Levetiracetam in brain ischemia: clinical implications in neuroprotection and prevention of post-stroke epilepsy

Epigenetic Regulation of Neuroinflammation in Alzheimer's Disease

Alzheimer's disease (AD) is a chronic and progressive neurodegenerative disease and clinically manifests with cognitive decline and behavioral disabilities. Over the past years, mounting studies have demonstrated that the inflammatory response plays a key role in the onset and development of AD, and neuroinflammation has been proposed as the third major pathological driving factor of AD, ranking after the two well-known core pathologies, amyloid β (Aβ) deposits and neurofibrillary tangles (NFTs). Epigenetic mechanisms, referring to heritable changes in gene expression independent of DNA sequence alterations, are crucial regulators of neuroinflammation which have emerged as potential therapeutic targets for AD. Upon regulation of transcriptional repression or activation, epigenetic modification profiles are closely involved in inflammatory gene expression and signaling pathways of neuronal differentiation and cognitive function in central nervous system disorders. In this review, we summarize the current knowledge about epigenetic control mechanisms with a focus on DNA and histone modifications involved in the regulation of inflammatory genes and signaling pathways in AD, and the inhibitors under clinical assessment are also discussed.

Clinical characteristics and outcomes of patients with post-stroke epilepsy: protocol for an individual patient data meta-analysis from the International Post-stroke Epilepsy Research Repository (IPSERR)

INTRODUCTION

Despite significant advances in managing acute stroke and reducing stroke mortality, preventing complications like post-stroke epilepsy (PSE) has seen limited progress. PSE research has been scattered worldwide with varying methodologies and data reporting. To address this, we established the International Post-stroke Epilepsy Research Consortium (IPSERC) to integrate global PSE research efforts. This protocol outlines an individual patient data meta-analysis (IPD-MA) to determine outcomes in patients with post-stroke seizures (PSS) and develop/validate PSE prediction models, comparing them with existing models. This protocol informs about creating the International Post-stroke Epilepsy Research Repository (IPSERR) to support future collaborative research.

METHODS AND ANALYSIS

We utilised a comprehensive search strategy and searched MEDLINE, Embase, PsycInfo, Cochrane, and Web of Science databases until 30 January 2023. We extracted observational studies of stroke patients aged ≥18 years, presenting early or late PSS with data on patient outcome measures, and conducted the risk of bias assessment. We did not apply any restriction based on the date or language of publication. We will invite these study authors and the IPSERC collaborators to contribute IPD to IPSERR. We will review the IPD lodged within IPSERR to identify patients who developed epileptic seizures and those who did not. We will merge the IPD files of individual data and standardise the variables where possible for consistency. We will conduct an IPD-MA to estimate the prognostic value of clinical characteristics in predicting PSE.

ETHICS AND DISSEMINATION

Ethics approval is not required for this study. The results will be published in peer-reviewed journals. This study will contribute to IPSERR, which will be available to researchers for future PSE research projects. It will also serve as a platform to anchor future clinical trials.

TRIAL REGISTRATION NUMBER

NCT06108102.

Pharmacokinetic considerations surrounding the use of levetiracetam for seizure prophylaxis in neurocritical care - an overview

INTRODUCTION

Levetiracetam (LEV) is one of the most widely used anti-seizure medications (ASMs) in clinical practice. This is due both to a different mechanism of action when compared to other ASMs and its easy handling. Indeed, because of its interesting pharmacokinetic properties, it is often used outside of the labelled indications, notably in the neurocritical setting as prophylaxis of epileptic seizures.

AREAS COVERED

A literature search was conducted and the most relevant studies on the pharmacokinetic properties of LEV were selected by two independent investigators. Current evidence on the use of ASM prophylaxis in the neurocritical setting was also reviewed, highlighting and discussing the strengths and limits of LEV as drug of choice for anti-epileptic prophylaxis in this scenario.

EXPERT OPINION

LEV has a "near-ideal" pharmacokinetic profile, which makes it an attractive drug for ASM prophylaxis in neurocritical care. However, current recommendations restrict ASMs prophylaxis to very selected circumstances and the role of LEV is marginal. Moreover, studies are generally designed to compare LEV versus phenytoin, whereas studies comparing LEV versus placebo are lacking. Further randomized trials will be needed to better elucidate LEV utility and its neuroprotective role in the neurocritical setting.

Levetiracetam alleviates cognitive decline in Alzheimer’s disease animal model by ameliorating the dysfunction of the neuronal network

Background

Patients with Alzheimer’s disease (AD) have a significantly higher risk of seizures than other individuals in an age-matched population, suggesting a close association between epilepsy and AD. We aimed to examine the effects of levetiracetam (LEV)—a drug for treating seizures—on learning and memory and the neuropathological features of AD.

Methods

We crossbred APP23 mice with microtubule-associated protein tau (MAPT) transgenic mice to generate APP23/MAPT mice. These mice were treated with different concentrations of LEV in the presence of kainic acid (KA) for 3 months.

Results

Low doses of LEV alleviated the effects of KA on memory defects in APP23/MAPT mice. Mechanistic investigations showed that low concentrations of LEV decreased tau phosphorylation by reducing the activities of cyclin-dependent kinase 5 and glycogen synthase kinase 3α/β, thus rescuing neurons from synaptic dystrophy and apoptosis. Low doses of LEV inhibited the effects of KA (i.e., inducing neuroinflammation and impairing the autophagy of amyloid β-peptide), thus improving cognitive decline. High concentrations of LEV decreased the production and deposition of amyloid β-peptide (Aβ) by reducing the expression of β-site APP-cleaving enzyme 1 and presenilin 1. However, high concentrations of LEV also induced neuronal apoptosis, decreased movement ability in mice, and did not alleviate cognitive decline in AD mice.

