Animal models of intractable epilepsy

Multidrug resistance-associated protein is involved in the regulation of extracellular levels of phenytoin in the brain

The mechanisms that lead to drug resistance in epilepsy are not known. Recently, overexpression of multidrug transporters, such as multidrug resistance-associated protein (MRP), has been reported in surgically resected epileptogenic human brain tissue and suggested to contribute to the drug resistance of epilepsy. However, it is not known to what extent multidrug transporters such as MRP are involved in transport of antiepileptic drugs. In the present study, we used in vivo microdialysis in rats to study whether the concentration of phenytoin in the extracellular fluid of the cerebral cortex can be enhanced by inhibition of MRP, using the MRP inhibitor probenecid. Local perfusion with probenecid via the microdialysis probe significantly enhanced the extracellular concentration of phenytoin. The data indicate that MRP critically participates in the regulation of extracellular brain concentrations of the major antiepileptic drug phenytoin.

Lowering of the potassium concentration induces epileptiform activity in guinea-pig hippocampal slices

Extra- and intracellular recording techniques were used to study the epileptiform activity generated by guinea-pig hippocampal slices perfused with low potassium containing artificial cerebrospinal fluid. Extracellular field potentials were recorded in CA1 and CA3 regions along with intracellular recordings in CA3 subfield. Reduction of the extracellular potassium concentration [K(+)](o) from 4 to 2 mM caused a transient neuronal hyperpolarisation which was followed by a repolarisation and subsequent depolarisation period. Paroxysmal depolarisation shifts occurred during the transient hyperpolarisation period while epileptic field potentials (EFP) appeared in the late repolarisation or early depolarisation phase. EFP elicited by reduction of [K(+)](o) were neither affected by blockade of N-methyl-D-aspartate (NMDA) glutamate-subreceptor or gamma aminobutyric acid receptor, nor by application of the organic calcium channel blocker nifedipine or the anticonvulsant drugs carbamazepine and valproic acid. Upon application of non-NMDA glutamate-subreceptor blocker the EFP were abolished in all trials, while application of the organic calcium channel blocker verapamil only suppressed the EFP in some cases. The results point to a novel mechanism of epileptogenesis and may provide an in vitro model for the development of new drugs against difficult-to-treat epilepsy.

Overview of the Current Animal Models for Human Seizure and Epileptic Disorders

A diversity of animal models are available for the study of epilepsy and these models have a proven history in advancing our understanding of basic mechanisms underlying epileptogenesis and have been instrumental in the screening of novel antiepileptic drugs. This review addresses the criteria that should be met in a valid animal model and provides an overview of current animal models that are relevant to human conditions. In addition, models not specific for any one human condition but rather exhibiting partial or generalized seizures are discussed. While most human disorders are without any animal model, those models that are clinically relevant have strengths and weaknesses. Finally, although few relevant, well-characterized animal models have been added to the list over recent years, major advancements in molecular genetics are contributing to the discovery of novel pathways involved in epileptogenesis.

A spontaneous recurrent seizure-related Rattus NSF gene identified by linker capture subtraction

Spontaneous recurrent seizures (SRS) are the major clinical characteristic of epilepsy. In this study, using a SRS-behavior test combined with linker capture subtraction (LCS) to identify genes altered in their expression in response to a single kainic acid (KA)-induced SRS at 3 weeks in the rat hippocampal formation. Dot blot analysis of the differentially expressed cDNA fragments with LCS showed the down-regulation of one cDNA related to SRS, which was designated epilepsy-related gene 1 (ERG1). Northern blot analysis showed that ERG1 mRNA was reduced by KA administration with and without SRS, but more so with SRS. This differential expression had also been confirmed by in situ hybridization, which showed that ERG1 mRNA was down-regulated in the dorsal dentate granule cells (dDGCs) of the hippocampal formation, but remarkable up-regulated in the amygdalohippocampal area (AHi), posteromedial cortical amygdaloid nucleus (PMCo) and perirhinal cortex (PRh). The complete cDNA of ERG1 was cloned, sequenced (AF142097). It encodes a Rattus homologue of N-ethylmaleimide-sensitive fusion protein (NSF), which is an ATPase that plays a key role in mediating docking and/or fusion of transport vesicles in the multi-step pathways of vesicular transport. Sequence analysis revealed that ERG1 has high sequence similarity with the cDNA of the Mus musculus suppressor of K(+) transport growth defect (SKD2), N-ethylmaleimide(NEM)-sensitive fusion protein of Chinese hamster and human NEM-sensitive factor (HSU03985).

Selection of antiepileptic drug polytherapy based on mechanisms of action: the evidence reviewed

PURPOSE

When monotherapy with antiepileptic drugs (AEDs) fails, combination therapy is tried in an attempt to improve effectiveness by improving efficacy, tolerability, or both. We reviewed the available studies (both animal and human) on AED polytherapy to determine whether AEDs can be selected for combination therapy based on their mechanisms of action, and if so, which combinations are associated with increased effectiveness. Because various designs and methods of analysis were used in these studies, it was also necessary to evaluate the appropriateness of these approaches.

METHODS

Published papers reporting on AED polytherapy in animals or humans were identified by Medline search and by checking references cited in these papers.

RESULTS

Thirty-nine papers were identified reporting on two-drug AED combinations. Several combinations were reported to offer improved effectiveness, but no uniform approach was used in either animal or human studies for the evaluation of pharmacodynamic drug interactions; efficacy was often the only end point.

