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Epileptogenic but MRI-normal perituberal tissue in Tuberous Sclerosis Complex contains tuber-specific abnormalities
© Sosunov et al.; licensee BioMed Central. 2015
Received: 21 January 2015
Accepted: 3 February 2015
Published: 2 April 2015
Recent evidence has implicated perituberal, MRI-normal brain tissue as a possible source of seizures in tuberous sclerosis complex (TSC). Data on aberrant structural features in this area that may predispose to the initiation or progression of seizures are very limited. We used immunohistochemistry and confocal microscopy to compare epileptogenic, perituberal, MRI-normal tissue with cortical tubers.
In every sample of epileptogenic, perituberal tissue, we found many abnormal cell types, including giant cells and cytomegalic neurons. The majority of giant cells were surrounded by morphologically abnormal astrocytes with long processes typical of interlaminar astrocytes. Perituberal giant cells and astrocytes together formed characteristic “microtubers”. A parallel analysis of tubers showed that many contained astrocytes with features of both protoplasmic and gliotic cells.
Microtubers represent a novel pathognomonic finding in TSC and may represent an elementary unit of cortical tubers. Microtubers and cytomegalic neurons in perituberal parenchyma may serve as the source of seizures in TSC and provide potential targets for therapeutic and surgical interventions in TSC.
Cortical tubers are a hallmark of the brain pathology and a main source of epileptic activity in patients with tuberous sclerosis complex (TSC) . TSC is an autosomal dominant disorder caused by mutations in TSC1 or TSC2. Loss of function of these genes leads to activation of the mTOR cascade, which is critical for cellular growth and development of numerous organ systems [2-4].
Tubers are a type of cerebral cortical malformation that are characterized by a prominent irregularity in neocortical cytoarchitecture. Tubers are composed of abnormal cells including giant cells, dysplastic/cytomegalic neurons, and aberrant tuber astrocytes. Although tubers are generally thought to be a source of ictal activity in TSC epilepsy, seizure initiation from perituberal tissue has been documented in several reports suggesting other mechanisms for epileptogenesis than the effects of tubers on network excitability [5-9].
Perituberal “MRI-normal” tissue is often resected during TSC epilepsy surgery as part of the epileptogenic zone, and is usually considered to be a structurally “normal” area of brain adjoining a nearby epileptogenic cortical tuber. For example, Wang et al.  reported an epileptogenic focus in a TSC patient who displayed no cortical tubers by MRI. However, analysis of gliosis in TSC revealed perituberal collections of giant cells and gliotic astrocytes that we designated “microtubers” . A recent autopsy study also detected considerable TSC pathology outside of cortical tubers, including lamination abnormalities, heterotopias, and giant cells . These authors also designated pathological clusters of giant cells and dystrophic neurons outside of tubers as “microtubers.”
In this study, we have examined MRI-normal, perituberal tissues in patients who had surgical resections for epilepsy. The resected tissue included perituberal tissue as part of the epileptogenic zone in many of these patients. In every sample of epileptogenic, perituberal tissue, we found abnormal cellular pathology, including cytomegalic neurons, giant cells, and gliotic astrocytes. Most of the perituberal giant cells or groups of giant cells in the cortex were surrounded by gliotic astrocytes, together forming “microtubers”. We fully describe the features of perituberal “microtubers” and focus on the importance of pathological gliotic astrocytes together with giant cells as the fundamental elements of these potentially epileptogenic structures.
Materials and Methods
Specimens including cortical tubers (n = 16) and MRI normal perituberal tissue (n = 10) were obtained from TSC patients with medically refractory epilepsy who were undergoing epilepsy surgical resection. In one case, hippocampus with MRI normal architecture was resected as the epileptogenic area together with adjoining cortical tubers. The mean age of the 16 patients was 9.8 ± 1.5 years (range: 2.5 – 23 years), with 9 females and 7 males. The epileptogenicity of the resected tubers and perituberal tissue was established during invasive subdural intracranial monitoring of patients, as previously described . Perituberal tissue did not show any abnormalities on detailed preoperative MRI examination using imaging protocols designed to maximize preoperative detection of malformations of cortical development. The location of the tuberal tissue and MRI normal perituberal tissue was confirmed intraoperatively by gross visual inspection, as well as by frameless stereotactic intraoperative MRI based surgical navigation. All patient protocols were approved by the Institutional Review Boards of Columbia University Medical Center and New York University Medical Center.