Conclusion

Our results support the hypothesis that aberrant network activity contributes to the synaptic and cognitive deficits in APP23/MAPT mice. A low concentration of LEV may help ameliorate abnormalities of AD; however, a high LEV concentration did not induce similar results.

Levetiracetam Mechanisms of Action: From Molecules to Systems

Epilepsy is a chronic disease that affects millions of people worldwide. Antiepileptic drugs (AEDs) are used to control seizures. Even though parts of their mechanisms of action are known, there are still components that need to be studied. Therefore, the search for novel drugs, new molecular targets, and a better understanding of the mechanisms of action of existing drugs is still crucial. Levetiracetam (LEV) is an AED that has been shown to be effective in seizure control and is well-tolerable, with a novel mechanism of action through an interaction with the synaptic vesicle protein 2A (SV2A). Moreover, LEV has other molecular targets that involve calcium homeostasis, the GABAergic system, and AMPA receptors among others, that might be integrated into a single mechanism of action that could explain the antiepileptogenic, anti-inflammatory, neuroprotective, and antioxidant properties of LEV. This puts it as a possible multitarget drug with clinical applications other than for epilepsy. According to the above, the objective of this work was to carry out a comprehensive and integrative review of LEV in relation to its clinical uses, structural properties, therapeutical targets, and different molecular, genetic, and systemic action mechanisms in order to consider LEV as a candidate for drug repurposing.

Seizures and epilepsy in patients with ischaemic stroke

BACKGROUND

With the increased efficacy of stroke treatments, diagnosis and specific treatment needs of patients with post-stroke seizures (PSS) and post-stroke epilepsy have become increasingly important. PSS can complicate the diagnosis of a stroke and the treatment of stroke patients, and can worsen post-stroke morbidity. This narrative review considers current treatment guidelines, the specifics of antiseizure treatment in stroke patients as well as the state-of-the-art in clinical and imaging research of post-stroke epilepsy. Treatment of PSS needs to consider indications for antiseizure medication treatment as well as individual clinical and social factors. Furthermore, potential interactions between stroke and antiseizure treatments must be carefully considered. The relationship between acute recanalizing stroke therapy (intravenous thrombolysis and mechanical thrombectomy) and the emergence of PSS is currently the subject of an intensive discussion. In the subacute and chronic post-stroke phases, important specific interactions between necessary antiseizure and stroke treatments (anticoagulation, cardiac medication) need to be considered. Among all forms of prevention, primary prevention is currently the most intensively researched. This includes specifically the repurposing of drugs that were not originally developed for antiseizure properties, such as statins. PSS are presently the subject of extensive basic clinical research. Of specific interest are the role of post-stroke excitotoxicity and blood-brain barrier disruption for the emergence of PSS in the acute symptomatic as well as late (> 1 week after the stroke) periods. Current magnetic resonance imaging research focussing on glutamate excitotoxicity as well as diffusion-based estimation of blood-brain barrier integrity aim to elucidate the pathophysiology of seizures after stroke and the principles of epileptogenesis in structural epilepsy in general. These approaches may also reveal new imaging-based biomarkers for prediction of PSS and post-stroke epilepsy.

CONCLUSION

PSS require the performance of individual risk assessments, accounting for the potential effectiveness and side effects of antiseizure therapy. The use of intravenous thrombolysis and mechanical thrombectomy is not associated with an increased risk of PSS. Advances in stroke imaging may reveal biomarkers for PSS.

Superior antioxidant and anti-ischemic neuroprotective effects of cerebrolysin in heat stroke following intoxication of engineered metal Ag and Cu nanoparticles: A comparative biochemical and physiological study with other stroke therapies

Military personnel are often exposed to high environmental heat associated with industrial or ambient abundance of nanoparticles (NPs) affecting brain function. We have shown that engineered metal NPs Ag and Cu exacerbate hyperthermia induced brain pathology. Thus, exploration of novel drug therapy is needed for effective neuroprotection in heat stroke intoxicated with NPs. In this investigation neuroprotective effects of cerebrolysin, a balanced composition of several neurotrophic factors and active peptides fragments exhibiting powerful antioxidant and anti-ischemic effects was examined in heat stroke after NPs intoxication. In addition, its efficacy is compared to currently used drugs in post-stroke therapies in clinics. Thus, levertiracetam, pregabalin, topiramat and valproate were compared in standard doses with cerebrolysin in heat stroke intoxicated with Cu or Ag NPs (50-60nm, 50mg/kg, i.p./day for 7 days). Rats were subjected to 4h heat stress (HS) in a biological oxygen demand incubator at 38°C (Relative Humidity 45-47%; Wind velocity 22.4-25.6cm/s) that resulted in profound increase in oxidants Luminol, Lucigenin, Malondialdehyde and Myeloperoxidase, and a marked decrease in antioxidant Glutathione. At this time severe reductions in the cerebral blood flow (CBF) was seen together with increased blood-brain barrier (BBB) breakdown and brain edema formation. These pathophysiological responses were exacerbated in NPs treated heat-stressed animals. Pretreatment with cerebrolysin (2.5mL/kg, i.v.) once daily for 3 days significantly attenuated the oxidative stress, BBB breakdown and brain edema and improved CBF in the heat stressed group. The other drugs were least effective on brain pathology following heat stroke. However, in NPs treated heat stressed animals 5mL/kg conventional cerebrolysin and 2.5mL/kg nanowired cerebrolysin is needed to attenuate oxidative stress, BBB breakdown, brain edema and to improve CBF. Interestingly, the other drugs even in higher doses used are unable to alter brain pathologies in NPs and heat stress. These observations are the first to demonstrate that cerebrolysin is the most superior antioxidant and anti-ischemic drug in NPs exposed heat stroke, not reported earlier.