CONCLUSIONS

There is evidence that AED polytherapy based on mechanisms of action may enhance effectiveness. In particular, combining a sodium channel blocker with a drug enhancing GABAergic inhibition appears to be advantageous. Combining two GABA mimetic drugs or combining an AMPA antagonist with an NMDA antagonist may enhance efficacy, but tolerability is sometimes reduced. Combining two sodium channel blockers seems less promising. However, given the incomplete knowledge of the pathophysiology of seizures and indeed of the exact mechanisms of action of AEDs, an empirical but rational approach for evaluating AED combinations is of fundamental importance. This would involve appropriate testing of all possible combinations in animal models and subsequent evaluation of advantageous combinations in clinical trials. Testing procedures in animals should include the isobologram method, and the concept of drug load should be the basis of studies in patients with epilepsy.

The new antiepileptic drugs lamotrigine and felbamate are effective in phenytoin-resistant kindled rats

We evaluated the anticonvulsant efficacy of the antiepileptic drugs (AEDs) lamotrigine (LTG) and felbamate (FBM) in amygdala kindled rats that had been preselected with respect to their response to phenytoin. Anticonvulsant response was tested by determining the afterdischarge threshold (ADT), i.e., a sensitive measure for drug effects on focal seizure activity. By repeated testing with the phenytoin prodrug fosphenytoin, 3 groups of kindled rats were separated: rats in which consistent anticonvulsant effects were obtained (phenytoin responders), rats which showed no anticonvulsant response (phenytoin nonresponders), and rats with variable responses (variable phenytoin responders). The latter, largest group was used to evaluate at which doses LTG and FBM exerted significant anticonvulsant effects on ADT 1 h after i.p. drug administration. Effective doses were then used for drug testing in phenytoin responders and nonresponders. Both LTG and FBM proved to be effective anticonvulsant drugs in the kindling model by markedly increasing the ADT. Seizure severity and duration recorded at ADT currents were hardly reduced, indicating that both drugs predominantly affect induction of focal seizures and not seizure spread from the focus. In phenytoin nonresponders, LTG and FBM significantly increased ADT, which is in line with their proven efficacy in patients with refractory partial epilepsy in whom phenytoin has failed. However, LTG and, more markedly, FBM were clearly more efficacious in increasing ADT in phenytoin responders than in nonresponders, substantiating that the difference in phenytoin response between these groups of kindled rats extends to other AEDs. The data in this study reveal that phenytoin nonresponders are a unique model for the search for new AEDs with improved efficacy in refractory partial epilepsy.

Spike doublets in neurons of the lateral amygdala: mechanisms and contribution to rhythmic activity

A majority of projection neurons in the lateral amygdala generate oscillatory spike firing in the theta-frequency range, largely due to intrinsic membrane properties. Here we report on the occurrence of spike doublets in about 70% of these cells. Spike doublets consisted of a fast initial and a second slower component, which were mediated by sodium- and calcium-dependent mechanisms, respectively. With increased level of depolarization, there was a gradual transition of fast action potentials, regular alternation of fast action potentials and spike doublets, regular spike doublets, and high-threshold oscillations. Fast Fourier transforms demonstrated the rhythmic nature of spike doublets at around 3 Hz with an intra-doublet frequency of 25-80 Hz. Spike doublets may thus contribute to the overall rhythmicity in the membrane potential patterns of projection cells and support the integration of synaptic input signals.

Anticonvulsant efficacy of gabapentin and levetiracetam in phenytoin-resistant kindled rats

We evaluated the anticonvulsant efficacy of the new antiepileptic drugs (AEDs) gabapentin and levetiracetam in amygdala kindled rats that had been preselected with respect to their response to phenytoin. Anticonvulsant response was tested by determining the afterdischarge threshold (ADT), i.e. a sensitive measure for drug effects on focal seizure activity. By repeated testing with the phenytoin prodrug fosphenytoin, three groups of kindled rats were separated: rats in which consistent anticonvulsant effects were obtained (phenytoin responders), rats which showed no anticonvulsant response (phenytoin nonresponders), and rats with variable responses (variable phenytoin responders). The latter, largest group was used to evaluate at which doses gabapentin and levetiracetam exerted significant anticonvulsant effects on ADT 1 h after i.p. drug administration. Effective doses were then used for drug testing in phenytoin responders and nonresponders. Both gabapentin and levetiracetam proved to be effective anticonvulsant drugs in the kindling model by significantly increasing the ADT. In addition, both drugs markedly decreased seizure severity recorded at ADT currents, indicating that these drugs affect seizure threshold in the epileptic focus and seizure spread from the focus in the kindling model. When the threshold for secondary generalized seizures (GST) was determined in addition to ADT, gabapentin and levetiracetam strikingly increased this threshold compared to predrug control. In phenytoin nonresponders, gabapentin and levetiracetam significantly increased ADT and GST, which is in line with their proven efficacy in patients with refractory partial epilepsy in whom older AEDs have failed. In phenytoin responders, gabapentin tended to be more efficacious in increasing ADT and GST than in nonresponders, substantiating that the difference between these groups of kindled rats extends to other AEDs. In contrast to gabapentin, levetiracetam was more efficacious in increasing ADT in nonresponders than in responders. The data of this study substantiate that phenytoin nonresponders are a unique model for the search of new AEDs with improved efficacy in refractory partial epilepsy.

