title: Insular-opercular seizures manifesting with sleep-related paroxysmal motor behaviors: a stereo-EEG study.
abstract: OBJECTIVE
  Sleep-related complex motor seizures are a common feature of nocturnal frontal lobe epilepsy. Nevertheless, recent studies also suggest that sleep-related hypermotor seizures can originate in the insula. The present study describes the electroclinical features of eight drug-resistant epileptic patients with insular-opercular seizures manifesting with nocturnal complex motor seizures.
  
  
  METHODS
  Patients underwent a comprehensive presurgical evaluation, which included history, interictal electroencephalography (EEG), scalp video-EEG monitoring, high-resolution magnetic resonance imaging (MRI), and intracerebral recording by stereo-EEG.
  
  
  RESULTS
  Almost all patients reported an initial sensation consisting of viscerosensitive or somatosensory symptoms. Ictal clinical signs were represented by tonic-dystonic asymmetric posturing and/or hyperkinetic automatisms, including bimanual/bipedal activity and ballistic movements. Some patients exhibited dysarthric speech, hypersalivation, and apnea. Interictal and ictal EEG provided lateralizing information in the majority of patients. In three patients, MRI showed a focal anatomical abnormality in the insular-opercular region. Stereo-EEG ictal recordings demonstrated that the epileptic discharge involved simultaneously the insular cortex and the opercular region. Complex motor manifestations appeared when the ictal discharge showed an extrainsular spreading to frontomesial regions (cingulum, superior frontal gyrus, and supplementary motor area) and/or to internal and neocortical temporal lobe structures. Six patients received an insular-opercular cortical resection; three of them are seizure free (minimum follow-up 24 months) and in one a marked reduction in seizure frequency was obtained. Two patients have been operated on recently. Histology revealed a focal cortical dysplasia in three patients. One patient excluded from surgery died for sudden unexpected death in epilepsy during sleep.
  
  
  CONCLUSIONS
  Our data strengthen the concept that sleep-related complex motor attacks can originate in the insula, and provide useful electroclinical information to differentiate this localization from those with similar clinical characteristics. Furthermore, this study indicates that in these drug-resistant patients, surgical treatment represents a highly effective treatment option.
authors: C. Munari Center of Epilepsy Surgery, Niguarda Hospital, Milan, Italy.
authors: Paola
authors: P
authors: Proserpio
authors: Massimo
authors: M
authors: Cossu
authors: Stefano
authors: S
authors: Francione
authors: Laura
authors: L
authors: Tassi
authors: Roberto
authors: R
authors: Mai
authors: Giuseppe
authors: G
authors: Didato
authors: Laura
authors: L
authors: Castana
authors: Francesco
authors: F
authors: Cardinale
authors: Ivana
authors: I
authors: Sartori
authors: Francesca
authors: F
authors: Gozzo
authors: Alberto
authors: A
authors: Citterio
authors: Marco
authors: M
authors: Schiariti
authors: Giorgio
authors: G
authors: Lo Russo
authors: Lino
authors: L
authors: Nobili
mesh_terms: D001921:Brain / Q000473:pathology / Q000503:physiopathology; D004569:Electroencephalography; D017034:Epilepsy, Frontal Lobe / Q000503:physiopathology; D005260:Female; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D020183:Nocturnal Paroxysmal Dystonia / Q000473:pathology / Q000503:physiopathology*; D012640:Seizures / Q000473:pathology / Q000503:physiopathology*; D012890:Sleep / Q000502:physiology; D013003:Somatosensory Cortex / Q000473:pathology / Q000503:physiopathology