Imaging epileptogenic tubers in children with tuberous sclerosis complex using α-[11C]methyl-L-tryptophan positron emission tomography

Several reports have indicated that cortical resection is effective in alleviating intractable epilepsy in children with tuberous sclerosis complex (TSC). Because of the multitude of cortical lesions, however, identifying the epileptogenic tuber(s) is difficult and often requires invasive intracranial electroencephalographic (EEG) monitoring. As increased concentrations of serotonin and serotonin-immunoreactive processes have been reported in resected human epileptic cortex, we used alpha-[C-11]methyl-L-tryptophan ([C-11]AMT) positron emission tomography (PET) to test the hypothesis that serotonin synthesis is increased interictally in epileptogenic tubers in patients with TSC. Nine children with TSC and epilepsy, aged 1 to 9 years (mean, 4 years 1 month), were studied. All children underwent scalp video-EEG monitoring, PET scans of glucose metabolism and serotonin synthesis, and EEG monitoring during both PET studies. [C-11]AMT scans were coregistered with magnetic resonance imaging and with glucose metabolism scans. Whereas glucose metabolism PET showed multifocal cortical hypometabolism corresponding to the locations of tubers in all 9 children, [C-11]AMT uptake was increased in one tuber (n = 3), two tubers (n = 3), three tubers (n = 1), and four tubers (n = 1) in 8 of the 9 children. All other tubers showed decreased [C-11]AMT uptake. Ictal EEG data available in 8 children showed seizure onset corresponding to foci of increased [C-11]AMT uptake in 4 children (including 2 with intracranial EEG recording). In 2 children, ictal EEG was nonlocalizing, and in I child there was discordance between the region of increased [C-11]AMT uptake and the region of ictal onset on EEG. The only child whose [C-11]AMT scan showed no regions of increased uptake had a left frontal seizure focus on EEG; however, at the time of his [C-11]AMT PET scan, his seizures had come under control. [C-11]AMT PET may be a powerful tool in differentiating between epileptogenic and nonepileptogenic tubers in patients with TSC.