Kindling alters the anticonvulsant efficacy of phenytoin in Wistar rats

We have previously shown that subgroups can be selected from large groups of amygdala kindled Wistar rats which either respond consistently or do not respond to the anticonvulsant effect of phenytoin. Phenytoin nonresponders were proposed as a model for pharmaco-resistant temporal lobe epilepsy. In the present study we examined whether the differences of individual rats in response to phenytoin are already present before kindling or are a consequence of kindling. For this purpose, 52 rats were once tested with phenytoin, then kindled, and then repeatedly tested with phenytoin for selection of subgroups. For subgroup selection after kindling, the phenytoin prodrug fosphenytoin was used because of its water solubility and its improved tolerability and absorption after i.p. administration in rats. Before kindling, phenytoin significantly increased the afterdischarge threshold (ADT), i.e. a sensitive measure of focal seizure activity, but there was large individual variation with only 32 of the 52 rats reacting with an ADT increase, while the remaining rats showed either no effect or ADT decreases. After kindling, the selection resulted in 16 rats with consistent ADT increases in response to phenytoin and ten nonresponders (the remaining 26 rats showed variable responses). Unexpectedly, in rats which were responders after kindling, phenytoin exerted no significant anticonvulsant effect before kindling, while kindled nonresponders were very sensitive to phenytoin before kindling, indicating that the kindling process was responsible for the loss of anticonvulsant efficacy in kindled nonresponders and the development of phenytoin's efficacy in kindled responders. The present results substantiate that kindled subgroups of Wistar rats with different response to phenytoin are a valuable source for studying the mechanisms underlying the development of pharmaco-resistant limbic seizures.

Anticonvulsant efficacy of topiramate in phenytoin-resistant kindled rats

PURPOSE

We evaluated the anticonvulsant efficacy of topiramate (TPM), a structurally novel antiepileptic drug (AED), in amygdala kindled rats that had been preselected with respect to their response to phenytoin (PHT).

METHODS

Anticonvulsant response was tested by determining the afterdischarge threshold (ADT; i.e., a sensitive measure for drug effects on focal seizure activity). By repeated testing with the PHT prodrug fosphenytoin (FOS) three groups of kindled rats were separated: rats in which consistent anticonvulsant effects were obtained (PHT responders), rats that showed no anticonvulsant response (PHT nonresponders), and rats with variable responses (variable PHT responders). The latter, largest group was used to evaluate at which doses and pretreatment times TPM exerted significant anticonvulsant effects on ADT. For this purpose, TPM was tested at four doses (20, 40, 80, 160 mg/kg i.p.) and two pretreatment times (1 and 4 h). The most effective treatment protocol was then used for TPM testing in PHT responders and nonresponders.

RESULTS

TPM proved to be an effective AED in the kindling model. At 40 mg/kg, significant ADT increases were obtained after both 1 and 4 h after administration. In addition to the effect on focal seizure threshold, seizure severity and duration recorded at ADT were decreased by TPM, indicating that this drug acts on both seizure threshold and seizure spread. In PHT nonresponders, TPM significantly increased ADT, which is in line with its proven efficacy in patients with refractory partial epilepsy in whom phenytoin has failed. However, TPM was more efficacious in increasing ADT in PHT responders than in nonresponders, substantiating that the difference between these groups of kindled rats extends to other AEDs. Repeated testing of kindled rats with TPM indicated that, similar to PHT, there are individual kindled rats without anticonvulsant response to TPM (i.e., TPM nonresponders).

CONCLUSIONS

The data of this study substantiate that PHT nonresponders are a unique model for the search of new AEDs with improved efficacy in refractory partial epilepsy.

Spatio-temporal profile of DNA fragmentation and its relationship to patterns of epileptiform activity following focally evoked limbic seizures

The specific electrographic activity responsible for seizure-induced DNA damage remains little explored. We therefore examined the regional and temporal appearance of DNA fragmentation and cell death and its relationship to specific electrographic seizure patterns in a rat model of focally evoked limbic epilepsy. Animals received intra-amygdaloid injection of kainic acid (KA) to induce seizures for 45 min during continuous electroencephalographic (EEG) monitoring, after which diazepam (30 mg/kg) was administered. DNA polymerase I-mediated biotin-dATP nick translation (PANT) and terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling (TUNEL) were used to detect single- and double-stranded DNA breaks, respectively. Injection of 0.01 microg KA induced seizures characterized by ictal fast activity but without consequent brain injury. By contrast, 0.1 microg KA induced an additional pattern of seizure activity characterized by bursts of high frequency polyspike paroxysmal discharges. In these animals, there was a significant reduction in numbers of pyramidal neurons within the ipsilateral and contralateral CA3 subfield of the hippocampus, detectable as little as 4 h following seizures. PANT- and TUNEL-positive cells appeared in similar numbers 16 h following seizure cessation within the CA3, declining after 72-96 h. Varying the duration of polyspike paroxysmal discharges determined that as little as 30 s elicited maximal injury. These data suggest single- and double-stranded DNA breaks are generated during the cell death process and are consequent on a specific component of seizure activity electrographically determined.