Internal Carotid Dissection as the Cause of Stroke in Childhood

Internal carotid artery (ICA) dissection is a cause of stroke, but it is often underdiagnosed in children. ICAs' risk factors and pathogenic mechanisms are poorly understood, and the treatment is still empirical. We report the case of a previously healthy 9-year-old girl who presented with involuntary hypertonic closure of the right hand associated with transient difficulty for both fine movements of the right arm and speech. She had a history of minor cervical trauma occurring 20 days prior to our observation without other associated risk factors. Magnetic resonance imaging and magnetic resonance angiography showed ischemic lesions due to the left ICA dissection. Treatment with both acetylsalicylic acid and levetiracetam allowed recanalization of the ICA associated with the resolution of clinical signs. Our clinical case suggests that the ICA dissection must be suspected early whenever a child manifests mild neurologic deficits after a cervical trauma, especially if they are associated with headache and/or cervical pain. Moreover, the management of ICA dissection must be improved.

Drug Repurposing in Neurological Disorders: Implications for Neurotherapy in Traumatic Brain Injury

Traumatic brain injury (TBI) remains a significant leading cause of death and disability among adults and children globally. To date, there are no Food and Drug Administration-approved drugs that can substantially attenuate the sequelae of TBI. The innumerable challenges faced by the conventional de novo discovery of new pharmacological agents led to the emergence of alternative paradigm, which is drug repurposing. Repurposing of existing drugs with well-characterized mechanisms of action and human safety profiles is believed to be a promising strategy for novel drug use. Compared to the conventional discovery pathways, drug repurposing is less costly, relatively rapid, and poses minimal risk of the adverse outcomes to study on participants. In recent years, drug repurposing has covered a wide range of neurodegenerative diseases and neurological disorders including brain injury. This review highlights the advances in drug repurposing and presents some of the promising candidate drugs for potential TBI treatment along with their possible mechanisms of neuroprotection. Edaravone, glyburide, ceftriaxone, levetiracetam, and progesterone have been selected due to their potential role as putative TBI neurotherapeutic agents. These drugs are Food and Drug Administration-approved for purposes other than brain injuries; however, preclinical and clinical studies have shown their efficacy in ameliorating the various detrimental outcomes of TBI.

Predictors of Seizure Recurrence after Acute Symptomatic Seizures in Ischemic Stroke Patients

PURPOSE

Seizure is a well-recognized complication of both remote and acute ischemic strokes. Predictors of seizure recurrence and epilepsy in patients with ischemic stroke who develop acute symptomatic seizures (ASyS) on continuous electroencephalography (cEEG) have not been well studied.

METHODS

We present a five-year retrospective study of acute and remote ischemic stroke patients who developed ASyS on cEEG. We then identified risk factors for the development of seizure recurrence.

RESULTS

Sixty-five patients with ischemic stroke and ASyS were identified and reviewed. All ASyS were noted to be nonconvulsive seizures. Clinical recurrence of seizures was identified in 19 of these patients (29.2%) at follow-up. Rate of seizure recurrence was higher in remote ischemic stroke patients (84.2%), compared to acute ischemic stroke patients (15.8%, p = 0.0116, OR 0.17, 95% CI 0.049-0.65). Sharp waves/spikes on follow-up EEG significantly correlated with seizure recurrence (p = 0.006, OR 0, 95% CI 0-0.3926). Patients discharged on ≥3 antiepileptic drugs (AEDs) were at a higher risk of having seizure recurrence (p = 0.0015, OR 0.05, 95% CI 0.0089-0.37).

CONCLUSION

We identified risk factors of seizure recurrence in patients with ASyS as remote ischemic stroke, requiring multiple AEDs, and the presence of sharp waves on follow-up EEG. This study highlights the usefulness of cEEG in evaluating patients with acute or remote strokes.

Age-Dependency of Levetiracetam Effects on Exocytotic GABA Release from Nerve Terminals in the Hippocampus and Cortex in Norm and After Perinatal Hypoxia

Perinatal hypoxia can lead to multiple chronic neurological deficits, e.g., mental retardation, behavioral abnormalities, and epilepsy. Levetiracetam (LEV), 2S-(2-oxo-1-pyrrolidiny1) butanamide, is an anticonvulsant drug with proven efficiency in treating patients with focal and generalized seizures. Rats were underwent hypoxia and seizures at the age of 10-12 postnatal days (pd). The ambient level and depolarization-induced exocytotic release of [³H]GABA (γ-aminobutyric acid) were analyzed in nerve terminals in the hippocampus and cortex during development at the age of pd 17-19 and pd 24-26 (infantile stage), pd 38-40 (puberty) and pd 66-73 (young adults) in norm and after perinatal hypoxia. LEV had no effects on the ambient [³H]GABA level. The latter increased during development and was further elevated after perinatal hypoxia in nerve terminals in the hippocampus during the whole period and in the cortex in young adults. Exocytotic [³H]GABA release from nerve terminals increased after perinatal hypoxia during development in the hippocampus and cortex, however this effect was preserved at all ages during blockage of GABA transporters by NO-711 in the hippocampus only. LEV realized its anticonvulsant effects at the presynaptic site through an increase in exocytotic release of GABA. LEV exerted more significant effect after perinatal hypoxia than in norm. Action of LEV was strongly age-dependent and can be registered in puberty and young adults, but the drug was inert at the infantile stage.

Effects of levetiracetam on astroglial release of kynurenine-pathway metabolites

BACKGROUND AND PURPOSE

Several preclinical studies have demonstrated the unique profiles of levetiracetam (LEV), inhibits spontaneous absence epilepsy models but does not affect traditional convulsion models; however, the detailed pharmacological mechanisms of action of LEV remain to be clarified.

