Insular epilepsy has caught increasing attention in the presurgical evaluation of drug-resistant focal epilepsies, and it is evident that intracranial EEG recordings can be considered the best method to investigate such a deep-seated area of the brain, especially in non-lesional patients. Intracranial EEG recordings allow us to better understand the organization of epileptic EEG discharges involving the insular cortex and the complexity of the relationships between the insula and the different connected regions of the brain, particularly the opercular region. This peculiarity thus explains the heterogeneous clinical presentation of seizures arising from insular or insulo-opercular structures. While most patients have an epileptogenic zone extending beyond the insula, some have very focal ictal insular discharges, allowing the possibility of a restricted surgical resection. Consequently, only an appropriate sampling of the insula and of extra-insular connected structures can permit a precise identification of the epileptogenic zone and planning for a tailored resection.

Surgery for medically intractable childhood seizures originating in the opercular-insular cortex has only been undertaken in the last decade. While the need for SEEG interrogation and rates of post-operative seizure-freedom in children are comparable to adults, several important differences distinguish the pediatric experience. Most pediatric surgical candidates are pre-verbal or non-verbal and cannot describe subjective sensory or affective seizure manifestations. There is a higher representation of frontal lobe seizure semiology compared to adults, whereas ictal and inter-ictal electrographic discharges are typically more widespread throughout the cerebral hemisphere. Cortical malformations constitute the primary underlying pathological finding in the majority of pediatric cases. The recent surgical success in medically refractory children provides a compelling rationale to pursue further clinical studies and offer surgical candidacy in selected patients.