Development of kindling and spontaneous seizures after massed stimulation of different loci in the rat piriform cortex

Massed electrical stimulation of the anterior piriform cortex (PC) in rats using short (5 min) interstimulus intervals has previously been reported to induce severe chronic epilepsy with spontaneous seizures and has thus proposed to represent a novel model of temporal lobe epilepsy. In the present study, we used this stimulation protocol to evaluate the frequency and severity of recurrent spontaneous seizures produced in this way. In addition to the locus in the anterior PC previously used for massed stimulation (MS), we also stimulated rats via a locus in the transition zone between anterior and posterior PC ("central PC"), which previously was found to be more sensitive to electrical stimulation than various other loci in the anterior or posterior PC. During MS (71 stimulations for 1 s each at twice afterdischarge threshold), focal and infrequent secondary generalized seizures occurred in both groups, but there was no consistent progressive increase in seizure severity with increasing number of seizures, possibly as a result of postictal inhibitory processes. Following MS, rats were restimulated after 1, 2, 4, and 7 weeks, using five stimuli at 5-min interstimulus periods at each retest period. In both PC-implanted groups, seizure severity and seizure duration progressively increased over the period of the retests, indicating a delayed development of kindling. Spontaneous seizures were only observed rarely, so that MS of the PC is certainly no effective means of producing recurrent spontaneous seizures.

A new model of chronic temporal lobe epilepsy induced by electrical stimulation of the amygdala in rat

Spontaneous seizures are the hallmark of human epilepsy but they do not occur in most of the epilepsy models that are used to investigate the mechanisms of epilepsy or to test new antiepileptic compounds. This study was designed to develop a new focal epilepsy model that mimics different aspects of human temporal lobe epilepsy (TLE), including the occurrence of spontaneous seizures. Self-sustained status epilepticus (SSSE) lasting for 6-20 h was induced by a 20-30 min stimulation of the lateral nucleus of the amygdala (100 ms train of 1 ms, 60 Hz bipolar pulses, 400 microA, every 0.5 s). Stimulated rats (n = 16) were monitored with a video-EEG recording system every other day (24 h/day) for 6 months, and every other video-EEG recording was analyzed. Spontaneous epileptic seizures (total number 3698) were detected in 13 of the 15 animals (88%) after a latency period of 6 to 85 days (median 33 days). Four animals (31%) had frequent (697-1317) seizures and 9 animals (69%) had occasional seizures (1-107) during the 6-months follow-up period. Fifty-seven percent of the seizures occurred during daytime (lights on 07:00-19:00 h). At the end of the follow-up period, epileptic animals demonstrated impaired spatial memory in the Morris water-maze. Histologic analysis indicated neuronal loss in the amygdala, hippocampus, and surrounding cortical areas, and mossy fiber sprouting in the dentate gyrus. The present data indicate that focal stimulation of the amygdala initiates a cascade of events that lead to the development of spontaneous seizures in rats. This model provides a new tool to better mimic different aspects of human TLE for investigation of the pathogenesis of TLE or the effects of new antiepileptic compounds on status epilepticus, epileptogenesis, and spontaneous seizures.

Modifications of seizure susceptibility in Drosophila

In a given population, certain individuals are much more likely to have seizures than others. This increase in seizure susceptibility can lead to spontaneous seizures, such as seen in idiopathic epilepsy, or to symptomatic seizures that occur after insults to the nervous system. Despite the frequency of these seizure disorders in the human population, the genetic and physiological basis for these defects remains unclear. The present study makes use of Drosophila as a potentially powerful model for understanding seizure susceptibility in humans. In addition to the genetic and molecular advantages of using Drosophila, it has been found that seizures in Drosophila share much in common with seizures seen in humans. However, the most powerful aspect of this model lies in the ability to accurately measure seizure susceptibility across genotypes and over time. In the current study seizure susceptibility was quantified in a variety of mutant and wild-type strains, and it was found that genetic mutations can modulate susceptibility over an extremely wide range. This genetic modulation of seizure susceptibility apparently occurs without affecting the threshold of individual neurons. Seizure susceptibility also varied depending on the experience of the fly, decreasing immediately after a seizure and then gradually increasing over time. A novel phenomenon was also identified in which seizures are suppressed after certain high-intensity stimuli. These results demonstrate the utility of Drosophila as a model system for studying human seizure disorders and provide insights into the possible mechanisms by which seizure susceptibility is modified.

Corneal kindling in mice: behavioral and pharmacological differences to conventional kindling

