Role of the Insula in Temporal Lobe Epilepsy Surgery Failure

  • Vamsi Krishna Yerramneni
  • Alain Bouthillier
  • Dang Khoa NguyenEmail author


Despite decades of research, the rate of epilepsy surgery failures in patients with drug refractory seizures remains important (30% for temporal and 50% for frontal lobe surgeries). Inaccurate localization or delimitation of the epileptic focus are the two most likely explanations and might be due to misleading clinical symptoms (as a result of local or propagated epileptic activity to other brain areas within the epileptic network) as well as limitations of standard localization tools. Indeed, MRI fails to identify an epileptogenic lesion in 25% of temporal and 45% of frontal epilepsy cases; scalp EEG, SPECT, and PET scans have limited spatial and/or temporal resolution; and although intracranial EEG electrodes are closer to bioelectric sources of epileptic activity, the focus might not be sampled if not initially felt to be an area of suspected epileptogenicity.

Until recently, the insula has largely been ignored as a possible site of seizures. Using invasive sampling of the insula with depth electrodes, we and others have showed that in some cases failure to recognize insular seizures was responsible for their poor postoperative seizure outcome. Indeed, since the insula is highly connected with the frontal, temporal, and parietal lobes, seizures arising from the insula may be difficult to distinguish from those originating from these other areas and are thus most of the time overlooked. In this chapter, we will review the existing literature supporting the role of the insula as a cause of epilepsy surgery failures and provide illustrative cases.


Insular epilepsy Insular cortex epilepsy Operculo-insular epilepsy Temporal plus epilepsy Temporo-insular epilepsy Epilepsy surgery 







Magnetic resonance imaging


Positron emission tomography




Single-photon emission computed tomography


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Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Vamsi Krishna Yerramneni
    • 1
  • Alain Bouthillier
    • 1
  • Dang Khoa Nguyen
    • 2
    • 3
    • 4
    Email author
  1. 1.Service de NeurochirurgieCentre Hospitalier de l’Université de MontréalMontrealCanada
  2. 2.Centre de Recherche du Centre Hospitalier de l’Université de MontréalMontrealCanada
  3. 3.Département de NeurosciencesUniversité de MontréalMontrealCanada
  4. 4.Service de NeurologieCentre Hospitalier de l’Université de MontréalMontrealCanada

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