Polymicrogyria of the Unilateral Temporal Lobe in a Transsexual Patient—Case Report

doi:10.4236/nm.2013.44037

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Neuroscience & Medicine, 2013, 4, 263-266

Published Online December 2013 (http://www.scirp.org/journal/nm)

http://dx.doi.org/10.4236/nm.2013.44037

Open Access NM

263

Polymicrogyria of the Unilateral Temporal Lobe in a

Transsexual Patient—Case Report

Ana Starcevic1, Dusica Markovic Zigic2, Branislav Filipovic1

1Institute of Anatomy “Niko Miljanic”, Faculty of Medicine, University of Belgrade, Belgrade, Serbia; 2Psychiatry Hospital, Clinical

Center Dedinje “Dr Dragisa Misovic”, Belgrade, Serbia.

Email: [email protected]

Received April 19th, 2013; revised May 18th, 2013; accepted June 14th, 2013

which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Introduction: Polymicrogyria, the appearance of irregular small and over numbered gyri on the surface of the brain,

has been reported as the most frequent finding, when exists, on the temporal lobe. Case Presentation: A patient, male,

age of 35, came to the regular head and brain MRI scan due to psychiatric and hormonal treatment within transsexu al-

ism. There were no data of epilepsy in a patient’s history. MRI scans were acquired with a 1.5 T Siemens Magnetom

system with a standard head coil. Three-dimensional 3D RAGE, contiguous 1.0 mm slice, and 1 acquisition sequence

underwent final 3D rendering and subsequent volumetry. On the definitive 3D image, we have rev ealed an unusual gy-

risation on the left temporal lobe which had a picture of partial polymicrogyria. Conclusion: This is a unique finding, to

our knowledge, of the unilateral temporal polymicrogyria in a person with transsexualism. Although polymicrogyria is

mostly related to epileptifom attacks, its impact on the transsexualism appearance is opened to be examined.

Keywords: Transsexualism; Polymicrogyria; MRI

1. Introduction

Transsexuality is characterized by a strong conviction of

having been born in the wrong body and is also consid-

ered to be the extreme end of the spectrum of gender

identity disorders characterized by a pursuit of sex reas-

signment surgery [1]. Transsexuals experience them-

selves as being of the opposite sex, despite having the

biological characteristics of one sex. There can be seen a

strong psychological rejection of the actual body. Fe-

male-to-male transsexuals and male-to-female transsexu-

als are characterized by persistent male or female identi-

fication and constant feeling of being trapped in the

wrong body, which is seems to be their permanent kind

of a obsessive thought and final life goal as gender iden-

tification is the basic human psychological characteris-

tics.

There might be many factors that can influence the

development of this disorder and it has been implicated

that genetic, hormonal and psychological factors are the

most dominant. There is also a fact that there must be a

morphological substrate like in every disorder that serves

like a base or material for development of the disorder.

Polymicrogyria is one of the most common malforma-

tions of cortical development. It is often associated with

specific syndromes, and has a wide variety of clinical

presentation [2-4]. It is considered to be a cortical mal-

formation development in which normal process of cor-

tical development is somehow stopped by different fac-

tors. Some of them are defined in the late stage of neu-

ronal migration or in the early stage of neuronal organi-

sation [4,5]. Polymicrogyria is a malformation with many

faces, so it is of major significance to have that in mind

when examing the MRI scans. It is mostly related to epi-

leptic attacks, and its impact on the transsexualism ap-

pearance is opened to be examined.

2. Case Presentation

Our patient is male to female transsexual, thirty five

years of age. He was reported to Counsiling Service for

Sexual and Gender Identity Disorder. During the inter-

view, he gave data on feeling different since childhood as

a female trapped in a male body. He mentioned he liked

to play more with h is girlfriends and felt like he is one of

them. It was at the age of four. His mother thought it was

Polymicrogyria of the Unilateral Temporal Lobe in a Transsexual Pa ti en t—Case Report

264

a transit stage of childhood.

The patient went through regular psychological and

neurological examination. His psychical and neurological

status showed no symptoms and no signs of epilepsy or

any other associated disease. He is left handed and has no

data of drug history. This is an unoperated patient, un-

treated by hormone therapy. He is currently undergoing

real life test under occasional psychiatric supervision and

support. He has two children from two marriages, eight

years old son and three months old daughter. The patient

is bacheleor in electric sciences, working two jobs which

are not in his field of professional interest.

There were some problems during his first marriage.

He had difficulties in expressing his true feeling. A

chance to express his true feeling was given in the pre-

sent marriage. Nevertheless, he is still submitted to occa-

sional psychological torture by his ex wife who consi-

ders him as a monster. On the other hand he found very

big support in his present wife who accepted his condi-

tion.

In the course of diagnostic and scientific evaluation,

MRI brain scan w as performed. During th e procedure an

unusual gyrisation of the left temporal lobe was revealed.

That was considered to be partial polymicrogyria.

MRI exams were performed on SIEMENS AVANTO

TIM 1.5 T (SIEMENS, Erlangen, Germany) using 3-

DFLAIR (TR/TI/TE = 6000/2200/300 ms) and MPRAGE

(TR/TE = 2000/5 ms) sequences.

