Abstract Working memory depends on coordinated activity across distributed brain networks, but how these interactions support recognition, encoding, and retrieval remains unclear. Here, we analyzed intracranial local field potentials from 1,652 sites in 36 epilepsy patients performing a naturalistic card-matching task. Phase-amplitude and phase-phase coupling revealed widespread condition-dependent interactions, with frontal and temporal regions emerging as recurrent network hubs. Event-related analyses showed reproducible within-trial coupling dynamics across participants. Directed phase transfer entropy further identified frequency-specific information flow, including frontal regions acting as a theta-band source and an alpha-band sink. Finally, a time-delay-embedded hidden Markov model identified task-locked latent states with condition-dependent occupancy trajectories and distinct coherence profiles. Together, these results suggest that working memory is implemented through dynamic, directionally organized large-scale networks, in which frontotemporal hubs coordinate flexible transitions among distributed neural states rather than operating in isolation.

OBJECTIVE:Epileptic spasms (ES) in children carry a high risk of neurodevelopmental delay, yet predictors of long-term surgical outcome remain incompletely defined. This study aimed to evaluate seizure outcomes following epilepsy surgery and to identify independent prognostic factors for postoperative recurrence. METHODS:This retrospective cohort study included 73 patients (47 males, 64%; median age at surgery: 37 months, IQR: 20-55.5) with drug-resistant ES who underwent resective or ablative surgery at Guangdong Sanjiu Brain Hospital in China between January 2015 and September 2024, with regular follow-up at least 12 months after epilepsy surgery. Independent predictors of recurrence were identified using multivariate Cox proportional hazards regression, and Kaplan-Meier analysis was performed to compare seizure-free survival stratified by seizure duration (SD) and residual lesion status. RESULTS:Seizure-free rates were 75.3% at 1 year and 55.1% at last follow-up. Mean follow-up was 61.36 ± 26.10 months (range: 12-132). Among malformation of cortical development (MCD) subtypes, focal cortical dysplasia (FCD) type II demonstrated the highest 5-year seizure-free rate (100%), whereas mild MCD (m-MCD) showed the lowest (33.3%; p = 0.039). On multivariate Cox analysis, residual lesion on postoperative MRI was the strongest independent predictor of recurrence (HR = 5.13; 95% CI: 2.28-11.51; p < 0.001), followed by SD exceeding 36 months (HR = 2.49; 95% CI: 1.17-5.29; p = 0.018). Kaplan-Meier analysis confirmed a twofold difference in 5-year seizure-free survival between patients with duration ≤36 versus >36 months (73% vs. 36%; log-rank p = 0.00069), and significantly better seizure-free survival in patients without residual lesions (log-rank p < 0.0001). SIGNIFICANCE:Complete lesion resection and early surgical intervention (SD ≤36 months) are independently associated with favorable long-term seizure outcomes in children with drug-resistant ES. Pathological subtype, particularly FCD type II, further refines prognostic stratification. These findings support prompt surgical referral and underscore the importance of achieving complete lesion removal to optimize postoperative seizure control. PLAIN LANGUAGE SUMMARY:Some children develop a severe form of epilepsy called epileptic spasms that cannot be controlled with medication. In this study of 73 children who had brain surgery for this condition, more than half remained seizure-free after 5 years. Children who had surgery earlier-before seizures had continued for 3 years-and those in whom the entire abnormal brain tissue was removed did significantly better in the long run. These findings suggest that referring children for surgery sooner rather than later can meaningfully improve their chances of living seizure-free.

