PMC5967225_01
Hippocampal slices of fluid attenuated inversion recovery magnetic resonance imaging at lateral ventricles level (A) and next slice above A (B). The patient showed multiple cortical tubers on bilateral hemispheres, including in the inferior frontal gyrus (arrow head) and inferior parietal lobule (arrow).
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F1
MRI revealed multiple cortical tubers on bilateral hemispheres, including tubers in the inferior frontal gyrus and inferior parietal lobule (Figure 1). 18F-fluorodeoxyglucose-positron emission tomography (PET) showed low-uptake areas corresponding to the cortical tubers, whereas C-11-methionine PET did not show any high or low-uptake areas. Initially, the anterior region from the frontal cortical tuber was resected (Figure 2, resection area 1), and we evaluated language function using electrical cortical stimulation (ECS; biphasic stimulation on each pair of adjacent contacts, 8-12 mA, pulse width 0.1 msec, 50 Hz, 1-5 s) during the cortical resections.
Schema of the patient's left hemisphere, cortical tubers (yellow regions), intracranial electrodes (light blue disks), results of extraoperative functional mapping of anterior language area (red shaded), posterior language area (white shaded), motor area of face/larynx/tongue (green loop), hand (orange loop), and hand sensory area (purple loop), ictal onset electrodes (pink stars), and resection areas (yellow dot loops: 1-3). We implanted 92 electrodes [2 grid electrodes (8 x 5, 4 x 5), 3 strip electrodes (10, 8, 8), and 1 depth electrode (6)]. One cortical tuber was present below and over the anterior language area. Another cortical tuber distributed posterior to the posterior language area. Ictal onset electrodes partially overlapped with the anterior and posterior language areas. The resections were performed from the resection areas of 1, 2, to 3. During the resection surgery, the patient presented with speech difficulty after the resection of site A, and retardation in responsive naming, paraphasia, and phonological recall after the resection of site B.
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F2
We conducted an intracranial EEG analysis (EEG-1200, Neurofax, Nihon Kohden), using 92 electrodes [2 grid electrodes (8 x 5, 4 x 5), 3 strip electrodes (10, 8, 8), and 1 depth electrode (6)] (Figure 2). Although she represented retardations or disruptions at picture naming and responsive naming and mistakes at token test in both language areas, more severe disturbances and paraphasia occurred during the stimulations to posterior language area (Figure 2, red and white shaded areas). The ictal fast activities started separately and simultaneously in the frontal and parietal regions (Figure 2, pink stars). Initially, the anterior region from the frontal cortical tuber was resected (Figure 2, resection area 1), and we evaluated language function using electrical cortical stimulation (ECS; biphasic stimulation on each pair of adjacent contacts, 8-12 mA, pulse width 0.1 msec, 50 Hz, 1-5 s) during the cortical resections. We then resected the posterior regions (Figure 2, resection areas 2 and 3) that extended to the posterior language area.