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Tan Y, Hashimoto K. Therapeutic potential of ketamine in management of epilepsy: Clinical implications and mechanistic insights. Asian J Psychiatr 2024; 101:104246. [PMID: 39366036 DOI: 10.1016/j.ajp.2024.104246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Revised: 09/11/2024] [Accepted: 09/14/2024] [Indexed: 10/06/2024]
Abstract
Epilepsy, a widespread neurological disorder, affects approximately 50 million people worldwide. This disorder is typified by recurring seizures due to abnormal neuron communication in the brain. The seizures can lead to severe ischemia and hypoxia, potentially threatening patients' lives. However, with proper diagnosis and treatment, up to 70 % of patients can live without seizures. The causes of epilepsy are complex and multifactorial, encompassing genetic abnormalities, structural brain anomalies, ion channel dysfunctions, neurotransmitter imbalances, neuroinflammation, and immune system involvement. These factors collectively disrupt the crucial balance between excitation and inhibition within the brain, leading to epileptic seizures. The management of treatment-resistant epilepsy remains a considerable challenge, necessitating innovative therapeutic approaches. Among emerging potential treatments, ketamine-a drug traditionally employed for anesthesia and depression-has demonstrated efficacy in reducing seizures. It is noteworthy that, independent of its anti-epileptic effects, ketamine has been found to improve the balance between excitatory and inhibitory (E/I) activities in the brain. The balance is crucial for maintaining normal neural function, and its disruption is widely considered a key driver of epileptic seizures. By acting on N-methyl-D-aspartate (NMDA) receptors and other potential mechanisms, ketamine may regulate neuronal excitability, reduce excessive synchronized neural activity, and counteract epileptic seizures. This positive impact on E/I balance reinforces the potential of ketamine as a promising drug for treating epilepsy, especially in patients who are insensitive to traditional anti-epileptic drugs. This review aims to consolidate the current understanding of ketamine's therapeutic role in epilepsy. It will focus its impact on neuronal excitability and synaptic plasticity, its neuroprotective qualities, and elucidate the drug's potential mechanisms of action in treating epilepsy. By scrutinizing ketamine's impact and mechanisms in various types of epilepsy, we aspire to contribute to a more comprehensive and holistic approach to epilepsy management.
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Affiliation(s)
- Yunfei Tan
- Center for Rehabilitation Medicine, Department of Psychiatry, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, Zhejiang, China.
| | - Kenji Hashimoto
- Chiba University Center for Forensic Mental Health, Chiba 260-8677, Japan.
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2
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Clark JR, Batra A, Tessier RA, Greathouse K, Dickson D, Ammar A, Hamm B, Rosenthal LJ, Lombardo T, Koralnik IJ, Skolarus LE, Schroedl CJ, Budinger GRS, Wunderink RG, Dematte JE, Ungvari Z, Liotta EM. Impact of healthcare system strain on the implementation of ICU sedation practices and encephalopathy burden during the early COVID-19 pandemic. GeroScience 2024:10.1007/s11357-024-01336-4. [PMID: 39243283 DOI: 10.1007/s11357-024-01336-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2024] [Accepted: 08/31/2024] [Indexed: 09/09/2024] Open
Abstract
The COVID-19 pandemic posed unprecedented challenges to healthcare systems worldwide, particularly in managing critically ill patients requiring mechanical ventilation early in the pandemic. Surging patient volumes strained hospital resources and complicated the implementation of standard-of-care intensive care unit (ICU) practices, including sedation management. The objective of this study was to evaluate the impact of an evidence-based ICU sedation bundle during the early COVID-19 pandemic. The bundle was designed by a multi-disciplinary collaborative to reinforce best clinical practices related to ICU sedation. The bundle was implemented prospectively with retrospective analysis of electronic medical record data. The setting was the ICUs of a single-center tertiary hospital. The patients were the ICU patients requiring mechanical ventilation for confirmed COVID-19 between March and June 2020. A learning health collaborative developed a sedation bundle encouraging goal-directed sedation and use of adjunctive strategies to avoid excessive sedative administration. Implementation strategies included structured in-service training, audit and feedback, and continuous improvement. Sedative utilization and clinical outcomes were compared between patients admitted before and after the sedation bundle implementation. Quasi-experimental interrupted time-series analyses of pre and post intervention sedative utilization, hospital length of stay, and number of days free of delirium, coma, or death in 21 days (as a quantitative measure of encephalopathy burden). The analysis used the time duration between start of the COVID-19 wave and ICU admission to identify a "breakpoint" indicating a change in observed trends. A total of 183 patients (age 59.0 ± 15.9 years) were included, with 83 (45%) admitted before the intervention began. Benzodiazepine utilization increased for patients admitted after the bundle implementation, while agents intended to reduce benzodiazepine use showed no greater utilization. No "breakpoint" was identified to suggest the bundle impacted any endpoint measure. However, increasing time between COVID-19 wave start and ICU admission was associated with fewer delirium, coma, and death-free days (β = - 0.044 [95% CI - 0.085, - 0.003] days/wave day); more days of benzodiazepine infusion (β = 0.056 [95% CI 0.025, 0.088] days/wave day); and a higher maximum benzodiazepine infusion rate (β = 0.079 [95% CI 0.037, 0.120] mg/h/wave day). The evidence-based practice bundle did not significantly alter sedation utilization patterns during the first COVID-19 wave. Sedation practices deteriorated and encephalopathy burden increased over time, highlighting that strategies to reinforce clinical practices may be hindered under conditions of extreme healthcare system strain.
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Affiliation(s)
- Jeffrey R Clark
- Northwestern University-Feinberg School of Medicine, Chicago, IL, USA
- Columbia University Irving Medical Center, New York, NY, USA
| | - Ayush Batra
- Ken & Ruth Davee Department of Neurology, Northwestern University-Feinberg School of Medicine, 625 N. Michigan Ave, Suite 1150, Chicago, IL, 60611, USA
| | - Robert A Tessier
- Northwestern University-Feinberg School of Medicine, Chicago, IL, USA
| | - Kasey Greathouse
- Northwestern University-Feinberg School of Medicine, Chicago, IL, USA
| | - Dan Dickson
- Northwestern University-Feinberg School of Medicine, Chicago, IL, USA
| | - Abeer Ammar
- Northwestern University-Feinberg School of Medicine, Chicago, IL, USA
| | - Brandon Hamm
- Department of Psychiatry and Behavioral Sciences, Northwestern University-Feinberg School of Medicine, Chicago, IL, USA
| | - Lisa J Rosenthal
- Department of Psychiatry and Behavioral Sciences, Northwestern University-Feinberg School of Medicine, Chicago, IL, USA
| | - Theresa Lombardo
- Northwestern University-Feinberg School of Medicine, Chicago, IL, USA
| | - Igor J Koralnik
- Ken & Ruth Davee Department of Neurology, Northwestern University-Feinberg School of Medicine, 625 N. Michigan Ave, Suite 1150, Chicago, IL, 60611, USA
| | - Lesli E Skolarus
- Ken & Ruth Davee Department of Neurology, Northwestern University-Feinberg School of Medicine, 625 N. Michigan Ave, Suite 1150, Chicago, IL, 60611, USA
| | - Clara J Schroedl
- Department of Medicine, Division of Pulmonary and Critical Care, Northwestern University-Feinberg School of Medicine, Chicago, IL, USA
| | - G R Scott Budinger
- Department of Medicine, Division of Pulmonary and Critical Care, Northwestern University-Feinberg School of Medicine, Chicago, IL, USA
| | - Richard G Wunderink
- Department of Medicine, Division of Pulmonary and Critical Care, Northwestern University-Feinberg School of Medicine, Chicago, IL, USA
| | - Jane E Dematte
- Department of Medicine, Division of Pulmonary and Critical Care, Northwestern University-Feinberg School of Medicine, Chicago, IL, USA
| | - Zoltan Ungvari
- Vascular Cognitive Impairment, Neurodegeneration and Healthy Brain Aging Program, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Stephenson Cancer Center, University of Oklahoma, Oklahoma City, OK, USA
- Oklahoma Center for Geroscience and Healthy Brain Aging, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Department of Health Promotion Sciences, College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- International Training Program in Geroscience, Doctoral College/Department of Public Health, Semmelweis University, Budapest, Hungary
| | - Eric M Liotta
- Ken & Ruth Davee Department of Neurology, Northwestern University-Feinberg School of Medicine, 625 N. Michigan Ave, Suite 1150, Chicago, IL, 60611, USA.
- International Training Program in Geroscience, Doctoral College/Department of Public Health, Semmelweis University, Budapest, Hungary.
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3
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Waris A, Asim M, Ullah A, Alhumaydhi FA. Various pharmacological agents in the pipeline against intractable epilepsy. Arch Pharm (Weinheim) 2024; 357:e2400229. [PMID: 38767508 DOI: 10.1002/ardp.202400229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 04/25/2024] [Accepted: 04/29/2024] [Indexed: 05/22/2024]
Abstract
Epilepsy is a noncommunicable chronic neurological disorder affecting people of all ages, with the highest prevalence in low and middle-income countries. Despite the pharmacological armamentarium, the plethora of drugs in the market, and other treatment options, 30%-35% of individuals still show resistance to the current medication, termed intractable epilepsy/drug resistance epilepsy, which contributes to 50% of the mortalities due to epilepsy. Therefore, the development of new drugs and agents is needed to manage this devastating epilepsy. We reviewed the pipeline of drugs in "ClinicalTrials. gov," which is the federal registry of clinical trials to identify drugs and other treatment options in various phases against intractable epilepsy. A total of 31 clinical trials were found regarding intractable epilepsy. Among them, 48.4% (15) are about pharmacological agents, of which 26.6% are in Phase 1, 60% are in Phase 2, and 13.3% are in Phase 3. The mechanism of action or targets of the majority of these agents are different and are more diversified than those of the approved drugs. In this article, we summarized various pharmacological agents in clinical trials, their backgrounds, targets, and mechanisms of action for the treatment of intractable epilepsy. Treatment options other than pharmacological ones, such as devices for brain stimulation, ketogenic diets, gene therapy, and others, are also summarized.
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Affiliation(s)
- Abdul Waris
- Department of Biomedical Sciences, City University of Hong Kong, Kowloon Tong, Hong Kong
| | - Muhammad Asim
- Department of Neurosciences, City University of Hong Kong, Kowloon Tong, Hong Kong
- Centre for Regenerative Medicine and Health (CRMH), Hong Kong SAR
| | - Ata Ullah
- Department of Biomedical Sciences, City University of Hong Kong, Kowloon Tong, Hong Kong
| | - Fahad A Alhumaydhi
- Department of Medical Laboratories, College of Applied Medical Sciences, Qassim University, Buraydah, Saudi Arabia
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Finney JD, Schuler PD, Rudloff JR, Agostin N, Lobanov OV, Siegler J, Shah MI, Guterman EL, Chamberlain JM, Ahmad FA. Evaluation of the Use of Ketamine in Prehospital Seizure Management: A Retrospective Review of the ESO Database. PREHOSP EMERG CARE 2024:1-8. [PMID: 39058382 DOI: 10.1080/10903127.2024.2382367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Revised: 07/12/2024] [Accepted: 07/14/2024] [Indexed: 07/28/2024]
Abstract
OBJECTIVES Benzodiazepines are the primary antiseizure medication used by Emergency Medical Services (EMS) for seizures. Available literature in the United States and internationally shows 30% to 40% of seizures do not terminate with benzodiazepines called benzodiazepine refractory status epilepticus (BRSE). Ketamine is a potential treatment for BRSE due to its unique pharmacology. However, its application in the prehospital setting is mostly documented in case reports. Little is known about its use by EMS professionals for seizure management, whether as initial treatment or for BRSE, creating an opportunity to describe its current use and inform future research. METHODS We performed a retrospective review of 9-1-1 EMS encounters with a primary or secondary impression of seizure using the ESO Data Collaborative from 2018 to 2021. We isolated encounters during which ketamine was administered. We excluded medication administrations prior to EMS arrival and encounters without medication administration. Subgroup analysis was performed to control for airway procedure as an indication for ketamine administration. We also evaluated for co-administration with other antiseizure medications, dose and route of administration, and response to treatment. RESULTS We identified 99,576 encounters that met inclusion. There were 2,531/99,576 (2.54%) encounters with ketamine administration and 50.7% (1,283/2,531) received ketamine without an airway procedure. There were 616 cases (48%, 616/1,283) where ketamine was given without another antiseizure medication (ASM) and without any airway procedure. The remaining 667 (52%) cases received ketamine with at least one other ASM, most commonly midazolam (89%, 593/667). Adjusted for the growth in the ESO dataset, ketamine use by EMS professionals during encounters for seizures without an airway procedure increased from 0.90% (139/15,375) to 1.45% (416/28,651) an increase of 62% over the study period. CONCLUSIONS In this retrospective review of the ESO Data Collaborative, ketamine administration for seizure encounters without an airway procedure increased over the study period, both as a single agent and with another ASM. Most ketamine administrations were for adult patients in the south and in urban areas. The frequency of BRSE, the need for effective treatment, and the growth in ketamine use warrant prospective prehospital research to evaluate the value of ketamine in prehospital seizure management.