Histology and immunohistochemistry
Specimens were fixed in 4% paraformaldehyde in PBS for 14–18 h (4°C). 40 μm sections were prepared with a vibratome (Leica VT1000S) and stored in cryoprotectant solution at -20°C. Standard procedure for Nissl staining with cresyl violet was used for routine analysis of tissue.
Primary antibodies used for immunohistochemistry
Glial fibrillary acidic protein (GFAP)
Sigma-Aldrich, St. Louis, MO
Glial fibrillary acidic protein (GFAP)
DAKO, Carpinteria, CA
Glial fibrillary acidic protein (GFAP)
Covance, Berkeley, CA
MIllipore, San Diego, CA
Santa Cruz Biotechnology, Santa Cruz, CA
Novocastra Lab, Newcastle upon Tyne, UK
Cell Signaling Technology, Inc, Boston, MA
R&D Systems, Inc., Minnezpolis, MN
Pan-neuronal neurofilament marker SMI 311
ICN Biomedicals, Inc., Aurora, OH
Biocare Madical, LLC, Concord, CA
Phospho-S6 ribosomal protein (Ser 235/236)*
Phospho-S6 ribosomal protein (Ser 240/244)*
Phospho-p44/42 MAPK (Erk1/2) (Thr202/Tyr204)
Tumor necrosis factor alpha (TNF alpha)
Neurotropin receptor p75NTR
Promega Corp.,Madison, WI
Secondary antibodies include: conjugated to fluorophores: anti-mouse Alexa Fluor 488, 594, and 633; anti-chicken Alexa Fluor 594, 633; anti-rabbit Alexa Fluor 594; anti-goat Alexa Fluor 594, 633; anti-guinea pig Alexa Fluor 594, 633, all from goat or donkey (1:300, Molecular Probes, Eugene, OR).
Antigen retrieval procedure was performed with Antigen Unmasking Solution (Vector Laboratories, Inc., Burlingame, CA) by boiling for 40 sec in a microwave.
For light microscopy sections were pretreated in 3% H2O2 in methanol (30 min, at room temperature [RT]) and after blocking in 10% donkey serum (30 min, RT) incubated overnight (4°C) with primary antibodies. After washing sections were incubated with biotinylated secondary antibodies (1:1000, 1 hr, RT) and then, after washing, with avidin–biotin-peroxidase complex (ABC, Vector Lab.) (1 hr, RT). Peroxidase activity was visualized with 0.03% DAB (Sigma) with 0.005% H2O2 in 0.05 M Tris buffer. Sections were transferred to glass slides, dehydrated in a graded ethanol series and mounted in DPX (Sigma).
For double- and triple-immunofluorescence, after blocking with 10% normal goat (or donkey) serum (30 min, RT), free-floating sections were incubated in a mixture of primary antibodies raised in different species for overnight (4°C). For visualization, Alexa Fluor-conjugated secondary antibodies were used for 1 h at RT. Fluorescent Nissl reagent (NeuroTrace 640/660 deep-red, 1:150, Molecular Probes) was applied simultaneously with secondary antibodies in cases of double-immunostaining for visualization of general histological structure.
Blocking serum, primary, secondary antibodies, and fluorescent Nissl reagent were applied in 0.2 % Triton X-100 in PBS. Sections for fluorescent microscopy were mounted on slides in Vectashield (Vector Lab). To control the specificity of immunostaining, primary antibodies were omitted and substituted with appropriate normal serum. Slides were viewed using a confocal microscope (Bio-Rad Radiance 2000, Nikon E800).
Quantitative immunohistochemical analysis
We determined the size of microtubers using the diameter of the area occupied by astrocytes with high levels of GFAP or vimentin in the images (merged from the stacks of adjacent 6 images [1024 × 1024 pixel resolution, observed area 606 × 606 μm] captured at a distance of 1 μm from each other) obtained with a confocal microscope. In cases of oval-shaped microtubers, the longest diameter was measured. The border of microtubers was considered as the point at which the immunostaining of GFAP/vimentin decreased significantly. The long processes of astrocytes were excluded in the determination of borders. Furthermore, since most tubers contained astrocytes that did not stain with anti-GS antibodies, a double immunostaining for GS and either GFAP or vimentin showed the border clearly.
