Corticotropin-releasing factor mediated muscle atonia in pons and medulla

Behavioral response and transmitter release during atonia elicited by medial medullary stimulation

Activation of the medial medulla is responsible for rapid eye movement (REM) sleep atonia and cataplexy. Dysfunction can cause REM sleep behavior disorder and other motor pathologies. Here we report the behavioral effects of stimulation of the nucleus gigantocellularis (NGC) and nucleus magnocellularis (NMC) in unrestrained cats. In waking, 62% of the medial medullary stimulation sites suppressed muscle tone. In contrast, stimulation at all sites, including sites where stimulation produced no change or increased muscle tone in waking, produced decreased muscle tone during slow-wave sleep. In the decerebrate cat electrical stimulation of the NGC increased glycine and decreased norepinephrine (NE) release in the lumbar ventral horn, with no change in γ-aminobutyric acid (GABA) or serotonin (5-HT) release. Stimulation of the NMC increased both glycine and GABA release and also decreased both NE and 5-HT release in the ventral horn. Glutamate levels in the ventral horn were not changed by either NGC or NMC stimulation. We conclude that NGC and NMC play neurochemically distinct but synergistic roles in the modulation of motor activity across the sleep-wake cycle via a combination of increased release of glycine and GABA and decreased release of 5-HT and NE. Stimulation of the medial medulla that elicited muscle tone suppression also triggered rapid eye movements, but never produced the phasic twitches that characterize REM sleep, indicating that the twitching and rapid eye movement generators of REM sleep have separate brain stem substrates.

Conditional corticotropin-releasing hormone overexpression in the mouse forebrain enhances rapid eye movement sleep

Impaired sleep and enhanced stress hormone secretion are the hallmarks of stress-related disorders, including major depression. The central neuropeptide, corticotropin-releasing hormone (CRH), is a key hormone that regulates humoral and behavioral adaptation to stress. Its prolonged hypersecretion is believed to play a key role in the development and course of depressive symptoms, and is associated with sleep impairment. To investigate the specific effects of central CRH overexpression on sleep, we used conditional mouse mutants that overexpress CRH in the entire central nervous system (CRH-COE-Nes) or only in the forebrain, including limbic structures (CRH-COE-Cam). Compared with wild-type or control mice during baseline, both homozygous CRH-COE-Nes and -Cam mice showed constantly increased rapid eye movement (REM) sleep, whereas slightly suppressed non-REM sleep was detected only in CRH-COE-Nes mice during the light period. In response to 6-h sleep deprivation, elevated levels of REM sleep also became evident in heterozygous CRH-COE-Nes and -Cam mice during recovery, which was reversed by treatment with a CRH receptor type 1 (CRHR1) antagonist in heterozygous and homozygous CRH-COE-Nes mice. The peripheral stress hormone levels were not elevated at baseline, and even after sleep deprivation they were indistinguishable across genotypes. As the stress axis was not altered, sleep changes, in particular enhanced REM sleep, occurring in these models are most likely induced by the forebrain CRH through the activation of CRHR1. CRH hypersecretion in the forebrain seems to drive REM sleep, supporting the notion that enhanced REM sleep may serve as biomarker for clinical conditions associated with enhanced CRH secretion.

Medullary circuitry regulating rapid eye movement sleep and motor atonia

Considerable data support a role for glycinergic ventromedial medulla neurons in the mediation of the postsynaptic inhibition of spinal motoneurons necessary for the motor atonia of rapid-eye movement (REM) sleep in cats. These data are, however, difficult to reconcile with the fact that large lesions of the rostral ventral medulla do not result in loss of REM atonia in rats. In the present study, we sought to clarify which medullary networks in rodents are responsible for REM motor atonia by retrogradely tracing inputs to the spinal ventral horn from the medulla, ablating these medullary sources to determine their effects on REM atonia and using transgenic mice to identify the neurotransmitter(s) involved. Our results reveal a restricted region within the ventromedial medulla, termed here the "supraolivary medulla" (SOM), which contains glutamatergic neurons that project to the spinal ventral horn. Cell-body specific lesions of the SOM resulted in an intermittent loss of muscle atonia, taking the form of exaggerated phasic muscle twitches, during REM sleep. A concomitant reduction in REM sleep time was observed in the SOM-lesioned animals. We next used mice with lox-P modified alleles of either the glutamate or GABA/glycine vesicular transporters to selectively eliminate glutamate or GABA/glycine neurotransmission from SOM neurons. Loss of SOM glutamate release, but not SOM GABA/glycine release, resulted in exaggerated muscle twitches during REM sleep that were similar to those observed after SOM lesions in rats. These findings, together, demonstrate that SOM glutamatergic neurons comprise key elements of the medullary circuitry mediating REM atonia.