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Affiliation(s)
- Joseph Daniel Finney
- Department of Pediatrics, Washington University in Saint Louis, Saint Louis, Missouri
| | - Paul D Schuler
- Department of Emergency Medicine, School of Medicine, University of Missouri, Columbia, Missouri
| | - James R Rudloff
- Department of Pediatrics, Institute for Informatics Data Science and Biostatistics, Washington University in Saint Louis, St. Louis, Missouri
| | - Nicholas Agostin
- Department of Pediatrics, Washington University in Saint Louis, Saint Louis, Missouri
| | - Oleg V Lobanov
- Department of Neurology, Washington University in St. Louis, St. Louis, Missouri
| | - Jeffrey Siegler
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Manish I Shah
- Department of Emergency Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Elan L Guterman
- Philip R. Lee Institute for Health Policy Studies and Department of Neurology, University of California, San Francisco, California
| | - James M Chamberlain
- Pediatrics and Emergency Medicine, George Washington University, Washington, District of Columbia
| | - Fahd A Ahmad
- Department of Pediatrics, Washington University in Saint Louis, Saint Louis, Missouri
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Plante V, Basu M, Gettings JV, Luchette M, LaRovere KL. Update in Pediatric Neurocritical Care: What a Neurologist Caring for Critically Ill Children Needs to Know. Semin Neurol 2024; 44:362-388. [PMID: 38788765 DOI: 10.1055/s-0044-1787047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2024]
Abstract
Currently nearly one-quarter of admissions to pediatric intensive care units (PICUs) worldwide are for neurocritical care diagnoses that are associated with significant morbidity and mortality. Pediatric neurocritical care is a rapidly evolving field with unique challenges due to not only age-related responses to primary neurologic insults and their treatments but also the rarity of pediatric neurocritical care conditions at any given institution. The structure of pediatric neurocritical care services therefore is most commonly a collaborative model where critical care medicine physicians coordinate care and are supported by a multidisciplinary team of pediatric subspecialists, including neurologists. While pediatric neurocritical care lies at the intersection between critical care and the neurosciences, this narrative review focuses on the most common clinical scenarios encountered by pediatric neurologists as consultants in the PICU and synthesizes the recent evidence, best practices, and ongoing research in these cases. We provide an in-depth review of (1) the evaluation and management of abnormal movements (seizures/status epilepticus and status dystonicus); (2) acute weakness and paralysis (focusing on pediatric stroke and select pediatric neuroimmune conditions); (3) neuromonitoring modalities using a pathophysiology-driven approach; (4) neuroprotective strategies for which there is evidence (e.g., pediatric severe traumatic brain injury, post-cardiac arrest care, and ischemic stroke and hemorrhagic stroke); and (5) best practices for neuroprognostication in pediatric traumatic brain injury, cardiac arrest, and disorders of consciousness, with highlights of the 2023 updates on Brain Death/Death by Neurological Criteria. Our review of the current state of pediatric neurocritical care from the viewpoint of what a pediatric neurologist in the PICU needs to know is intended to improve knowledge for providers at the bedside with the goal of better patient care and outcomes.
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Affiliation(s)
- Virginie Plante
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Meera Basu
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts
| | | | - Matthew Luchette
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Kerri L LaRovere
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts
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Kornilov E, Baker Erdman H, Kahana E, Fireman S, Zarchi O, Israelashvili M, Reiner J, Glik A, Weiss P, Paz R, Bergman H, Tamir I. Interleaved Propofol-Ketamine Maintains DBS Physiology and Hemodynamic Stability: A Double-Blind Randomized Controlled Trial. Mov Disord 2024; 39:694-705. [PMID: 38396358 DOI: 10.1002/mds.29746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 12/18/2023] [Accepted: 02/06/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND The gold standard anesthesia for deep brain stimulation (DBS) surgery is the "awake" approach, using local anesthesia alone. Although it offers high-quality microelectrode recordings and therapeutic-window assessment, it potentially causes patients extreme stress and might result in suboptimal surgical outcomes. General anesthesia or deep sedation is an alternative, but may reduce physiological testing reliability and lead localization accuracy. OBJECTIVES The aim is to investigate a novel anesthesia regimen of ketamine-induced conscious sedation for the physiological testing phase of DBS surgery. METHODS Parkinson's patients undergoing subthalamic DBS surgery were randomly divided into experimental and control groups. During physiological testing, the groups received 0.25 mg/kg/h ketamine infusion and normal saline, respectively. Both groups had moderate propofol sedation before and after physiological testing. The primary outcome was recording quality. Secondary outcomes included hemodynamic stability, lead accuracy, motor and cognitive outcome, patient satisfaction, and adverse events. RESULTS Thirty patients, 15 from each group, were included. Intraoperatively, the electrophysiological signature and lead localization were similar under ketamine and saline. Tremor amplitude was slightly lower under ketamine. Postoperatively, patients in the ketamine group reported significantly higher satisfaction with anesthesia. The improvement in Unified Parkinson's disease rating scale part-III was similar between the groups. No negative effects of ketamine on hemodynamic stability or cognition were reported perioperatively. CONCLUSIONS Ketamine-induced conscious sedation provided high quality microelectrode recordings comparable with awake conditions. Additionally, it seems to allow superior patient satisfaction and hemodynamic stability, while maintaining similar post-operative outcomes. Therefore, it holds promise as a novel alternative anesthetic regimen for DBS. © 2024 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Evgeniya Kornilov
- Department of Anesthesiology, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
- Department of Neurobiology, Weizmann Institute of Science, Rehovot, Israel
| | - Halen Baker Erdman
- Department of Medical Neurobiology, Hebrew University, Jerusalem, Israel
| | - Eilat Kahana
- Department of Anesthesiology, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
| | - Shlomo Fireman
- Department of Anesthesiology, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
| | - Omer Zarchi
- Intraoperative Neurophysiology Unit, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
| | | | - Johnathan Reiner
- Department of Neurology, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
| | - Amir Glik
- Department of Neurology, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
- Cognitive Neurology Clinic, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Penina Weiss
- Occupational Therapy Department, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
| | - Rony Paz
- Department of Neurobiology, Weizmann Institute of Science, Rehovot, Israel
| | - Hagai Bergman
- Department of Medical Neurobiology, Hebrew University, Jerusalem, Israel
- Department of Neurosurgery, Hadassah Medical Center, Hebrew University, Jerusalem, Israel
- The Edmond and Lily Safra Center for Brain Sciences, Hebrew University, Jerusalem, Israel
| | - Idit Tamir
- Department of Neurosurgery, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
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Williams NC, Morgan LA, Friedman J, Siegler J. Ketamine Efficacy for Management of Status Epilepticus: Considerations for Prehospital Clinicians. Air Med J 2024; 43:84-89. [PMID: 38490790 DOI: 10.1016/j.amj.2023.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 09/10/2023] [Accepted: 09/21/2023] [Indexed: 03/17/2024]
Abstract
Current first-line therapies for seizure management recommend benzodiazepines, which target gamma-aminobutyric acid type A channels to stop the seizure activity. However, seizures may be refractory to traditional first-line therapies, transitioning into status epilepticus and becoming resistant to gamma-aminobutyric acid type A augmenting drugs. Although there are other antiseizure medications available for clinicians to use in the intensive care unit, these options can be less readily available outside of the intensive care unit and entirely absent in the prehospital setting. Instead, patients frequently receive multiple doses of first-line agents with increased risk of hemodynamic or airway collapse. Ketamine is readily available in the prehospital setting and emergency department, has well-established antiseizure effects with a favorable safety profile, and is a drug often used for several other indications. This article aimed to explore the utilization of ketamine for seizure management in the prehospital setting, reviewing seizure pathophysiology, established treatment mechanisms of action and pharmacokinetics, and potential benefits of early ketamine use in status epilepticus.
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Affiliation(s)
| | - Lindsey A Morgan
- Department of Neurology, Division of Pediatric Neurology, University of Washington, Seattle, WA; Center for Integrative Brain Research, Seattle Children's Research Institute, Seattle, WA
| | | | - Jeffrey Siegler
- Department of Emergency Medicine, Washington University School of Medicine, St Louis, MO
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Faísco A, Dinis R, Seixas T, Lopes L. Ketamine in Chronic Pain: A Review. Cureus 2024; 16:e53365. [PMID: 38435232 PMCID: PMC10908414 DOI: 10.7759/cureus.53365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2024] [Indexed: 03/05/2024] Open
Abstract
Ketamine has been used in the treatment of several pain syndromes, particularly those with a relevant neuropathic component. Sub-anesthetic doses of ketamine produce a potent analgesic effect, due to its inhibition of N-methyl-D-aspartate receptors and enhancement of descending inhibitory pathways. Its short-term analgesic effect is well-documented perioperatively, with an associated reduction in postoperative chronic pain and opioid consumption. Despite some evidence regarding its long-term benefits, the number of clinical studies is still limited. In addition to its analgesic effects, ketamine also possesses an anti-depressive action, which might be useful in the treatment of chronic pain patients. Several side effects have been described, the psychomimetic ones being the most relevant due to their impact on treatment adhesion. At present, co-administration of ketamine and benzodiazepines or α2-agonists facilitates its clinical application. Despite current evidence and increasing use, further investigation is still needed regarding its long-term safety profile and clearer risk-benefit analysis.
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Affiliation(s)
- Ana Faísco
- Department of Anaesthesiology, Hospital Professor Doutor Fernando Fonseca, Amadora, PRT
| | - Rita Dinis
- Department of Anaesthesiology, Hospital Professor Doutor Fernando Fonseca, Amadora, PRT
| | - Tânia Seixas
- Department of Anaesthesiology, Hospital Professor Doutor Fernando Fonseca, Amadora, PRT
| | - Luís Lopes
- Department of Anaesthesiology, Hospital Professor Doutor Fernando Fonseca, Amadora, PRT
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9
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Shehata IM, Kohaf NA, ElSayed MW, Latifi K, Aboutaleb AM, Kaye AD. Ketamine: Pro or antiepileptic agent? A systematic review. Heliyon 2024; 10:e24433. [PMID: 38293492 PMCID: PMC10826813 DOI: 10.1016/j.heliyon.2024.e24433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 01/08/2024] [Accepted: 01/09/2024] [Indexed: 02/01/2024] Open
Abstract
Purpose of Review: This evidence-based systematic review evaluated the safety of ketamine as regard the potential to provoke epilepsy to help better guide anesthesiologists in their practice. Recent findings Ketamine, originally developed as a dissociative anesthetic, has gained attention for its potential therapeutic applications in various medical conditions, including epilepsy. Ketamine is generally well-tolerated and widely used in anesthesia, however, conflicting data are confusing the anesthesiologists regarding the potential risk of seizures associated with its use. The literature that claimed the proepileeptic property are inconsistent and the mechanism of action is unclear. Moreover, the case reports had been in same certain contexts, such as procedural sedation where ketamine was used as a single agent. On the other hand, the retrospective data analysis confirmed the positive role ketamine plays as antiepileptic agent. Summary Many studies have shown promising results for the use of ketamine as antiepileptic agent. In case of epileptic patients, there is no contraindication for using ketamine, however, combining with benzodiazepine or propofol may enhance the safety.
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Affiliation(s)
| | - Neveen A. Kohaf
- Department of Clinical Pharmacy, Alazhar, University, Cairo, 11651, Egypt
| | - Mohamed W. ElSayed
- Geisel School of Medicine at Dartmouth, New Hampshire Hospital, SUNY School of Graduate Studies, USA
| | - Kaveh Latifi
- Department of Anesthesiology and Pain Medicine, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | | | - Alan David Kaye
- Departments of Anesthesiology and Pharmacology, Toxicology, and Neurosciences, Louisiana State University Health Sciences Center Shreveport, Shreveport, LA, 71103, USA
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10
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Nakada R, Terasawa Y, Sato T, Takatsu H, Kaito N, Iguchi Y. [A case of cryptogenic new-onset refractory status epilepticus (NORSE) in which cerebrospinal fluid IL-6 was elevated with increased seizure frequency early in the disease: a case report]. Rinsho Shinkeigaku 2023; 63:843-846. [PMID: 37989289 DOI: 10.5692/clinicalneurol.cn-001879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2023]
Abstract
A 25-year-old male presented with clonic seizures three days following a fever. The patient developed status epilepticus and required mechanical ventilation and intravenous anesthesia. The patient's epileptic seizures persisted despite administering intravenous anesthesia and multiple anti-epileptic drugs. The clinical presentation in this case, without pre-existing relevant neurological disorder and an active structural, toxic, or metabolic cause in the acute phase, was compatible with new-onset refractory status epilepticus (NORSE). After immunotherapy, including intravenous methylprednisolone, plasma exchange, and intravenous immunoglobulin therapy, the epileptic discharge on electroencephalogram (EEG) decreased gradually, and mechanical ventilation was discontinued. Neversless the final outcome was poor. The patient's condition was finally diagnosed as cryptogenic NORSE. The IL-6 levels in the cerebrospinal fluid showed a significant increase between day 6 and 11 after onset, during which time there was a rapid escalation in seizure frequency on EEG. Considering this, IL-6 may be involved in the process of seizure exacerbation.