The numbers of (1) giant cells (detected with GS and p-S6 immunostaining), (2) p-S6+, p44/42+, and SPARC+ astrocytes in microtubers (detected in double immunostained sections for p-S6/p44/42/SPARC and GFAP), (3) CD68- and IBA1-immunolabeled microglial cells (in microtubers in double immunostaining with GFAP, and in tuber border area in double immunostaining with GS) were quantified in the images merged from a stacks of adjacent 6 images (1024 × 1024 pixel resolution, observed area 606 × 606 μm) captured at a distance of 0.5 μm from each other. Only cells with clearly outlined nuclei were counted.
The size of a giant cells was quantified based on OD of the area occupied by the cell body immunoreactive for p-S6 and GS. In perituberal areas, the data on giant cells in microtubers and giant cells located in normal parenchyma were pooled together because we did not find significant differences between these types of cells. Images were obtained from stacks of 6 images (1024 × 1024 pixel resolution, observed area 148 × 148 μm, step 0.5 μm). Only those cells that were unequivocally indentified as giant cells (based on a large size, irregular shape, and immunostaining) were taken into consideration.
To determine the level of GS, CD68 and Iba1 immunoreactivity, optical density (OD) was measured in the area of interest (in microtubers, occupied with reactive astrocytes with high levels of GFAP) in the images prepared as above (area of observation was 295 × 295 μm) that were transferred to Adobe Photoshop, grayscaled and used for analysis of OD with Scion Image Beta 4.02 (public domain). Level of EAAT2 immunoreactivity was measured based on OD obtained from merged stacks of adjacent 6 images (1024 × 1024 pixel resolution, observed area 148 x 148 μm) captured at a distance of 0.25 μm from each other). EAAT2 and GFAP immunoreactivities correspond to different cellular compartments (cytoplasm and plasma membrane, respectively) and the surface occupied by GFAP and EAAT2 inversely correlate (more cytoplasm in the area used for analysis of OD, less plasma membranes). To determine the OD of EAAT2 we used an equation: ODEAAT2 = ODEAAT2/(SAOI − ODGFAP − ODNissl), where SAOI stands for the area of the image where OD was determined, ODGFAP and ODNissl stand for area occupied with GFAP OD and nuclei, respectively. Thus we have calculated arbitrary units, that indicate the EAAT2 OD for arbitrary units of plasma membrane.
More than 6 images were used from each case from every area of interest (perituberal area, microtubers, tubers, tuber borders) for quantification of cell number and OD.
Data are expressed as mean ± SEM. Differences in the incidence were analyzed by Chi-square test. Continuous parameters were analyzed with Student’s t-test or with one- way ANOVA where appropriate. P < 0.05 was considered significant.
Defining the borders of cortical tubers
Tuber-specific cellular abnormalities in perituberal MRI-normal tissue
Most of the observations presented in this section were obtained from MRI-normal, epileptogenic perituberal tissue (n = 10) that was dissected during surgery separately from tubers. Macroscopic tubers were never found in these samples of tissue.
Microtubers are common pathological feature of perituberal tissue
In the perituberal gray matter, giant cells were usually surrounded by fibrous-like astrocytes with long processes displaying high levels of GFAP and CD44. These small astrogliotic islands were clearly outlined from the neighboring normal parenchyma containing protoplasmic astrocytes (Figure 1a,b,c; 2). We previously designated these microscopic islands as “microtubers” , in contrast to the canonical cortical “macrotubers” detected by MRI. They were relatively homogeneous in size, with an average diameter of 284.7 ± 17.3 μm (n = 70; range: max 461.6 μm, min 158.6 μm). If we consider the shape of microtubers as roughly spherical, we estimate that one microtuber is composed, on average, of ~ 27 astrocytes and includes ~ 20 neurons.
Two types of microtubers were distinguished based on the shapes and immune profile of astrocytes. The majority (∼80%) of microtubers (which we designated as type I) contained many astrocytes with long processes that radiated for several hundred micrometers into the adjacent gray matter, which was occupied by protoplasmic astrocytes (Figure 2a,b,d). The processes of these cells were devoid of the miniature lamellipodial-like processes that are a characteristic feature of protoplasmic astrocytes. Such structural feature was especially obvious when cells were immunostained for the plasma membrane glycoprotein CD44 (Figure 2b1). A minority (~20%) of microtubers (designated type II) were largely composed of astrocytes with processes of normal length endowed with many miniature lamellipodial leaf-like extensions that produced the typical bushy-like appearance of protoplasmic astrocytes (Figure 2a,c). However, in contrast to typical protoplasmic astrocytes, these cells were CD44+ (Figure 2c). It is worth noting that some type II microtubers contained only a few (2–4 in a plane of inspection) reactive-like astrocytes neighboring a giant cell (Figure 2e).