Slice thickness in former case was 1 mm (no gap),

while in latter cases images with same thickness were

obtained with post-reconstruction from 1 mm sagittal

MR scans. After completion of examination, MR images

were transferred to personal computer and processed

using MIPAV software package (National Institute of

Health, Bethesda, USA). Separation of brain tissue from

surrounding structures on sagittal 3DFLAIR and

MPRAGE images and brain volume estimation was per-

formed using Brain extraction tool (BET). Rendering

procedure was used to generate 3D view of brain surface.

Estimation (i.e. segmentation) of gray and white matter

volumes was performed using fuzzy means algorithm

implemented in MIPAV.

We noted peculiar shape of the Sylvian fissure on the

polymicrogyric hemisphere with the absence of ascend-

ing branch (Figure 1). The posterior branch is inter-

rupted and terminates at the level of the preoccipital

notch (Figure 2). The cause of interruption is polymi-

crogyria in the parietotemporal region (Figure 3).

Brain segmentation showed difference in white matter

volume but not in grey volume. There were no differ-

ences in estimated brain volume.

3. Discussion

Although public awareness is dramatically increased in

past few decades, our scientific understanding and ex-

planation of gender iden tity disorder is still very poor and

pretty limited. The factors can be different, but we can

determine on genetic, endocrine or hormonal or psycho-

social [6-8].

There is an impressive data gathered predominantly

from laboratory animals, of the influence of gonadal

steroid hormones on the prenatal or perinatal sexual dif-

ferentiation of the brain. Studies in humans have shown

that levels of circulating sex steroids and estrogen feed-

back on luteinizing hormone do not differ between

transsexuals and controls [9-11]. Testicular hormones

also play very important ro le in the sexual differen tiation

Figure 1. Three different MRI aspect show specific region of parieto-temporal lobe with a peculiar shape of the Sylvian fis-

sure on the polymicrogyric hemisphere with the absence of ascending branch.

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Polymicrogyria of the Unilateral Temporal Lobe in a Transsexual Pa ti en t— Case Report 265

Figure 2. 3D FLAIR-parasagittal view of affected parieto-

temporal region; posterior branch is interrupted and ter-

minates at the level of the preoccipital notc h.

Figure 3. 3D FLAIR-axial view of affected parietotemporal

region; the cause of interruption is polymicrogyria in the

parietotemporal region.

of the genitalia. Follow up studies of the patients with

clinical syndromes in which the hormonal environment

of the fetus has been atypical, have provided data on

possible effects of prenatal sex steroids on sexual orien-

tation and gender role stereotypes [12-14].

Behaviorists state that an infant’s mind is a blank slate

upon which social factors and conditioning act to pro-

duce all aspects of personality, including gender [7]. This

belief takes the form of an axiom in their works and that

is a basic assumption not based in evidence but upon

which they derive results.

Sexual brain differentiation through embryonic devel-

opment deviates from the sexual differentiation of the

rest of the body [5] and that is why we state that neuro-

anatomy plays a critical role in determining gender iden-

tity and can help us in identifying underlying mecha-

nisms of transsexualism.

The human brain differentiates early in development

both structurally and functionally in a sexually dimorphic

way [15] which leads to the fact that transsexualism is a

sexual differentiation disorder of the sex dimorphic brain

[13]. There are a number of different studies that exam-

ined brain structure and their correlate to this gender

identity disorder [16]. Some of them are postmortem

studies, which revieled anatomical supstrates which are

sexually dimorphic like bed nucleus of stria terminalis

[5], INAH3 [17] and number of neurons [18]. There were

also data presented on brain assymetry and cortical cy-

toarchitectonics areas which were included in Fmri ex-

amination in transsexuals.

Resent advances in imaging have shown that po-

lymicrogyria have many apperiances on MRI imaging

which leads us to conclusion that is apperently more

various malformation than described before. It is often

associated with specific syndromes [19-22]. It is very

common seen in epilepsy. Our patient did not give us

data on epilepsy or any other clinical syndrome that can

ocure in transsexualism. Development of cerebral cortex

is so complex that it is no suprising that disruptions of

the processes of late cortical migration and cortical or-

ganisation at different stages might result in slightly dif-

ferent malformations and different clinical implications

and manifestations, even within transsexualism. The ap-

periance can be shown like small and very delicate gyri

or thick and irregulary, bumpy [4,23]. The cortex can also

have an apperiance of palisade. There are number of fac-

tors that can tribute to this cond ition, bu t we take stage of

maturity or myelination of the brain like one of the most

affective because the degree of myelination affects the

apperance. In unmyelinated regions the inner surface of

the polymicrogyric cortex looks thin and pretty bumpy,

while in myleinated areas it looks thicker and smoother.

Polymicrogyria is a malformation with many faces so it

is of major significance to have that in mind when ex-

aming the MRI scans.

All mentioned genetic, hormonal and psychosocial

factors cannot influence independetly, but yes predomi-

nantly by each in specific conditions. United influence

can tribute to the development of transsexualism.

The exact underlying mechanisms and determinants

remain to be established in future work, where interplay

between genetic determination, hormonal exposure, and

environment is very likely.

4. Conclusion

This is a first case, to our knowladge, which dealt with

polymicrogyria, and which was revealed in a transsexual

patient. There is no other brain abnormality or disfunc-

tion obtained in this patient. Although there is no evi-

dence of the polymicrogyria to influence the appearance

of transsexuality, further investigations ought to lead to

the detection of possible brain abnormalities of any kind

of MRI scans of the transsexuals.

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