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Affiliation(s)
- Ryoji Nakada
- Department of Neurology, The Jikei University School of Medicine
| | - Yuka Terasawa
- Department of Neurology, The Jikei University School of Medicine
| | - Takeo Sato
- Department of Neurology, The Jikei University School of Medicine
| | - Hiroki Takatsu
- Department of Neurology, The Jikei University School of Medicine
| | - Nobuyoshi Kaito
- Department of Neurosurgery, The Jikei University School of Medicine
| | - Yasuyuki Iguchi
- Department of Neurology, The Jikei University School of Medicine
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11
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Schep LJ, Slaughter RJ, Watts M, Mackenzie E, Gee P. The clinical toxicology of ketamine. Clin Toxicol (Phila) 2023:1-14. [PMID: 37267048 DOI: 10.1080/15563650.2023.2212125] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 05/01/2023] [Accepted: 05/04/2023] [Indexed: 06/04/2023]
Abstract
INTRODUCTION Ketamine is a pharmaceutical drug possessing both analgesic and anaesthetic properties. As an anaesthetic, it induces anaesthesia by producing analgesia with a state of altered consciousness while maintaining airway tone, respiratory drive, and hemodynamic stability. At lower doses, it has psychoactive properties and has gained popularity as a recreational drug. OBJECTIVES To review the epidemiology, mechanisms of toxicity, pharmacokinetics, clinical features, diagnosis and management of ketamine toxicity. METHODS Both OVID MEDLINE (January 1950-April 2023) and Web of Science (1900-April 2023) databases were searched using the term "ketamine" in combination with the keywords "pharmacokinetics", "kinetics", "poisoning", "poison", "toxicity", "ingestion", "adverse effects", "overdose", and "intoxication". Furthermore, bibliographies of identified articles were screened for additional relevant studies. These searches produced 5,268 non-duplicate citations; 185 articles (case reports, case series, pharmacokinetic studies, animal studies pertinent to pharmacology, and reviews) were considered relevant. Those excluded were other animal investigations, therapeutic human clinical investigations, commentaries, editorials, cases with no clinical relevance and post-mortem investigations. EPIDEMIOLOGY Following its introduction into medical practice in the early 1970s, ketamine has become a popular recreational drug. Its use has become associated with the dance culture, electronic and dubstep dance events. MECHANISM OF ACTION Ketamine acts primarily as a non-competitive antagonist on the glutamate N-methyl-D-aspartate receptor, causing the loss of responsiveness that is associated with clinical ketamine dissociative anaesthesia. PHARMACOKINETICS Absorption of ketamine is rapid though the rate of uptake and bioavailability is determined by the route of exposure. Ketamine is metabolized extensively in the liver. Initially, both isomers are metabolized to their major active metabolite, norketamine, by CYP2B6, CYP3A4 and CYP2C9 isoforms. The hydroxylation of the cyclohexan-1-one ring of norketamine to the three positional isomers of hydroxynorketamine occurs by CYP2B6 and CYP2A6. The dehydronorketamine metabolite occurs either by direct dehydrogenation from norketamine via CYP2B6 metabolism or non-enzymatic dehydration of hydroxynorketamine. Norketamine, the dehydronorketamine isomers, and hydroxynorketamine have pharmacological activity. The elimination of ketamine is primarily by the kidneys, though unchanged ketamine accounts for only a small percentage in the urine. The half-life of ketamine in humans is between 1.5 and 5 h. CLINICAL FEATURES Acute adverse effects following recreational use are diverse and can include impaired consciousness, dizziness, irrational behaviour, hallucinations, abdominal pain and vomiting. Chronic use can result in impaired verbal information processing, cystitis and cholangiopathy. DIAGNOSIS The diagnosis of acute ketamine intoxication is typically made on the basis of the patient's history, clinical features, such as vomiting, sialorrhea, or laryngospasm, along with neuropsychiatric features. Chronic effects of ketamine toxicity can result in cholangiopathy and cystitis, which can be confirmed by endoscopic retrograde cholangiopancreatography and cystoscopy, respectively. MANAGEMENT Treatment of acute clinical toxicity is predominantly supportive with empiric management of specific adverse effects. Benzodiazepines are recommended as initial treatment to reduce agitation, excess neuromuscular activity and blood pressure. Management of cystitis is multidisciplinary and multi-tiered, following a stepwise approach of pharmacotherapy and surgery. Management of cholangiopathy may require pain management and, where necessary, biliary stenting to alleviate obstructions. Chronic effects of ketamine toxicity are typically reversible, with management focusing on abstinence. CONCLUSIONS Ketamine is a dissociative drug employed predominantly in emergency medicine; it has also become popular as a recreational drug. Its recreational use can result in acute neuropsychiatric effects, whereas chronic use can result in cystitis and cholangiopathy.
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Affiliation(s)
- Leo J Schep
- Professional Practice Fellow, Department of Biochemistry, University of Otago, Dunedin, New Zealand
| | | | - Martin Watts
- Emergency Department, Southland Hospital, Invercargill, New Zealand
| | - Elliot Mackenzie
- Obstetrics and Gynaecology, Women and Childrens Health. Dunedin Public Hospital, Dunedin, New Zealand
| | - Paul Gee
- National Poisons Centre, University of Otago, Dunedin, New Zealand
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
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12
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Soliman SS, Mahmoud AM, Elghobashy MR, Zaazaa HE, Sedik GA. Point-of-care electrochemical sensor for selective determination of date rape drug "ketamine" based on core-shell molecularly imprinted polymer. Talanta 2023; 254:124151. [PMID: 36463800 DOI: 10.1016/j.talanta.2022.124151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 11/12/2022] [Accepted: 11/27/2022] [Indexed: 11/30/2022]
Abstract
Misuse of illicit drugs is a serious problem that became the primary concern for many authorities worldwide. Point-of-care (POC) diagnostic tools can provide accurate and fast screening information that helps to detect illicit drugs in a short time. A portable, disposable and reproducible core-shell molecularly imprinted polymer (MIP) screen-printed sensor was synthesized as a POC analyzer for the assay of the date rape drug "ketamine hydrochloride" in different matrices. Firstly, the screen-printed electrode substrate was modified electrochemically with polyaniline (PANI) as an ion-to-electron transducer interlayer to improve the potential signal stability. Secondly, core-shell MIP was prepared, the core consisting of silica nanoparticles prepared by Stober's method, while the MIP shell was synthesized onto silica nanoparticles surface by copolymerizing methacrylic acid functional monomer and the crossing agent; ethylene glycol dimethacrylate in the presence of ketamine as a template molecule. Finally, the core-shell MIP was incorporated into the PVC membrane as an ionophore and drop-casted over PANI modified screen-printed carbon electrode. The imprinting process and the morphology of MIP were examined using scanning electron microscopy, Fourier-transform infrared and X-ray photoelectron spectroscopic methods. The sensor exhibited a short response time within 3-5 s in a pH range (2.0-5.0). The potential profile indicated a linear relationship in a dynamic concentration range of 1.0 × 10-6 M to 1.0 × 10-2 M with a slope of 54.7 mV/decade. The sensor was employed to determine ketamine in biological matrices and beverages.
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Affiliation(s)
- Shymaa S Soliman
- Analytical Chemistry Department, Faculty of Pharmacy, October 6 University, October 6 City, Giza, 12858, Egypt
| | - Amr M Mahmoud
- Analytical Chemistry Department, Faculty of Pharmacy, Cairo University, El-Kasr-El Aini Street, Cairo, 11562, Egypt
| | - Mohamed R Elghobashy
- Analytical Chemistry Department, Faculty of Pharmacy, October 6 University, October 6 City, Giza, 12858, Egypt; Analytical Chemistry Department, Faculty of Pharmacy, Cairo University, El-Kasr-El Aini Street, Cairo, 11562, Egypt
| | - Hala E Zaazaa
- Analytical Chemistry Department, Faculty of Pharmacy, Cairo University, El-Kasr-El Aini Street, Cairo, 11562, Egypt
| | - Ghada A Sedik
- Analytical Chemistry Department, Faculty of Pharmacy, Cairo University, El-Kasr-El Aini Street, Cairo, 11562, Egypt.
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13
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Huang TH, Lai MC, Chen YS, Huang CW. The Roles of Glutamate Receptors and Their Antagonists in Status Epilepticus, Refractory Status Epilepticus, and Super-Refractory Status Epilepticus. Biomedicines 2023; 11:biomedicines11030686. [PMID: 36979664 PMCID: PMC10045490 DOI: 10.3390/biomedicines11030686] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 02/18/2023] [Accepted: 02/21/2023] [Indexed: 03/30/2023] Open
Abstract
Status epilepticus (SE) is a neurological emergency with a high mortality rate. When compared to chronic epilepsy, it is distinguished by the durability of seizures and frequent resistance to benzodiazepine (BZD). The Receptor Trafficking Hypothesis, which suggests that the downregulation of γ-Aminobutyric acid type A (GABAA) receptors, and upregulation of N-methyl-D-aspartate (NMDA) and α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptors play major roles in the establishment of SE is the most widely accepted hypothesis underlying BZD resistance. NMDA and AMPA are ionotropic glutamate receptor families that have important excitatory roles in the central nervous system (CNS). They are both essential in maintaining the normal function of the brain and are involved in a variety of neuropsychiatric diseases, including epilepsy. Based on animal and human studies, antagonists of NMDA and AMPA receptors have a significant impact in ending SE; albeit most of them are not yet approved to be in clinically therapeutic guidelines, due to their psychomimetic adverse effects. Although there is still a dearth of randomized, prospective research, NMDA antagonists such as ketamine, magnesium sulfate, and the AMPA antagonist, perampanel, are regarded to be reasonable optional adjuvant therapies in controlling SE, refractory SE (RSE) or super-refractory SE (SRSE), though there are still a lack of randomized, prospective studies. This review seeks to summarize and update knowledge on the SE development hypothesis, as well as clinical trials using NMDA and AMPA antagonists in animal and human studies of SE investigations.
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Affiliation(s)
- Tzu-Hsin Huang
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70142, Taiwan
- Zhengxin Neurology & Rehabilitation Center, Tainan 70459, Taiwan
| | - Ming-Chi Lai
- Department of Pediatrics, Chi-Mei Medical Center, Tainan 71004, Taiwan
| | - Yu-Shiue Chen
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70142, Taiwan
| | - Chin-Wei Huang
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70142, Taiwan
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14
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Buratti S, Giacheri E, Palmieri A, Tibaldi J, Brisca G, Riva A, Striano P, Mancardi MM, Nobili L, Moscatelli A. Ketamine as advanced second-line treatment in benzodiazepine-refractory convulsive status epilepticus in children. Epilepsia 2023; 64:797-810. [PMID: 36792542 DOI: 10.1111/epi.17550] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 02/11/2023] [Accepted: 02/13/2023] [Indexed: 02/17/2023]
Abstract
Status epilepticus (SE) is one of the most common neurological emergencies in children. To date, there is no definitive evidence to guide treatment of SE refractory to benzodiazepines. The main objectives of treatment protocols are to expedite therapeutic decisions and to use fast- and short-acting medications without significant adverse effects. Protocols differ among institutions, and most frequently valproate, phenytoin, and levetiracetam are used as second-line treatment. After failure of first- and second-line medications, admission to the intensive care unit and continuous infusion of anesthetics are usually indicated. Ketamine is a noncompetitive N-methyl-D-aspartate receptor antagonist that has been safely used for the treatment of refractory SE in adults and children. In animal models of SE, ketamine demonstrated antiepileptic and neuroprotective properties and synergistic effects with other antiseizure medications. We reviewed the literature to demonstrate the potential role of ketamine as an advanced second-line agent in the treatment of SE. Pharmacological targets, pathophysiology of SE, and the receptor trafficking hypothesis are reviewed and presented. The pharmacology of ketamine is outlined with related properties, advantages, and side effects. We summarize the most recent and relevant publications on experimental and clinical studies on ketamine in SE. Key expert opinion is also reported. Considering the current knowledge on SE pathophysiology, early sequential polytherapy should include ketamine for its wide range of positive assets. Future research and clinical trials on SE pharmacotherapy should focus on the role of ketamine as second-line medication.
