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The human insular lobe was initially described by the anatomist Reil JC (Reil, 1809). This lobe is the first in the cerebral cortex that develops and differentiates in the fetus (Streeter, 1912; Kodam, 1926; Afif et al., 2007). A recent study demonstrates that the formation of insular cortex begins by its inferior region that will later become the limen insula (Afif et al., 2007). This cortical development progresses in parallel with that of the middle cerebral artery (MCA) and its branches in the superior and posterosuperior axis (Afif et al., 2007). The insula consists of three short and two long gyri separated by the central insular sulcus, which defines the anterior and posterior insula (Varnavas & Grand, 1999; Ture et al., 1999; Naidich et al., 2004; Afif & Mertens, 2010). The opercularization is the result of important development of the surrounding insular cortex (frontal, parietal and temporal lobes). Progressive development over the entire surface of the insular cortex encloses the sylvian fissure. Due to its deep anatomic position and dense surrounding vascular network, few studies involving direct electrical stimulation (ES) of the insular cortex during surgical procedures have been reported (Penfield & Jasper, 1954; Penfield & Faulk, 1955; Oppenheimer et al., 1992; Duffau et al. 2001, 2009). Immunocytochemistry, functional imaging, direct ES, and lesion studies suggest an important role for the insular cortex. Such roles include language production and grammatical processing (Raichle, 1991; McCarthy et al., 1993; Wise et al., 1999; Price, 2000, 2001; Ackermann & Riecker, 2004; Isnard et al., 2004; Riecker et al., 2005; Friederici et al., 2006; Kato et al., 2007; Afif et al., 2010a), pain modulation (Tarkka & Treede, 1993; Frot & Mauguiere, 1999; Ostrowsky et al., 2000; Peyron et al., 2004; Craig, 2004; Isnard et al., 2005; Brooks et al., 2005 ; Schreckenberger et al., 2005; Mazzola et al., 2006; Henderson et al., 2006, 2007; Afif et al., 2008b), visceral sensory processing (Ostrowsky et al., 2000; Dupont et al., 2003; Isnard et al., 2004), bradycardia (Seeck et al., 2003), dysphagia (Danieles & Foundas, 1997) and auditory processing (Manes et al., 1999; Lewis et al., 2000; Shergill et al., 2000; Bamiou et al., 2003; Afif et al., 2010b).

Robotic Arm and Imaging in Neurosurgical Stereotactic Interventions: Oblique Insular Electrodes Implanted in Patients with Epilepsy