Effects of bilateral kindling or bilateral sub-threshold stimulation of the amygdala or septum on muricide, ranacide, intraspecific aggression and passive avoidance in the rat

Deep brain stimulation of the basolateral amygdala for treatment-refractory combat post-traumatic stress disorder (PTSD): study protocol for a pilot randomized controlled trial with blinded, staggered onset of stimulation

BACKGROUND

Combat post-traumatic stress disorder (PTSD) involves significant suffering, impairments in social and occupational functioning, substance use and medical comorbidity, and increased mortality from suicide and other causes. Many veterans continue to suffer despite current treatments. Deep brain stimulation (DBS) has shown promise in refractory movement disorders, depression and obsessive-compulsive disorder, with deep brain targets chosen by integration of clinical and neuroimaging literature. The basolateral amygdala (BLn) is an optimal target for high-frequency DBS in PTSD based on neurocircuitry findings from a variety of perspectives. DBS of the BLn was validated in a rat model of PTSD by our group, and limited data from humans support the potential safety and effectiveness of BLn DBS.

METHODS/DESIGN

We describe the protocol design for a first-ever Phase I pilot study of bilateral BLn high-frequency DBS for six severely ill, functionally impaired combat veterans with PTSD refractory to conventional treatments. After implantation, patients are monitored for a month with stimulators off. An electroencephalographic (EEG) telemetry session will test safety of stimulation before randomization to staggered-onset, double-blind sham versus active stimulation for two months. Thereafter, patients will undergo an open-label stimulation for a total of 24 months. Primary efficacy outcome is a 30% decrease in the Clinician Administered PTSD Scale (CAPS) total score. Safety outcomes include extensive assessments of psychiatric and neurologic symptoms, psychosocial function, amygdala-specific and general neuropsychological functions, and EEG changes. The protocol requires the veteran to have a cohabiting significant other who is willing to assist in monitoring safety and effect on social functioning. At baseline and after approximately one year of stimulation, trauma script-provoked 18FDG PET metabolic changes in limbic circuitry will also be evaluated.

DISCUSSION

While the rationale for studying DBS for PTSD is ethically and scientifically justified, the importance of the amygdaloid complex and its connections for a myriad of emotional, perceptual, behavioral, and vegetative functions requires a complex trial design in terms of outcome measures. Knowledge generated from this pilot trial can be used to design future studies to determine the potential of DBS to benefit both veterans and nonveterans suffering from treatment-refractory PTSD.

TRIAL REGISTRATION

PCC121657, 19 March 2014.

The amygdala as a target for behavior surgery

The amygdala was a popular target during the era of psychosurgery, specifically for the treatment of intractable aggression. This mesiotemporal structure was thought to primarily mediate fear and anger. However, recent evidence suggests that the amygdala is part of a complex network that mediates the formation of a larger repertoire of positive and negative emotions. Dysfunctions within the network or the amygdala itself can lead to various mental illnesses. In those cases, deep brain stimulation (DBS) applied focally may treat the symptoms. This review presents data supporting the potential therapeutic role of DBS of the amygdala in the treatment of anxiety disorders, addiction, and mood disorders. The success of DBS for psychiatric conditions will likely depend on our ability to precisely determine the optimal target for a specific case.

Antagonism of peripheral inflammation reduces the severity of status epilepticus

Status epilepticus (SE) is one of the most serious manifestations of epilepsy. Systemic inflammation and damage of blood-brain barrier (BBB) are etiologic cofactors in the pathogenesis of pilocarpine SE while acute osmotic disruption of the BBB is sufficient to elicit seizures. Whether an inflammatory-vascular-BBB mechanism could apply to the lithium-pilocarpine model is unknown. LiCl facilitated seizures induced by low-dose pilocarpine by activation of circulating T-lymphocytes and mononuclear cells. Serum IL-1beta levels increased and BBB damage occurred concurrently to increased theta EEG activity. These events occurred prior to SE induced by cholinergic exposure. SE was elicited by lithium and pilocarpine irrespective of their sequence of administration supporting a common pathogenetic mechanism. Since IL-1beta is an etiologic trigger for BBB breakdown and its serum elevation occurs before onset of SE early after LiCl and pilocarpine injections, we tested the hypothesis that intravenous administration of IL-1 receptor antagonists (IL-1ra) may prevent pilocarpine-induced seizures. Animals pre-treated with IL-1ra exhibited significant reduction of SE onset and of BBB damage. Our data support the concept of targeting systemic inflammation and BBB for the prevention of status epilepticus.