EXPERIMENTAL APPROACH

We determined the interaction between LEV and IFNγ regarding astroglial release of anti-convulsive (kynurenic acid and xanthurenic acid), pro-convulsive (quinolinic acid) and anti-convulsive but pro-absence (cinnabarinic acid) kynurenine-pathway metabolites from rat cortical primary cultured astrocytes using ultra-HPLC equipped with MS.

KEY RESULTS

IFNγ increased basal astroglial release of cinnabarinic acid and quinolinic acid but decreased that of kynurenic acid and xanthurenic acid. IFNγ enhanced inositol 1,4,5-trisphosphate (IP₃ ) receptor agonist (adenophostin A, AdA)-induced astroglial release of kynurenine-pathway metabolites, without affecting AMPA-induced release. LEV increased basal astroglial release of kynurenic acid and xanthurenic acid without affecting cinnabarinic acid or quinolinic acid. Chronic and acute LEV administration inhibited AMPA- and AdA-induced kynurenine-pathway metabolite release. Upon chronic administration, LEV enhanced stimulatory effects of IFNγ on kynurenic acid and xanthurenic acid, and reduced its stimulatory effects on cinnabarinic acid and quinolinic acid. Furthermore, LEV inhibited stimulatory effects of chronic IFNγ on AdA-induced release of kynurenine-pathway metabolites.

CONCLUSIONS AND IMPLICATIONS

This study demonstrated several mechanisms of LEV: (i) inhibition of AMPA- and AdA-induced astroglial release, (ii) inhibition of IFNγ-induced IP₃ receptor activation and (iii) inhibition of release of cinnabarinic acid and quinolinic acid with activation of that of kynurenic acid induced by IFNγ. These combined actions of LEV may contribute to its unique profile.

Research on the Effects of Levetiracetam in Spinal Cord Injury Model in Rats: An Experimental Study

Purpose: Despite advances in spinal biomechanic research, surgical techniques, and rehabilitation processes, no significant improvement has been identified in the treatment of spinal cord injury (SCI) and neurological recovery. Aim of the Study: This study was designed to investigate the potential therapeutic effects of methylprednisolone and levetiracetam on SCI. Materials and Methods: In this study, 42 male Wistar Albino rats, each weighing 300-350 g, were separated into three main groups: control group, acute and subacute stage groups. With the exception of the control group, a T7-8 dorsal laminectomy was performed on the spinal column of the rats. A temporary vascular aneurysm clip was then applied to the spinal cord for 1 min to create SCI and methylprednisolone or levetiracetam was administered intraperitoneally to all except the control and SHAM control groups. The damaged spinal cord was removed for histopathological and biochemical examinations. Results: Both pharmacological agents were determined to have improved the histopathological architecture in damaged neural tissues during the acute period of SCI, but could not sustain this activity in the subacute period. Neither pharmacological agent affected the biochemical data in the acute nor subacute stages. Conclusions: Both pharmacological agents showed histopathological healing effects in injured tissues during the acute phase of SCI in this rat model but these effects could not be sustained in the subacute period. No effect on biochemical data was seen in either the acute or subacute period. There is a need for further advanced studies to determine the effects of levetiracetam on the healing processes in SCI.

Comparison between the effect of human Wharton's jelly-derived mesenchymal stem cells and levetiracetam on brain infarcts in rats

BACKGROUND

Stroke represents one of the major causes of death worldwide. Neuroprotection remains an important goal of stroke therapy. Stem cell therapeutic effect is attributed to the neuroprotective effect and the regulation of the oxidant stress. Levetiracetam (LEV), a second-generation antiepileptic drug, was reported to confer neuronal protection after cerebral ischemia reperfusion.

AIM

To investigate the effect of human Wharton's jelly-derived mesenchymal stem cells (WJ-MSCs) and LEV on the size of brain infarcts, the histological structure, the neurotrophic, and the antioxidant gene expression in middle cerebral artery occlusion in rats.

METHOD

The rats were divided into five equal groups of 12 rats each as follows. Sham control group: received phosphate-buffered saline (PBS); ischemia/reperfusion (I/R) group: received PBS before ligation; stem cell-treated group: the animal received MSCs before ligation; LEV-treated group: the animal received LEV before occlusion; combined group: the animals received both MSCs and LEV before occlusion. Hematoxylin and eosin staining was performed to study the histological structure of the brain. Real-time polymerase chain reaction (RT-PCR) was performed to assess gene expression.

RESULTS

Both MSCs and LEV improved memory and learning in the treated groups compared with I/R group. Significant reduction of the infarct size in WJ-MSC- or LEV-treated groups when compared with untreated ones was found. By RT-PCR, a significant decrease of the expression values of glial-derived neurotrophic factor (GDNF), brain-derived neurotrophic factor (BDNF), phosphatidylethanolamine binding protein 1 (PEBP1), and copper-zinc SOD (Cu/ZnSOD) genes and a significant increase of pro-oxidant iNOS gene in the I/R rats compared with the sham group was detected. There was a significant increase in the expression values of GDNF, BDNF, PEBP1, and Cu/ZnSOD genes in both treated groups when compared with the I/R group. Rats treated with WJ-MSCs showed better results than rats treated with LEV. Finally, the combined use of LEV and WJ-MSCs was the most effective regimen as regard infarction volume and functional learning and memory tests.

CONCLUSION

In the brain ischemia model, combined WJ-MSCs and LEV have demonstrated striking protective effects in brain infarction by the modulation of the oxidant status and neuroprotective effect.

Does Levetiracetam Administration Prevent Cardiac Damage in Adulthood Rats Following Neonatal Hypoxia/Ischemia-Induced Brain Injury?