Electrical kindling via unilateral implanted depth electrodes in rats is currently the most commonly used model for temporal lobe epilepsy, but the use of this model in drug screening for the identification of novel anticonvulsants is markedly hampered by the laborious and time-consuming preparation and the size of the animals. Kindling of male mice via transcorneal electrical stimulation has recently proposed as a cost-effective screening model that may improve the preclinical evaluation of efficacy and adverse effect potential of drug candidates for treatment of partial epilepsy. In the present study, corneal kindling was characterized and compared in male and female mice. In fully kindled mice, the anticonvulsant efficacy of the standard antiepileptic drug phenytoin was determined. Large groups of kindled mice were used to examine whether phenytoin non-responders can be selected in the corneal kindling model as reported previously for amygdala kindling. Furthermore, in view of the enhanced adverse effect potential of NMDA antagonists in amygdala kindled rats, it was evaluated whether corneally kindled mice also differ in this respect from non-kindled animals. Mice of both genders could be kindled by twice daily transcorneal stimulation within 10-12 days. However, in contrast to traditional kindling, corneal kindling was associated with a high frequency of mortality, and persistence of the fully kindled state after 4 weeks without stimulation was not pronounced. Phenytoin proved highly potent and efficacious to block corneally kindled seizures. Only one non-responder could be selected out of 75 fully kindled mice repeatedly tested with phenytoin. At 6 days after the last kindled seizure, kindled mice were more sensitive than non-kindled mice to phencyclidine-like behavioral adverse effects of the competitive NMDA antagonist D-CPPene, but this altered sensitivity was not long-lasting, having almost disappeared 27 days after the last seizure, indicating that, in contrast to traditional kindling, brain alterations after corneal kindling are not permanent. In summary, although corneal kindling may have advantages for the identification of new drugs during initial screening of large numbers of compounds, it cannot replace traditional electrical kindling during later phases of drug development. Furthermore, the high mortality and insufficient persistence of corneal kindling in mice detract from the use of this model for repeated drug testing in the same group of animals.

New anti-epileptic drugs

Epilepsy represents the most common serious neurological disorder, with a prevalence of 0.4 - 1%. Approximately 30% of patients are resistant to currently available drugs. New anti-epileptic drugs are needed to treat refractory epilepsy, improve upon current therapies, improve the prognosis of epilepsy and to prevent the epileptogenic process. Designing compounds with specific physiological targets would seem the most rational method of anti-epileptic drug development, but results from this approach have been disappointing; the widespread screening of compounds in animal models has been much more fruitful. Older methods of animal screening have used acute seizure models, which bear scant relationship to the human condition. More modern methods have included the development of animal models of chronic epilepsy; although more expensive, it is likely that these models will be more sensitive and more specific in determining anti-epileptic efficacy. In this review, we consider the possible physiological targets for anti-epileptic drugs, the animal models of epilepsy, problems with clinical trials and ten promising anti-epileptic drugs in development (AWD 131-138, DP16 (DP-VPA), ganaxolone, levetiracetam, losigamone, pregabalin, remacemide, retigabine, rufinamide and soretolide). Perhaps the most important advances will come about from the realisation that epilepsy is a symptom, not a disease. Preclinical testing should be used to determine the spectrum of epilepsies that a drug can treat, and to direct later clinical trials, which need to select patients based on carefully defined epilepsy syndromes and aetiologies. Not only will such an approach improve the sensitivity of clinical trials, but also will lead to a more rational basis on which to treat.

The effects of cannabinoids on the brain

Cannabinoids have a long history of consumption for recreational and medical reasons. The primary active constituent of the hemp plant Cannabis sativa is delta9-tetrahydrocannabinol (delta9-THC). In humans, psychoactive cannabinoids produce euphoria, enhancement of sensory perception, tachycardia, antinociception, difficulties in concentration and impairment of memory. The cognitive deficiencies seem to persist after withdrawal. The toxicity of marijuana has been underestimated for a long time, since recent findings revealed delta9-THC-induced cell death with shrinkage of neurons and DNA fragmentation in the hippocampus. The acute effects of cannabinoids as well as the development of tolerance are mediated by G protein-coupled cannabinoid receptors. The CB1 receptor and its splice variant CB1A, are found predominantly in the brain with highest densities in the hippocampus, cerebellum and striatum. The CB2 receptor is found predominantly in the spleen and in haemopoietic cells and has only 44% overall nucleotide sequence identity with the CB1 receptor. The existence of this receptor provided the molecular basis for the immunosuppressive actions of marijuana. The CB1 receptor mediates inhibition of adenylate cyclase, inhibition of N- and P/Q-type calcium channels, stimulation of potassium channels, and activation of mitogen-activated protein kinase. The CB2 receptor mediates inhibition of adenylate cyclase and activation of mitogen-activated protein kinase. The discovery of endogenous cannabinoid receptor ligands, anandamide (N-arachidonylethanolamine) and 2-arachidonylglycerol made the notion of a central cannabinoid neuromodulatory system plausible. Anandamide is released from neurons upon depolarization through a mechanism that requires calcium-dependent cleavage from a phospholipid precursor in neuronal membranes. The release of anandamide is followed by rapid uptake into the plasma and hydrolysis by fatty-acid amidohydrolase. The psychoactive cannabinoids increase the activity of dopaminergic neurons in the ventral tegmental area-mesolimbic pathway. Since these dopaminergic circuits are known to play a pivotal role in mediating the reinforcing (rewarding) effects of the most drugs of abuse, the enhanced dopaminergic drive elicited by the cannabinoids is thought to underlie the reinforcing and abuse properties of marijuana. Thus, cannabinoids share a final common neuronal action with other major drugs of abuse such as morphine, ethanol and nicotine in producing facilitation of the mesolimbic dopamine system.

