Phenytoin and retinal spreading depression

Visual Disturbances Spectrum in Pediatric Migraine

Migraine is a complex neurological disorder with partially unknown pathophysiological mechanisms. The prevalence in childhood ranges from 7.7% to 17.8%, thus representing the most frequent primary headache. In half of the cases, migraine is accompanied or preceded by various neurological disturbances, among which the visual aura is the best known. In literature, other conditions, such as Alice in Wonderland Syndrome and Visual Snow syndrome, are characterized by visual manifestations and are often associated with migraine. The aim of this narrative review is to describe the spectrum of visual disturbances in pediatric migraine and their pathophysiological mechanisms.

Association of cortical spreading depression and seizures in patients with medically intractable epilepsy

OBJECTIVE

Monitoring of the ultra-low frequency potentials, particularly cortical spreading depression (CSD), is excluded in epilepsy monitoring due to technical barriers imposed by the scalp ultra-low frequency electroencephalogram (EEG). As a result, clinical studies of CSD have been limited to invasive EEG. Therefore, the occurrence of CSD and its interaction with epileptiform field potentials (EFP) require investigation in epilepsy monitoring.

METHODS

Using a novel AC/DC-EEG approach, the occurrence of DC potentials in patients with intractable epilepsy presenting different symptoms of aura was investigated during long-term video-EEG monitoring.

RESULTS

Various forms of slow potentials, including simultaneous negative direct current (DC) potentials and prolonged EFP, propagated negative DC potentials, and non-propagated single negative DC potentials were recorded from the scalp of the epileptic patients. The propagated and single negative DC potentials preceded the prolonged EFP with a time lag and seizure appeared at the final shoulder of some instances of the propagated negative DC potentials. The slow potential deflections had a high amplitude and prolonged duration and propagated slowly through the brain. The high-frequency EEG was suppressed in the vicinity of the negative DC potential propagations.

CONCLUSIONS

The study is the first to report the recording of the propagated and single negative DC potentials with EFP at the scalp of patients with intractable epilepsy. The negative DC potentials preceded the prolonged EFP and may trigger seizures. The propagated and single negative DC potentials may be considered as CSD.

SIGNIFICANCE

Recordings of CSD may serve as diagnostic and prognostic monitoring tools in epilepsy.

Relevance of excitable media theory and retinal spreading depression experiments in preclinical pharmacological research

In preclinical neuropharmacological research, molecular, cell-based, and systems using animals are well established. On the tissue level the situation is less comfortable, although during the last decades some effort went into establishing such systems, i.e. using slices of the vertebrate brain together with optical and electrophysiological techniques. However, these methods are neither fast, nor can they be automated or upscaled. By contrast, the chicken retina can be used as a suitable model. It is easy accessible and can be kept alive in vitro for hours up to days. Due to its structure, in addition the retina displays remarkable intrinsic optical signals, which can be easily used in experiments. Also to electrophysiological methods the retina is well accessible. In excitable tissue, to which the brain and the retina belong, propagating excitation waves can be expected, and the spreading depression is such a phenomenon. It has been first observed in the forties of the last century. Later, Martins-Ferreira established it in the chicken retina (retinal spreading depression or RSD). The electrophysiological characteristics of it are identical with those of the cortical SD. The metabolic differences are known and can be taken into account. The experimental advantage of the RSD compared to the cortical SD is the pronounced intrinsic optical signal (IOS) associated with the travelling wave. This is due to the maximum transparency of retinal tissue in the functional state; thus any physiological event will change it markedly and therefore can be easily seen even by naked eye. The theory can explain wave spread in one (action potentials), two (RSDs) and three dimensions (one heart beat). In this review we present the experimental and the excitable media context for the data interpretation using as example the cholinergic pharmacology in relation to functional syndromes. We also discuss the intrinsic optical signal and how to use it in pre-clinical research.