Mouse strain differences in the effects of corticotropin releasing hormone (CRH) on sleep and wakefulness

Corticotropin releasing hormone (CRH) plays a major role in central nervous system responses to stressors and has been implicated in stress-induced alterations in sleep. In the absence of stressors, CRH contributes to the regulation of spontaneous waking. We examined the effects of CRH and astressin (AST), a non-specific CRH antagonist, on wakefulness and sleep in two mouse strains with differential responsiveness to stress to determine whether CRH might also differentially affect undisturbed sleep and activity. Less reactive C57BL/6J (n=7) and high reactive BALB/cJ (n=7) male mice were implanted with a transmitter for determining sleep via telemetry and with a guide cannula aimed into a lateral ventricle. After recovery from surgery and habituation to handling, ICV microinjections of CRH (0.04, 0.2, and 0.4 microg), AST (0.1, 0.4, and 1.0 microg) or vehicle alone (pyrogen-free saline, 0.2 microl) were administered during the fourth hour after lights on and sleep was recorded for the subsequent 8 h. Comparisons of wakefulness and sleep were conducted across conditions and across strains. In C57BL/6J mice, REM was significantly decreased after microinjections of CRH (0.2 microg) and CRH (0.4 microg), and NREM and total sleep were decreased after microinjections of CRH (0.4 microg). CRH (0.04 microg) and AST did not significantly change wakefulness or sleep. In BALB/cJ mice, CRH (0.4 microg) increased wakefulness and decreased NREM, REM and total sleep. AST decreased active wakefulness and significantly increased REM at the low and high dosages. These findings demonstrate that CRH produces changes in arousal when given to otherwise undisturbed mice. Strain differences in the effects of CRH and AST may be linked to the relative responsiveness of C57BL/6J and BALB/cJ mice to stressors and to underlying differences in the CRH system.

Arousal of cerebral cortex electroencephalogram consequent to high-frequency stimulation of ventral medullary reticular formation

We have theorized that large neurons in the ventral and medial reticular formation of the medulla are critical for both autonomic and cortical arousal. To test this theory, we anesthetized rats with urethane, lowered concentric bipolar stimulating electrodes into the medullary reticular formation, and implanted electroencephalogram (EEG) and ECG recording electrodes. We stimulated in the medulla with pulse frequencies ranging from 50 to 300 Hz while recording cortical EEG and ECG. These female rats were ovariectomized, and one subgroup was administered estradiol. Electrical stimulation at either 200 or 300 Hz among the large medullary reticular neurons in nucleus paragigantocellularis (PGi) caused a significant reduction in the portion of the EEG power spectrum represented by delta-waves (0.1-4 Hz) and -waves (4.1-8 Hz). Correspondingly, there were increases in gamma-wave power (22-50 Hz), especially when using 300 Hz. Stimulation at </=100 Hz produced fewer changes in cortical EEG. The major features of these results were not significantly different according to estradiol treatment. In contrast, estradiol administration significantly lowered ECG. Electrical stimulation in PGi increased ECG in vehicle control animals, but decreased it in estradiol-treated animals. Regarding the EEG, we conclude that, even in anesthetized animals, stimulation of PGi reticular neurons can increase cortical arousal and that high frequencies of stimulation amplify this effect.

Active medullary control of atonia in week-old rats

Muscle atonia is a central feature of adult REM sleep which has recently been demonstrated to be a component of sleep in rats as young as 2 days of age (P2). The neural generation of atonia, which depends on mesopontine and medullary structures, is not fully understood in adults and has never been described in infants. In the present experiments we used electrical stimulation in decerebrated pups to identify an inhibitory area within the medial medulla of P7-10 rats. Muscle tone inhibition was consistently found on or near the midline within the ventromedial medulla, dorsal to the inferior olive, in an area that includes the nucleus gigantocellularis, nucleus paramedianus, and raphe obscurus. Chemical infusions in the same region revealed inhibitory responses to quisqualic acid but not to carbachol or corticotropin-releasing factor. Next, extracellular recordings within the medullary inhibitory area revealed neurons with atonia-on profiles; tone-on neurons were also found, typically at more lateral sites. Finally, in non-decerebrated pups, chemical lesions within the inhibitory area resulted in significant reductions in atonia durations, as well as decoupling of atonia from a second component of infant sleep, myoclonic twitching; specifically, twitches occasionally occurred during periods of high muscle tone, a condition reminiscent of "REM without atonia" as described in adults. In summary, we document the existence of an area within the ventromedial medulla of infant rats that (i) causes atonia when stimulated; (ii) contains units that exhibit atonia-related discharge profiles during sleep-wake cycling; and (iii) when lesioned, results in the partial loss of atonia and decoupling of the components of sleep. All together, these findings demonstrate that muscle atonia is actively regulated very early in ontogeny.