Valproate: a reappraisal of its pharmacodynamic properties and mechanisms of action

Valproate is currently one of the major antiepileptic drugs with efficacy for the treatment of both generalized and partial seizures in adults and children. Furthermore, the drug is increasingly used for therapy of bipolar and schizoaffective disorders, neuropathic pain and for prophylactic treatment of migraine. These various therapeutic effects are reflected in preclinical models, including a variety of animal models of seizures or epilepsy. The incidence of toxicity associated with the clinical use of valproate is low, but two rare toxic effects, idiosyncratic fatal hepatotoxicity and teratogenicity, necessitate precautions in risk patient populations. Studies from animal models on structure-relationships indicate that the mechanisms leading to hepatotoxicity and teratogenicity are distinct and also differ from the mechanisms of anticonvulsant action of valproate. Because of its wide spectrum of anticonvulsant activity against different seizure types, it has repeatedly been suggested that valproate acts through a combination of several mechanisms. As shown in this review, there is substantial evidence that valproate increases GABA synthesis and release and thereby potentiates GABAergic functions in some specific brain regions, such as substantia nigra, thought to be involved in the control of seizure generation and propagation. Furthermore, valproate seems to reduce the release of the epileptogenic amino acid gamma-hydroxybutyric acid and to attenuate neuronal excitation induced by NMDA-type glutamate receptors. In addition to effects on amino acidergic neurotransmission, valproate exerts direct effects on excitable membranes, although the importance of this action is equivocal. Microdialysis data suggest that valproate alters dopaminergic and serotonergic functions. Valproate is metabolized to several pharmacologically active metabolites, but because of the low plasma and brain concentrations of these compounds it is not likely that they contribute significantly to the anticonvulsant and toxic effects of treatment with the parent drug. By the experimental observations summarized in this review, most clinical effects of valproate can be explained, although much remains to be learned at a number of different levels of valproate's mechanisms of action.

Clinical aspects and biological bases of drug-resistant epilepsies

The definition of drug-resistant epilepsy (DRE) is elusive and still controversial owing to some unresolved questions such as: how many drugs should be tried before a patient is considered intractable; to which extent side-effects may be acceptable; how many years are necessary before establishing drug resistance. In some cases, the view of epilepsy as a progressive disorder constitutes another important issue. Despite the use of new antiepileptic drugs (AEDs), intractable epilepsy represents about 20-30% of all cases, probably due to the multiple pathogenetic mechanisms underlying refractoriness. Several risk factors for pharmacoresistance are well known, even if the list of clinical features and biological factors currently accepted to be associated with difficult-to-treat epilepsy is presumably incomplete and, perhaps, disputable. For some of these factors, the biological basis may be common, mainly represented by mesial temporal sclerosis or by the presence of focal lesions. In other cases, microdysgenesis or dysplastic cortex, with abnormalities in the morphology and distribution of local-circuit (inhibitory) neurons, may be responsible for the severity of seizures. The possible influence of genes in conditioning inadequate intraparenchimal drug concentration, and the role of some cytokines determining an increase in intracellular calcium levels or an excessive growth of distrophic neurites, constitute other possible mechanisms of resistance. Several hypotheses on the mechanisms involved in the generation of DRE have been indicated: (a) ontogenic abnormalities in brain maturation; (b) epilepsy-induced alterations in network, neuronal, and glial properties in seizure-prone regions such as the hippocampus; (c) kindling phenomenon; (d) reorganization of cortical tissue in response to seizure-induced disturbances in oxygen supply. Such hypotheses need to be confirmed with suitable experimental models of intractable epilepsy that are specifically dedicated, which have until now been lacking.

Characterization of phenytoin-resistant kindled rats, a new model of drug-resistant partial epilepsy: influence of genetic factors

It has been recently shown that a subpopulation of amygdala-kindled Wistar rats can be selected which do not respond to phenytoin with an increase in afterdischarge threshold (ADT). Such non-responders could be a perfect model for studying the mechanisms of pharmacoresistance of complex partial seizures. Further studies on these rats suggested that the lack of anticonvulsant response was not due to the influence of experimental factors, but is an inherent property of each rat. In this study the influence of genetic factors on the pharmacoresistance to phenytoin by breeding Wistar rats which have been selected for their ability to consistently respond or not respond to phenytoin is examined. Male and female Wistar rats were implanted with bipolar electrodes in the basolateral amygdala and kindled. The fully kindled rats were repeatedly tested for their ability to respond to phenytoin (75 mg/kg i.p.) with an ADT increase. Responders and non-responders were mated and the offspring underwent the same kindling and repeated phenytoin testing procedure. Altogether, four generations of kindled rats were studied. The incidence of responses to phenytoin, i.e. ADT increased by more than 20% of control, was significantly higher in the F2 generation of the responder line compared to the non-responder line, but the number of responders and non-responders in the offspring generations F1-F3 did not significantly increase. The data suggest that the ability to respond or not to respond to phenytoin is genetically determined, although it does not follow a simple scheme of inheritance. The low reproductive success of the kindled and phenytoin-treated rats made it impossible to achieve a strain of phenytoin non-responders.