Migraine preventive drugs differentially affect cortical spreading depression in rat

Cortical spreading depression (CSD) is the most likely cause of the migraine aura. Drugs with distinct pharmacological properties are effective in the preventive treatment of migraine. To test the hypothesis that their common denominator might be suppression of CSD we studied in rats the effect of three drugs used in migraine prevention: lamotrigine which is selectively effective on the aura but not on the headache, valproate and riboflavin which have a non-selective effect. Rats received for 4 weeks daily intraperitoneal injections of one of the three drugs. For valproate and riboflavin we used saline as control, for lamotrigine its vehicle dimethyl sulfoxide. After treatment, cortical spreading depressions were elicited for 2h by occipital KCl application. We measured CSD frequency, its propagation between a posterior (parieto-occipital) and an anterior (frontal) electrode, and number of Fos-immunoreactive nuclei in frontal cortex. Lamotrigine suppressed CSDs by 37% and 60% at posterior and anterior electrodes. Valproate had no effect on posterior CSDs, but reduced anterior ones by 32% and slowed propagation velocity. Riboflavin had no significant effect at neither recording site. Frontal Fos expression was decreased after lamotrigine and valproate, but not after riboflavin. Serum levels of administered drugs were within the range of those usually effective in patients. Our study shows that preventive anti-migraine drugs have differential effects on CSD. Lamotrigine has a marked suppressive effect which correlates with its rather selective action on the migraine aura. Valproate and riboflavin have no effect on the triggering of CSD, although they are effective in migraine without aura. Taken together, these results are compatible with a causal role of CSD in migraine with aura, but not in migraine without aura.

Spreading depression: from serendipity to targeted therapy in migraine prophylaxis

Despite the relatively well-characterized headache mechanisms in migraine, upstream events triggering individual attacks are poorly understood. This lack of mechanistic insight has hampered a rational approach to prophylactic drug discovery. Unlike targeted abortive and analgesic interventions, mainstream migraine prophylaxis has been largely based on serendipitous observations (e.g. propranolol) and presumed class effects (e.g. anticonvulsants). Recent studies suggest that spreading depression is the final common pathophysiological target for several established or investigational migraine prophylactic drugs. Building on these observations, spreading depression can now be explored for its predictive utility as a preclinical drug screening paradigm in migraine prophylaxis.

Association of seizures with cortical spreading depression and peri-infarct depolarisations in the acutely injured human brain

OBJECTIVE

To test the co-occurrence and interrelation of ictal activity and cortical spreading depressions (CSDs) - including the related periinfarct depolarisations in acute brain injury caused by trauma, and spontaneous subarachnoid and/or intracerebral haemorrhage.

METHODS

63 patients underwent craniotomy and electrocorticographic (ECoG) recordings were taken near foci of damaged cortical tissue for up to 10 days.

RESULTS

32 of 63 patients exhibited CSDs (5-75 episodes) and 11 had ECoGraphic seizure activity (1-81 episodes). Occurrence of seizures was significantly associated with CSD, as 10 of 11 patients with seizures also had CSD (p=0.007, 2-tailed Fishers exact test). Clinically overt seizures were only observed in one patient. Each patient with CSD and seizures displayed one of four different patterns of interaction between CSD and seizures. In four patients CSD was immediately preceded by prolonged seizure activity. In three patients the two phenomena were separated in time: multiple CSDs were replaced by ictal activity. In one patient seizures appeared to trigger repeated CSDs at the adjacent electrode. In 2 patients ongoing repeated seizures were interrupted each time CSD occurred.

CONCLUSIONS

Seizure activity occurs in association with CSD in the injured human brain.

SIGNIFICANCE

ECoG recordings in brain injury patients provide insight into pathophysiological mechanisms, which are not accessible by scalp EEG recordings.

Migraine prophylactic drugs work via ion channels

In recent decades, the concept of a vascular origin of migraine has been replaced by theories based on a neuronal pathophysiology. These theories all involve rapid changes in the functioning of the brain, particularly the brain stem, and the trigeminal nerves. While such paroxysmal changes in function could be the result of altered synaptic transmission, or other physiological changes, they could also be due to changes in the function of voltage-regulated sodium and calcium ion channels. Support for this view of migraine as a channelopathy comes from an examination of the likely mechanism of action of migraine prophylactic drugs. It is the present hypothesis that most of the widely used drugs for migraine prevention work by inhibiting the function of one or both of these ion channels. A review of the laboratory research done on most of the commonly used migraine prophylactic drugs, divided into five classes, reveals that they all may work on sodium channels, calcium channels, or both. If this is the common mechanism of action of migraine prophylactics, it should lead toward the development of more effective prophylactic drugs.