ABSTRACT Background This study aims to explore the stimulation‐induced eye movements (EMs) from various branches of the precentral sulcus (PrCS) and to learn if the epileptogenic area influences EMs effects. Methods The high‐frequency direct electrical stimulation mapping reports were completed from patients with SEEG exploration. The counts of gender, the distribution of EMs effects sites, the seizure onset age, course of epilepsy, age of stimulation, and stimulation intensity were analyzed. The correlation factors of the EMs positive cases were studied through the multivariate regression method. Results The PrCS through 778 contacts of 77 patients was studied from July 2015 to December 2020. A total of 18 patients showed induced EMs in the PrCS. The average stimulation intensity was 22.0 ± 1.3 mA. In positive cases, 279 contacts were explored on the PrCS, and 24.51% were positive. Overall, 60.32% sites were in the superior PrCS (SP), and 39.68% sites were in the inferior PrCS (IP). The SP was more likely to have a stimulating response to EMs than the IP (p = 0.017). The major EM effect was deviation, with a total of 39.68% positive sites in 11 cases, namely, 16 sites in the SP and 9 sites in the IP. Multiple regression analysis indicated that the positive EMs cases were only correlated with whether seizure onset zone (SOZ) was located on prCS (p = 0.004), but not with age of onset, duration, frequency of seizures, preoperative intelligence quotient (IQ), and age of stimulation. Conclusion Deviation was the major type of positive EMs by directly stimulating the prCS. The SP was more sensitive to stimulation than the inferior branch was. The positive EM's chance showed a certain correlation with whether the prCS was inside the SOZ or not.

Objective Insular epilepsy poses significant diagnostic challenges due to its distinctive anatomical location and heterogeneous clinical manifestations. This study aims to develop a comprehensive classification system based on anatomo-electro-clinical features through stereoelectroencephalography (SEEG) analysis. The research seeks to elucidate the specific correspondence between clinical phenotypes and ictal electro-anatomical propagation patterns, investigate the network dynamics underlying various clinical phenotypes, and establish a theoretical framework for the precise diagnosis and personalized treatment of insular epilepsy. Methods This single-center retrospective case series included 20 patients with pure insular epilepsy confirmed by stereoelectroencephalography (SEEG) who were treated at Guangdong Sanjiu Brain Hospital between January 2015 and July 2024. The cohort comprised 12 males and 8 females with a mean age of 14.25 ± 9.8 years. All patients underwent individualized SEEG electrode implantation (mean 12.5 ± 2.3 electrodes per patient), comprehensively covering all insular subregions (anterior and posterior insula) and key brain areas in potential propagation pathways. A standardized protocol was employed for systematic analysis of: (1) ictal onset zone localization and electro-anatomical propagation patterns; (2) ictal semiology and clinical phenotype analysis based on video-SEEG recordings; and (3) surgical strategies, pathological findings, and outcome assessment (Engel classification, with follow-up periods ranging from 6 months to 8 years). Results The study identified five characteristic clinical phenotypes: the BATS phenotype (35.0 %), tonic-hypermotor phenotype (25.0 %), hypermotor-autonomic phenotype (25.0 %), pure sensory phenotype (10.0 %), and pure autonomic phenotype (5.0 %). These phenotypes demonstrated specific correspondence with six distinct SEEG propagation patterns. Posterior insular epilepsy (70.0 %) preferentially propagated through sensorimotor networks, whereas anterior insular epilepsy (30.0 %) primarily spread via limbic system networks. Focal cortical dysplasia was the predominant pathological finding (94.7 %). All surgical patients (n = 19) achieved Engel Ia outcome, with follow-up periods ranging from 6 months to 8 years. Conclusion This study established an anatomo-electro-clinical classification system for insular epilepsy and elucidated the specific correspondence between clinical phenotypes and neuronal network propagation patterns. This correspondence reflects the characteristic propagation of epileptic activity through pre-existing functional connectivity networks, providing a theoretical foundation for the precise diagnosis and personalized treatment of insular epilepsy.