Prolonged seizure suppression by a single implantable polymeric-TRH microdisk preparation

Thyrotropin-releasing hormone (TRH; Protirelin) is an endogenous neuropeptide known to have anticonvulsant effects in several seizure models and in intractable epileptic patients. Like most neuropeptides, its duration of action may be limited by a lack of sustained site-specific bioavailability. To attempt to provide long-term delivery, we attached TRH to a biodegradable polyanhydride copolymer as a sustained-release carrier. Utilizing the rat kindling model of temporal lobe epilepsy, a single TRH microdisk implanted stereotaxically into the seizure focus (amygdala) significantly suppressed kindling expression when assessed by the number of stimulations required to reach each behavioral stage and to become fully kindled (8.63 +/- 0.92 vs. 16.17 +/- 1.37; Mean +/- S.E.M.). Two indices of seizure severity, afterdischarge duration (Mean +/- S.E.M., sec.) (stimulated amygdala [87.40 +/- 5.47 vs. 51.80 +/- 15.65] and unstimulated amygdala [89.60 +/- 5.55 vs. 48.67 +/- 15.8] and clonus duration (71.2 +/- 5.94 vs. 29.40 +/- 8.87; Mean +/- S.E.M., sec.), were also significantly reduced by a single polymeric-TRH implant. Fifty days after initiation of the study a significant reduction in clonus duration (53.90 +/- 3.27 vs. 40.09 +/- 4.14) still remained in the TRH-implanted groups. This report is the first to provide evidence in support of in situ microdisk pharmacotherapy for potential neuropeptide delivery in intractable epilepsy and possibly other neurological disorders.

Selection of phenytoin responders and nonresponders in male and female amygdala-kindled Sprague-Dawley rats

PURPOSE

We recently described that, by repeated testing of the anticonvulsant phenytoin (PHT), it is possible to select responders and nonresponders from large populations of amygdala-kindled Wistar rats. Whereas responders show marked and reproducible increases of focal seizure threshold (afterdischarge threshold: ADT) on repeated testing of PHT, 75 mg/kg i.p., nonresponders do not show any significant ADT increase after this dose, thus allowing use of these subgroups in the search for mechanisms of pharmacoresistance in temporal lobe epilepsy. In this study, we examined whether PHT responders and nonresponders can also be selected from large groups of kindled rats of the Sprague-Dawley strain.

METHODS

Male and female Sprague-Dawley rats were amygdala kindled, followed by once weekly i.p. testing of PHT.

RESULTS

In contrast to recent experiments in Wistar rats, 75 mg/kg PHT did not induce significant ADT increases in Sprague-Dawley rats, indicating strain differences in response to this drug after kindling. When the dose was lowered to 50 or 25 mg/kg, significant and reproducible ADT increases were obtained in Sprague-Dawley rats of both genders. Therefore these doses were used for selection of responders and nonresponders in a total of 42 rats. Almost 50% of the rats were PHT responders, whereas no rat was a nonresponder when tested in up to six subsequent drug trials. Many rats were variable responders (i.e., showed ADT increases in some but not all trials), which was not due to low or variable drug absorption after i.p. injection.

CONCLUSIONS

The data indicate that, in contrast to Wistar rats, Sprague-Dawley rats are not suited for selection of PHT nonresponders, but rather are quite responsive to this drug. A further difference to the Wistar strain is the truncated dose-response with loss of anticonvulsant efficacy at 75 mg/kg in kindled Sprague-Dawley rats, which may, at least in part, explain the inconsistent results reported on the anticonvulsant efficacy of PHT in this strain in the literature. The lack of anticonvulsant activity after administration of 75 mg/kg may be a result of kindling, because administration of this dose before kindling causes a significant ADT increase in this strain. This kindling-induced alteration of the anticonvulsant activity of PHT is a phenomenon that contrasts Sprague-Dawley with Wistar rats and deserves further investigation.

Characterization of phenytoin-resistant kindled rats, a new model of drug-resistant partial epilepsy: comparison of inbred strains

PURPOSE

Previous work from our laboratory showed that amygdala-kindled Wistar outbred rats can be selected according to the increase of afterdischarge threshold (ADT) after phenytoin application. Animals that consistently do not respond to phenytoin (PHT) with an ADT increase (non-responders) are the first animal model of pharmacoresistant complex partial seizures. In this study, we determined the ability to respond to PHT in male kindled rats of different inbred strains.

METHODS

The experiments were performed in fully kindled rats of five different inbred strains, Wistar-Kyoto, Lewis, Fischer 344, ACI, and Brown Norway. The response type of each rat was revealed by four consecutive PHT applications (75 mg/kg, i.p.) in fully kindled rats.

RESULTS

PHT application resulted in plasma concentrations ranging from some 16 microg/ml in Lewis rats to 35 microg/ml in Fischer 344 rats, and in slight ataxia, most strongly in Fischer 344 rats. The rats of each strain did not show a homogeneous response to PHT. A significant increase of ADT was found after 86-97% of applications in Lewis, Wistar-Kyoto, and Fischer 344 rats. In contrast, Brown Norway rats responded in only 34% of experiments. This led to a considerable number of responders (i.e., consistent ADT increase by >20%) in Fischer 344, Wistar-Kyoto, and Lewis rats. The only strain revealing nonresponders (i.e., consistent lack of ADT increase by >20% with PHT treatment) was Brown Norway.

CONCLUSIONS

Inbred strains, although genetically more homogenous than outbred strains, differ in their response to PHT. Brown Norway rats can offer advantages for further detailed investigation of the resistance to PHT in the kindling model of complex partial seizures.

