Hemimegalencephaly: foetal tauopathy with mTOR hyperactivation and neuronal lipidosis

Hemimegalencephaly (HME) is a hamartomatous malformation of one cerebral hemisphere. As this is a disorder of cellular growth and lineage, we sought evidence of an early ontogenetic disturbance of microtubular assembly or function.

Three male infants with HME had brain resections for refractory epilepsy. One died postoperatively at 2.5 months and an autopsy was performed. Two were isolated cases and one has Proteus syndrome. The phosphorylated form of the microtubule-associated protein tau was studied, transmission electron microscopy (EM) was performed, and activation of the mTOR pathway was defined.

The hippocampus and neocortex of HME exhibited cytoarchitectural abnormalities and intense tau immunoreactivity. The post-mortem non-HME hemisphere exhibited sparse dysmorphic tau-reactive cortical neurones, intense only in the cingulate gyrus, a few isolated dysmorphic white matter neurons and none in subcortical structures. Numerous enlarged and dysmorphic cells exhibited P-4E-BP1 and phosphoribosomal P-S6 immunoreactivity, indicating mTOR activation. Control brains were negative for tau expression and mTOR activation. EM in each case showed abundant lipid in neurones and astrocytic end-feet on capillaries, and well-preserved mitochondria; oil red O in frozen sections and semi-thin sections also showed lipid storage by light microscopy.

Because HME tissue exhibited enhanced levels of phosphorylated tau protein and evidence of mTOR hyperactivation, we propose that the pathogenesis of HME may involve an early defect in microtubules, likely related to the AKT3 gene. Lipidosis of neurones and glia suggests metabolic impairment of yet undetermined type and relation to tauopathy in HME. Perinatal treatment of HME with everolimus theoretically is plausible.