Cardiovascular abnormalities are widespread when a newborn is exposed to a hypoxic-ischemic injury in the neonatal period. Although the neuroprotective effects of levetiracetam (LEV) have been reported after hypoxia, the cardioprotective effects of LEV have not been documented. Therefore, we aimed to investigate whether levetiracetam (LEV) has a protective effect on cardiac-contractility and ultrastructure of heart muscle in rats exposed to hypoxia-ischemia (HI) during the neonatal period. A total of 49 seven-day-old rat pups were separated into four groups. For HI induction, a combination of right common carotid artery ligation with 8% oxygen in seven-day-old rat pups for 2 h was performed for saline, LEV100, and LEV200 groups. Just after hypoxia, LEV100 and LEV200 groups were administered with 100 mg/kg and 200 mg/kg of LEV, respectively. The arteries of rats in the control group were only detected; no ligation or hypoxia was performed. At the end of the 16th week after HI, cardiac mechanograms were recorded, and samples of tissue were explored by electronmicroscopy.While ventricular contractility in the control group was similar to LEV100, there were significant decreases in both saline and LEV200 groups (p < 0.05). Although ventricular contractile duration of the control and saline groups was found to be similar, durations in the LEV100 and LEV200 groups were significantly higher (p < 0.05). After HI, mitochondrial damage and ultrastructural deteriorative alterations in ventricles and atriums of the LEV-administered groups were significantly less severe than the saline group. The present study showed that neonatal HI caused long-term cardiac dysfunction and ultrastructural deteriorations in cardiac muscles. LEV administration just after HI might possess some protective effects against myocardial damage and contractility.

Impact of Oxidative Stress and Newer Antiepileptic Drugs on the Albumin and Cortisol Value in Severe Motor and Intellectual Disabilities With Epilepsy

Background

Epilepsy is a common complication in patients with severe motor and intellectual disabilities (SMID). There are no reports as yet of the effects of these medications in vivo other than their epileptic efficacy. The purpose of this study was to clarify the effects of the newer antiepileptic drugs (AEDs) on the blood biochemical parameters and oxidative stress in SMID with epilepsy by comparing the therapeutic effects between a group of patients receiving lamotrigine (LTG) and levetiracetam (LEV) in addition to the conventional AEDs (newer AED group) and a group receiving conventional AEDs alone (old AED group).

Methods

The study population consisted of 44 SMID patients with epilepsy, of which 23 were allocated to the newer AED group and 21 were allocated to the old AED group. In the newer AED group, measurements of the reactive oxygen metabolites (d-ROMs), biological antioxidant potential (BAP) and serum albumin were carried out at the following two time points: 1 week before and 1 year after the start of administration of the newer AEDs. In the old AED group, measurements of the same variables were performed at two time points 1 year apart.

Results

A significant decrease of the d-ROM levels and a significant increase of the BAP were noted in the newer AED group. A significant elevation of the serum albumin was also evident. In the old AED group, a significant increase of the d-ROMs levels was noted at the second measurement. Cortisol levels which have been described to be related to the albumin, revealed a significant decrease of the serum cortisol in relation to elevation of serum albumin in the newer AED group.

Conclusions

The present study results suggest that the addition of newer AEDs reduces the oxidative stress load and improves the antioxidant potential of the body. Furthermore, the present data also demonstrate that the newer AEDs have indirect impact on biological parameters.

Association Between Prolonged Seizures and Malignant Middle Cerebral Artery Infarction in Children With Acute Ischemic Stroke

BACKGROUND

Malignant middle cerebral artery infarct syndrome is a potentially fatal complication of stroke that is poorly understood in children. We studied the frequency, associated characteristics, and outcomes of this condition in children.

METHODS

Children, aged two months to 18 years with acute middle cerebral artery infarct diagnosed at our center between January 2005 and December 2012 were studied. Associations with malignant middle cerebral artery infarct syndrome were sought, including age, seizures, neurological deficit severity (Pediatric National Institute of Health Stroke Severity Score), stroke etiology, fever, blood pressure, blood glucose, infarct location, infarct volume (modified pediatric Alberta Stroke Program Early Computed Tomography Score), and arterial occlusion. Death and neurological outcomes were determined.

RESULTS

Among 66 children with middle cerebral artery stroke, 12 (18%) developed malignant middle cerebral artery infarct syndrome, fatal in three. Prolonged seizures during the first 24 hours (odds ratio, 25.51; 95% confidence interval, 3.10 to 334.81; P = 0.005) and a higher Pediatric National Institute of Health Stroke Severity Score (odds ratio, 1.22; 95% confidence interval, 1.08 to 1.45; P = 0.006) were independently associated with malignant middle cerebral artery infarct syndrome. All children aged greater than two years with a Pediatric National Institute of Health Stroke Severity Score ≥8 and initial seizures ≥5 minutes duration developed malignant middle cerebral artery infarct syndrome (100%).

CONCLUSIONS

Malignant middle cerebral artery infarct syndrome affects nearly one in five children with acute middle cerebral artery stroke. Children with higher Pediatric National Institute of Health Stroke Severity Scores and prolonged initial seizures are at greatly increased risk for malignant middle cerebral artery infarct syndrome. Children with middle cerebral artery infarcts warrant intensive neuroprotective management and close monitoring to enable early referral for hemicraniectomy surgery.

Abbreviated levetiracetam treatment effects on behavioural and histological outcomes after experimental TBI

OBJECTIVE

Long-term prophylactic treatment with levetiracetam (LEV) has multiple neuroprotective effects in a traumatic brain injury (TBI) rat model. Although a rational time-frame of seizure prophylactic treatment with LEV for after TBI is not well established, clinical prophylaxis with LEV often includes treatment duration similar to clinical treatment guidelines with Phenytoin. Thus, this study investigated the effects of abbreviated LEV treatment on behavioural function and histological evidence of neuroprotection.

