Insular epilepsy etiology: clinical manifestation and management tactics for cerebral cavernous angiomas

Insular epilepsy is currently of special interest for world epileptology. Many authors including W. Penfield and H. Jasper, suggested the relation between unsuccessful temporal resection and undiagnosed epileptic focus localization in insula. Despite increased interest to insular epilepsy, the data on etiologic structure remain sparse. The current paper presents literature review of etiologic role of cavernous angiomas in the origin of insular epilepsy and dissects management tactics on a clinical example. Literature search was performed in Web of Science and «Russian Science Citation Index» databases using keywords «insular epilepsy» (in English and Russian). Using a clinical example, features of manifestation and diagnosis of insular epilepsy are discussed. The international and national data on the morphological structure, localization and features of manifestations of cerebral cavernous angiomas are given. Epilepsy caused by cavernous angiomas constitute 0.4-0.9% in the general structure of the disease, and their ratio increases in the structure of pharmacoresistant forms. Management tactics for the patients with insular epilepsy was analyzed with the use of International League Against Epilepsy guidelines on cavernoma-related epilepsy (2013). Conclusion is made that solitary seizure in epilepsy onset is an indication for magnetic resonance imaging of the brain to exclude structural pathology. High-field magnetic resonance imaging according to epilepsy program is preferable. With no pathological signs on magnetic resonance imaging scans and clinical signs of vascular pathology, magnetic resonance angiography is helpful to exclude vascular malformations. Early microsurgical removal of cavernous angioma as an etiological substrate of epilepsy decreases the risk of pharmacoresistant epilepsy.