Accurate detection and resection of the epileptogenic zone (EZ) in patients with long-term epilepsy-associated tumors (LEATs) are significantly correlated with favorable seizure prognosis. However, the relationship between tumors and the EZ remains unknown. This study aimed to evaluate the spatial relationship between LEATs and the EZ, as well as the electrophysiological features of LEATs. We retrospectively studied five patients with LEATs who underwent deep electrode implantation and EZ resection in the hospital. The clinical characteristics, surgical outcomes, localizing features and intracranial SEEG results were reviewed. One female and four males (mean age: 25.2 years; median age: 24 years; range: 13–45 years) were included in the study. Five-to-eleven electrodes (mean: 8.4) were implanted per patient. The EZ was located in the tumor and nearby cortex in three cases and in the tumor and distant areas in two cases. Pathological examination revealed ganglioglioma in four cases, two of which were associated with hippocampal sclerosis, and the other case showed a multinodular and vacuolating neuronal tumor with gliosis. All patients were seizure-free for at least 24 months postoperatively. SEEG provides valuable insights into the electrophysiological mechanisms of LEATs. The EZ often contains brain tissue around the tumor. However, only a few cases, particularly those with temporoparietal occipital (TPO) area involvement, a long history of epilepsy and other abnormalities on MRI, such as hippocampal sclerosis and focal cortical dysplasia, may include distant areas.

目的 探讨机器人辅助立体定向活检术在脑深部病变中的应用价值.方法 2015年6月至2021年5月实施机器人辅助脑内深部病变活检术38例,对病人的临床资料进行回顾性分析.结果 38例行41个靶点活检(3例行双靶点活检).7例首次穿刺术中冰冻切片病理检查结果为阴性,其中6例通过调整穿刺点再次穿刺为阳性,1例术后常规病理为阳性.所有病人均得到确诊,确诊率为100%.38例术后病理结果显示胶质瘤 24例(WHO分级Ⅰ～Ⅱ级4例,Ⅲ～Ⅳ级 20例),淋巴瘤9例,生殖细胞瘤4例,淀粉样变性1例.术后发现术区血肿6例,包括5例无症状性小出血和1例严重迟发性脑出血导致死亡.结论 神经外科机器人引导下脑深部病变活检术具有精准、微创、阳性率高的特点,选择合适的病人并掌握神经外科机器人的使用方法,结合术前影像确定靶点、术中冰冻切片病理检查等方法是提高脑深部病变立体定向活检术确诊率并减少相关并发症的关键.

BACKGROUND:Deep brain stimulation (DBS) of the subthalamic nucleus (STN) is an established and effective neurosurgical treatment for relieving motor symptoms in Parkinson disease. The localization of key brain structures is critical to the success of DBS surgery. However, in clinical practice, this process is heavily dependent on the radiologist's experience. METHODS:In this study, we propose an automatic localization method of key structures for STN-DBS surgery via prior-enhanced multi-object magnetic resonance imaging segmentation. We use the U-Net architecture for the multi-object segmentation, including STN, red nucleus, brain sulci, gyri, and ventricles. To address the challenge that only half of the brain sulci and gyri locate in the upper area, potentially causing interference in the lower area, we perform region of interest detection and ensemble joint processing to enhance the segmentation performance of brain sulci and gyri. RESULTS:We evaluate the segmentation accuracy by comparing our method with other state-of-the-art machine learning segmentation methods. The experimental results show that our approach outperforms state-of-the-art methods in terms of segmentation performance. Moreover, our method provides effective visualization of key brain structures from a clinical application perspective and can reduce the segmentation time compared with manual delineation. CONCLUSIONS:Our proposed method uses deep learning to achieve accurate segmentation of the key structures more quickly than and with comparable accuracy to human manual segmentation. Our method has the potential to improve the efficiency of surgical planning for STN-DBS.