RESEARCH DESIGN

Pre-clinical trial of abbreviated LEV dosing in an experimental model of TBI Methods: After either controlled cortical impact (CCI) injury or sham surgery, rats received three 50 mg kg(-1) doses over 24 hours or vehicle. After injury/sham surgery, beam performance, spatial learning, contusion volume size and hippocampal neuron survival were assessed.

RESULTS

Abbreviated LEV did not improve motor or cognitive performance after TBI. Further, abbreviated LEV did not improve hippocampal neuron sparing or contusion volumes compared with vehicle controls.

CONCLUSIONS

Together with previous work assessing daily LEV treatment, these results suggest that longer-term therapy may be required to confer beneficial effects within these domains. These findings may guide (1) future experimental studies assessing minimal effective dosing for neuroprotection and anti-epileptogenesis and (2) treatment guideline updates for seizure prophylaxis post-TBI.

Neuroprotective effects of chronic administration of levetiracetam in a rat model of diabetic neuropathy

OBJECTIVE

Diabetic neuropathy (DNP) is a frequent and serious complication of diabetes mellitus (DM) that leads to progressive and length-dependent loss of peripheral nerve axons. The purpose of the present study is to assess the neuroprotective effects of levetiracetam (LEV) on DNP in a streptozotocin (STZ)-induced DM model in rats.

METHODS

Adult Sprague-Dawley rats were administered with STZ (60mg/kg) to induce diabetes. DNP was confirmed by electromyography (EMG) and motor function test on 21st day following STZ injection. Study groups were assigned as follows; Group 1: Naïve control (n=8), Group 2: DM+1mL/kg saline (n=12), Group 3: DM+300mg/kg LEV (n=10), Group 4: DM+600mg/kg LEV (n=10). LEV was administered i.p. for 30 consecutive days. Then, EMG, motor function test, biochemical analysis (plasma lipid peroxides and total anti-oxidant capacity), histological and immunohistochemical analysis of sciatic nerves (TUNEL assay, bax, caspase 3, caspase 8 and NGF) were performed to evaluate the efficacy of LEV.

RESULTS

Treatment of diabetic rats with LEV significantly attenuated the inflammation and fibrosis in sciatic nerves and prevented electrophysiological alterations. Immunohistochemistry of sciatic nerves showed a considerable increase in bax, caspase 3 and caspase 8 and a decrease in NGF expression in saline-treated rats whereas LEV significantly suppressed apoptosis markers and prevented the reduction in NGF expression. Besides, LEV considerably reduced plasma lipid peroxides and increased total anti-oxidant capacity in diabetic rats.

CONCLUSIONS

The results of the present study suggest that LEV may have therapeutic effects in DNP through modulation of anti-oxidant and anti-apoptotic pathways.

Levetiracetam attenuates rotenone-induced toxicity: A rat model of Parkinson's disease

Levetiracetam (LEV), a second-generation anti-epileptic drug, is used for treatment of both focal and generalized epilepsy. Growing body of evidence suggests that LEV may have neuroprotective effects. The present study was undertaken to investigate the neuroprotective effects of LEV on rotenone-induced Parkinson's disease (PD) in rats. Twenty-four adult Sprague-Dawley rats were infused with rotenone (3 μg/μl in DMSO) or vehicle (1 μl DMSO) into the left substantia nigra pars compacta (SNc) under stereotaxic surgery. PD model was assessed by rotational test ten days after drug infusion. The valid PD rats were randomly distributed into two groups; Group 1 (n=8) and Group 2 (n=8) were administered saline (1 ml/kg/day, i.p.) and LEV (600 mg/kg/day, i.p.) through 21 days, respectively. The effects of LEV treatment were evaluated by behavioral (rotation score), biochemical (brain homovalinic acid level and oxidant/antioxidant status) and immunohistochemical (tyrosine hydroxylase) parameters. Apomorphine-induced rotations in PD rats were significantly suppressed by LEV treatment. While unilateral rotenone lesion induced a dramatic loss of dopaminergic neurons both in the striatum and SNc, LEV treatment significantly attenuated the degenerative changes in dopaminergic neurons. Furthermore, LEV significantly decreased lipid peroxide levels, a marker of lipid peroxidation, and induced glutathione levels, catalase and superoxide dismutase activity in PD rats compared with saline group. We conclude that LEV may have beneficial effects on dopaminergic neurons against rotenone-induced injury. The underlying mechanism may be associated with the attenuation of oxidative stress.

Neuroprotection as a Potential Therapeutic Perspective in Neurodegenerative Diseases: Focus on Antiepileptic Drugs

Neuroprotection is conceived as one of the potential tool to prevent or slow neuronal death and hence a therapeutic hope to treat neurodegenerative diseases, like Parkinson's and Alzheimer's diseases. Increase of oxidative stress, mitochondrial dysfunction, excitotoxicity, inflammatory changes, iron accumulation, and protein aggregation have been identified as main causes of neuronal death and adopted as targets to test experimentally the putative neuroprotective effects of various classes of drugs. Among these agents, antiepileptic drugs (AEDs), both the old and the newer generations, have shown to exert protective effects in different experimental models. Their mechanism of action is mediated mainly by modulating the activity of sodium, calcium and potassium channels as well as the glutamatergic and GABAergic (gamma-aminobutyric acid) synapses. Neurological pathologies in which a neuroprotective action of AEDs has been demonstrated in specific experimental models include: cerebral ischemia, Parkinson's disease, and Alzheimer's disease. Although the whole of experimental data indicating that neuroprotection can be achieved is remarkable and encouraging, no firm data have been produced in humans so far and, at the present time, neuroprotection still remains a challenge for the future.

Predictors of acute symptomatic seizures after intracranial hemorrhage in infants

OBJECTIVE

To determine the prevalence of acute symptomatic seizures in infants with supratentorial intracranial hemorrhage, to identify potential risk factors, and to determine the effect of acute seizures on long-term morbidity and mortality.

