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Objective: Ecstatic seizures (EcS) have captured scientific interest due to their potential origin in anterior insular networks, emphasizing the insula's role in self-processing. Their frequency in epilepsy or insular pathology has not been systematically studied. Present study aimed to examine the frequency and clinical characteristics of EcS in epilepsy patients, and the potential occurrence of ecstatic symptoms in insula tumor patients.

Method: Preformatted questionnaires on symptom reporting were sent to 200 epilepsy patients and 40 with resected insular tumors. Patients reporting EcS-related symptoms underwent in-person interviews. Hospital records, including EEG and imaging, were analyzed. Seizure-related experiences with supernatural, religious, spiritual, mystical, or ecstatic features were referred to as "numinous-like symptoms" throughout the article.

Results: Interestingly, a variety of rare, numinous-like ictal experiences were found, all of which are discussed in this study. In the epilepsy cohort, 83 patients responded, five (6.0 %) reported symptoms that qualified them for interview and final analysis. In the tumor cohort, 23 patients responded, two (8.7 %) reported relevant symptoms, both with pre-existing epilepsy. During the interviews, we identified EcS (n = 1), ictal out-of-body experiences (OBE) (n = 2), and ictal sensed presence (SenP) (n = 5); one patient experienced both SenP and OBE. Three SenP patients had seizure origin in the right hemisphere: two had resected tumors in the temporo-insular region and one had mesial temporal sclerosis. The EcS patient had aphasia as an early seizure symptom and leftsided temporal interictal epileptiform activity. The remaining patients had less distinct investigational results.

Conclusion: Our findings indicate that seizure-related numinous-like experiences are not uncommon and should be actively assessed, given the difficulty and reluctance of patients to speak about them, and their relevance for evaluating seizure freedom and differential diagnoses. Neuroscientifically, these phenomena offer insight into consciousness: EcS and OBE occupy distinct nodes in self-processing networks, whereas SenP requires further cognitive, psychological, and phenomenological analysis to guide future neurobiological research.