Movement suppression during anesthesia: Neural projections from the mesopontine tegmentum to areas involved in motor control

Microinjection of pentobarbital and GABA(A)-receptor agonists into a brainstem region we have called the mesopontine tegmental anesthesia area (MPTA; Devor and Zalkind [2001] Pain 94:101-112) induces a general anesthesia-like state. As in systemic general anesthesia, rats show loss of the righting reflex, atonia, nonresponsiveness to noxious stimuli, and apparent loss of consciousness. GABA(A) agonist anesthetics acting on the MPTA might suppress movement by engaging endogenous motor regulatory systems previously identified in research on decerebrate rigidity and REM sleep atonia. Anterograde and retrograde tracing revealed that the MPTA has multiple descending projections to pontine and medullary areas known to be associated with motor control and atonia. Prominent among these are the dorsal pontine reticular formation and components of the rostral ventromedial medulla (RVM). The MPTA also has direct projections to the intermediate gray matter and ventral horn of the spinal cord via the lateral and anterior funiculi. These projections show a rostrocaudal topography: neurons in the rostral MPTA project to the RVM, but only minimally to the spinal cord, while those in the caudal MPTA project to both targets. Finally, the MPTA has ascending projections to motor control areas including the substantia nigra, subthalamic nucleus, and the caudate-putamen. Projections are bilateral with an ipsilateral predominance. We propose that GABA(A) agonist anesthetics induce immobility at least in part by acting on these endogenous motor control pathways via the MPTA. Analysis of MPTA connectivity has the potential for furthering our understanding of the neural circuitry responsible for the various functional components of general anesthesia.

A corticotropin-releasing hormone antisense oligodeoxynucleotide reduces spontaneous waking in the rat

We have previously hypothesized that corticotropin-releasing hormone (CRH) is involved in the regulation of physiological waking. In this study, we tested the hypothesis that reduction of CRH peptide would reduce spontaneous wakefulness of rats. We administered intracerebroventricularly into rats at several circadian time points antisense or sense DNA oligodeoxynucleotides (ODNs) corresponding to the initiation codon of CRH mRNA and determined subsequent effects on wakefulness and sleep of the rat. Our results indicate that CRH antisense oligodeoxynucleotides reduce spontaneous wakefulness during the dark (active) period, but not during the light (rest) period of the light/dark cycle. The alterations in time spent awake are due to reduced wake bout numbers, rather than a change in wake bout duration. These reductions in wakefulness were mirrored by increases in slow-wave sleep, while rapid eye movement sleep was not affected. Corticosterone, used as an index of CRH in the hypothalamus, was reduced by CRH antisense oligodeoxynucleotides during the same time that spontaneous wakefulness was reduced, suggesting CRH peptide modulation as the mediator of this response. In contrast, CRH sense oligodeoxynucleotides did not alter any parameter of this study during either the dark or light period. These findings provide additional support for the hypothesis that CRH is involved in the regulation/modulation of wakefulness.

Physiological and anatomical link between Parkinson-like disease and REM sleep behavior disorder

Parkinson's disease (PD) is a progressive neurodegenerative disease that is caused by a loss of neurons in the ventral midbrain. Parkinsonian patients often experience insomnia, parasomnias, and daytime somnolence. REM sleep behavior disorder (RBD) is characterized by vigorous movements during REM sleep, and may also be caused by neuronal degeneration in the central nervous system (CNS); however, the site of degeneration remains unclear. Both Parkinsonism and RBD become more prevalent with aging, with onset usually occurring in the sixties. Recent findings show that many individuals with RBD eventually develop Parkinsonism. Conversely, it is also true that certain patients diagnosed with Parkinsonism subsequently develop RBD. Postmortem examination reveals that Lewy bodies, Lewy neurites, and alpha-synuclein are found in brainstem nuclei in both Parkinsonism and RBD patients. In this article, we will discuss evidence that Parkinsonism and RBD are physiologically and anatomically linked, based on our animal experiments and other studies on human patients.

