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Teaching NeuroImages: Homotopic motor distribution on fMRI in closed-lip schizencephaly

A 16-year-old boy with intractable focal epilepsy with preserved awareness and attention-deficit/hyperactivity disorder underwent evaluation for epilepsy surgery. Epilepsy onset occurred at age 5 years; seizures arise from sleep and are characterized by right arm extension with preserved consciousness. Ictal EEG has no clear localization or lateralization. MRI brain demonstrates bifrontal closed-lip schizencephaly. Functional MRI (fMRI) shows homotopic distribution of tongue/finger/foot motor function at the edge of and along the depth of the schizencephalic cleft, supported by intracranial mapping (figures 1 and 2). fMRI is a reliable tool to identify the eloquent cortex in the planning for epilepsy surgery.1,2