4-Aminopyridine improves clinical signs in multiple sclerosis

Effect of digitalis on clinical symptoms and conduction variables in patients with multiple sclerosis

Digitalis has been shown to reverse conduction block in demyelinated nerve fibers in experimental animals. In the search for a symptomatic treatment of multiple sclerosis, digoxin (0.02 mg per kilogram of body weight) was given intravenously to 7 patients with probable or clinically definite multiple sclerosis. All of these patients had temperature-dependent symptoms. In 3 patients, improvement of clinical deficits was observed concurrent with significant changes in evoked potential findings. Digitalis derivatives may be useful in ameliorating symptoms in selected patients with multiple sclerosis.

Preliminary trial of 3,4-diaminopyridine in patients with multiple sclerosis

Ten patients with multiple sclerosis (MS) were enrolled in a preliminary trial of the potassium channel blocker, 3,4-diaminopyridine, to evaluate drug toxicity and pharmacokinetics. The patients were treated with oral 3,4-diaminopyridine, first with increasing single doses up to 100 mg and then with divided dosage for up to 3 weeks. Paresthesias were reported by all patients and abdominal pain was dose limiting in 6 patients. 3,4-Diaminopyridine levels and half-life varied widely from patient to patient. Cerebrospinal fluid levels of 3,4-diaminopyridine were about 10% of those in serum. Neither seizures nor epileptiform changes on electroencephalographic examination occurred. Small reversible improvements in specific neurological deficits were seen on examination in all patients and reversible improvement in visual evoked response latencies were found in 2 patients. These results suggest that further study of 3,4-diaminopyridine in patients with MS is warranted.

Ion channel organization of the myelinated fiber

The myelinated axon provides a model in which it is possible to examine how various types of ion channels are incorporated into a membrane to form an excitable neuronal process. The available evidence now indicates that mammalian myelinated fibers contain a repertoire of physiologically active membrane molecules including at least four types of ion channels and an electrogenic Na+,K(+)-pump. Physiological properties of myelinated fibers reflect the distribution of these various types of channels and pumps, as well as interactions with myelinating Schwann cells in the PNS or oligodendrocytes in the CNS. A growing body of data also suggests a role for astrocytes and Schwann cells at nodes of Ranvier. This article reviews the current understanding of the ion channel organization of the mammalian myelinated fiber.

Orally administered 4-aminopyridine improves clinical signs in multiple sclerosis

4-Aminopyridine (4-AP), a potassium channel blocker, restores conduction in blocked, demyelinated animal nerve. Its administration to multiple sclerosis (MS) patients produces transient neurological improvements. Vision improves after either oral or intravenous administration, whereas motor function improvement has been reported only with the latter. To assess further its potential as a practical symptomatic treatment, we studied the efficacy of single, oral doses of 4-AP on both visual and motor signs in MS. Twenty temperature-sensitive male MS patients were given either 10 to 25 mg of 4-AP or identically appearing lactose placebo capsules. Static quantitative perimetry, critical flicker-fusion, visual acuity, visual evoked potentials, and videotaped neurological examinations were monitored. All of 15 MS patients given 4-AP mildly to markedly improved. Motor functions (power, coordination, gait) improved in 9 of 13 involved, vision in 11 of 13, and oculomotor functions in 1 of 2. Improvements developed gradually at doses as low as 10 mg, usually beginning within 60 minutes after drug administration, and reversed gradually over 4 to 7 hours. No serious adverse effects occurred. No significant changes were observed in 5 MS patients given placebo. We conclude that orally administered 4-AP produces clinically important improvements in multiple, chronic deficits in MS. Further studies are warranted to assess efficacy and safety of prolonged administration.