Changes in inhibitory amino acid release linked to pontine-induced atonia: an in vivo microdialysis study

We hypothesized that cessation of brainstem monoaminergic systems and an activation of brainstem inhibitory systems are both involved in pontine inhibitory area (PIA) stimulation-induced muscle atonia. In our previous study (Lai et al., 2001), we found a decrease in norepinephrine and serotonin release in motoneuron pools during PIA stimulation-induced muscle tone suppression. We now demonstrate an increase in inhibitory amino acid release in motor nuclei during PIA stimulation in the decerebrate cat using in vivo microdialysis and HPLC analysis techniques. Microinjection of acetylcholine into the PIA elicited muscle atonia and simultaneously produced a significant increase in both glycine and GABA release in both the hypoglossal nucleus and the lumbar ventral horn. Glycine release increased by 74% in the hypoglossal nucleus and 50% in the spinal cord. GABA release increased by 31% in the hypoglossal nucleus and 64% in the spinal cord during atonia induced by cholinergic stimulation of the PIA. As with cholinergic stimulation, 300 msec train electrical stimulation of the PIA elicited a significant increase in glycine release in the hypoglossal nucleus and ventral horn. GABA release was significantly increased in the hypoglossal nucleus but not in the spinal cord during electrical stimulation of the PIA. Glutamate release in the motor nuclei was not significantly altered during atonia induced by electrical or acetylcholine stimulation of the PIA. We suggest that both glycine and GABA play important roles in the regulation of upper airway and postural muscle tone. A combination of decreased monoamine and increased inhibitory amino acid release in motoneuron pools causes PIA-induced atonia and may be involved in atonia linked to rapid eye-movement sleep.

Changes in inhibitory amino acid release linked to pontine-induced atonia: an in vivo microdialysis study

We hypothesized that cessation of brainstem monoaminergic systems and an activation of brainstem inhibitory systems are both involved in pontine inhibitory area (PIA) stimulation-induced muscle atonia. In our previous study (Lai et al., 2001), we found a decrease in norepinephrine and serotonin release in motoneuron pools during PIA stimulation-induced muscle tone suppression. We now demonstrate an increase in inhibitory amino acid release in motor nuclei during PIA stimulation in the decerebrate cat using in vivo microdialysis and HPLC analysis techniques. Microinjection of acetylcholine into the PIA elicited muscle atonia and simultaneously produced a significant increase in both glycine and GABA release in both the hypoglossal nucleus and the lumbar ventral horn. Glycine release increased by 74% in the hypoglossal nucleus and 50% in the spinal cord. GABA release increased by 31% in the hypoglossal nucleus and 64% in the spinal cord during atonia induced by cholinergic stimulation of the PIA. As with cholinergic stimulation, 300 msec train electrical stimulation of the PIA elicited a significant increase in glycine release in the hypoglossal nucleus and ventral horn. GABA release was significantly increased in the hypoglossal nucleus but not in the spinal cord during electrical stimulation of the PIA. Glutamate release in the motor nuclei was not significantly altered during atonia induced by electrical or acetylcholine stimulation of the PIA. We suggest that both glycine and GABA play important roles in the regulation of upper airway and postural muscle tone. A combination of decreased monoamine and increased inhibitory amino acid release in motoneuron pools causes PIA-induced atonia and may be involved in atonia linked to rapid eye-movement sleep.

Brainstem projections to the ventromedial medulla in cat: retrograde transport horseradish peroxidase and immunohistochemical studies

