Ecstatic Epileptic Seizures - the Role of the Insula in Altered Self-Awareness

Ecstatic auras are a rare but compelling epileptic entity. During the first seconds of the seizure, ecstatic auras provoke feelings of well-being, intense serenity, bliss, and enhanced self-awareness. They can be associated with the impression of dilated time, and are sometimes described as a mystic experience by some patients. The functional neuroanatomy of ecstatic seizures is still debated. During recent years several patients presenting with ecstatic auras have been reported by us and others; one of them even in the setting of pre-surgical electrical brain stimulation. According to the results of nuclear brain imaging and electrical stimulation, the common seizure localization in those patients appeared to be the anterior-dorsal insular cortex, where we thus propose to locate this rare ictal phenomenon. Here we summarize the role of the multiple cognitive, affective, sensory and autonomic functions of the insular cortex, which may be integrated into the creation of self-awareness, and how this system may become dysfunctional on several levels during ecstatic auras.