The genetic landscape and classification of infantile epileptic spasms syndrome requiring surgery due to suspected focal brain malformations

Infantile epileptic spasms syndrome is a severe epilepsy of infancy that is often associated with focal malformations of cortical development. This study aimed to elucidate the genetic landscape and histopathologic aetiologies of infantile epileptic spasms syndrome due to focal malformations of cortical development requiring surgery. Fifty-nine children with a history of infantile epileptic spasms syndrome and focal malformations of cortical development on MRI were studied. Genetic testing of resected brain tissue was performed by high-coverage targeted panel sequencing or exome sequencing. Histopathology and MRI were reviewed, and integrated clinico-pathological diagnoses were established. A genetic diagnosis was achieved in 47 children (80% of cohort). Germline pathogenic variants were identified in 27/59 (46%) children, in <i>TSC2</i> (x19), <i>DEPDC5</i> (x2), <i>CDKL5</i> (x2), <i>NPRL3</i> (x1), <i>FGFR1</i> (x1), <i>TSC1</i> (x1), and one child with both a <i>TUBB2A</i>/<i>TUBB2B</i> deletion and a pathogenic variant in <i>COL4A1</i> (x1). Pathogenic brain somatic variants were identified in 21/59 (36%) children, in <i>SLC35A2</i> (x9), <i>PIK3CA</i> (x3), <i>AKT3</i> (x2), <i>TSC2</i> (x2), <i>MTOR</i> (x2), <i>OFD1</i> (x1), <i>TSC1</i> (x1) and <i>DEPDC5</i> (x1). One child had 'two-hit' diagnosis, with both germline and somatic pathogenic <i>DEPDC5</i> variants in trans. Multimodal data integration resulted in clinical diagnostic reclassifications in 24% of children, emphasizing the importance of combining genetic, histopathologic and imaging findings. Mammalian target of rapamycin pathway variants were identified in most children with tuberous sclerosis or focal cortical dysplasia type II. All nine children with somatic <i>SLC35A2</i> variants in brain were reclassified to mild malformation of cortical development with oligodendroglial hyperplasia in epilepsy. Somatic mosaicism was a major cause of focal cortical dysplasia type II/hemimegalencephaly (81%) and mild malformation of cortical development with oligodendroglial hyperplasia (100%). The genetic landscape of infantile epileptic spasms syndrome due to focal malformations comprises germline and somatic variants in a range of genes, with mTORopathies and <i>SLC35A2</i>-related mild malformation of cortical development with oligodendroglial hyperplasia being the major causes. Multimodal data integration incorporating genetic data aids in optimizing diagnostic pathways and can guide surgical decision-making and inform future research and therapeutic interventions.