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Affiliation(s)
- Silvia Buratti
- Neonatal and Pediatric Intensive Care Unit, Emergency Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Emanuele Giacheri
- Intermediate Care Unit, Emergency Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Antonella Palmieri
- Emergency Medicine Unit, Emergency Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Jessica Tibaldi
- Emergency Medicine Unit, Emergency Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Giacomo Brisca
- Intermediate Care Unit, Emergency Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Antonella Riva
- Department of Neuroscience (DINOGMI), University of Genoa, Genoa, Italy
| | - Pasquale Striano
- Department of Neuroscience (DINOGMI), University of Genoa, Genoa, Italy.,Pediatric Neurology and Muscular Disease Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | | | - Lino Nobili
- Department of Neuroscience (DINOGMI), University of Genoa, Genoa, Italy.,Child Neuropsychiatry Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Andrea Moscatelli
- Neonatal and Pediatric Intensive Care Unit, Emergency Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
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15
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Davis JA, Grau JW. Protecting the injured central nervous system: Do anesthesia or hypothermia ameliorate secondary injury? Exp Neurol 2023; 363:114349. [PMID: 36775099 DOI: 10.1016/j.expneurol.2023.114349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 01/13/2023] [Accepted: 02/06/2023] [Indexed: 02/12/2023]
Abstract
Traumatic injury to the central nervous system (CNS) and stroke initiate a cascade of processes that expand the area of tissue loss. The current review considers recent studies demonstrating that the induction of an anesthetic state or cooling the affected tissue (hypothermia) soon after injury can have a therapeutic effect. We first provide an overview of the neurobiological processes that fuel tissue loss after traumatic brain injury (TBI), spinal cord injury (SCI) and stroke. We then examine the rehabilitative effectiveness of therapeutic anesthesia across a variety of drug categories through a systematic review of papers in the PubMed database. We also review the therapeutic benefits hypothermia, another treatment that quells neural activity. We conclude by considering factors related to the safety, efficacy and timing of treatment, as well as the mechanisms of action. Clinical implications are also discussed.
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Affiliation(s)
- Jacob A Davis
- Cellular and Behavioral Neuroscience, Department of Psychology, Texas A&M University, College Station, TX 77843, USA.
| | - James W Grau
- Cellular and Behavioral Neuroscience, Department of Psychology, Texas A&M University, College Station, TX 77843, USA
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16
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Wieser M, Beckmann KM, Kutter APN, Mauri N, Richter H, Zölch N, Bektas RN. Ketamine administration in idiopathic epileptic and healthy control dogs: Can we detect differences in brain metabolite response with spectroscopy? Front Vet Sci 2023; 9:1093267. [PMID: 36686158 PMCID: PMC9853535 DOI: 10.3389/fvets.2022.1093267] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 12/12/2022] [Indexed: 01/07/2023] Open
Abstract
Introduction In recent years ketamine has increasingly become the focus of multimodal emergency management for epileptic seizures. However, little is known about the effect of ketamine on brain metabolites in epileptic patients. Magnetic resonance spectroscopy (MRS) is a non-invasive technique to estimate brain metabolites in vivo. Our aim was to measure the effect of ketamine on thalamic metabolites in idiopathic epileptic (IE) dogs using 3 Tesla MRS. We hypothesized that ketamine would increase the glutamine-glutamate (GLX)/creatine ratio in epileptic dogs with and without antiseizure drug treatment, but not in control dogs. Furthermore, we hypothesized that no different responses after ketamine administration in other measured brain metabolite ratios between the different groups would be detected. Methods In this controlled prospective experimental trial IE dogs with or without antiseizure drug treatment and healthy client-owned relatives of the breeds Border Collie and Greater Swiss Mountain Dog, were included. After sedation with butorphanol, induction with propofol and maintenance with sevoflurane in oxygen and air, a single voxel MRS at the level of the thalamus was performed before and 2 min after intravenous administration of 1 mg/kg ketamine. An automated data processing spectral fitting linear combination model algorithm was used to estimate all commonly measured metabolite ratios. A mixed ANOVA with the independent variables ketamine administration and group allocation was performed for all measured metabolites. A p < 0.05 was considered statistically significant. Results Twelve healthy control dogs, 10 untreated IE and 12 treated IE dogs were included. No significant effects for GLX/creatine were found. However, increased glucose/creatine ratios were found (p < 0.001) with no effect of group allocation. Furthermore, increases in the GABA/creatine ratio were found in IEU dogs. Discussion MRS was able to detect changes in metabolite/creatine ratios after intravenous administration of 1 mg/kg ketamine in dogs and no evidence was found that excitatory effects are induced in the thalamus. Although it is beyond the scope of this study to investigate the antiseizure potential of ketamine in dogs, results of this research suggest that the effect of ketamine on the brain metabolites could be dependent on the concentrations of brain metabolites before administration.
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Affiliation(s)
- Manuela Wieser
- Section of Anesthesiology, Department of Clinical Diagnostics and Services, University of Zurich, Zurich, Switzerland,*Correspondence: Manuela Wieser ✉
| | | | - Annette P. N. Kutter
- Section of Anesthesiology, Department of Clinical Diagnostics and Services, University of Zurich, Zurich, Switzerland
| | - Nico Mauri
- Department of Clinical Diagnostics and Services, Clinic for Diagnostic Imaging, University of Zurich, Zurich, Switzerland,Vetimage Diagnostik AG, Oberentfelden, Switzerland
| | - Henning Richter
- Department of Clinical Diagnostics and Services, Clinic for Diagnostic Imaging, University of Zurich, Zurich, Switzerland
| | - Niklaus Zölch
- Department of Forensic Medicine and Imaging, Institute of Forensic Medicine, University of Zurich, Zurich, Switzerland
| | - Rima Nadine Bektas
- Section of Anesthesiology, Department of Clinical Diagnostics and Services, University of Zurich, Zurich, Switzerland
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17
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Ornowska M, Wormsbecker A, Andolfatto G, Leung T, Khan I, Medvedev G. The use of ketamine as a neuroprotective agent following cardiac arrest: A scoping review of current literature. CNS Neurosci Ther 2022; 29:104-110. [PMID: 36184822 PMCID: PMC9804040 DOI: 10.1111/cns.13983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 09/12/2022] [Accepted: 09/13/2022] [Indexed: 02/06/2023] Open
Abstract
AIMS The objective of this article is to summarize the state of the literature surrounding the use of ketamine as a neuroprotective agent following cardiac arrest. METHODS Five electronic databases were used to search for studies related to the use of ketamine for neuroprotection following cardiac arrest. This search was performed once in May 2020, and an updated search was conducted in May 2021 and March 2022. RESULTS All searches combined retrieved 181 results; no clinical trials were identified. As such, the authors were limited to writing a scoping review of the literature rather than a systematic review. CONCLUSIONS The current state of the literature describes the mechanism of action of ketamine as a neuroprotective agent through its action as an NMDA antagonist. There is evidence of its efficacy as a neuroprotective agent in preclinical models of cardiac arrest. Current published clinical work supports the use of ketamine ameliorating neurologic outcomes in other conditions such as epilepsy, traumatic brain injury, and depression. The current state of the literature is reflective of the notion that the use of ketamine following cardiac arrest may result in improved neurologic outcomes. Future research directions should focus on the use of ketamine as a possible clinical intervention following cardiac arrest.
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Affiliation(s)
- Marlena Ornowska
- Department of Biomedical PhysiologySimon Fraser UniversityBurnabyBritish ColumbiaCanada
| | - Andrew Wormsbecker
- Royal Columbian Hospital, Fraser Health AuthorityNew WestminsterBritish ColumbiaCanada,Division of Critical Care, Department of MedicineUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Gary Andolfatto
- Department of Emergency Medicine, Department of MedicineUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Tim S. Leung
- Royal Columbian Hospital, Fraser Health AuthorityNew WestminsterBritish ColumbiaCanada,Faculty of Pharmaceutical SciencesUniversity of British ColumbiaVancouverBritish ColumbiaCanada,Lower Mainland Pharmacy ServicesVancouverBritish ColumbiaCanada
| | - Idan Khan
- Royal Columbian Hospital, Fraser Health AuthorityNew WestminsterBritish ColumbiaCanada,Department of Emergency Medicine, Department of MedicineUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - George Medvedev
- Royal Columbian Hospital, Fraser Health AuthorityNew WestminsterBritish ColumbiaCanada,Division of Neurology, Department of MedicineUniversity of British ColumbiaVancouverBritish ColumbiaCanada
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18
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Cuenca CM, Borgman MA, Dengler BA, Schauer SG. Incidence of post-traumatic seizures in children during combat operations in Afghanistan and Iraq. Injury 2022; 53:3297-3300. [PMID: 35831207 DOI: 10.1016/j.injury.2022.07.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 06/15/2022] [Accepted: 07/03/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Children represent a significant portion of the patient population treated at combat support hospitals. There is significant data regarding post injury seizures in adults but with children it is lacking. We seek to describe the incidence of post-traumatic seizures within this population. METHODS This is a secondary analysis of previously described data from the Department of Defense Trauma Registry (DODTR). Within our dataset, we searched for documentation of seizures after admission. RESULTS Of the 3439 encounters in our dataset, we identified 37 casualties that had a documented seizure after admission. Most were in the 1-4 year age group (37.8%), male (59.4%), injured by explosive (40.5%), with serious injuries to the head/neck (75.6%). The median ISS was higher in the seizure group (22 versus 10, p<0.001). Most survived to hospital discharge with no statistically significant increased mortality noted in the seizure group (seizure 90.2% versus 91.8%, p = 1.000). In the prehospital setting, the seizure group was more frequently intubated (16.2% versus 6.0%, p = 0.023), received ketamine (20.0% versus 3.2%, p<0.001), and administered an anti-seizure medication (5.4% versus 0.1%, p = 0.001). In the hospital setting, the seizure group was more frequently intubated (56.7% versus 17.7%, p<0.001), had intracranial pressure monitoring (24.3% versus 2.6%, p<0.001), craniectomy (10.8% versus 2.5%, p = 0.014), and craniotomy (21.6% versus 4.7%, p<0.001). CONCLUSIONS Within our dataset, we found an incidence of 1% of pediatric casualties experiencing a post-traumatic seizure. While this number appears infrequent, there is likely significant under detection of subclinical seizures.
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Affiliation(s)
- Camaren M Cuenca
- US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas, USA
| | | | - Bradley A Dengler
- Department of Neurosurgery, Walter Reed National Military Medical Center, Bethesda Maryland, USA
| | - Steven G Schauer
- US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas, USA; Brooke Army Medical Center, JBSA Fort Sam Houston, Texas, USA; Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.
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19
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Seillier C, Lesept F, Toutirais O, Potzeha F, Blanc M, Vivien D. Targeting NMDA Receptors at the Neurovascular Unit: Past and Future Treatments for Central Nervous System Diseases. Int J Mol Sci 2022; 23:ijms231810336. [PMID: 36142247 PMCID: PMC9499580 DOI: 10.3390/ijms231810336] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 08/30/2022] [Accepted: 09/02/2022] [Indexed: 11/16/2022] Open
Abstract
The excitatory neurotransmission of the central nervous system (CNS) mainly involves glutamate and its receptors, especially N-methyl-D-Aspartate receptors (NMDARs). These receptors have been extensively described on neurons and, more recently, also on other cell types. Nowadays, the study of their differential expression and function is taking a growing place in preclinical and clinical research. The diversity of NMDAR subtypes and their signaling pathways give rise to pleiotropic functions such as brain development, neuronal plasticity, maturation along with excitotoxicity, blood-brain barrier integrity, and inflammation. NMDARs have thus emerged as key targets for the treatment of neurological disorders. By their large extracellular regions and complex intracellular structures, NMDARs are modulated by a variety of endogenous and pharmacological compounds. Here, we will present an overview of NMDAR functions on neurons and other important cell types involved in the pathophysiology of neurodegenerative, neurovascular, mental, autoimmune, and neurodevelopmental diseases. We will then discuss past and future development of NMDAR targeting drugs, including innovative and promising new approaches.
