Cell-type-informed genotyping of mosaic focal epilepsies reveals cell-autonomous and non-cell-autonomous disease-associated transcriptional programs

Recent studies demonstrate growing roles for genetic mosaicism in neurodevelopmental and neuropsychiatric disorders, with the paradigm being drug-resistant pediatric focal epilepsy related to activating somatic variants in the PI3K-mTOR pathway. While identifying the genotype-associated changes at the single-cell level is fundamental to understanding disease pathophysiology, this remains technically challenging in human tissue samples with existing methods. Here, we performed single-nucleus RNA-sequencing (snRNA-seq) of 20 focal cortical dysplasia (FCD) samples removed surgically for treatment of drug-resistant epilepsy, and 10 non-FCD controls, and we developed a new approach, Genotyping Of Transcriptomes Enhanced with Nanopore sequencing (GO-TEN), that combines targeted complementary (c)DNA sequencing with snRNA-seq to perform concurrent single-nucleus genotyping and transcriptional analysis. We find that mosaic pathogenic variants in FCD do not produce a detectable novel cell identity, but instead we observe conserved cell types present both in FCD cases and non-FCD control specimens. Similarly, GO-TEN analysis shows that most pathogenic variant-carrying cells have well-differentiated neuronal or glial identities and are enriched for layer II-III excitatory neurons. We identify cell-intrinsic disruption of glutamate and GABA-A signaling pathways in variant-carrying neurons and altered intercellular signaling, making potential mechanisms for epileptogenesis in FCD. In summary, by addressing genotype-specific changes in mosaic epilepsy-associated lesions, our study highlights new potential disease mechanisms and therapeutic targets.