Astrocytes in both types of microtubers were characterized by diminished immunoreactivity for glutamate transporters (EAAT2 and EAAT1) (only EAAT2 was quantified, OD, arbitrary units, 0.1 ± 0.03 in microtubers vs 0.6 ± 0.3 in surrounding normal parenchyma, p < 0.001) and for GS (OD, arbitrary units, 1199.7 ± 296.6 in microtubersvs 9874.4 ± 1321.8 in surrounding normal parenchyma, p < 0.001) (Figure 3e-g). This decrease in GS and glutamate transporters was particularly prominent in the central part of microtubers, where many neurons were surrounded by astrocytes lacking these proteins (Figure 3e-g).
Many astrocytes in microtubers showed p-S6 immunoreactivity (Figure 4a,c,d). Especially prominent p-S6 expression was observed in microtubers located in deep cortical layers (255 of 349 astrocytes in V-VI layers vs. 46 of 123 astrocytes in upper I-IV layers, p < 0.001).
To gain additional insight into the characteristics of astrocytes in microtubers, we tested activation (phosphorylation) of p44/42 MAPK (p44), which was previously shown to be activated in tubers . We found that many astrocytes in microtubers displayed a high level of p44 (Figure 4b,c). Microtubers located in deep cortical layers and in white matter contained more p44+ astrocytes than those in upper gray matter layers (56 of 121 cells in upper layers vs. 156/184 in deep layers, p < 0.001). Only a few (6/61) giant cells revealed immunoreactivity for p44 (Figure 4c). Many p44+ astrocytes were also immunopositive for p-S6 (in deep cortical microtubers ~ 80%, 214 of 305 p44+ astrocytes) (Figure 4c). Many SPARC+ astrocytes were also p-S6+ (Figure 4d).
We assayed also whether giant cells contain tumor necrosis factor alpha (TNFα), as shown previously . TNFα is a cytokine that is responsible for induction of reactive changes in astrocytes in variable brain pathologies . We found that many giant cells were TNFα+ (in microtubers 14 of 21 cells, in macrotubers 77/115, p = 0.722) (Figure 5c,d).
In perituberal tissue, in addition to giant cells in microtubers, we also found scattered giant cells surrounded by normal appearing protoplasmic astrocytes (Figure 5e,f,g). There were <1/10th as many of these isolated giant cells in comparison to giant cells within microtubers (24 versus 235 cells), and they were found predominantly in upper (I – III) cortical layers (19 of 24).
An examination of a single TSC patient’s hippocampus that had a normal MRI appearance but was resected as part of the epileptogenic zone revealed microtubers and cytomegalic neurons in Ammon’s horn (Figure 6d,e), as well as in the hilus (not shown). This further supports the idea that microtubers represent important parts of epileptogenic zones apart from tubers.
Cytomegalic neurons in perituberal tissue
Analysis of specimens stained with the pan-neuronal marker NeuN did not show any peculiar features of the neuronal population (cellular density, cytoarchitecture, aberrant cellular types) in microtubers (Figure 6f).
Cytomegalic/dysplastic neurons similar to those characteristically found in tubers were also consistently found in perituberal gray matter. These cells were morphologically identified as large cells with long processes that were immunopositive for neuronal (neurofilaments [NF], microtubule-associated proteins [MAP2], and NeuN) markers and immunonegative for giant cell markers (GS, vimentin, nestin) (Figure 6g,h). Many giant cells in perituberal tissue and tubers were also positive for NF and/or MAP2 (Figure 6i,j, shown only NF). However, in contrast to cytomegalic neurons, the NF+/MAP+ giant cells expressed astrocyte-specific markers, e.g. GS and vimentin, had a bizarre shape, and one or several, eccentrically-located nuclei.
The majority of cytomegalic (67 of 73), as well as some normal-shaped neurons, in perituberal tissue were p-S6 immunoreactive (Figure 6h). However, we did not consider this staining property to be a reliable marker of a neuronal abnormality, since many neurons in neocortical and hippocampal gray matter in samples of brains obtained from temporal lobe epilepsy and other non-epilepsy surgeries revealed high levels of p-S6 immunoreactivity (unpublished data).