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Affiliation(s)
- Célia Seillier
- Normandie University, UNICAEN, INSERM, GIP Cyceron, Institute Blood and Brain @Caen-Normandie (BB@C), UMR-S U1237, Physiopathology and Imaging of Neurological Disorders (PhIND), 14000 Caen, France
| | - Flavie Lesept
- Lys Therapeutics, Cyceron, Boulevard Henri Becquerel, 14000 Caen, France
| | - Olivier Toutirais
- Normandie University, UNICAEN, INSERM, GIP Cyceron, Institute Blood and Brain @Caen-Normandie (BB@C), UMR-S U1237, Physiopathology and Imaging of Neurological Disorders (PhIND), 14000 Caen, France
- Department of Immunology and Histocompatibility (HLA), Caen University Hospital, CHU, 14000 Caen, France
| | - Fanny Potzeha
- Lys Therapeutics, Cyceron, Boulevard Henri Becquerel, 14000 Caen, France
| | - Manuel Blanc
- Lys Therapeutics, Cyceron, Boulevard Henri Becquerel, 14000 Caen, France
| | - Denis Vivien
- Normandie University, UNICAEN, INSERM, GIP Cyceron, Institute Blood and Brain @Caen-Normandie (BB@C), UMR-S U1237, Physiopathology and Imaging of Neurological Disorders (PhIND), 14000 Caen, France
- Department of Clinical Research, Caen University Hospital, CHU, 14000 Caen, France
- Correspondence:
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20
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Al-Gailani L, Al-Kaleel A, Arslan G, Ayyıldız M, Ağar E. THE effect of general anesthetics on genetic absence epilepsy in WAG/Rij rats. Neurol Res 2022; 44:995-1005. [PMID: 35786420 DOI: 10.1080/01616412.2022.2095706] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
AIM To establish safe and straightforward anesthesia used in experiments, we examined the effect of ketamine, ketamine/xylazine, urethane, chloral hydrate, pentobarbital, isoflurane, dexmedetomidine, and dexmedetomidine/ketamine on epileptiform activity in genetic absence epilepsy (WAG\Rij) rats. MATERIALS AND METHOD Sixty-three male WAG/Rij rats weighing (170-190 g) were used. Tripolar electrodes were inserted into the skull. After ECoG activities were recorded for each animal for 2 hours as controls, , the anesthetic substances were administered and the recording continued for another 2 hours. All the anesthetic substances were administered intraperitoneally except isoflurane, which was administered by inhalation.The PowerLab system was used for electrophysiological activity recording and analysis. RESULTS The administration of ketamine (90 mg/kg), ketamine/xylazine (90/10 mg/kg), urethane (1.25 g/kg), chloral hydrate (175 mg/kg), pentobarbital (50-90 mg/kg), isoflurane (induction 5%, maintaining 3-4%), dexmedetomidine (0.5-1 mg/kg), and dexmedetomidine/ketamine (50/90 mg/kg), significantly decreased the total number of SWD, the total number of spikes, and the SWD duration (p < 0,05). The mean duration of SWD was not affected in pentobarbital (50-90 mg/kg), isoflurane (induction 5%, maintaining 3-4%), dexmedetomidine (0.5-1 mg/kg), and Dexmedetomidine/ketamine (50/90 mg/kg) groups (p > 0.05). Time scale showed a significant decrease in the total number of SWD in the first 20 minutes (P < 0.001) for all groups except dexmedetomidine (0.5-1 mg/kg), and dexmedetomidine/ketamine (50/90 mg/kg) groups (p > 0.05). CONCLUSION The anesthetics we used significantly reduced the epileptiform activity immediately after the administration, except dexmedetomidine and dexmedetomidine/ketamine groups, so we recommend using dexmedetomidine and Dexmedetomidine/ketamine in electrophysiological studies accompanied by anesthetics.
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Affiliation(s)
- Lubna Al-Gailani
- Department of Physiology, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey.,Faculty of Medicine, Cyprus International University, Nicosia, Cyprus
| | - Ali Al-Kaleel
- Faculty of Medicine, Cyprus International University, Nicosia, Cyprus
| | - Gökhan Arslan
- Department of Physiology, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Mustafa Ayyıldız
- Department of Physiology, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Erdal Ağar
- Faculty of Medicine, Giresun University, Giresun, Turkey
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21
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Choudhury SP, Bano S, Sen S, Suchal K, Kumar S, Nikolajeff F, Dey SK, Sharma V. Altered neural cell junctions and ion-channels leading to disrupted neuron communication in Parkinson's disease. NPJ Parkinsons Dis 2022; 8:66. [PMID: 35650269 PMCID: PMC9160246 DOI: 10.1038/s41531-022-00324-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Accepted: 05/05/2022] [Indexed: 12/16/2022] Open
Abstract
Parkinson's disease (PD) is a neurological disorder that affects the movement of the human body. It is primarily characterized by reduced dopamine levels in the brain. The causative agent of PD is still unclear but it is generally accepted that α-synuclein has a central role to play. It is also known that gap-junctions and associated connexins are complicated structures that play critical roles in nervous system signaling and associated misfunctioning. Thus, our current article emphasizes how, alongside α-synuclein, ion-channels, gap-junctions, and related connexins, all play vital roles in influencing multiple metabolic activities of the brain during PD. It also highlights that ion-channel and gap-junction disruptions, which are primarily mediated by their structural-functional changes and alterations, have a role in PD. Furthermore, we discussed available drugs and advanced therapeutic interventions that target Parkinson's pathogenesis. In conclusion, it warrants creating better treatments for PD patients. Although, dopaminergic replenishment therapy is useful in treating neurological problems, such therapies are, however, unable to control the degeneration that underpins the disease, thereby declining their overall efficacy. This creates an additional challenge and an untapped scope for neurologists to adopt treatments for PD by targeting the ion-channels and gap-junctions, which is well-reviewed in the present article.
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Affiliation(s)
- Saptamita Paul Choudhury
- School of Biotechnology, Kalinga Institute of Industrial Technology, Bhubaneswar, Odisha, 751024, India
| | - Sarika Bano
- Dr. B.R. Ambedkar Center for Biomedical Research, University of Delhi, Delhi, 110007, India
| | - Srijon Sen
- Indian Institute of Technology-Kharagpur, Kharagpur, 721302, India
| | - Kapil Suchal
- Department of Pharmacy, Panipat Institute of Engineering and Technology, Panipat, India
| | - Saroj Kumar
- Deparment of Biophysics, All India Institute of Medical Sciences, New Delhi, 110029, India
- Department of Health, Education and Technology, Lulea University of Technology, Lulea, Sweden
| | - Fredrik Nikolajeff
- Department of Health, Education and Technology, Lulea University of Technology, Lulea, Sweden
| | - Sanjay Kumar Dey
- Dr. B.R. Ambedkar Center for Biomedical Research, University of Delhi, Delhi, 110007, India.
| | - Vaibhav Sharma
- Department of Health, Education and Technology, Lulea University of Technology, Lulea, Sweden.
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22
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Wang S, Chen G, Merlo Pich E, Affinito J, Cwik M, Faessel HM. Pharmacokinetics, pharmacodynamics and safety assessment of multiple doses of soticlestat in healthy volunteers. Br J Clin Pharmacol 2022; 88:2899-2908. [PMID: 35001412 PMCID: PMC9305210 DOI: 10.1111/bcp.15225] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 12/16/2021] [Accepted: 12/19/2021] [Indexed: 11/26/2022] Open
Abstract
AIMS Soticlestat, a first-in-class inhibitor of cholesterol 24-hydroxylase (also known as cytochrome P450 46A1), is currently in development for the treatment of developmental and epileptic encephalopathies. Here, we report safety, tolerability, pharmacokinetic and pharmacodynamic outcomes from a phase I, randomized, double-blind, placebo-controlled, multiple-rising-dose study of soticlestat in healthy adults. METHODS Five cohorts of healthy subjects (n = 8 each, randomized 6:2 soticlestat:placebo) received oral soticlestat 100-600 mg once daily (QD) or 300 mg twice daily (BID) for 10-14 days. Serial blood and urine samples were obtained on days 1, 7 (blood only) and 14. RESULTS Soticlestat in the dose range 100-400 mg/day for up to 14 days was generally well tolerated. In total, 45 treatment-emergent adverse events (TEAEs) were reported; most (91%) were transient and mild in intensity. Two subjects experienced TEAEs leading to discontinuation: one receiving soticlestat 600 mg QD reported a severe event of acute psychosis; another receiving 300 mg BID reported a mild event of confusional state. Steady-state exposure to soticlestat increased in a slightly greater than dose-proportional manner across the dose range 100-400 mg QD. Peak plasma concentrations were reached within 0.33-0.5 hour, and soticlestat elimination half-life was approximately 4 hours. Renal excretion of soticlestat was negligible. Soticlestat 100-400 mg QD reduced 24S-hydroxycholesterol levels by 46.8 (coefficient of variation [CV%] -9.2) to -62.7% (CV% -7.3) at steady state; values of enzymatic inhibition were compatible with antiepileptic effects observed in preclinical models. CONCLUSION The pharmacokinetic and pharmacodynamic profiles of soticlestat characterized here provided a data-driven rationale for clinical trial dose selection.
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Affiliation(s)
- Shining Wang
- Quantitative Clinical PharmacologyTakeda Pharmaceuticals International Co.CambridgeMAUSA
| | - Grace Chen
- Quantitative Clinical PharmacologyTakeda Pharmaceuticals International Co.CambridgeMAUSA
| | - Emilio Merlo Pich
- Clinical ScienceTakeda Pharmaceuticals International AGZurichSwitzerland
| | - John Affinito
- Patient Safety EvaluationTakeda PharmaceuticalsDeerfieldIllinoisUSA
| | - Michael Cwik
- Clinical Biomarker Innovation and DevelopmentTakeda PharmaceuticalsCambridgeMAUSA
| | - Hélène M. Faessel
- Quantitative Clinical PharmacologyTakeda Pharmaceuticals International Co.CambridgeMAUSA
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23
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Kessi M, Peng J, Duan H, He H, Chen B, Xiong J, Wang Y, Yang L, Wang G, Kiprotich K, Bamgbade OA, He F, Yin F. The Contribution of HCN Channelopathies in Different Epileptic Syndromes, Mechanisms, Modulators, and Potential Treatment Targets: A Systematic Review. Front Mol Neurosci 2022; 15:807202. [PMID: 35663267 PMCID: PMC9161305 DOI: 10.3389/fnmol.2022.807202] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 04/06/2022] [Indexed: 12/04/2022] Open
Abstract
Background Hyperpolarization-activated cyclic nucleotide-gated (HCN) current reduces dendritic summation, suppresses dendritic calcium spikes, and enables inhibitory GABA-mediated postsynaptic potentials, thereby suppressing epilepsy. However, it is unclear whether increased HCN current can produce epilepsy. We hypothesized that gain-of-function (GOF) and loss-of-function (LOF) variants of HCN channel genes may cause epilepsy. Objectives This systematic review aims to summarize the role of HCN channelopathies in epilepsy, update genetic findings in patients, create genotype–phenotype correlations, and discuss animal models, GOF and LOF mechanisms, and potential treatment targets. Methods The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, for all years until August 2021. Results We identified pathogenic variants of HCN1 (n = 24), HCN2 (n = 8), HCN3 (n = 2), and HCN4 (n = 6) that were associated with epilepsy in 74 cases (43 HCN1, 20 HCN2, 2 HCN3, and 9 HCN4). Epilepsy was associated with GOF and LOF variants, and the mechanisms were indeterminate. Less than half of the cases became seizure-free and some developed drug-resistant epilepsy. Of the 74 cases, 12 (16.2%) died, comprising HCN1 (n = 4), HCN2 (n = 2), HCN3 (n = 2), and HCN4 (n = 4). Of the deceased cases, 10 (83%) had a sudden unexpected death in epilepsy (SUDEP) and 2 (16.7%) due to cardiopulmonary failure. SUDEP affected more adults (n = 10) than children (n = 2). HCN1 variants p.M234R, p.C329S, p.V414M, p.M153I, and p.M305L, as well as HCN2 variants p.S632W and delPPP (p.719–721), were associated with different phenotypes. HCN1 p.L157V and HCN4 p.R550C were associated with genetic generalized epilepsy. There are several HCN animal models, pharmacological targets, and modulators, but precise drugs have not been developed. Currently, there are no HCN channel openers. Conclusion We recommend clinicians to include HCN genes in epilepsy gene panels. Researchers should explore the possible underlying mechanisms for GOF and LOF variants by identifying the specific neuronal subtypes and neuroanatomical locations of each identified pathogenic variant. Researchers should identify specific HCN channel openers and blockers with high binding affinity. Such information will give clarity to the involvement of HCN channelopathies in epilepsy and provide the opportunity to develop targeted treatments.