Propagation velocity and triggering threshold of retinal spreading depression are not correlated

Spreading depression (SD) is a pronounced but transient disturbance of cellular homeostasis in the neuropil of the central nervous system which spreads in a wave-like manner across the tissue. At the wavefront the cells depolarize and a distinct ion redistribution between intra- and extracellular space is observed. In the aftermath of SD the recovering tissue is refractory: during an early absolute refractory period no further SD can be triggered, during the subsequent relative refractory period SD waves spread at lower velocity than usual. In this paper we shall examine the influence of temperature on SD triggering and on SD propagation in the chicken retina (retinal spreading depression, rSD) and we shall examine rSD triggering and rSD propagation in the refractory period. It will be shown that cooling decreases the threshold of rSD triggering, i.e. it becomes easier to trigger rSD when the temperature is reduced. At the same time cooling slows rSD propagation. In contrast, during the relative refractory period triggering rSD is more difficult than usual while rSD propagation is also slowed. These results demonstrate that the propagation velocity of rSD is not correlated with the triggering threshold. In particular, the propagation velocity of rSD must not be used to predict the influence of experimental conditions on the triggering threshold.

Retinal ischemia: mechanisms of damage and potential therapeutic strategies

Retinal ischemia is a common cause of visual impairment and blindness. At the cellular level, ischemic retinal injury consists of a self-reinforcing destructive cascade involving neuronal depolarisation, calcium influx and oxidative stress initiated by energy failure and increased glutamatergic stimulation. There is a cell-specific sensitivity to ischemic injury which may reflect variability in the balance of excitatory and inhibitory neurotransmitter receptors on a given cell. A number of animal models and analytical techniques have been used to study retinal ischemia, and an increasing number of treatments have been shown to interrupt the "ischemic cascade" and attenuate the detrimental effects of retinal ischemia. Thus far, however, success in the laboratory has not been translated to the clinic. Difficulties with the route of administration, dosage, and adverse effects may render certain experimental treatments clinically unusable. Furthermore, neuroprotection-based treatment strategies for stroke have so far been disappointing. However, compared to the brain, the retina exhibits a remarkable natural resistance to ischemic injury, which may reflect its peculiar metabolism and unique environment. Given the increasing understanding of the events involved in ischemic neuronal injury it is hoped that clinically effective treatments for retinal ischemia will soon be available.

Phenytoin delays ischemic depolarization, but cannot block its long-term consequences, in the rat hippocampal slice

The anticonvulsant phenytoin has been reported to block anoxia-induced losses of synaptic activity in the rat hippocampal slice and experimental ischemia-induced losses of synaptic activity in the guinea pig hippocampal slice. We examined phenytoin in our rat hippocampal slice model of experimental ischemia (anoxia +2 mM D-glucose). In this model, ischemic depolarization (ID) occurs 4-5 min after the introduction of anoxic medium, and oxygen and D-glucose are restored 1 min after the onset of ID. In control slices, synaptic recovery is never observed following ID in 2 mM D-glucose. Phenytoin (30,100 and 300 microM), perfused for 20 min prior to, and for 10 min following anoxia, did not allow for synaptic recovery following ID. At the higher concentrations, however, it did increase the latency to ID. In addition, the presynaptic volley (PV), which normally disappears at the time of ID, was lost substantially earlier in the presence of phenytoin. These findings suggest that the anti-ischemic effects of phenytoin reported by others are due to delay of ID. This may suggest that phenytoin will be effective in preventing global ischemia-induced damage only when the ischemic insult is of short duration.

Spreading depression of Leão in rodent and human cortex

Spreading depression (SD) has been implicated in the pathophysiology of a number of neurological conditions. The same methodology was used to elicit SD in anesthetized rats and in non-anesthetized patients undergoing cortical resections for intractable epilepsy. A slowly spreading DC potential shift (mean -9 mV) occurred in the cortex of 10 of 15 rats in association with attenuation of the electrocorticogram but this could not be reproduced in any of the human cortices (n = 23) where the mean potential shift was -0.56 mV (P < 0.0001). SD is more difficult to elicit in human than rodent cortex and may not occur in man.