SUMMARY
Purpose
Interictal increase of 11C-alpha-methyl-L-tryptophan (AMT) on PET can be seen in cortical epileptic foci, and is particularly common in cortical developmental malformations. Therefore, in the present study, we evaluated the clinical and histopathological correlates of AMT-PET abnormalities in children with intractable epilepsy undergoing resective surgery.
Methods
Thirty children (mean age: 6.7 ± 3.2 years) were included in this study. All patients received AMT PET as part of their presurgical evaluation and subsequently underwent epilepsy surgery. MRI scans were normal in 15, showed non-specific changes in 8, and suggested malformations of cortical development (MCD) in 9 children. Asymmetry indices (AIs) were calculated to determine increased AMT uptake.
Key findings
Histopathology revealed MCD in 16 (53%) children, including 12 with cortical dysplasia (CD) [mild MCD=3; CD type IA=2; CD type IIA=2 and CD type IIB (severe CD with balloon cells)=5]. Polymicrogyria and heterotopias (P&H) were seen in 3 cases and subependymal heterotopias (SEH) in 1 child. The remaining 14 cases showed normal histopathology with varying degrees of gliosis. Increased AMT uptake was found in all 5 with CD type IIB, and all 3 with P&H, but in none with mild MCD and types IA-IIA CD or SEH. Whereas all 5 children with CD IIB and 2 with P&H had excellent surgical outcome (class-I), children with milder CD or SEH had variable surgical outcome. The 14 patients with normal histopathology included 7 patients with focally increased and 7 with normal AMT uptake. While patients with normal pathology and normal AMT-PET had better surgical outcome (class I=5; II=2), those with normal pathology, normal MRI but abnormal AMT-PET had poor surgical outcome (class III=4; IV=3).
Significance
Increased AMT uptake in children with CD may predict type IIB dysplasia (with balloon cells) and good surgical outcome Histopathological similarities between CD type IIB and epileptogenic cortical tubers may imply a common role of the inflammatory kynurenine pathway of tryptophan metabolism in these lesions. In children with normal histopathology, there is a subgroup with increased AMT uptake and poor surgical outcome.