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Affiliation(s)
- Miriam Kessi
- Department of Pediatrics, Xiangya Hospital, Central South University, Changsha, China
- Hunan Intellectual and Developmental Disabilities Research Center, Changsha, China
- Department of Pediatrics, Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Jing Peng
- Department of Pediatrics, Xiangya Hospital, Central South University, Changsha, China
- Hunan Intellectual and Developmental Disabilities Research Center, Changsha, China
| | - Haolin Duan
- Department of Pediatrics, Xiangya Hospital, Central South University, Changsha, China
- Hunan Intellectual and Developmental Disabilities Research Center, Changsha, China
| | - Hailan He
- Department of Pediatrics, Xiangya Hospital, Central South University, Changsha, China
- Hunan Intellectual and Developmental Disabilities Research Center, Changsha, China
| | - Baiyu Chen
- Department of Pediatrics, Xiangya Hospital, Central South University, Changsha, China
- Hunan Intellectual and Developmental Disabilities Research Center, Changsha, China
| | - Juan Xiong
- Department of Pediatrics, Xiangya Hospital, Central South University, Changsha, China
- Hunan Intellectual and Developmental Disabilities Research Center, Changsha, China
| | - Ying Wang
- Department of Pediatrics, Xiangya Hospital, Central South University, Changsha, China
- Hunan Intellectual and Developmental Disabilities Research Center, Changsha, China
| | - Lifen Yang
- Department of Pediatrics, Xiangya Hospital, Central South University, Changsha, China
- Hunan Intellectual and Developmental Disabilities Research Center, Changsha, China
| | - Guoli Wang
- Department of Pediatrics, Xiangya Hospital, Central South University, Changsha, China
- Hunan Intellectual and Developmental Disabilities Research Center, Changsha, China
| | - Karlmax Kiprotich
- Department of Epidemiology and Medical Statistics, School of Public Health, Moi University, Eldoret, Kenya
| | - Olumuyiwa A. Bamgbade
- Department of Anesthesiology and Pharmacology, University of British Columbia, Vancouver, BC, Canada
| | - Fang He
- Department of Pediatrics, Xiangya Hospital, Central South University, Changsha, China
- Hunan Intellectual and Developmental Disabilities Research Center, Changsha, China
| | - Fei Yin
- Department of Pediatrics, Xiangya Hospital, Central South University, Changsha, China
- Hunan Intellectual and Developmental Disabilities Research Center, Changsha, China
- *Correspondence: Fei Yin
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Brisca G, Pirlo D, Prato G, Tortora D, Siri L, Nobili L, Tardini G, Consales A, Moscatelli A, Buratti S. Efficacy of Ketamine Use in Refractory Status Epilepticus Associated With Hemimegalencephaly. Pediatr Emerg Care 2022; 38:e1090-e1091. [PMID: 35226636 DOI: 10.1097/pec.0000000000002654] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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25
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Machado RA, Patel J, Elsayed MS. The role of ketamine-induced beta activity in the treatment of refractory status epilepticus. Is the EEG useful to determine responder's rate? A retrospective study. Epilepsy Behav 2022; 127:108512. [PMID: 34974373 DOI: 10.1016/j.yebeh.2021.108512] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 12/09/2021] [Accepted: 12/12/2021] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Multiple investigations have been done to evaluate the possible effect of ketamine in the treatment of status epilepticus (SE). OBJECTIVES To evaluate the electrographic effect of ketamine on EEG, and its clinical utility following-up refractory and super refractory status epilepticus (SRSE). METHODS Retrospective review of 24 patients with SE. Clinical record and Video-electroencephalogram (video-EEG) of all included patients were reviewed. The patients' EEGs were then monitored for any immediate changes after administration of the first dose of ketamine as well as at the time patients would be predicted to have peak serum concentration of ketamine. Patients with cessation of electrographic seizures and no SE recurrence within the same admissions were categorized as "Responders". Statistical differences between qualitative variables were analyzed using chi square test. Differences between median were analyzed by Mann-Whitney U test. Difference between groups were considered significant when p < 0.05. RESULTS We identified 24 patients with SE. Twelve out of 24 (50%) had SRSE and 12 out of 24 (50%) had refractory status epilepticus (RSE). The appearance of superimposed beta activity after ketamine was initiated was associated with a higher responder rate (100% versus 33.3% in the responder group versus the non-responder group respectively). Notably, the presence of a burst suppression pattern had no significant association with one group compared to the other (41.6% versus 33.3%, in the responder group vs the non-responder group respectively). CONCLUSIONS Background superimposed beta activity induced by ketamine is an early and reliable EEG finding associated with status epilepticus termination.
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Affiliation(s)
| | - Janaki Patel
- Wayne State University/Detroit Medical Center, United States
| | - Mona S Elsayed
- Adult Comprehensive Epilepsy Program, Wayne State University/Detroit Medical Center, United States
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Ioku T, Inoue T, Kuki I, Imai K, Yamamoto A, Cho M. [A case of febrile infection-related epilepsy syndrome requiring prolonged intensive care management: a trial of intravenous ketamine and intrathecal dexamethasone therapy]. Rinsho Shinkeigaku 2022; 62:123-129. [PMID: 35095046 DOI: 10.5692/clinicalneurol.cn-001624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A 16-year-old male was brought to the emergency room with fever and status epilepticus, and was diagnosed with febrile infection-related epilepsy syndrome (FIRES). Seizure control was not achieved and the patient developed multiple complications. Ketamine infusion therapy and intrathecal dexamethasone therapy were administered, in addition to other anti-seizure treatment and immunotherapy for super-refractory status epilepticus (SRSE). The patient was weaned from the ventilator on day 170 and was able to live at home, although he continued to experience monthly focal motor seizures and moderate motor impairment. This case suggests that more aggressive treatment might be an option in FIRES with prolonged SRSE.
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Affiliation(s)
- Tetsuya Ioku
- Department of Neurology and Stroke Treatment, Kyoto First Red Cross Hospital
| | - Takeshi Inoue
- Child and Adolescent Epilepsy Center, Department of Pediatric Neurology, Osaka City General Hospital
| | - Ichiro Kuki
- Child and Adolescent Epilepsy Center, Department of Pediatric Neurology, Osaka City General Hospital
| | - Keisuke Imai
- Department of Neurology and Stroke Treatment, Kyoto First Red Cross Hospital
| | - Atsushi Yamamoto
- Department of Neurology and Stroke Treatment, Kyoto First Red Cross Hospital
| | - Masanori Cho
- Department of Neurology and Stroke Treatment, Kyoto First Red Cross Hospital
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27
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da Silva Fiorin F, de Araújo E Silva M, Rodrigues AC. Electrical stimulation in animal models of epilepsy: A review on cellular and electrophysiological aspects. Life Sci 2021; 285:119972. [PMID: 34560081 DOI: 10.1016/j.lfs.2021.119972] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 09/02/2021] [Accepted: 09/17/2021] [Indexed: 01/24/2023]
Abstract
Epilepsy is a debilitating condition, primarily refractory individuals, leading to the search for new efficient therapies. Electrical stimulation is an important method used for years to treat several neurological disorders. Currently, electrical stimulation is used to reduce epileptic crisis in patients and shows promising results. Even though the use of electricity to treat neurological disorders has grown worldwide, there are still many caveats that must be clarified, such as action mechanisms and more efficient stimulation treatment parameters. Thus, this review aimed to explore the comprehension of the main stimulation methods in animal models of epilepsy using rodents to develop new experimental protocols and therapeutic approaches.
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Affiliation(s)
- Fernando da Silva Fiorin
- Graduate Program in Neuroengineering, Edmond and Lily Safra International Institute of Neuroscience, Santos Dumont Institute, Brazil.
| | - Mariane de Araújo E Silva
- Graduate Program in Neuroengineering, Edmond and Lily Safra International Institute of Neuroscience, Santos Dumont Institute, Brazil
| | - Abner Cardoso Rodrigues
- Graduate Program in Neuroengineering, Edmond and Lily Safra International Institute of Neuroscience, Santos Dumont Institute, Brazil
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Howing CE, Razi F, Hakmeh W. Resolution of status epilepticus after ketamine administration. Am J Emerg Med 2021; 54:328.e1-328.e2. [PMID: 34763960 DOI: 10.1016/j.ajem.2021.10.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 10/28/2021] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND Status Epilepticus is the most common non-traumatic neurologic emergency in childhood. Current algorithms prioritize the use of benzodiazepines as first line treatment followed by Levetiracetam or Valproic Acid, possibly Fosphenytoin and eventually high dose Propofol and intubation. CASE REPORT A 9-month old girl was brought to the emergency department with a continuous seizure involving the right upper and lower extremity for 45 min prior to arrival. Patient received a dose of rectal Diazepam, intramuscular Midazolam, 2 doses of Lorazepam, Levetiracetam, Fosphenytoin and 2 additional doses of Lorazepam. The seizure remained refractory and generalized. In anticipation of intubation, and because of its action on the NMDA receptor, Ketamine (1 mg/kg IV) was administered. The clonic movements and eye deviations stopped. Patient was intubated for airway protection, sedated with Propofol, then admitted to the PICU. EEG showed no evidence of a seizure pattern. Labs (CBC, CMP, COVID) were unremarkable except for WBC 24.5, blood glucose of 346 and CO2 of 17 with normal anion gap. Urinalysis showed a urinary tract infection. Patient was at her baseline on 1 week post-discharge re-evaluation. Ketamine theoretically may abort seizures through blockade of NMDA receptors which are unregulated in status epilepticus. To date, no randomized controlled trials have been reported. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Ketamine may have a role in treating status epilepticus. It may be considered for induction for rapid sequence intubation and possibly as a third or fourth line agent in refractory cases.
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Affiliation(s)
- Colleen Elizabeth Howing
- Department of Emergency Medicine, Western Michigan University Homer Stryker M.D. School of Medicine, 1000 Oakland Drive, Kalamazoo, MI 49008, United States of America
| | - Farzad Razi
- Wayne State University School of Medicine, 540 E. Canfield St., Detroit, MI 48201, United States of America
| | - Wael Hakmeh
- Department of Emergency Medicine, Western Michigan University Homer Stryker M.D. School of Medicine, 1000 Oakland Drive, Kalamazoo, MI 49008, United States of America.
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Schwenk ES, Pradhan B, Nalamasu R, Stolle L, Wainer IW, Cirullo M, Olsen A, Pergolizzi JV, Torjman MC, Viscusi ER. Ketamine in the Past, Present, and Future: Mechanisms, Metabolites, and Toxicity. Curr Pain Headache Rep 2021; 25:57. [PMID: 34269883 DOI: 10.1007/s11916-021-00977-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2021] [Indexed: 12/01/2022]
Abstract
PURPOSE OF REVIEW While ketamine's analgesia has mostly been attributed to antagonism of N-methyl-D-aspartate receptors, evidence suggests multiple other pathways are involved in its antidepressant and possibly analgesic activity. These mechanisms and ketamine's role in the nociplastic pain paradigm are discussed. Animal studies demonstrating ketamine's neurotoxicity have unclear human translatability and findings from key rodent and human studies are presented. RECENT FINDINGS Ketamine's metabolites, and (2R,6R)-hydroxynorketamine in particular, may play a greater role in its clinical activity than previously believed. The activation of α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) and the mammalian target of rapamycin by ketamine are mechanisms that are still being elucidated. Ketamine might work best in nociplastic pain, which involves altered pain processing. While much is known about ketamine, new studies will continue to define its role in clinical medicine. Evidence supporting ketamine's neurotoxicity in humans is lacking and should not impede future ketamine clinical trials.
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Affiliation(s)
- Eric S Schwenk
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, 111 South 11th Street, Gibbon Building, 8290, Philadelphia, PA, 19107, USA.
| | - Basant Pradhan
- Psychiatry & Pediatrics, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Rohit Nalamasu
- Department of Physical Medicine and Rehabilitation, University of Nebraska Medical Center, Omaha, NE, USA
| | | | | | - Michael Cirullo
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Alexander Olsen
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, 111 South 11th Street, Gibbon Building, 8290, Philadelphia, PA, 19107, USA
| | | | - Marc C Torjman
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, 111 South 11th Street, Gibbon Building, 8290, Philadelphia, PA, 19107, USA
| | - Eugene R Viscusi
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, 111 South 11th Street, Gibbon Building, 8290, Philadelphia, PA, 19107, USA
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Wabl R, Terman SW, Kwok M, Elm J, Chamberlain J, Silbergleit R, Hill CE. Efficacy of Home Anticonvulsant Administration for Second-Line Status Epilepticus Treatment. Neurology 2021; 97:e720-e727. [PMID: 34187862 DOI: 10.1212/wnl.0000000000012414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 05/11/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To investigate whether receiving a second-line anticonvulsant medication that is part of a patient's home regimen influences outcomes in benzodiazepine-refractory convulsive status epilepticus. METHODS Using the Established Status Epilepticus Treatment Trial data, allocation to a study drug included in the patient's home anticonvulsant medication regimen was compared to receipt of an alternative second-line study medication. The primary outcome was cessation of clinical seizures with improved consciousness by 60 minutes after study drug initiation. Secondary outcomes were seizure cessation adjudicated from medical records and adverse events. We performed inverse probability of treatment-weighted (IPTW) logistic regressions. RESULTS Of 462 patients, 232 (50%) were taking 1-2 of the 3 study medications at home. The primary outcome was observed in 39/89 (44%) patients allocated to their home medication vs 76/143 (53%) allocated to a nonhome medication (IPTW odds ratio [OR] 0.66, 95% confidence interval [CI] 0.39-1.14). The adjudicated outcome occurred in 37/89 (42%) patients vs 82/143 (57%), respectively (IPTW OR 0.52, 95% CI 0.30-0.89). There was no interaction between study levetiracetam and home levetiracetam and there were no differences in adverse events. CONCLUSION There was no difference in the primary outcome for patients who received a home medication vs nonhome medication. However, the retrospective evaluation suggested an association between receiving a nonhome medication and seizure cessation. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that for patients with refractory convulsive status epilepticus, use of a home second-line anticonvulsant compared to a nonhome anticonvulsant did not significantly affect the probability of stopping seizures.
