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A 16-year-old boy with intractable epilepsy

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1 A 16-year-old boy with intractable epilepsy
Teaching NeuroImages Neurology Resident and Fellow Section © 2016 American Academy of Neurology

2 Vignette A 16-year-old male with intractable focal epilepsy with preserved awareness and Attention Deficit Hyperactivity Disorder underwent evaluation for epilepsy surgery Epilepsy onset occurred at age 5 years; seizures arise from sleep and are characterized by right arm extension with preserved consciousness. Ictal EEG has no clear localization or lateralization High resolution 3T MRI, fMRI and depth electrodes placement were performed Bartolini L et al. © 2016 American Academy of Neurology

3 Imaging Bartolini L et al.
Figure 1. 3T brain MRI and fMRI of a 16-year-old child with intractable focal epilepsy due to schizencephaly and polymicrogyria Axial T1-weighted (left) and axial and coronal T2-weighted (right) images demonstrate polymicrogyria extending from the cerebral convexity to the ventricular margin. Focal cleft where abnormal gray matter meets the ependymal surface is consistent with closed-lip schizencephaly (A). Activation with repetitive bilateral foot (B), bilateral finger (C) and tongue tapping (D) reveals homotopic distribution of motor cortex with hand deep into the cleft centrally, foot mesially, and mouth laterally at the edge of the area of schizencephaly. The threshold for the study was set at top 5% of voxels.   Bartolini L et al. © 2016 American Academy of Neurology

4 Imaging Bartolini L et al.
Figure 2. Skull radiograph from the same patient showing depth electrode placement. Motor mapping is shown as red dots next to the electrodes. Right lateral (RL): stimulation of electrodes 1-2 resulted in motion of the left hand; Right medial (RM): stimulation of 1-2 resulted in left arm and face motion, 3-4 jaw motion, 5-6 left side of mouth motion, 7-8 left knee twitch; Left lateral (LL): stimulation of electrodes 1-2 resulted in right hand then right arm then right leg twitch, 3-4 right leg extension, 5 right foot twitch. Bartolini L et al. © 2016 American Academy of Neurology

5 Homotopic motor distribution on fMRI in closed-lip schizencephaly
MRI brain demonstrates bifrontal closed-lip schizencephaly. Functional MRI (fMRI) shows homotopic distribution of tongue/finger/foot motor function at the edge of and along the depth of the schizencephalic cleft. fMRI is a reliable tool to identify the eloquent cortex in the planning for epilepsy surgery. References: 1. Martinez-Rios C, McAndrews MP, Logan W, Krings T, Lee D, Widjaja E. MRI in the evaluation of localization-related epilepsy. J Magn Reson Imaging. 2016;44(1):12-22. 2. Gaillard WD, Berl MM. Functional magnetic resonance imaging: functional mapping. Handb Clin Neurol. 2012;107: Bartolini L et al. © 2016 American Academy of Neurology

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