Electrogenic pump (Na+/K(+)-ATPase) activity in rat optic nerve

Rat optic nerves were studied in a sucrose gap chamber in order to study the origin of a late afterhyperpolarization that follows repetitive activity. The results provide evidence for electrogenic pump (Na+/K(+)-ATPase) activity in central nervous system myelinated axons and demonstrate an effect on axonal excitability. Repetitive stimulation (25-200 Hz; 200-5000 ms) led to a prolonged, temperature-dependent post-train afterhyperpolarization with duration up to about 40 s. The post-train afterhyperpolarization was blocked by the Na+/K(+)-ATPase blockers strophanthidin and ouabain, and the substitution of Li+ for Na+ in the test solution, which also blocks Na+/K(+)-ATPase. The peak amplitude of the post-train afterhyperpolarization was minimally changed by the potassium-channel blocker tetraethylammonium (10 mM), and the Ca2(+)-channel blocker CoCl2 (4 mM). Hyperpolarizing constant current did not reverse the afterhyperpolarization. The amplitude of the hyperpolarization was increased in the presence of the potassium-channel blocker 4-aminopyridine (1 mM). In the presence of 4-amino-pyridine, the post-train hyperpolarization was much reduced by strophanthidin, except for a residual early component lasting several hundred milliseconds which was blocked by the potassium-channel blocker tetraethylammonium. This finding indicates that after exposure to 4-aminopyridine, repetitive stimulation leads to activation of a tetraethylammonium-sensitive K(+)-channel that contributes during the first several hundred milliseconds to the post-train afterhyperpolarization. The amplitude of the compound action potential elicited by a single submaximal stimulus during the post-train hyperpolarization was smaller than that of the control response. The decrement in amplitude was not present under identical stimulation conditions when the post-train hyperpolarization was blocked by strophanthidin, indicating that the hyperpolarization associated with repetitive stimulation reduced excitability.(ABSTRACT TRUNCATED AT 250 WORDS)

Value of hyperventilation in pattern-reversal visual evoked potentials

The effects of a standard 3 minutes' hyperventilation on the full-field pattern-reversal visual evoked potential (VEP) were studied in 33 normal subjects, 30 definite multiple sclerosis patients and in twenty-five patients with abnormal VEPs due to either tumourous compression of the anterior visual pathways or optic atrophy of other origin. Significantly greater reductions in P100 latency occurred in multiple sclerosis patients in comparison with controls (p less than 0.05). This change appeared to be specific for demyelinative type of lesion, for it was not found in cases with other types of pathology. Hyperventilation also increased the sensitivity of visual pathway impairment detection in multiple sclerosis.

Demyelination in spinal cord injury

Morphological and physiological studies demonstrate that demyelination constitutes a significant component of the pathology in compressive spinal cord injury. In many cases of spinal cord injury, a rim of demyelinated axons surrounds a central core of hemorrhagic necrosis. This provides a pathophysiological basis for "discomplete" spinal cord injuries, characterized by apparently complete transection as judged by clinical criteria, but with neurophysiological evidence of conduction through the level of damage. Recovery of conduction in demyelinated axons may permit recovery of function, and can be mediated by several mechanisms, including remyelination by oligodendrocytes or Schwann cells. Alternatively, conduction of action potentials can occur in the absence of remyelination, but this requires plasticity of the demyelinated axon. The biophysics of conduction favors recovery of electrogenesis after demyelination of small diameter axons. This may account, in part, for the observation that functional recovery is more common after demyelination of visual, compared to spinal, axons. Restoration or modification of conduction in demyelinated fibers represents an important strategy for promoting functional recovery in spinal cord injury.

Effect of digitalis on central demyelinative conduction block in vivo

In searching for agents effective in treating multiple sclerosis, we studied the effect of a short-acting digitalis, ouabain, on conduction block in an animal model of central nervous system demyelination. The electrogenic sodium/potassium pump, which digitalis specifically inhibits, is responsible for part of the resting membrane potential and also the activity-related membrane hyperpolarization following high-frequency impulses. The latter causes intermittent conduction block in demyelinated fibers. Therefore, digitalis might be expected to reverse demyelinative conduction blocks by reducing the threshold at the blocking node. Somatosensory evoked potentials were monitored in 11 rats with spinal cord demyelination before and after systemic administration of ouabain (0.1-0.6 mg or 0.21-1.58 mg/kg IP). In all rats, slowed conduction velocity of the compound action potential through the lesion was significantly reversed, and failure to transmit high-frequency impulses was improved upon. The amplitude of the cortical somatosensory evoked potentials also increased significantly. Digitalis is a promising therapeutic agent for trial in patients with multiple sclerosis.

Comparison of vestibular and auditory startle responses in the rat and cat

Cats, humans, and many other animals show stereotyped EMG responses in limb and axial muscles if suddenly dropped into free-fall. In cats, these free-fall responses (FFR) consist of highly synchronized bursts in most limb and axial muscles at 18-22 ms. We have used FFR to evaluate descending motor function and recovery in chronic spinal injured cats. Here FFR are compared with auditory evoked startle reflexes (ASR) in the hindlimb muscles of the rat and cat to determine whether they are related, and whether they could be used to evaluate descending motor function in the rat. ASR and FFR in the two species were similar except that the earliest components for both responses occurred around 9 ms in the rat versus 18-20 ms in the cat. Also, FFR in cats were usually more consistent and greater in amplitude during repeated drops than in rats, while the converse was true for ASR. Rat FFR amplitudes increased significantly after administering ketamine or 4-aminopyridine (4-AP), especially with both drugs together, while ASR amplitudes did not. FFR in cats recorded under ketamine analgesia were not normally improved by 4-AP. Finally, both FFR and ASR were suppressed by pentobarbital, chloralose, or motor activity. These data suggest that: (1) FFR appears to be a vestibular evoked startle reflex; (2) in the rat, ASR should be useful as a test of descending motor function following spinal injury, and (3) the combination of ketamine and 4-AP may be useful in revealing the presence of functional spinal pathways after CNS trauma.