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Affiliation(s)
- Rafael Wabl
- From the Department of Neurology (R.W.), University of Washington, Seattle; Departments of Neurology (S.W.T., C.E.H.) and Emergency Medicine (R.S.), University of Michigan, Ann Arbor; Department of Emergency Medicine (M.K.), Irving Medical Center, Columbia University, New York, NY; Department of Public Health Sciences (J.E.), Medical University of South Carolina, Charleston; and Division of Emergency Medicine (J.C.), Children's National Medical Center, Washington, DC.
| | - Samuel W Terman
- From the Department of Neurology (R.W.), University of Washington, Seattle; Departments of Neurology (S.W.T., C.E.H.) and Emergency Medicine (R.S.), University of Michigan, Ann Arbor; Department of Emergency Medicine (M.K.), Irving Medical Center, Columbia University, New York, NY; Department of Public Health Sciences (J.E.), Medical University of South Carolina, Charleston; and Division of Emergency Medicine (J.C.), Children's National Medical Center, Washington, DC
| | - Maria Kwok
- From the Department of Neurology (R.W.), University of Washington, Seattle; Departments of Neurology (S.W.T., C.E.H.) and Emergency Medicine (R.S.), University of Michigan, Ann Arbor; Department of Emergency Medicine (M.K.), Irving Medical Center, Columbia University, New York, NY; Department of Public Health Sciences (J.E.), Medical University of South Carolina, Charleston; and Division of Emergency Medicine (J.C.), Children's National Medical Center, Washington, DC
| | - Jordan Elm
- From the Department of Neurology (R.W.), University of Washington, Seattle; Departments of Neurology (S.W.T., C.E.H.) and Emergency Medicine (R.S.), University of Michigan, Ann Arbor; Department of Emergency Medicine (M.K.), Irving Medical Center, Columbia University, New York, NY; Department of Public Health Sciences (J.E.), Medical University of South Carolina, Charleston; and Division of Emergency Medicine (J.C.), Children's National Medical Center, Washington, DC
| | - James Chamberlain
- From the Department of Neurology (R.W.), University of Washington, Seattle; Departments of Neurology (S.W.T., C.E.H.) and Emergency Medicine (R.S.), University of Michigan, Ann Arbor; Department of Emergency Medicine (M.K.), Irving Medical Center, Columbia University, New York, NY; Department of Public Health Sciences (J.E.), Medical University of South Carolina, Charleston; and Division of Emergency Medicine (J.C.), Children's National Medical Center, Washington, DC
| | - Robert Silbergleit
- From the Department of Neurology (R.W.), University of Washington, Seattle; Departments of Neurology (S.W.T., C.E.H.) and Emergency Medicine (R.S.), University of Michigan, Ann Arbor; Department of Emergency Medicine (M.K.), Irving Medical Center, Columbia University, New York, NY; Department of Public Health Sciences (J.E.), Medical University of South Carolina, Charleston; and Division of Emergency Medicine (J.C.), Children's National Medical Center, Washington, DC
| | - Chloe E Hill
- From the Department of Neurology (R.W.), University of Washington, Seattle; Departments of Neurology (S.W.T., C.E.H.) and Emergency Medicine (R.S.), University of Michigan, Ann Arbor; Department of Emergency Medicine (M.K.), Irving Medical Center, Columbia University, New York, NY; Department of Public Health Sciences (J.E.), Medical University of South Carolina, Charleston; and Division of Emergency Medicine (J.C.), Children's National Medical Center, Washington, DC
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Szarmach J, Cubała WJ, Włodarczyk A, Gałuszko-Węgielnik M. Somatic Comorbidities and Cardiovascular Safety in Ketamine Use for Treatment-Resistant Depression. ACTA ACUST UNITED AC 2021; 57:medicina57030274. [PMID: 33809766 PMCID: PMC8002231 DOI: 10.3390/medicina57030274] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 03/12/2021] [Accepted: 03/15/2021] [Indexed: 01/15/2023]
Abstract
Background and Objectives: There is evidence for ketamine efficacy in treatment-resistant depression (TRD). Several safety and tolerability concerns arise that some psychotropic agents may provide blood pressure or/and heart rate alterations. The aim of this study is to review blood pressure measurements in course of the treatment with ketamine on treatment refractory inpatients with somatic comorbidities in the course of MDD and BP. Materials and Methods: The study population of 49 patients comprised MDD and BP subjects treated with ketamine registered in the naturalistic observational protocol of treatment-resistant mood disorders (NCT04226963). Results: The conducted analysis showed that among people suffering from hypertension there is a higher increase in systolic blood pressure (RR) after infusion 2 (p = 0.004) than among people who do not suffer from hypertension. Patients with hypertension have a higher increase in diastolic RR compared to those not suffering from hypertension (p = 0,038). Among the subjects with diabetes mellitus, significant differences occurred for infusions 2 (p = 0.020), 7 (p = 0.020), and 8 (p = 0.035) for heart rate (HR), compared to subjects without diabetes mellitus. A higher increase in diastolic RR was noted in the group of subjects suffering from diabetes mellitus (p = 0.010) compared to those who did not. In the hyperlipidemic patients studied, a significantly greater decrease in HR after infusion 5 (p = 0.031) and systolic RR after infusion 4 (p = 0.036) was noted compared to nonpatients. People after a stroke had significantly higher increases in diastolic RR after infusions 4 (p = 0.021) and 6 (p = 0.001) than those who did not have a stroke. Patients suffering from epilepsy had a significantly greater decrease in systolic RR after the 8th infusion (p = 0.017) compared to those without epilepsy. Limitations: The study may be underpowered due to the small sample size. The observations apply to inhomogeneous TRD population in a single-site with no blinding and are limited to the acute administration. Conclusions: This study supports evidence for good safety and tolerability profile for short-term IV ketamine use in TRD treatment. However, risk mitigation measures are to be considered in patients with metabolic and cardiovascular comorbidities.
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Roynard P, Bilderback A, Dewey CW. Intravenous Ketamine Bolus(es) for the Treatment of Status Epilepticus, Refractory Status Epilepticus, and Cluster Seizures: A Retrospective Study of 15 Dogs. Front Vet Sci 2021; 8:547279. [PMID: 33681317 PMCID: PMC7925624 DOI: 10.3389/fvets.2021.547279] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 01/07/2021] [Indexed: 12/02/2022] Open
Abstract
Status epilepticus (SE) and cluster seizures (CS) are common occurrences in veterinary neurology and frequent reasons of admission to veterinary hospitals. With prolonged seizure activity, gamma amino-butyric acid (GABA) receptors (GABAa receptors) become inactive, leading to a state of pharmacoresistance to benzodiazepines and other GABAergic medications, which is called refractory status epilepticus (RSE). Prolonged seizure activity is also associated with overexpression of N-methyl-D-aspartic (NMDA) receptors. Rodent models have shown the efficacy of ketamine (KET) in treating RSE, and its use has been reported in one canine case of RSE. Boluses of KET 5 mg/kg IV have become the preferred treatment for RSE in our hospital. A retrospective study was performed to evaluate and report our experience with KET IV bolus to treat prolonged and/or repeated seizure activity in cases of canine CS, SE, and RSE. A total of 15 dogs were retrieved, for 20 hospitalizations and 28 KET IV injections over 3 years. KET IV boluses were used 12 times for RSE (9 generalized seizures, 3 focal seizures) and KET terminated the episode of RSE 12/12 times (100%); however, seizures recurred 4/12 times (33%) within ≤6 h of KET IV bolus. When used for CS apart from episodes of RSE, KET IV bolus was associated with termination of the CS episode only 4/14 times (29%). Only 4/28 (14%) KET IV boluses were associated with adverse effects imputable only to the use of KET. One dog experienced a short, self-limited seizure activity during administration of KET IV, which was most likely related to a pre-mature use of KET IV (i.e., before GABAergic resistance and NMDA receptor overexpression had taken place). This study indicates that KET 5 mg/kg IV bolus may be successful for the treatment of RSE in dogs.
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Affiliation(s)
- Patrick Roynard
- Long Island Veterinary Specialists, Department of Neurology/Neurosurgery, Plainview, NY, United States
| | - Ann Bilderback
- VCA Northwest Veterinary Specialists, Clackamas, OR, United States
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Borowicz-Reutt KK, Czuczwar SJ, Rusek M. Interactions of antiepileptic drugs with drugs approved for the treatment of indications other than epilepsy. Expert Rev Clin Pharmacol 2020; 13:1329-1345. [PMID: 33305639 DOI: 10.1080/17512433.2020.1850258] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Introduction: Comorbidities of epilepsy may significantly interfere with its treatment as diseases in the general population are also encountered in epilepsy patients and some of them even more frequently (for instance, depression, anxiety, or heart disease). Obviously, some drugs approved for other than epilepsy indications can modify the anticonvulsant activity of antiepileptics. Areas covered: This review highlights the drug-drug interactions between antiepileptics and aminophylline, some antidepressant, antiarrhythmic (class I-IV), selected antihypertensive drugs and non-barbiturate injectable anesthetics (ketamine, propofol, etomidate, and alphaxalone). The data were reviewed mainly from experimental models of seizures. Whenever possible, clinical data were provided. PUBMED data base was the main search source.Expert opinion: Aminophylline generally reduced the protective activity of antiepileptics, which, to a certain degree, was consistent with scarce clinical data on methylxanthine derivatives and worse seizure control. The only antiarrhythmic with this profile of action was mexiletine when co-administered with VPA. Among antidepressants and non-barbiturate injectable anesthetics, trazodone, mianserin and etomidate or alphaxalone, respectively, negatively affected the anticonvulsant action of some antiepileptic drugs. Clinical data indicate that only amoxapine, bupropion, clomipramine and maprotiline should be used with caution. Possibly, drugs reducing the anticonvulsant potential of antiepileptics should be avoided in epilepsy patients.
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Affiliation(s)
- Kinga K Borowicz-Reutt
- Independent Unit of Experimental Neuropathophysiology, Department of Pathophysiology, Medical University of Lublin , Lublin, Poland
| | | | - Marta Rusek
- Department of Pathophysiology, Medical University of Lublin , Lublin, Poland.,Department of Dermatology, Venereology and Pediatric Dermatology, Laboratory for Immunology of Skin Diseases, Medical University of Lublin , Lublin, Poland
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Di Cesare F, Cagnardi P, Villa R, Rabbogliatti V, Lucatello L, Capolongo F, Gioeni D, Capasso M, Magnone W, Ravasio G. Dexmedetomidine and ketamine simultaneous administration in tigers ( Panthera tigris): pharmacokinetics and clinical effects. Vet Rec Open 2020; 7:e000412. [PMID: 33178436 PMCID: PMC7640590 DOI: 10.1136/vetreco-2020-000412] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 07/04/2020] [Accepted: 09/26/2020] [Indexed: 01/15/2023] Open
Abstract
Background The study determines the pharmacokinetic profiles of dexmedetomidine (DEX), ketamine (KET) and its active metabolite, norketamine (NORKET), after simultaneous administration. Moreover, the study evaluates the sedative effects of this protocol, its influence on the main physiological variables and the occurrence of adverse effects. Methods Eighteen captive tigers were initially administered with a mixture of DEX (10 µg/kg) and KET (2 mg/kg) by remote intramuscular injection. In case of individual and specific needs, the protocol was modified and tigers could receive general anaesthesia, propofol or additional doses of DEX and KET. Results Based on the immobilisation protocol, nine animals were assigned to the standard protocol group and the other nine to the non-standard protocol group. Higher area under the first moment curve (AUMC0-last) and longer mean residence time (MRT0-last) (P<0.05) were observed in the non-standard protocol group for DEX, KET and NORKET, and higher area under the concentration-time curve from administration to the last measurable concentration (AUC0-last) only for KET. The KET metabolisation rate was similar (P=0.296) between groups. No differences between groups were detected in terms of stages of sedation and recoveries. All physiological variables remained within normality ranges during the whole observation period. During the hospitalisation period, no severe adverse reactions and signs of resedation were observed. Conclusion The simultaneous administration of 10 µg/kg of DEX and 2 mg/kg of KET can be considered an effective protocol for chemical immobilisation of captive tigers, along with dosage adjusments or when other drugs are needed.