目的 总结脑膜血管瘤病的临床特点、治疗经验及预后.方法 回顾性分析广东三九脑科医院2016年6月-2021年1月期间收治的6例脑膜血管瘤病患者的临床资料,并结合相关文献进行复习.结果 6例患者中,临床发作表现为全身强直阵挛发作1例,部分发作继发全身强直阵挛发作5例.术中皮层监测提示所有患者病变部位有癫痫样放电,均在术中皮层脑电图监测引导下行病灶+病灶周围皮层致痫灶切除手术治疗.术后均给予抗癫痫药物治疗,术后Engel分级均为Ⅰ级,术后近期及远期均无明显并发症出现.结论 反复癫痫发作的患者,如果颅脑MRI提示长T1长T2异常信号影,T2 Flair呈内低外高信号影,T1增强可见部分强化,CT扫描提示,钙化病变应考虑脑膜血管瘤病的诊断可能.脑膜血管瘤病经过电生理评估和多学科讨论确定致痫区后,给予病灶和周围致痫区切除术,手术疗效好,术后复发风险低,所以脑膜血管瘤病伴癫痫患者可通过手术获得良好受益,早期手术受益远远大于风险.

Objective: Stereoelectroencephalogram (SEEG) has been widely adapted to detect the electrical activity of patients with epilepsy. Due to the low-quality, large-amount, high-dimensionality characteristics of SEEG data, it is still challenging to comprehensively employ the SEEG signals to automatically and precisely determine the seizure onset zone (SOZ). This is because there is lack of an effective criterion for clinicians to select the target electrodes, which is of great importance for SOZ localization. Methods: We propose a SOZ localization method via analyzing the long-term SEEG monitoring for preoperative planning of epilepsy surgery. Considering that high frequency oscillations can reflect physiological brain activity of epileptic patients, we first extract the high-frequency features of the SEEG signals and utilize the convolutional neural network (CNN) to detect the interictal and seizure segments. Then we propose a novel criterion, namely adaptive high frequency epileptogenicity index (AHFEI), to determine the target electrodes. Results: We compare our SEEG-determined target electrodes with three preoperative planning of successful focal epilepsy resective surgery cases, finding that most localization results of our method are in consistent with clinical successful decision making, while the performance of our method outperforms than the state-of-the-art method for SOZ localization. Conclusion: Our SEEG-determined SOZ localization method can assist clinicians in preliminarily selecting the potential target electrodes according to long-term SEEG data automatically and effectively. Clinical Impact: The proposed automatic SOZ localization method has achieved satisfactory performance in the preliminary study, which has the great potential to be integrated into function-structure fused clinical decision-making system.

Objective:To explore the efficacy and safety of conformal radiofrequency thermocoagulation (RF-TC) guided by stereo-electroencephalography (SEEG) based on three-dimensional images for the treatment of epilepsy caused by focal cortical dysplasia (FCD).Methods:A retrospective study was conducted on the clinical data of 19 patients with drug-refractory epilepsy admitted to the Epilepsy Centre of Guangdong Sanjiu Brain Hospital from September 2017 to December 2019. The lesion in all patients was confirmed to be FCD and had clear boundaries based on preoperative evaluation including imaging and electroencephalography. The maximum diameter of lesions ranged from 1.4 cm to 4.0 cm with an average of 2.3±0.7 cm. All patients underwent SEEG electrode placement. During the design of electrode placement scheme, the software of 3D-Slicer was used to reconstruct the three-dimensional MRI images and the lesions were tried to be covered by the SEEG electrode contacts as much as possible. RF-TC was performed to ablate the lesion. Regular follow-up was performed post operation. The modified Engel classification was used to evaluate the outcome of seizure control.Results:In 19 patients, 9±2 SEEG electrodes/case (6-12 electrodes/case) were implanted, and the number of electrodes passing through the lesion was 5±2/case (2-8/case). The RF-TC target points during treatment were 25±13/case (6-52/case), and RF-TC was completed in 1 to 4 times/case. Eight patients experienced temporary muscle strength decline after operation, but all recovered completely before being discharged from the hospital. All 19 patients were followed up for 17±8 months (6-33 months). At the last follow-up, there were 16 cases classified as grade Ⅰ, 2 cases as grade Ⅱ, and 1 case as grade Ⅲ based on the modified Engel classification. None of the patients had permanent neurological deficits.Conclusion:For patients with drug-refractory epilepsy caused by FCD with established epileptogenicity, clear boundaries and limited scope, the SEEG-guided conformal thermocoagulation based on three-dimensional imaging has few complications and a good prognosis.