Amygdaloid kindling is anxiogenic but fails to alter object recognition or spatial working memory in rats

Kindling in rats produces enduring behavioral changes that parallel the psychobehavioral disturbances frequently accompanying temporal lobe epilepsy. Some evidence suggests that the site of kindling is an important determinant of the type of behavioral changes observed following kindling, although this variable has not been systematically investigated. In the present experiments, the effects of amygdaloid kindling were assessed on a battery of behavioral tests we used previously to assess the effects of kindling in dorsal hippocampus or perirhinal cortex. Three generalized seizures were kindled with stimulation in or near the basolateral amygdala. One week later, rats were tested successively on measures of anxiety, activity, object recognition memory, and spatial working memory over a period of 3 weeks. Amygdaloid kindling produced increased anxiety, but spared all other behaviors assessed. This pattern of results is partially distinct from the previously described effects of perirhinal cortical kindling, which increases anxiety but also impairs object recognition memory, and is completely distinct from dorsal hippocampal kindling, which selectively increases activity and impairs spatial working memory. The observations suggest that kindling of distinct highly interconnected temporal lobe sites produces distinct patterns of behavioral comorbidity. The underlying mechanisms are thus most likely localized to intrinsic circuits at the site of seizure origination.

In vivo and in vitro effects of pilocarpine: relevance to ictogenesis

OBJECTIVES

A common experimental model of status epilepticus (SE) utilizes intraperitoneal administration of the cholinergic agonist pilocarpine preceded by methyl-scopolamine treatment. Currently, activation of cholinergic neurons is recognized as the only factor triggering pilocarpine SE. However, cholinergic receptors are also widely distributed systemically and pretreatment with methyl-scopolamine may not be sufficient to counteract the effects of systemically injected pilocarpine. The extent of such peripheral events and the contribution to SE are unknown and the possibility that pilocarpine also induces SE by peripheral actions is yet untested.

METHODS

We measured in vivo at onset of SE: brain and blood pilocarpine levels, blood-brain barrier (BBB) permeability, T-lymphocyte activation and serum levels of IL-1beta and TNF-alpha. The effects of pilocarpine on neuronal excitability was assessed in vitro on hippocampal slices or whole guinea pig brain preparations in presence of physiologic or elevated [K+](out).

RESULTS

Pilocarpine blood and brain levels at SE were 1400 +/- 200 microM and 200 +/- 80 microM, respectively. In vivo, after pilocarpine injection, increased serum IL-1beta, decreased CD4:CD8 T-lymphocyte ratios and focal BBB leakage were observed. In vitro, pilocarpine failed to exert significant synchronized epileptiform activity when applied at concentrations identical or higher to levels measured in vivo. Intense electrographic seizure-like events occurred only in the copresence of levels of K+ (6 mM) mimicking BBB leakage.

CONCLUSIONS

Early systemic events increasing BBB permeability may promote entry of cofactors (e. g. K+) into the brain leading to pilocarpine-induced SE. Disturbance of brain homeostasis represents an etiological factor contributing to pilocarpine seizures.

The mnemonic effects of kindling

Kindling produces enduring changes in the brain that are evident in not only enhanced susceptibility to seizure-evoking stimuli but also alterations in non-epileptic behaviors or functions. The present review examines the effects of kindling on one class of non-epileptic functions, learning and memory, and explores the dependence of these effects on variables such as the site of kindling, extent of kindling, and interval between kindling and testing. Current research shows that kindling is capable of altering performance on a variety of tasks including those that require spatial cognition, aversive conditioning, and object-related cognition and that non-mnemonic effects are unlikely, in at least some cases, to underlie these effects. Consideration of the conditions under which these effects are observed indicates a distinct relation between specific mnemonic effects and both the site and extent of kindling. Continued characterization of the mnemonic effects of kindling should provide a theoretical framework to guide discovery of their underlying mechanisms, which, in turn, may lead to rational therapy for mnemonic dysfunction associated with epilepsy and insights into the mechanisms of learning and memory.

The long lasting effects of electrical simulation of the medial preoptic area and medial amygdala on maternal behavior in female rats

A program of repeated electrical (kindling-like) stimulation of the medial preoptic area (MPOA) or the medial amygdala (MedAmyg) on maternal and other behaviors were investigated. Stimulation was applied daily for 14 days (or until a stage 3 motor seizure was observed) using 2 s trains of biphasic square wave pulses at 60 Hz, 1 ms duration and 300-500 microA. Confirmation of afterdischarge using these parametres was established. In the first experiment, maternally experienced (but not post-partum) MedAmyg stimulated animals became maternal more slowly than did MedAmyg not stimulated animals or than MPOA stimulated animals. In the second experiment, virgin animals were used. MPOA stimulation enhanced the female's preference for pup associated environments in the conditioned place preference (CPP) paradigm. MedAmyg stimulation had no effect on CPP performance, but produced a decreased preference for pup odors in a modified hole board test and increased 'anxiety' in the open field. These results confirm that the MPOA and the MedAmyg are involved in facilitating and attenuating maternal responsiveness and related (precursor?) behaviors, respectively. It appears that chronic (kindling-like) stimulation of these neural substrates enhances their functions.