DESIGN

Children less than 24 months with intracranial hemorrhage were identified from a neurocritical care database. All patients who received seizure prophylaxis beginning at admission were included in the study. Risk factors studied were gender, etiology, location of hemorrhage, seizure(s) on presentation, and the presence of parenchymal injury. Acute clinical and electrographic seizures were identified from hospital medical records. Subsequent development of late seizures was determined based on clinical information from patients' latest follow-up.

SETTING AND PATIENTS

Patients with idiopathic neonatal intracranial hemorrhage, premature infants, and those with prior history of seizures were excluded from analysis. Seventy-two infants met inclusion criteria.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Forty percent of infants had acute symptomatic seizures. The prevalence was similar regardless of whether etiology of hemorrhage was traumatic or nontraumatic. Seizures on presentation and parenchymal injury were independent risk factors of acute seizures (p = 0.001 and p = 0.006, respectively). Younger children and women were also at higher risk (p < 0.05). Twenty percent had electrographic-only seizures, and those with parenchymal injury trended toward an increased risk (p < 0.1). Acute seizures were not predictive of mortality, but nearly twice as many patients with acute seizures developed late seizures when compared with those without. Electrographic seizures and parenchymal injury were also predictive of development of late seizures (p < 0.001 and p = 0.013, respectively).

CONCLUSIONS

Despite seizure prophylaxis, infants with supratentorial intracranial hemorrhage are at high risk for acute symptomatic seizures. This is regardless of the etiology of hemorrhage. Younger patients, women, patients with parenchymal injury, and patients presenting with seizure are most likely to develop acute seizures. Although the benefits of seizure prophylaxis have not been studied in this specific population, these results suggest that it is an important component of acute care following intracranial hemorrhage.

The antiepileptic drug levetiracetam suppresses non-convulsive seizure activity and reduces ischemic brain damage in rats subjected to permanent middle cerebral artery occlusion

The antiepileptic drug Levetiracetam (Lev) has neuroprotective properties in experimental stroke, cerebral hemorrhage and neurotrauma. In these conditions, non-convulsive seizures (NCSs) propagate from the core of the focal lesion into perilesional tissue, enlarging the damaged area and promoting epileptogenesis. Here, we explore whether Lev neuroprotective effect is accompanied by changes in NCS generation or propagation. In particular, we performed continuous EEG recordings before and after the permanent occlusion of the middle cerebral artery (pMCAO) in rats that received Lev (100 mg/kg) or its vehicle immediately before surgery. Both in Lev-treated and in control rats, EEG activity was suppressed after pMCAO. In control but not in Lev-treated rats, EEG activity reappeared approximately 30-45 min after pMCAO. It initially consisted in single spikes and, then, evolved into spike-and-wave and polyspike-and-wave discharges. In Lev-treated rats, only rare spike events were observed and the EEG power was significantly smaller than in controls. Approximately 24 hours after pMCAO, EEG activity increased in Lev-treated rats because of the appearance of polyspike events whose power was, however, significantly smaller than in controls. In rats sacrificed 24 hours after pMCAO, the ischemic lesion was approximately 50% smaller in Lev-treated than in control rats. A similar neuroprotection was observed in rats sacrificed 72 hours after pMCAO. In conclusion, in rats subjected to pMCAO, a single Lev injection suppresses NCS occurrence for at least 24 hours. This electrophysiological effect could explain the long lasting reduction of ischemic brain damage caused by this drug.

The beneficial effects of levetiracetam on polyneuropathy in the early stage of sepsis in rats: electrophysiological and biochemical evidence

ABSTRACT Critical illness polyneuropathy (CIP) is a common complication in long (≥1 week) critical/intensive care hospitalizations. Rapidly progressing atrophy and weakness of the limb, trunk and, particularly, respiratory muscles may lead to severe morbidity or mortality. The aim of the present study was to investigate the protective effects of levetiracetam (LEV) on CIP in the early stage of sepsis in rats. We simulated CIP by a surgically induced sepsis model and verified it by lower-limb electromyography (EMG) (amplitude and duration of CMAP, and distal latency). We evaluated the effects of various doses of LEV treatment (300, 600, and 1200 mg/kg i.p.) on CIP by performing electrophysiology, and determining plasma tumor necrosis factor (TNF)-α, lipid peroxides (malondialdehyde, MDA) levels, and total antioxidant capacity (TAC). Our data showed: (1) significant suppression of CMAP amplitude and prolongation of distal latency in the saline-treated sepsis group, and distal latency as well as CMAP amplitudes benefiting best from the 600 mg/kg LEV treatment; (2) significant rise in plasma TNF-α and MDA levels in the saline-treated sepsis group, but significant ameliorations by the 600 and 1200 mg/kg LEV treatment; (3) highly significant suppression of TAC in the saline-treated group, but profound reversals in all LEV-treated groups. We conclude that 300, 600, and 1200 mg/kg i.p. doses of post-septic treatment by LEV has possibly acted in a dose-dependent manner to both protect and restore the affected peripheral nerves' axon and myelin following surgical disturbance of the cecum to induce sepsis and consequent polyneuropathy.

Intravenous lacosamide as treatment option in post-stroke non convulsive status epilepticus in the elderly: a proof-of-concept, observational study

PURPOSE

To evaluate the efficacy and safety of intravenously administered lacosamide (iv LCM) in post-stroke non convulsive status epilepticus (NCSE) in elderly patients.

METHODS

We enrolled 16 patients (7 M/9 F; 77 ± 7 years of age) with NCSE. iv LCM was used in all the patients as initial treatment (i.e. patients were directly started on LCM) at a loading dose of 400 mg over 30 min, followed by a mean maintenance dose of 400 mg per day. iv LCM was considered as effective in patients who experience no NCSE for 24 h following treatment, as evaluated by EEG recording and clinical observation.

