ABSTRACT
We present a case of preserved corticospinal connectivity in a cortical tuber, in a 10 year-old boy with intractable epilepsy and tuberous sclerosis complex (TSC). The patient had multiple subcortical tubers, one of which was located in the right central sulcus. In preparation for epilepsy surgery, motor mapping, by neuronavigated transcranial magnetic stimulation (nTMS) coupled with surface electromyography (EMG) was performed to locate the primary motor cortical areas. The resulting functional motor map revealed expected corticospinal connectivity in the left precentral gyrus. Surprisingly, robust contralateral deltoid and tibialis anterior motor evoked potentials (MEPs) were also elicited with direct stimulation of the cortical tuber in the right central sulcus. MRI with diffusion tensor imaging (DTI) tractography confirmed corticospinal fibers originating in the tuber. As there are no current reports of preserved connectivity between a cortical tuber and the corticospinal tract, this case serves to highlight the functional interdigitation of tuber and eloquent cortex. Our case also illustrates the widening spectrum of neuropathological abnormality in TSC that is becoming apparent with modern MRI methodology. Finally, our finding underscores the need for further study of preserved function in tuber tissue during presurgical workup in patients with TSC.
ABSTRACT
Low frequency repetitive TMS (rTMS) of a cortical seizure focus is emerging as an antiepileptic treatment. While conventional rTMS stimulators activate only superficial cortical areas, reaching deep epileptic foci, for example in temporal lobe epilepsy (TLE), is possible using specially designed H-coils. We report the results of rTMS in a young adult with pharmacoresistant bilateral TLE who underwent three courses (of 10, 15, and 30 daily sessions) of unilateral rTMS over the hemisphere from which seizures originated most often. Seizure frequency was assessed before and after each block of rTMS sessions, as was the tolerability of the procedure. Seizure frequency declined significantly, by 50 to 70% following each rTMS course. All sessions were well-tolerated.