Decreased voluntary ethanol selection in amygdala-kindled rats

Kindled and control rats were exposed to either ethanol or dextrose solutions in the limited access paradigm, a paradigm that allows access to the test solution for only 1 h each day. Limited access trials were initiated either 24 h or 30 days after the fifth stage 5 seizure had been elicited in the kindled subjects. As previously reported, increased voluntary ethanol selection was observed in the limited access paradigm. Kindled subjects, however, ingested significantly less ethanol than controls. This difference was found both when limited access trials were started 24 h after the last seizure and when they were started 30 days after the last seizure. Kindled and control subjects did not differ in their intake of dextrose solutions.

Functional dissociation of acute and persistent cognitive deficits accompanying amygdala-kindled seizures

The effects of amygdala-kindled seizures on cognitive function were examined using long-delay flavor-aversion and passive-avoidance conditioning paradigms in rats. Experiments were conducted to compare the functional consequences of unilateral and bilateral kindled seizures (transient deficits) with those due to a kindling history only (persistent deficits). Animals with a history of unilateral or bilateral kindling demonstrated flavor-aversion conditioning that varied inversely with the delay separating saccharin (CS) and lithium (US). Unilateral stimulation during the CS-US interval produced an attenuation of flavor-aversion conditioning that was independent of delay value; bilateral stimulation eliminated conditioning all together. The effects of kindling and kindled seizures on passive-avoidance conditioning were functionally identical. Animals with a history of unilateral kindling demonstrated strong evidence of conditioning with no effect of posttraining seizures. In contrast, animals with a history of bilateral kindling were impaired in a passive-avoidance task. The impairment was evident in the presence or absence of seizure induction during training. Electrographic and behavioral indices of epileptiform activity produced by unilateral and bilateral stimulation failed to reveal any differences in seizure duration or severity. The results support the conclusion that cognitive disruption by amygdala-kindled seizures is task-dependent, does not show a temporal dependence, and cannot be explained on the basis of electrographic or behavioral measures of seizure severity alone.

Behavioral effects of kainic acid administration on the immature brain

Prepubescent male rats with an amygdaloid electrode in place were administered kainic acid (KA) intraperitoneally (i.p.) while controls received phosphate-buffered saline (PBS). All KA-treated animals developed status epilepticus with bilateral forelimb clonus and ictal discharges on the EEG. The rats were then tested as adults for learning, memory, emotionality, social interaction, and activity level using the T maze, water maze, handling test, home cage intruder test, and open field test. KA-treated rats learned at a slower rate in the water maze and T maze than the controls. In addition, KA-treated rats had evidence of impaired memory during spatial bias testing in the water maze. In the home cage intruder test, KA-treated animals were more submissive and less aggressive than control animals. Finally, KA-treated animals were significantly more active than control animals in the open field test. This study demonstrates that KA administration to the immature brain, in a convulsant dose, results in permanent changes in behavior, learning, and memory.

A [14C]2-deoxyglucose analysis of the functional neural pathways of the limbic forebrain in the rat. V. The septal area

The [14C]2-deoxyglucose (2-DG) metabolic mapping technique has been used to identify the regions responding with an augmented rate of metabolism following focal electrical stimulation of various sites within the lateral septal nucleus and medial septal nucleus/diagonal band (MSN/DB) complex in the rat. Since 2-DG uptake has been correlated with rates of functional activity, it was the intention of this study to suggest the anatomical substrates underlying various physiological and behavioral responses elicited by stimulation of the septal area. The results show that stimulation of any region within the lateral septal nucleus produced a profound bilateral activation of both the lateral septal nucleus, as well as the hippocampal formation. While stimulation of a number of different fiber systems associated with the lateral septum could contribute to the observed pattern of labeling, the data suggest that, functionally, a major consequence of such stimulation is the antidromic activation of CA3----lateral septum fibers to axonal branch points, beyond which, orthodromic propagation of the impulse produces activation in CA3 target regions, including subfields CA1 and CA3, as well as the lateral septal nucleus, bilaterally. In addition, regions typically manifesting metabolic activation following stimulation of the lateral septal nucleus included the ipsilateral diagonal band of Broca, nucleus accumbens, lateral preoptic area and lateral hypothalamus, posteriorly, and the prelimbic cortex, anteriorly. Occasionally, target regions of the postcommissural fornix, including the medial mammillary nucleus and anterior thalamic nuclei were also activated following stimulation of the lateral septal nucleus. In contrast to the widespread pattern of activation resulting from stimulation of the lateral septal nucleus, stimulation of the MSN/DB complex produced activation which was largely confined to the medial forebrain bundle. In a final phase of the experiment, afterdischarge activity was elicited by sodium penicillin injection into the lateral septal nucleus. Such treatment produced more widespread 2-DG uptake, including more extensive activation within the lateral septal nucleus, hippocampal formation, amygdala, and thalamus. Additionally, the prefrontal cortex and temporal neocortex were activated.