目的 研究颞叶外节细胞胶质瘤(GG)继发癫痫的临床特点和手术治疗方式及疗效.方法 回顾性分析手术治疗并经病理证实的20例颞叶外节细胞胶质瘤继发癫痫患者的临床资料.术后癫痫控制效果按改良Engel分级标准评定;分析患者的发作表现、病变部位、影像学特点、病理改变、手术方式及病变切除程度与癫痫控制的关系.结果 节细胞胶质瘤位于额叶者2例、顶叶7例、枕叶5例、颞枕交界处6例.MRI检查显示肿瘤为囊性者5例、囊实性6例、实性9例;增强扫描病变有强化12例,病变周围水肿5例.CT检查示病变有钙化4例.癫痫发作表现为简单部分性发作(伴意识保留的局灶性发作)者4例,复杂部分性发作(伴意识障碍的局灶性发作)5例,继发性全面性强直阵挛(局灶进展到双侧的强直阵挛发作)11例.肿瘤次全切除者2例,全切除15例,扩大切除3例.术后病理检查示合并脑皮质发育不良者2例.术后随访1～3年,癫痫控制效果为Engel Ⅰ级17例(85.0％),Ⅱ级2例(10.0％),Ⅲ级1例(5.0％).预后相关临床因素分析显示,肿瘤切除的方式和程度与预后有关.结论 颞叶外节细胞胶质瘤继发癫痫多为药物难治性,手术切除可取得良好效果.术前须综合评估病变部位和临床、影像学特点等资料制定手术策略,术中尽可能行肿瘤加致痫皮层全切除,以提高疗效.必要时可考虑先行SEEG电极植入后,再行致痫灶精准切除术.

目的 探讨神经外科机器人引导下立体定向活检脑深部病变诊断中的应用价值.方法 回顾性分析2015年6月至2020年9月收治的26例脑深部病变患者的临床资料,患者均在ROSA机器人或者SINO机器人辅助下行无框架立体定向活检术.结果 26名患者在共行29个病变靶点的穿刺活检.有3名患者首次术中冰冻结果为阴性,术中调整穿刺深度后取得阳性结果,共行32次穿刺活检病理检查.26名患者通过神经外科机器人引导下立体定向活检首次穿刺阳性率为89.6％,总穿刺阳性率为93.75％.单次手术的活检确诊率100％.穿刺活检结果为胶质瘤15例(WHO Ⅰ-Ⅱ级2例,WHO Ⅲ-Ⅳ级14例),淋巴瘤6例、生殖细胞瘤4例,淀粉样变性1例.术后复查CT有4例出现无症状性颅内出血.患者均未发生永久性神经功能障碍和颅内感染.无手术相关死亡病例.结论 术中冰冻病理和多靶点活检能够提高诊断准确率.活检靶点的优先选择顺序能降低脑损伤风险和提高确诊率.神经外科机器人辅助下立体定向活检术具有微创、精准、安全等优点,适合作为脑深部疑难病变的确诊方法.

目的 探讨胚胎发育不良性神经上皮肿瘤(DNT)继发癫痫的临床特点和手术疗效.方法 回顾性分析2014年12月至2019年1月手术治疗并经病理证实的53例DNT合并癫痫的临床资料.结果 肿瘤次全切除9例,全切除23例,扩大切除21例.术后病理检查结果均为DNT,其中合并局灶性脑皮质发育不良20例、海马硬化4例、神经节细胞胶质瘤4例.术后随访1～3年,Engel分级Ⅰ级43例(81.1％;其中MRI分型Ⅰ型29例,Ⅱ型11例,Ⅲ型3例),Ⅱ级4例(7.5％),Ⅲ级4例(7.5％),Ⅳ级2例(3.8％);术后复查MRI未见肿瘤复发或进展.结论 DNT继发癫痫多为药物难治性癫痫,手术切除可取得良好效果.术前需综合评估病变部位和影像学特点等制定相应的手术方案,术中尽可能全切肿瘤,有助于提高手术疗效.

