Surgical Management Of Insular-Opercular Epilepsy In Children

Insular or insular-opercular epilepsy (IOE) is an underreported form of epilepsy, particularly in childhood. A high index of suspicion of insular epilepsy is imperative, as failure to recognize the insula as part of the epileptogenic zone is a well-recognized cause of persistent disabling seizures following frontal (FLE), temporal (TLE), or parietal lobe epilepsy (PLE) surgery in children. In fact, a third of pediatric IOE patients present after having failed prior resective epilepsy surgery. Advances in the presurgical workup and neurosurgical techniques over recent decades have allowed centers to safely perform invasive investigation and resective surgery for epilepsy originating from the insular and perisylvian region. Over the last decade, several groups have reported their experience with insular epilepsy surgery in pediatric cohorts. Epilepsy surgery is effective in well-selected candidates, and surgical morbidity is relatively low in experienced centers. Detailed working knowledge of insular and perisylvian anatomy and sound surgical technique are essential. This chapter reviews pertinent insular-perisylvian anatomy and function, provides an up-to-date summary of the presurgical workup, indications and different methods for extraoperative invasive investigation, and describes nuances in resective surgical technique for pediatric insular epilepsy. It also summarizes the available evidence in favor of surgery for IOE in childhood.