Stimulation of the nucleus magnocellularis (NMC) of the medulla produces changes in locomotion, muscle tone, heart rate, and blood pressure. Glutamatergic input has been found to modulate muscle tone, whereas cholinergic input has been found to mediate cardiovascular changes produced by stimulation of the NMC. The current study was designed to identify the brainstem afferents to NMC by using retrograde transport of wheat germ agglutinin and horseradish peroxidase (WGA-HRP) combined with glutamate and choline acetyltransferase (ChAT) immunohistochemical and nicotinamide adenine dinucleotide phosphate-diaphorase (NADPH-d) histochemical techniques. Fifty nanoliters of 2.5% WGA-HRP were microinjected into the NMC in the cat. A heavy density of WGA-HRP-labeled neurons was found in the ipsilateral mesencephalic reticular formation (MRF), periaqueductal gray, Kolliker-Fuse nucleus, and pontis centralis caudalis (PoC), in the contralateral pontis centralis oralis (PoO), and bilaterally in the nucleus paragigantocellularis lateralis. A moderate density of retrogradely labeled neurons was found in the ipsilateral side of the nuclei parvocellularis, retrorubral (RRN), PoO, and vestibular complex, in the contralateral PoC and nucleus gigantocellularis, and bilaterally in the inferior vestibular nucleus. Retrograde HRP/glutamate-positive cells could be found throughout the brainstem, with a high percentage in RRN, PoO, PoC, and MRF. Double-labeled WGA-HRP/ChAT neurons were found in the pedunculopontine nucleus. Double-labeled WGA-HRP/NADPH-d-positive neurons could be seen in many nuclei of the brainstem, although the number of labeled neurons was small. The dense glutamatergic projections to the NMC support the hypothesis that rostral brainstem glutamatergic mechanisms regulate muscle activity and locomotor coordination via the NMC, whereas the pontine cholinergic projections to the NMC participate in cardiovascular regulation.

The endocrinology of melancholic and atypical depression: relation to neurocircuitry and somatic consequences

The cardinal clinical manifestations of major depression with melancholic features include sustained anxiety and dread for the future as well as evidence of physiological hyperarousal (e.g., sustained hyperactivity of the two principal effectors of the stress response, the corticotropin-releasing-hormone, or CRH, system, and the locus ceruleus-norepinephrine, or LC-NE, system). Sustained stress system activation in melancholic depression is thought to confer both behavioral arousal as well as the hypercortisolism, sympathetic nervous system activation, and inhibition of programs for growth and reproduction that consistently occur in this disorder. Data also suggest that activation of the CRH and LC systems in melancholia are involved in the long-term medical consequences of depression such as premature coronary artery disease and osteoporosis, the two-three-fold preponderance of females in the incidence of major depression, and the mechanism of action of antidepressant drugs. In addition, recent data reveal important bidirectional interactions between stress-system hormonal factors in depression and neural substrates implicated in many discrete behavioral alterations in depression (e.g., the medial prefrontal cortex, important in shifting affect based on internal and external cues, the mesolimbic dopaminergic reward system, and the amygdala fear system). We have also advanced data indicating that the hypersomnia, hyperphagia, lethargy, fatigue, and relative apathy of the syndrome of atypical depression are associated with concomitant hypofunctioning of the CRH and LC-NE systems. These data indicate the need for an entirely different therapeutic strategy than that used in melancholia for the treatment of atypical depression, and they suggest that this subtype of major depression will be associated with its own unique repertoire of long-term medical consequences.

Locus coeruleus electrophysiological activity and responsivity to corticotropin-releasing factor in inbred hypertensive and normotensive rats

The spontaneously hypertensive rat (SHR) and its normotensive progenitor, the Wistar-Kyoto rat (WKY), have been shown to be differentially responsive to the behavioral and endocrine effects of both stress and corticotropin-releasing factor (CRF), both of which increase locus coeruleus (LC) electrophysiological activity. However, the effect of central administration of CRF in these rat strains has yet to be examined. In the present studies, LC electrophysiological responsivity to intracerebroventricular infusions of CRF was assessed in SHR, an inbred strain of WKY rats (the WKY[LJ] rat), and an outbred normotensive rat strain, Sprague-Dawley (SD) rats. Spontaneous LC discharge rate, mean arterial blood pressure and heart rate were also examined. LC activity was increased to the same extent in the three rat strains in response to a 3 microg dose of CRF. However, WKY(LJ) rats showed an exaggerated LC in response to a 1 microg dose of CRF in comparison to the other rat strains tested at this dose. Spontaneous discharge rates of individual LC neurons were lower in both SHR and WKY[LJ] rats than in SD rats. Further, the variability of the discharge rates of LC neurons was greater in WKY[LJ] rats than in the other two strains. These results indicate that the WKY[LJ] rat may provide a useful model for assessing the role of sensitivity to CRF in stress responsiveness.

