Neural correlates and network dynamics of uncommon semiologies in the cingulo-insulo-opercular network explored with Stereo-EEG

Objective: We investigated five uncommon semiologies associated with suspected cingulo-insulo-opercular network involvement using stereo-electroencephalography (SEEG): smiling, laughter, neck choreoathetosis, face wiping, and arm-over-head pose. Methods: Among 75 SEEG cases reviewed between February 2023 and August 2024, 11 patients exhibited at least one semiology of interest. Video-annotated peri-onset epochs were analyzed using an in-house MATLAB-based pipeline with band-specific filtering and event-related desynchronization/synchronization (ERDS) analysis across six frequency bands. Quantitative ERDS, patient-specific computed tomography/magnetic resonance imaging-based anatomical localization, regional clustering, null-control comparison, and false discovery rate correction were used to define semiology-associated networks. Results: All five semiologies converged on a shared cingulate-insula-centered network with recurrent involvement of frontal opercular, orbitofrontal, and lateral prefrontal regions. Face wiping showed a consistent postictal cingulo-insulo-frontal/opercular pattern, with anterior cingulate theta synchronization and orbitofrontal desynchronization within an overall delta-dominant profile. Laughter and smiling engaged overlapping anterior/mid-cingulate, insular, and opercular networks; laughter showed broader recruitment and relatively greater gamma/high-frequency representation, whereas smiling showed a more compact, predominantly delta and gamma-weighted pattern. Neck choreoathetosis mapped to a fronto-cingulo-insular-opercular network with dominant delta activity. Arm-over-head pose was associated with a compact cingulo-insulo-frontotemporal/opercular network characterized by marked delta predominance and negative change-based directionality. Network membership was stable across channel-selection thresholds. Conclusion: These uncommon ictal and postictal semiologies are associated with distinct but overlapping frequency-dependent cortical network signatures centered on the cingulo-insulo-opercular system. Significance: These findings may support SEEG interpretation, network-based localization, and presurgical hypothesis generation in patients with suspected cingulo-insulo-opercular epilepsy.