It is important to note that cytomegalic neurons were not a part of perituberal microtubers (found in 0/31 microtubers examined by double staining for NF/MAP2 and GFAP). In addition, we did not observe single giant cells near cytomegalic neurons (12 giant cells and 14 cytomegalic neurons examined in double immunostains for NF/MAP2 and p-S6). We also did not detect any significant alterations in NG2 cells or oligodendrocytephenotypes in microtubers (not shown), similar to our previous analysis of tubers .
Astrocyte heterogeneity in cortical tubers
Although most tubers were composed of a homogeneous population of gliotic astrocytes, in some areas within tubers it was possible to discriminate groups of astrocytes displaying higher levels of vimentin, p-S6, and p44 than neighboring gliotic astrocytes (Figure 7b,c,d). These cells were grouped around giant cells and might correspond to microtubers with astrocytes that did not reach the “final stage of gliotic maturation” observed in neighboring highly gliotic tuber astrocytes. The average diameter of such groups was 329 ± 15.1 μm (n = 15; range: max 459.3 μm, min 236.7 μm), overlapping extensively with the dimensions of the perituberal microtubers. Indeed, these groups within tubers exceeded the average dimension of microtubers in the perituberal parenchyma by less than the size of one astrocyte domain (~100 μm, not including the area of overlapping processes from neighboring cells ).
The level of microglial activation (based on immunoreactivity for CD68 and Iba1) in these transitional areas was similar to that in tubers and significantly exceeded that of the non-gliotic areas surrounding tubers (not shown).
The consistent presence of tuber-specific abnormalities in epileptogenic MRI-normal perituberal cortex and subcortical white matter favors the thesis that brain pathology in TSC is much more widespread than is usually considered and includes other forms of pathological alterations besides the classical entities of cortical tubers, subependymal nodules, and giant cell astrocytomas [22-25]. Recent analysis of autopsied patients with TSC showed that small groups of giant cells and neurons, named ‘microtubers’, were found all over the neocortex and even in cerebellum [12,26]. Our definition of ‘microtuber’ is quite different because we include aberrant astrocytes as essential components of microtubers. Thus we have excluded isolated giant cells not surrounded with aberrant astrocytes from this definition. Widespread perituberal micropathology of clusters of giant cells and dysplastic neurons was also reported recently in a series of surgically resected TSC tissues . These pathological alterations in the human brain in TSC resemble “diffuse” changes involving the whole brain observed in animal models of TSC [28-32] and thus may diminish critiques of these models based on the absence of prominent focal loci of aberrant brain architecture.
Is perituberal tissue an epileptogenic area?
What is the functional significance of aberrant cellular elements in perituberal tissue? Do they participate in seizure initiation and/or progression? Seizure origin in TSC is the subject of much debate with several observations favoring perituberal tissue as a source of spontaneous epileptiform activity [5-9]. We found that perituberal tissue contains both microtubers and cytomegalic neurons, both of which may contribute to the epileptogenicity of this tissue. Electrophysiological analysis of tubers and cortical dysplasia has shown that only cytomegalic/dysplastic neurons revealed features of hyperexcitabilty, while giant/balloon cells were electrophysiologically silent . Cytomegalic neurons in perituberal tissue may have similar or identical properties of their tuber counterparts and thus could potentially trigger ictal events. Similarly, the aberrant astrocytes that surround giant cells in “microtubers” are characterized by markedly diminished expression of EAAT1, EAAT2, and GS, proteins important for the uptake and metabolic conversion of glutamate to glutamine within astrocytes. We have found that similar astrocytes in tubers have deficient glutamate uptake . Thus, even normal neurons located in microtubers may be predisposed to overexcitation because of the profound diminution of astrocytic glutamate clearance [35,36]. Our finding of microtubers and cytomegalic neurons in an epileptogenic hippocampal focus (Figure 6) also supports the thesis that these aberrant perituberal components might be the triggers of perituberal seizures in TSC.
Microtubers and the derivation of tuber gliotic astrocytes
Despite great progress in the molecular biology of TSC, less is known about the origin and development of phenotypic features of abnormal cell types in the TSC brain. Analysis of microtubers may help to elucidate how tuber gliotic astrocytes develop.