RESULTS

LCM was effective in treating NCSE in eight of the sixteen patients in whom epileptic activity disappeared (7/8) or was significantly reduced (1/8) within 45-60 min after administration. None of these patients relapsed in the following 24 h. No adverse events were observed. A partial anterior circulation syndrome (PACS) was present in 10 patients while a total anterior circulation syndrome (TACS) in six.

CONCLUSIONS

This pilot study suggests that LCM exhibits safety and efficacy profiles which make it an optimal candidate as a first-choice drug against post-stroke NCSE in elderly patients. A prospective comparative trial is needed to confirm these preliminary data.

Antiepileptics topiramate and levetiracetam alleviate behavioral deficits and reduce neuropathology in APPswe/PS1dE9 transgenic mice

BACKGROUND

The close relationship between epileptic seizure and Alzheimer's disease (AD) has been demonstrated in the past decade. Valproic acid, a traditional first-line antiepileptic drug, exerted protective effects in transgenic models of AD. It remains uncertain whether new antiepileptic drugs could reverse neuropathology and behavioral deficits in AD transgenic mice.

AIMS

APPswe/PS1dE9 transgenic mice were used in this study, which over express the Swedish mutation of amyloid precursor protein together with presenilin 1 deleted in exon 9. 7-month-old APPswe/PS1dE9 transgenic mice were treated daily with 20 mg/kg topiramate (TPM) and 50 mg/kg levetiracetam (LEV) for 30 days by intraperitoneal injection to explore the effects of TPM and LEV on the neuropathology and behavioral deficits.

RESULTS

The results indicated that TPM and LEV alleviated behavioral deficits and reduced amyloid plaques in APPswe/PS1dE9 transgenic mice. TPM and LEV increased Aβ clearance and up-regulated Aβ transport and autophagic degradation. TPM and LEV inhibited Aβ generation and suppressed γ-secretase activity. TPM and LEV inhibited GSK-3β activation and increased the activation of AMPK/Akt activation. Further, TPM and LEV inhibited histone deacetylase activity in vivo.

CONCLUSIONS

Therefore, TPM and LEV might have the potential to treat AD effectively in patient care.

Hypoxic–ischemic brain injury and neuroprotection in the newborn infant

Recent clinical trials have confirmed that in term infants with moderate-to-severe hypoxic–ischemic encephalopathy, death and severe developmental disability can be reduced by early treatment with hypothermia. However, meta-analysis of these trials has confirmed that two-thirds of the survivors remain seriously impaired. The search for new neuroprotective interventions has therefore continued. Extensive research has identified the important biochemical pathways that result in neuronal loss, and the subsequent repair and regeneration processes. The most promising neuroprotective agents that limit the former, and promote the latter, are being tested in animal models of hypoxic–ischemic brain injury and are awaiting clinical trials. It is likely that a ‘cocktail’ of agents, affecting a number of pathways, will ultimately prove to be the most effective intervention. The latest additions to a long list of proposed substances are various stem cells that promote neurogenesis by releasing trophic substances into the injured brain. Future clinical trials are likely to employ early biomarkers, of which MRI and proton spectroscopy are probably the most predictive of long-term neurodevelopmental outcome. In conclusion, the exponential increase in knowledge in this field can be expected to provide many more neuroprotective agents within the next decade.

Guidelines for the treatment of acute ischaemic stroke

INTRODUCTION

Update of Acute Ischaemic Stroke Treatment Guidelines of the Spanish Neurological Society based on a critical review of the literature. Recommendations are made based on levels of evidence from published data and studies.

DEVELOPMENT

Organized systems of care should be implemented to ensure access to the optimal management of all acute stroke patients in stroke units. Standard of care should include treatment of blood pressure (should only be treated if values are over 185/105 mmHg), treatment of hyperglycaemia over 155 mg/dl, and treatment of body temperature with antipyretic drugs if it rises above 37.5 °C. Neurological and systemic complications must be prevented and promptly treated. Decompressive hemicraniectomy should be considered in cases of malignant cerebral oedema. Intravenous thrombolysis with rtPA should be administered within 4.5 hours from symptom onset, except when there are contraindications. Intra-arterial pharmacological thrombolysis can be considered within 6 hours, and mechanical thrombectomy within 8 hours from onset, for anterior circulation strokes, while a wider window of opportunity up to 12-24 hours is feasible for posterior strokes. There is not enough evidence to recommend routine use of the so called neuroprotective drugs. Anticoagulation should be administered to patients with cerebral vein thrombosis. Rehabilitation should be started as early as possible.

CONCLUSION

Treatment of acute ischaemic stroke includes management of patients in stroke units. Systemic thrombolysis should be considered within 4.5 hours from symptom onset. Intra-arterial approaches with a wider window of opportunity can be an option in certain cases. Protective and restorative therapies are being investigated.

Motor symptoms of schizophrenia: is tardive dyskinesia a symptom or side effect? A modern treatment

Abnormal involuntary dyskinetic movements in schizophrenia patients have been documented for more than 140 years. Clinicians should distinguish between two kinds of disturbances-spontaneous dyskinetic movements and movements induced by psychotropic medications-which may look familiar clinically. As a modern term, tardive dyskinesia (TD) is a potentially permanent neurological hyperkinetic movement disorder that occurs after months or years of taking psychotropic drugs. Several distinct forms of TD exist, specifically tardive akathisia, tardive blepharospasm, tardive dystonia, tardive gait, tardive myoclonus, tardive tremor, and tardive tics, and they have different pathophysiologies and treatment. The pathogenesis of TD remains unclear, and the pathophysiology is complex and multifactorial. Moreover, there is solid evidence of a genetic predisposition to TD. This article summarizes recent relevant publications concerning TD and the most recent studies regarding treatment of this disorder with antioxidative agents.