Objective: To explore the efficacy and safety of stereotactic electroencephalography (SEEG)-guided conformal radiofrequency thermocoagulation for epilepsy caused by focal cortical dysplasia (FCD) in eloquent cortex. Methods: The data of epilepsy patients with conformal thermocoagulation in the Epilepsy Center of Guangdong Sanjiu Brain Hospital from September 2017 to August 2020 were retrospectively analyzed. SEEG electrodes were placed in patients with drug-refractory epilepsy caused by FCD in eloquent cortex with limited boundaries, which was confirmed by preoperative evaluation methods such as imaging and electroencephalography. When designing the electrode placement plan, related software was used to reconstruct the three-dimensional MRI image and lesion. SEEG electrode contacts should be designed to fully cover the lesion as much as possible. After the completion of SEEG monitoring and cortical electrical stimulation, the pre-thermocoagulation and permanent thermocoagulation modes were used in sequence. The mode of direct damage between adjacent contacts of a single electrode and cross-destruction between adjacent contacts of multiple electrodes was combined to ablate the lesions point by point. Results: A total of 22 patients were enrolled, ranging from 2 to 30 years old, with an average age of (15±9) years old. MRI showed that FCD lesions located at pre-central gyrus in 19 cases, at post-central gyrus in 3 cases, at left frontal lobe in 3 cases, at both pre-central and post-central gyrus in 1 case and at both pre-central and left frontal lobe in 2 cases. The length of the lesion was 1.2-4.0 cm, with an average length of (2.2±0.7) cm. Moreover, 7-12 SEEG electrodes were implanted, with an average of (9±2) electrodes. The number of electrodes passing through the lesion was 2-8, with an average of 5±2. The number of thermocoagulation target points was 6 to 83, with an average of 29±18, while the number of target points which proved to have function by cortical simulation was 0-21, with a median of 3.5. The number of direct thermocoagulation target points was 6 to 58, with an average of 23±13, while the number of cross thermocoagulation target points was 0 to 30, with a median of 3. The completion of the whole thermocoagulation was divided into 2 to 5 times. There were 11 cases (50%) who experienced immediate muscle strength decline, 1 case (4.5%) showed slower speech speed during thermocoagulation, 3 cases (13.6%) exhibited muscle strength decline after thermocoagulation, however, only 1 case (4.5%) had permanent hemiparalysis. There were 17 cases of Engel Ⅰ (77.3%), 3 cases of Engel Ⅱ (13.6%), and 2 case of Engel Ⅲ (9.1%), respectively, after follow-up for 6-42 months, with an average of (20±10) months. Conclusion: SEEG-guided conformal radiofrequency thermocoagulation is safe and effective for epilepsy caused by FCD in eloquent cortex with limited boundaries.

目的 研究额眶回癫疒间的电临床症状学特点和手术疗效.方法 回顾性分析10例经立体定向脑电图(stereotactic electroencephalogram,SEEG)确诊为额眶回癫疒间的病例资料,总结头皮脑电图、发作症状学、影像学特点及SEEG监测结果的特点.所有病人行致疒间区切除,采用改良Engel分级评估病人术后癫疒间控制情况.结果 术前头皮脑电图显示:10例间期放电均位于一侧额颞区.SEEG监测提示:发作起始区均位于额眶区,其中7例早期扩散至前扣带回或岛叶而表现为过度运动性发作,2例扩散至颞岛叶而表现为自动运动性发作,1例扩散至额叶而表现为简单运动性发作.行额眶回致疒间灶切除8例,扩大切除2例.术后随访2～5年,癫疒间控制达EngelⅠ级8例,Ⅱ级1例,Ⅲ级1例.致疒间灶病理为结节性硬化1例,脑软化2例,FCDⅡa 2例,FCDⅡb 2例,FCDⅠb 3例.术后均未遗留明显功能障碍.结论 额眶回癫疒间间期放电常位于一侧额颞区,以复杂运动性发作为主,因早期扩散区不同导致不同的症状学表现.手术切除致疒间灶时,需警惕额眶回癫疒间附加症的可能.