Metabolic and behavioral consequences of lidocaine-kindled seizures

Daily administration of lidocaine results in progressive increases in frequency and duration of convulsions in response to a dose of drug which was previously subconvulsive--a pharmacological kindling phenomenon. The effects of such lidocaine-kindling on local cerebral glucose utilization were determined by the 2-[14C]deoxyglucose method. Lidocaine-treated animals, in the absence of convulsions, exhibited decreased glucose utilization in most brain structures compared to saline-treated animals and showed no increase in aggressive behavior. In animals displaying lidocaine-kindled convulsions there were marked increases in glucose utilization in either the hippocampus and amygdala or in perirhinal cortical areas during the seizure administration; these animals also displayed long-lasting increases in irritable behavior. Seizure duration was positively correlated with the rate of glucose utilization in the hippocampus, amygdala and septum, but inversely correlated in several non-limbic areas. These data suggest that lidocaine-kindled seizures are highly localized to limbic and perirhinal structures and are associated with important behavioral consequences.

An analysis of the mechanisms underlying septal area control of hypothalamically elicited aggression in the cat

This experiment was performed in order to examine several of the underlying mechanisms by which the septal area and adjacent regions regulate quiet biting attack behavior elicited from electrical stimulation of the hypothalamus in the cat. The results clearly indicate that stimulation of the septal area and anterior cingulate gyrus increased the latency for the occurrence of quiet biting attack behavior. Those sites within the septal area from which inhibition of attack can be produced are linked to sensory mechanisms associated with trigeminal reflexes activated during hypothalamic stimulation. Stimulation of these septal area sites decreased the lateral extent of the 'effective sensory fields' of the lipline established during hypothalamic stimulation, but did not appear to have any affect upon the latency of the hypothalamically elicited jaw-opening response. Deoxyglucose autoradiography revealed that the inhibition resulting from stimulation of the lateral septal area may be due to either the monosynaptic activation of the lateral hypothalamus or the disynaptic activation of this area utilizing a circuit involving the nuclei of the diagonal band of Broca.

Changes in amygdaloid afterdischarges and kindling effect following olfactory bulbectomy in the rat

Changes in the thresholds for afterdischarges and the formation of kindling effect in the medial amygdala following olfactory bulbectomy were investigated in the rat with chronic electrode implants. The threshold for afterdischarges in the amygdala of the olfactory bulbectomized rat (OB rat) was significantly decreased on day 4 after olfactory bulbectomy, however, no significant difference was found between OB and sham operated rats on days 7, 14 and 21 since the threshold in the sham group was also decreased at these periods after the surgery. The formation of kindling effect was remarkably accelerated in the OB rats. In this case, the number of days required to reach the stage 1 (Racine's classification) was significantly shortened. These results suggest that the activity of the medial amygdaloid nucleus is increased following olfactory bulbectomy.

The effect of amygdala kindling on spontaneous and cocaine-induced motor activity and lidocaine seizures

Interactions of amygdala kindling and drug effects were explored in two experiments. Pretreatment with cocaine (40 mg/kg, IP) for 10 days did not significantly affect the rate of amygdala kindling compared to saline or non-kindled controls. In contrast, daily amygdala kindling with 200 microA for 0.5 s for 20 days substantially altered subsequent behavioral responses in a long-lasting fashion. Animals showed decreased spontaneous vertical rearing activity, as well as decreased cocaine-induced vertical activity. In contrast, they were more reactive to the direct dopamine receptor agonist apomorphine. Eighteen days following completion of amygdala kindling, kindled animals were more sensitive to lidocaine-induced convulsions; 88% of kindled animals, but only 24% of the implanted sham-stimulated controls, had seizures. These data suggest that amygdala kindling may produce long-lasting changes in selected spontaneous and drug-induced behaviors, as well as convulsive thresholds. Possible physiological and neurological changes underlying this altered responsivity are discussed.