Limbic epileptogenesis alters the anticonvulsant efficacy of phenytoin in Sprague-Dawley rats

Studies on the anticonvulsant efficacy of the major antiepileptic drug phenytoin in kindled rats have often reported inconsistent effects. It has been proposed that technical and genetic factors or poor and variable absorption of phenytoin after i.p. or oral administration may be involved in the lack of consistent anticonvulsant activity of phenytoin in this model of temporal lobe epilepsy. We examined if kindling itself changes the anticonvulsant efficacy of phenytoin by testing this drug before and after amygdala kindling in male and female Sprague-Dawley rats. To exclude the possible bias of poor and variable absorption, blood was sampled in all experiments for drug analysis in plasma. The threshold for induction of focal seizures (afterdischarge threshold; ADT) was used for determining phenytoin's anticonvulsant activity. Before kindling, phenytoin, 75 mg/kg i.p., markedly increased ADT in both genders, although the effect was more pronounced in males. Following kindling, the anticonvulsant activity obtained with phenytoin, 75 mg/kg, before kindling was totally lost, and female rats even exhibited a proconvulsant effect upon administration of this dose, indicating that kindling had dramatically altered the anticonvulsant efficacy of phenytoin. Plasma levels of phenytoin were comparable before and after kindling, and were within or near to the 'therapeutic range' known from epileptic patients. When the dose of phenytoin was reduced to 50 or 25 mg/kg i.p., significant anticonvulsant effects on ADT were obtained. When phenytoin, 50 mg/kg, was administered i.p. or i.v. in the same group of fully kindled rats, both anticonvulsant activity and plasma drug levels were comparable with both routes, indicating that the i.p. route is suited for such studies. The data indicate that kindling alters the dose-response of phenytoin in that a high anticonvulsant dose becomes ineffective or proconvulsant after kindling, possibly by an increased sensitivity of the kindled brain to proconvulsant effects of phenytoin which normally only occur at much higher doses. If similar alterations evolve in humans during development of chronic epilepsy, this may be involved in the mechanisms leading to intractability of temporal lobe epilepsy.

Anticonvulsant effect of fosphenytoin in amygdala-kindled rats: comparison with phenytoin

Phenytoin has been reported to exert variable anticonvulsant effects in the kindling model of complex partial seizures. Phenytoin is only water soluble at a pH of more than 10, and it has been suspected that poor absorption of the drug is responsible for its lack of effect in some experiments. Recently, fosphenytoin, a prodrug of phenytoin, has been developed by phosphorylating phenytoin which makes the drug water soluble at physiological pH while it is rapidly transformed to phenytoin after injection. This study examined the anticonvulsant profile and the absorption after intraperitoneal injection of fosphenytoin, compared to its parental drug phenytoin. The pharmacokinetic parameters of phenytoin and fosphenytoin were compared by determining plasma levels of phenytoin after i.p. injection of 50 mg/kg phenytoin or the equivalent dose of 84 mg/kg of fosphenytoin in non-kindled female Wistar rats. After both injections the maximal plasma concentration of phenytoin was about 30 microg/ml. The relative bioavailability of fosphenytoin was 83%. In contrast to phenytoin, failed injections resulting in non-detectable plasma concentration of phenytoin were almost absent after fosphenytoin. In fully kindled female Wistar rats, fosphenytoin dose-dependently increased the focal seizure (afterdischarge) threshold. Seizure severity and duration at threshold were reduced only after the highest does of fosphenytoin tested (84 mg/kg). Thus, fosphenytoin showed anticonvulsant properties similar to phenytoin in amygdala kindled rats. We conclude that fosphenytoin is an adequate and reliable substitute for the parenteral injection of phenytoin in experimental seizure models of rats.

New visions in the pharmacology of anticonvulsion

Seizures are resistant to treatment with currently available anticonvulsant drugs in about 1 out of 3 patients with epilepsy. Thus, there is a need for new, more effective anticonvulsant drugs for intractable epilepsy. Furthermore, because of the inadequacy of the currently available anticonvulsant armamentarium with respect to safety, newly developed drugs should be less toxic than existing drugs. Previous and current strategies for development of novel anticonvulsants with improved efficacy or safety are critically discussed in this review. 'Old drugs' (or 'first generation' drugs), which were developed and introduced between 1910 and 1970, are compared with new anticonvulsants both in terms of clinical efficacy and safety and in terms of mechanisms of action. The new drugs are referred to as 'second generation' drugs, i.e. anticonvulsants which have been introduced into clinical practice in recent years, or 'third generation' drugs, i.e. compounds in the pipeline of development. In spite of some 30 years of 'modern' neuroscientific epilepsy research, most novel, clinically effective second generation anticonvulsants have been found by screening (i.e. serendipity) or structural variation of known drugs and not by rational strategies based on knowledge of processes involved in generation of seizures or in development of epilepsy. An exception are only the GABA (gamma-aminobutyrate)-mimetic drugs vigabatrin and tiagabine and, to some extent, gabapentin, which have been developed by a rational strategy, i.e. the 'GABA hypothesis' of epilepsy. The fact that preclinical seizure models used for identification and development of novel drugs have been originally validated by old drugs, i.e. conventional anticonvulsants, may explain that several of the new drugs possess mechanisms which do not differ from those of the standard drugs. This may also explain that none of the new drugs seems to offer any marked advantage towards the old, first generation drugs with respect to the ultimate goal of drug treatment of epilepsy, i.e. complete control of seizures, although some of the second generation drugs may have benefits in terms of side effects and tolerability. It is to be hoped that the various novel currently used or planned strategies for drug development produce more effective and safe anticonvulsants than previous strategies. This goal can only be achieved by strengthening our understanding of the fundamental pathophysiology of seizure expression and epileptogenesis as theoretical substrates for new pharmacological strategies, and by devising and refining laboratory models for studying new agents obtained by such strategies.