目的 总结SEEG引导下射频热凝毁损术治疗药物难治性癫痫的手术疗效及治疗体会.方法 对我科2016年12月至2018年5月进行SEEG引导下射频热凝毁损术治疗的13例药物难治性癫痫患者的临床资料进行回顾性分析,并复习相关文献.结果 本组纳入病种包括下丘脑错构瘤,侧脑室壁灰质异位结节及其他皮质发育异常.行SEEG引导下射频热凝毁损术后有7例出现短期并发症:3例偏瘫,2例发热、1例中枢性面瘫,1例视物模糊,出院时均完全恢复.术后常规服用抗痫药物,经过3个月至21个月的随访,10例患者Engle工级,2例EngleⅡ级,1例EngleⅣ级.发作未完全控制患者均再次行开颅手术切除致痫灶,病理分别为FCDⅡa型、MCD(大脑发育畸形)、灰质异位,疗效进一步随访中.结论 SEEG引导下射频热凝毁损术是癫痫外科治疗方案中的一项有力补充,选择合适的病例进行射频热凝毁损术安全有效,甚至可以达到无发作.

目的 研究神经内镜下大脑半球离断术的有效性和安全性.方法 回顾性分析1例药物难治性癫疒间病人的临床资料,采用神经内镜下大脑半球离断术,分析其术后疗效和并发症.结果 术后MRI提示左侧基底核区与周围脑叶完全离断,DTI提示各脑叶与基底核区无纤维传导束联系.术后2周内有发热,予腰大池置管引流后控制;无其他并发症.随访6个月,无癫疒间发作,达EngelⅠ级;神经认知功能较术前改善.结论 对药物难治性癫疒间行神经内镜下大脑半球离断术安全、微创、有效.

Background Insulo-opercular seizures are highly heterogeneous in seizure semiology and electrical features. Bilateral asymmetric limb posturing, as a classical pattern of supplementary sensorimotor area (SMA) seizure, also occurs in insulo-opercular epilepsy. This study was aimed to study the anatomo-electro-clinical correlations in bilateral asymmetric tonic seizures (BATS), in order to advance the understanding of insulo-opercular epilepsy. Methods Eight patients with insulo-opercular epilepsy as confirmed by stereoelectroencephalography (SEEG) and manifesting BATS as the major ictal motor sign, in Guangdong Sanjiu Brain Hospital Epilepsy Center from 2014 to 2018, were employed in this study. The BATS of the patients were evaluated, and the semiologic features and concomitant intracerebral EEG changes were quantified. Then the variables were examined with Cluster Analysis, and the semiologic features were correlated with anatomic localization using the Kendall correlation test. Results Of the 8 patients, the most frequent initial motor sign was bilateral asymmetric tonic posturing (62.5%). Facial tonic-clonic sign also had a high prevalence in the evolution of seizures (87.5%). The results of Cluster Analysis showed that the semiologic features were subdivided into two main groups, one group comprising exclusively BATS and the other including signs of focal tonic seizure, aura, focal limb tonic-clonic seizure (TCS), facial TCS, hypermotor behavior, eye movement, autonomic changes and generalized TCS. The BATS was strongly associated with the posterior long gyrus (PLG) of insula (t = 0.732) and parietal operculum (t = 1.000); the hypermotor behaviors were associated with the anterior long gyrus (ALG) (t = 0.770); and the autonomic changes were associated with the anterior limiting sulcus (ALS) (t = 0.734) and middle short gyrus (MSG) (t = 0.700). Conclusions The seizure semiology of insulo-opercular epilepsy is characterized, in temporal order, by BATS, with or without simultaneous hypermotor behaviors, and frequently ends up with facial tonic-clonic signs, which is different from that of the SMA seizure. The early spread network involving the posterior insular lobe and parietal operculum may contribute to this pattern of manifestation.