Cortical tubers are composed of tightly packed gliotic astrocytes that make immunohistochemical analysis of individual cell shape and properties very complicated, if possible at all. In contrast, in microtubers where cells are not so densely packed, we identified two types of astrocytes: 1) astrocytes with long, straight, main processes lacking miniature leaf-like protrusions (the majority of astrocytes) and 2) protoplasmic astrocytes revealing features of reactive cells (a minority of cells). The first, based on morphology and immune profile, are similar to the CD44+ long-process astrocytes found at the pial surface and in white matter [17,21]. We propose that the majority of gliotic tuber astrocytes are aberrant CD44+ long process/fibrous-like astrocytes that due to abnormal development appear and replace the normal protoplasmic astrocytes in gray matter. Thus, due to such aberrant development, astrocytes that usually are located in white matter and the pial surface populate the gray matter.
Although long-process astrocytes in normal gray matter were described by Ramon y Cajal , their appearance and functions in gray matter remain mysterious. It should be remarked that while the divergent development of neurons and glial cells (including astrocytes) is well studied [38,39], there is little known about the divergent origins of protoplasmic, CD44+ long process, and fibrous astrocytes.
The appearance of reactive-like astrocytes in microtubers raises critical questions about the relationship between giant cells and neighboring astrocytes. Why are giant cells often but not always surrounded by reactive protoplasmic astrocytes? What may be the cause of these reactive-like changes in astrocytes? One possibility based on our data is that giant cells may release cytokines, e.g. TNFα that promote local reactive changes in astrocytes. As is well known, TNFα is a powerful trigger of reactive changes in astrocytes .
Many astrocytes in microtubers and in tubers showed a high level of immunoreactivity for activated (phosphorylated) p44 MAPK. It should be noted that overactivation of p44 was consistently observed and considered as an important, although unexplained, mechanism in TSC-related neoplasms . p44 and mTOR pathways have close, although not completely understood, interrelations. p44 may inactivate the TSC1-TSC2 complex through phosphorylation of TSC2 ; while mTOR can provide negative (through p70 S6K1 and PI3K, ) or positive (through protein phosphatase 2A, ) feedback on p44. At this time, it remains unclear how p44 MAPK activation may be related to astrocyte changes in TSC.
The heterogeneity of the astrocyte population in microtubers and tubers shown in this study is in line with a recent detailed analysis of the glial and neuronal populations in tubers . These authors and our previous work  defined several types of aberrant astrocytes in tubers, including reactive astrocytes. Reactive changes in astrocytes, e.g. expression of p-S6 and p44, can be used as a good indicator of acute ongoing cellular alterations [19,44].
Are macrotubers built of microtubers?
Should microtubers be considered as elementary units or domains, which by consecutive aggregation create the main bodies of macrotubers? This “elementary unit” hypothesis is grounded largely on the anatomical observations: 1) rather homogeneous size of microtubers; 2) consistent association of microtubers with tuber borders; 3) appearance of microtuber-like areas with reactive astrocytes surrounding giant cells in tubers especially near their borders. We hypothesize that the CD44+ long-process astrocytes and the giant cells in individual microtubers comprise the progeny of one or more neural precursors in the embryonic ventricular zone (VZ) that have developed LOH at a TSC locus or have developed another mutation that interfere with their normal developmental program. VZ cells that remain heterozygous at the TSC 1 or 2 loci will generate normal cortical populations. Early genetic changes that give rise to large numbers of altered VZ cells may give rise to tubers, whereas late genetic changes, which give rise to one or only a few altered VZ cells may give rise to microtubers.
In this study we have focused on astrocyte changes at the perituberal border and in microtubers. This focus has allowed us to define tuber borders. It has also allowed us to define microtubers as units composed not only of giant cells but also of aberrant gliotic astrocytes which constitute and define features of macrotubers, e.g. hardness of the tubers. Such an approach provides novel insights into the cellular abnormalities in MRI normal epileptogenic perituberal tissue in TSC, and opens new perspectives to consider in the therapeutic and surgical treatment of TSC related epilepsy.
The authors thank Peter Canoll, Marisa Cotrina, Markel Olabarria-Larizgoita, and Eileen Guifoyle for discussions, valuable comments and suggestions. This research was supported by National Institutes of Health Grant NS42803 and by the Tuberous Sclerosis Alliance TSC Innovator Award.
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