Non-dominant, Non-lesional Insular epilepsy

This chapter presents a case of pharmacoresistant insular epilepsy of unknown etiology failing extended temporal lobectomy and MRI-guided laser interstitial thermoablation therapy of the amygdala. Ultimately, our patient received a responsive neurostimulation targeting the insula, leading to a favorable outcome in conjunction with anti-seizure medication adjustment. We shed light on the complexity of insular epilepsy as an under-recognized and misdiagnosed electroclinical entity due to its overlapping manifestations with temporal, frontal, and parietal epilepsies. We discuss the anatomy of the insula and its associated functions, its connectivities, electroclinical presentation, surgical approaches, and associated outcomes and complications. Lastly, we analyze semiologies such as ictal fear, hypersalivation and spitting, fencer posturing, pre- and post-ictal headache, and tongue bite.