating the tuber centre as the focus of epileptic activity, and other electrophysiological studies of dysmorphic neurons in focal cortical dysplasia, this study supports the hypothesis that dysmorphic neurons concentrated at the tuber centre are the seizure generators in TSC. Furthermore, our results support limiting resection to the tuber centre, decreasing the risk of neurological deficits when tubers are located within eloquent cortex.

Multilobar Epilepsy Surgery in Childhood and Adolescence: Predictors of Long-Term Seizure Freedom

Neurosurgery ◽  
2020 ◽  
Vol 88 (1) ◽  
pp. 174-182
Author(s):  
Evangelos Kogias ◽  
Thomas Bast ◽  
Susanne Schubert-Bast ◽  
Gert Wiegand ◽  
Armin Brandt ◽  
...  
Keyword(s):  
Epilepsy Surgery ◽  
Seizure Control ◽  
Focal Cortical Dysplasia ◽  
Benign Tumors ◽  
Seizure Freedom ◽  
Childhood And Adolescence ◽  
Epileptogenic Zone ◽  
Seizure Recurrence ◽  
Eloquent Cortex

Abstract BACKGROUND Although multilobar resections correspond to one-fifth of pediatric epilepsy surgery, there are little data on long-term seizure control. OBJECTIVE To investigate the long-term seizure outcomes of children and adolescents undergoing multilobar epilepsy surgery and identify their predictors. METHODS In this retrospective study, we considered 69 consecutive patients that underwent multilobar epilepsy surgery at the age of 10.0 ± 5.0 yr (mean ± SD). The magnetic resonance imaging revealed a lesion in all but 2 cases. Resections were temporo-parieto(-occipital) in 30%, temporo-occipital in 41%, parieto-occipital in 16%, and fronto-(temporo)-parietal in 13% cases. Etiologies were determined as focal cortical dysplasia in 67%, perinatal or postnatal ischemic lesions in 23%, and benign tumors in 10% of cases. RESULTS At last follow-up of median 9 yr (range 2.8-14.8), 48% patients were seizure free; 33% were off antiepileptic drugs. 10% of patients, all with dysplastic etiology, required reoperations: 4 of 7 achieved seizure freedom. Seizure recurrence occurred mostly (80%) within the first 6 mo. Among presurgical variables, only an epileptogenic zone far from eloquent cortex independently correlated with significantly higher rates of seizure arrest in multivariate analysis. Among postsurgical variables, the absence of residual lesion and of acute postsurgical seizures was independently associated with significantly higher rates of seizure freedom. CONCLUSION Our study demonstrates that multilobar epilepsy surgery is effective regarding long-term seizure freedom and antiepileptic drug withdrawal in selected pediatric candidates. Epileptogenic zones–and lesions–localized distant from eloquent cortex and, thus, fully resectable predispose for seizure control. Acute postsurgical seizures are critical markers of seizure recurrence that should lead to prompt reevaluation.

scholarly journals Seizure control after subtotal lesional resection

2013 ◽  
Vol 34 (6) ◽  
pp. E1 ◽  
Author(s):  
William C. Gump ◽  
Karen L. Skjei ◽  
Shefali N. Karkare
Keyword(s):  
Seizure Control ◽  
Focal Cortical Dysplasia ◽  
Extent Of Resection ◽  
Cortical Dysplasia ◽  
Vascular Lesions ◽  
Subtotal Resection ◽  
Seizure Freedom ◽  
Total Resection ◽  
Significant Opportunity ◽  
Significant Superiority

Reports on seizure outcomes following surgery for lesional epilepsy consistently cite extent of resection as a significant predictor of outcome. Unfortunately, gross-total resection is not technically feasible in all cases of medically refractory tumor-associated epilepsy. Here, the authors present the case of a 4-year-old girl whose epilepsy was medically controlled after 1-stage electrocorticography-guided subtotal resection (STR) of a large diffuse protoplasmic astrocytoma. They also review the modern literature on epilepsy associated with brain tumors. Outcomes are compared with those following surgical treatment of focal cortical dysplasia and vascular lesions. Gross-total lesional resection shows significant superiority across pathologies and anatomical regions. Despite a considerable number of STRs yielding seizure freedom, other favorable treatment factors have not been defined. Although gross-total lesional resection, if possible, is clearly superior, tailored surgery may still offer patients a significant opportunity for a good outcome. Treatment factors yielding successful seizure control following STR remain to be fully elucidated.

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