Effect of 4-aminopyridine on axonal conduction-block in chronic spinal cord injury

The spinal cords of 18 anesthetized cats were injured by standardized contusion. The animals were maintained for 4-16 months, then the thoracic spinal cord was isolated in vitro at 25 degrees C. Microelectrode recordings were made from single axons conducting through the lesion in ventral and lateral tracts. On warming the tissue, action potential conduction was found to block at temperatures below 36 degrees C in 29% of 129 axons tested. Of 17 axons in which it was possible to demonstrate a block below physiological temperature, apply 0.1-1 mM 4-AP, wait for 10 min and test conduction again, 7 showed increases in blocking temperature and 4 of these restored to conduction above 37 degrees C. The other 10 fibers showed no improvement in blocking temperature. 4-AP also increased the spontaneous activity of axons. It was concluded that 4-AP may eventually be useful in chronic spinal cord injuries, because it improves safety factor in some axons and increases excitability in others, which may compensate to some extent for the reduction in density of projections through the lesion.

Augmentation by 4-aminopyridine of vestibulospinal free fall responses in chronic spinal-injured cats

This study examines the effect of the potassium channel blocker 4-aminopyridine (4-AP) on free fall responses (FFR) in the hindlimb muscles of chronically spinal injured cats. The thoracic spinal cord of 7 adult female cats was injured by a standardized contusion method. At 3-7 months post-injury the FFR in 6 hindlimb muscles was recorded electromyographically in each animal, under ketamine sedation. The normal short-latency response to a sudden drop was severely attenuated in all injured animals and practically undetectable in 2 cases. Within 15 min following intravenous administration of 1 mg/kg 4-AP, there was profound augmentation of the amplitude of the FFR and a tendency toward normalization of latency in all animals, though the normal amplitude range was not attained. The same 4-AP dose produced a relatively small increase of FFR amplitude in only 2 of 4 normal, uninjured animals tested. The data are consistent with previous observations that low doses of 4-AP restore conduction in some critically demyelinated axons, and provide support for the hypothesis that conduction block in surviving axons is responsible for a proportion of the dysfunction in chronic spinal injury. Augmentation of FFR in injured animals may also result partly from increased transmitter release in both spinal cord and periphery, due to the presynaptic effects of 4-AP.

Physiological effects of 4-aminopyridine on demyelinated mammalian motor and sensory fibers

The selective response of demyelinated sensory fibers to 4-aminopyridine (4-AP) has been proposed as a mechanism underlying the reported paresthesias that complicate the use of this potassium-channel blocking agent in clinical trials for the treatment of multiple sclerosis and neuromuscular disorders. To identify differences in the electrophysiological response of specific fiber types to the application of 4-AP, rat ventral and dorsal spinal roots, demyelinated by intrathecal injections of lysophosphatidylcholine, were examined in vitro before and during potassium-channel blockade. The compound action potentials of demyelinated ventral roots showed a prominent postspike negativity associated with a broadening of single action potentials following application of 4-AP. Under similar conditions, whole root responses of demyelinated dorsal root axons also developed a late negativity, but individual fibers were observed to fire repetitively in response to a single stimulus. The data support the hypothesis that the prominent sensory dysfunctions reported in clinical trials of 4-AP are due to the selective response characteristics of sensory fibers.

Amantadine restores impulse conduction across demyelinated nerve segments

1. Drugs can be identified that relieve clinical symptoms of demyelinating diseases such as multiple sclerosis based on their ability to alter voltage-dependent ion channels in membranes and restore conduction in demyelinated nerve. Beneficial drugs either slow inactivation of membrane Na+ channels or block K+ channels. 2. Amantadine, an antiviral drug that slows Na+ inactivation in Myxicola giant axons, restores conduction in frog and rat sciatic nerves partially demyelinated by disruption of the perineurium (the 'perineurial window') loose ligatures, or lysolecithin. 3. A positive effect of amantadine on several different animal models supports the need for clinically oriented studies of amantadine and related inactivation-blocking agents in diseases such as multiple sclerosis.