Brainstem-mediated locomotion and myoclonic jerks. II Pharmacological effects

Previous studies in our laboratory have demonstrated that microinjection of N-methyl-D-aspartate (NMDA) agonist into the nucleus magnocellularis (NMC) of the medial medulla increases muscle tone and/or produces locomotion, while injection of corticotropin-releasing factor (CRF) and non-NMDA agonists into the same or nearby sites suppresses muscle tone. In the first paper of this series, we report that myoclonic twitches or coordinated rhythmic leg movement (locomotion) can be induced by either NMDA or hemorrhagic bilateral lesion of the ventral mesopontine junction (vMPJ). In this paper, we report that microinjection of CRF (10 nM) or non-NMDA agonists, kainic acid (0.1-0.2 mM) and quisqualic acid (1-10 mM), into the NMC block locomotion and myoclonic twitches. The latency and duration of CRF and non-NMDA agonist-induced blockade of motor activity were short, at 34 s and 3.6 min, respectively. However, microinjection of the NMDA agonists DL-2-amino-5-phosphonovaleric acid (APV; 50 mM) or DL-2-amino-5-phosphonopentanoic acid (AP5, 20 mM) block myoclonus at a latency of 0.6-3 min with the block lasting for a mean of 7 h. Thus, activation of non-NMDA receptors or inactivation of NMDA receptors in NMC can block myoclonus. An imbalance between the inputs to these receptor systems may contribute to the generation of abnormal motor activation in waking and sleep.

Corticotropin-releasing hormone involvement in stressor-induced alterations in sleep and in the regulation of waking

Sleep responds to a variety of stressors, but the precise mechanisms whereby these alterations occur are not known. Ample evidence, however, testifies to corticotropin-releasing hormone (CRH) being uniquely situated to contribute to stressor-induced alterations in sleep. Behavioral responses to most stressors include periods of increased arousal and waking, regardless of whether the stressor is psychological in nature or results in physical insult. Furthermore, a large body of evidence suggests that CRH may also contribute to the regulation and maintenance of physiological waking. In this paper we hypothesize that CRH mediates waking, particularly after periods of exposure to acute stressors. The complex interactions of multiple systems determine the behavioral response to a particular stressor. As such, many factors determine the time course and duration of response, including stressor type, and the status of a particular system at the time of stressor presentation. We briefly review data indicating that CRH mediates physiological and behavioral responses to stressors, and present new data supporting the hypothesis that CRH may also be involved in the physiological regulation of waking.

Hemilabyrinthectomy causes both an increase and a decrease in corticotropin releasing factor mRNA in rat inferior olive

It was previously shown [NeuroReport, 3 (1992) 829-832] that unilateral labyrinthectomy (UL) induces Fos expression in several brainstem regions, including the beta subnucleus of the inferior olive. Using isotopic 33P in situ hybridization, the present results demonstrate significant changes in oligonucleotide-probed mRNA levels for corticotropin-releasing factor (CRF) in the rat inferior olivary nucleus 4 days following unilateral labyrinthectomy (UL). In the medulla of normal animals there was strong CRF mRNA labeling in the inferior olivary nucleus, and weaker labeling in the vestibular nuclei and prepositus hypoglossi. Following unilateral labyrinthectomy, the contralateral olivary beta subnucleus showed a significant increase in CRF message, similar to the contralateral Fos labeling observed after hemilabyrinthectomy [NeuroReport, 3 (1992) 829-832]. In addition, the contralateral A and B subnuclei (IOA/B) of the inferior olive showed a strong increase in CRF labeling, while the ipsilateral dorsal cap of Kooy (IOK) showed a decrease. This novel bidirectional alteration in CRF message in different subdivisions of the same nuclear group indicates the existence of both up and down regulatory mechanisms controlling CRF peptide expression, and reflects the dynamic neurochemical alterations occurring during vestibular compensation.

Pathophysiology of massive infantile spasms: perspective on the putative role of the brain adrenal axis

Massive infantile spasms are an age-specific seizure syndrome of infancy. Uniquely, the spasms respond to hormonal manipulation using adrenocorticotropic hormone (ACTH) or glucocorticoids. A hypothesis explaining the efficacy of hormonal therapy, age-specificity, multiple causative factors, and spontaneous resolution of infantile spasms is presented. Corticotropin-releasing hormone (CRH), an excitant neuropeptide suppressed by ACTH/steroids, is implicated. Evidence for the age-specific convulsant properties of CRH is presented, and a putative scenario in which a stress-induced enhancement of endogenous CRH-mediated seizures is discussed. Clinical testing of the CRH-excess theory and its therapeutic implications are suggested.