Bilateral asymmetric tonic seizure in insuloopercular epilepsy:an anatomo-electroclinical study

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.