Figure 1
(A) Right-sided SEEG schema with 12 depth electrodes exploring the anterior and posterior perisylvian region (electrodes Q-T) and mesial frontal region/supplementary motor area (SMA; electrodes M and N). (B) Two representative seizures showing onset at contacts Q1,2 (frontal operculum/insula; red arrow) and U6,7 (planum temporal; green arrow) on a 15-second page (band pass: 5.3-300 Hz). The onset at these contacts was simultaneous in the second example, though in the first example the ictal discharge at U5,6 was delayed relative to that at Q1,2. These seizures occurred during sleep without report of aura. Clinical onset is denoted by the blue line. In other seizures, including the one with reported auditory aura, a build-up of spiking occurred in contacts Q1,2 for tens of seconds prior to ictal onset. Prominent early involvement was also noted in the mesial contacts of M and N (SMA; not shown), in addition to neighbouring perisylvian contacts. (C) Interictal FDG-PET showing hypometabolism in the right frontal operculum (arrow). (D) Ictal SPECT (Z=2) of a typical seizure recorded prior to SEEG evaluation. Injection was performed at nine seconds from clinical onset. There was a dominant focus in the left frontal operculum/insula and anterior cingulum. A lesser degree of hyperaemia was seen in the right insular region (crosshairs). Semiology of this seizure involved left face tonic contraction, suggestive of right opercular activation. (E) Post-resection MRI showing defect in the right frontal operculum and subjacent insula.