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Affiliation(s)
- Federica Di Cesare
- Scienze Veterinarie per la Salute, la Produzione Animale e la Sicurezza Alimentare, Università degli Studi di Milano, Milano, Lombardia, Italy
| | - Petra Cagnardi
- Medicina veterinaria, Università degli Studi di Milano, Milano, Lombardia, Italy
| | - Roberto Villa
- Scienze veterinarie per la salute, la produzione animale e la sicurezza alimentare, Università degli Studi di Milano, Milano, Lombardia, Italy
| | - Vanessa Rabbogliatti
- Medicina veterinaria, Università degli Studi di Milano, Milano, Lombardia, Italy
| | - Lorena Lucatello
- Biomedicina Comparata ed Alimentazione, Università degli Studi di Padova, Legnaro (PD), Veneto, Italy
| | - Francesca Capolongo
- Biomedicina Comparata ed Alimentazione, Università degli Studi di Padova, Legnaro (PD), Veneto, Italy
| | - Daniela Gioeni
- Medicina veterinaria, Università degli Studi di Milano, Milano, Lombardia, Italy
| | - Michele Capasso
- Medicina Veterinaria e Produzioni Animali, Università degli Studi di Napoli Federico II, Napoli, Campania, Italy
| | | | - Giuliano Ravasio
- Medicina veterinaria, Università degli Studi di Milano, Milano, Lombardia, Italy
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Spampanato J, Bealer SL, Smolik M, Dudek FE. Delayed Adjunctive Treatment of Organophosphate-Induced Status Epilepticus in Rats with Phenobarbital, Memantine, or Dexmedetomidine. J Pharmacol Exp Ther 2020; 375:59-68. [PMID: 32873622 DOI: 10.1124/jpet.120.000175] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 07/16/2020] [Indexed: 12/15/2022] Open
Abstract
Organophosphate (OP) exposure induces status epilepticus (SE), a medical emergency with high morbidity and mortality. Current standard medical countermeasures lose efficacy with time so that treatment delays, in the range of tens of minutes, result in increasingly poor outcomes. As part of the Countermeasures Against Chemical Threats Neurotherapeutics Screening Program, we previously developed a realistic model of delayed treatment of OP-induced SE using the OP diisopropyl fluorophosphate (DFP) to screen compounds for efficacy in the termination of SE and elimination of neuronal death. Male rats were implanted for electroencephalogram (EEG) recordings 7 days prior to experimentation. Rats were then exposed to DFP, and SE was induced for 60 minutes and then treated with midazolam (MDZ) plus one of three antiseizure drugs (ASDs)-phenobarbital (PHB), memantine (MEM), or dexmedetomidine (DMT)-in conjunction with antidotes. EEG was recorded for 24 hours, and brains were stained with Fluoro-Jade B for quantification of degenerating neurons. We found that PHB + MDZ induced a prolonged suppression of SE and reduced neuronal death. MEM + MDZ treatment exacerbated SE and increased mortality; however, surviving rats had fewer degenerating neurons. DMT + MDZ significantly suppressed SE with only a minimal reduction in neuronal death. These data demonstrate that delayed treatment of OP-induced SE with other ASDs, when added to MDZ, can achieve greater seizure suppression with additional reduction in degenerating neurons throughout the brain compared with MDZ alone. The effect of a drug on the severity of seizure activity did not necessarily determine the drug's effect on neuronal death under these conditions. SIGNIFICANCE STATEMENT: This study assesses the relative effectiveness of three different delayed-treatment regimens for the control of organophosphate-induced status epilepticus and reduction of subsequent neuronal death. The data demonstrate the potential for highly effective therapies despite significant treatment delay and a potential disconnect between seizure severity and neuronal death.
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Affiliation(s)
- Jay Spampanato
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Steven L Bealer
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Melissa Smolik
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - F Edward Dudek
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, Utah
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Alkhachroum A, Der-Nigoghossian CA, Mathews E, Massad N, Letchinger R, Doyle K, Chiu WT, Kromm J, Rubinos C, Velazquez A, Roh D, Agarwal S, Park S, Connolly ES, Claassen J. Ketamine to treat super-refractory status epilepticus. Neurology 2020; 95:e2286-e2294. [PMID: 32873691 DOI: 10.1212/wnl.0000000000010611] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Accepted: 05/14/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To test ketamine infusion efficacy in the treatment of super-refractory status epilepticus (SRSE), we studied patients with SRSE who were treated with ketamine retrospectively. We also studied the effect of high doses of ketamine on brain physiology as reflected by invasive multimodality monitoring (MMM). METHODS We studied a consecutive series of 68 patients with SRSE who were admitted between 2009 and 2018, treated with ketamine, and monitored with scalp EEG. Eleven of these patients underwent MMM at the time of ketamine administration. We compared patients who had seizure cessation after ketamine initiation to those who did not. RESULTS Mean age was 53 ± 18 years and 46% of patients were female. Seizure burden decreased by at least 50% within 24 hours of starting ketamine in 55 (81%) patients, with complete cessation in 43 (63%). Average dose of ketamine infusion was 2.2 ± 1.8 mg/kg/h, with median duration of 2 (1-4) days. Average dose of midazolam was 1.0 ± 0.8 mg/kg/h at the time of ketamine initiation and was started at a median of 0.4 (0.1-1.0) days before ketamine. Using a generalized linear mixed effect model, ketamine was associated with stable mean arterial pressure (odds ratio 1.39, 95% confidence interval 1.38-1.40) and with decreased vasopressor requirements over time. We found no effect on intracranial pressure, cerebral blood flow, or cerebral perfusion pressure. CONCLUSION Ketamine treatment was associated with a decrease in seizure burden in patients with SRSE. Our data support the notion that high-dose ketamine infusions are associated with decreased vasopressor requirements without increased intracranial pressure. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that ketamine decreases seizures in patients with SRSE.
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Affiliation(s)
- Ayham Alkhachroum
- From the Departments of Neurology (A.A., C.A.D.-N., E.M., N.M., R.L., K.D., W.-T.C., C.R., A.V., D.R., S.A., S.P., J.C.) and Neurosurgery (E.S.C.), Columbia University, New York, NY; and Departments of Critical Care Medicine and Clinical Neurosciences (J.K.), University of Calgary, Canada
| | - Caroline A Der-Nigoghossian
- From the Departments of Neurology (A.A., C.A.D.-N., E.M., N.M., R.L., K.D., W.-T.C., C.R., A.V., D.R., S.A., S.P., J.C.) and Neurosurgery (E.S.C.), Columbia University, New York, NY; and Departments of Critical Care Medicine and Clinical Neurosciences (J.K.), University of Calgary, Canada
| | - Elizabeth Mathews
- From the Departments of Neurology (A.A., C.A.D.-N., E.M., N.M., R.L., K.D., W.-T.C., C.R., A.V., D.R., S.A., S.P., J.C.) and Neurosurgery (E.S.C.), Columbia University, New York, NY; and Departments of Critical Care Medicine and Clinical Neurosciences (J.K.), University of Calgary, Canada
| | - Nina Massad
- From the Departments of Neurology (A.A., C.A.D.-N., E.M., N.M., R.L., K.D., W.-T.C., C.R., A.V., D.R., S.A., S.P., J.C.) and Neurosurgery (E.S.C.), Columbia University, New York, NY; and Departments of Critical Care Medicine and Clinical Neurosciences (J.K.), University of Calgary, Canada
| | - Riva Letchinger
- From the Departments of Neurology (A.A., C.A.D.-N., E.M., N.M., R.L., K.D., W.-T.C., C.R., A.V., D.R., S.A., S.P., J.C.) and Neurosurgery (E.S.C.), Columbia University, New York, NY; and Departments of Critical Care Medicine and Clinical Neurosciences (J.K.), University of Calgary, Canada
| | - Kevin Doyle
- From the Departments of Neurology (A.A., C.A.D.-N., E.M., N.M., R.L., K.D., W.-T.C., C.R., A.V., D.R., S.A., S.P., J.C.) and Neurosurgery (E.S.C.), Columbia University, New York, NY; and Departments of Critical Care Medicine and Clinical Neurosciences (J.K.), University of Calgary, Canada
| | - Wei-Ting Chiu
- From the Departments of Neurology (A.A., C.A.D.-N., E.M., N.M., R.L., K.D., W.-T.C., C.R., A.V., D.R., S.A., S.P., J.C.) and Neurosurgery (E.S.C.), Columbia University, New York, NY; and Departments of Critical Care Medicine and Clinical Neurosciences (J.K.), University of Calgary, Canada
| | - Julie Kromm
- From the Departments of Neurology (A.A., C.A.D.-N., E.M., N.M., R.L., K.D., W.-T.C., C.R., A.V., D.R., S.A., S.P., J.C.) and Neurosurgery (E.S.C.), Columbia University, New York, NY; and Departments of Critical Care Medicine and Clinical Neurosciences (J.K.), University of Calgary, Canada
| | - Clio Rubinos
- From the Departments of Neurology (A.A., C.A.D.-N., E.M., N.M., R.L., K.D., W.-T.C., C.R., A.V., D.R., S.A., S.P., J.C.) and Neurosurgery (E.S.C.), Columbia University, New York, NY; and Departments of Critical Care Medicine and Clinical Neurosciences (J.K.), University of Calgary, Canada
| | - Angela Velazquez
- From the Departments of Neurology (A.A., C.A.D.-N., E.M., N.M., R.L., K.D., W.-T.C., C.R., A.V., D.R., S.A., S.P., J.C.) and Neurosurgery (E.S.C.), Columbia University, New York, NY; and Departments of Critical Care Medicine and Clinical Neurosciences (J.K.), University of Calgary, Canada
| | - David Roh
- From the Departments of Neurology (A.A., C.A.D.-N., E.M., N.M., R.L., K.D., W.-T.C., C.R., A.V., D.R., S.A., S.P., J.C.) and Neurosurgery (E.S.C.), Columbia University, New York, NY; and Departments of Critical Care Medicine and Clinical Neurosciences (J.K.), University of Calgary, Canada
| | - Sachin Agarwal
- From the Departments of Neurology (A.A., C.A.D.-N., E.M., N.M., R.L., K.D., W.-T.C., C.R., A.V., D.R., S.A., S.P., J.C.) and Neurosurgery (E.S.C.), Columbia University, New York, NY; and Departments of Critical Care Medicine and Clinical Neurosciences (J.K.), University of Calgary, Canada
| | - Soojin Park
- From the Departments of Neurology (A.A., C.A.D.-N., E.M., N.M., R.L., K.D., W.-T.C., C.R., A.V., D.R., S.A., S.P., J.C.) and Neurosurgery (E.S.C.), Columbia University, New York, NY; and Departments of Critical Care Medicine and Clinical Neurosciences (J.K.), University of Calgary, Canada
| | - E Sander Connolly
- From the Departments of Neurology (A.A., C.A.D.-N., E.M., N.M., R.L., K.D., W.-T.C., C.R., A.V., D.R., S.A., S.P., J.C.) and Neurosurgery (E.S.C.), Columbia University, New York, NY; and Departments of Critical Care Medicine and Clinical Neurosciences (J.K.), University of Calgary, Canada
| | - Jan Claassen
- From the Departments of Neurology (A.A., C.A.D.-N., E.M., N.M., R.L., K.D., W.-T.C., C.R., A.V., D.R., S.A., S.P., J.C.) and Neurosurgery (E.S.C.), Columbia University, New York, NY; and Departments of Critical Care Medicine and Clinical Neurosciences (J.K.), University of Calgary, Canada.
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Gioeni D, Di Cesare F, D'Urso ES, Rabbogliatti V, Ravasio G. Ketamine-dexmedetomidine combination and controlled mild hypothermia for the treatment of long-lasting and super-refractory status epilepticus in 3 dogs suffering from idiopathic epilepsy. J Vet Emerg Crit Care (San Antonio) 2020; 30:455-460. [PMID: 32372564 DOI: 10.1111/vec.12956] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Revised: 10/04/2018] [Accepted: 10/31/2018] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To describe the use of a ketamine-dexmedetomidine combination and mild hypothermia for the treatment of status epilepticus in 3 dogs that did not respond to GABAergic medication. CASE SERIES SUMMARY Three dogs, each with a diagnosis of idiopathic epilepsy, were presented to the emergency department in a state of status epilepticus. The dogs were treated unsuccessfully with benzodiazepine as a first-line therapy that was followed by IV propofol anesthesia maintained for at least 12 hours. When general anesthesia was discontinued, seizures reoccurred. All 3 dogs then received a bolus of ketamine (1 mg/kg, IV) over a period of 5 minutes that was followed by a bolus of dexmedetomidine (3 μg/kg, IV) over the same time period and then followed by a continuous infusion for 12 hours of ketamine at a constant rate of 1 mg/kg/h and dexmedetomidine at a variable rate of 3-7 μg/kg/h. Body temperature was maintained between 36.7 and 37.7°C at a state of mild hypothermia throughout treatment. The dogs recovered uneventfully over 48 hours after treatment was discontinued with no evidence of seizures. No notable alterations in physiological parameters were observed during the drug infusions. All dogs were discharged following examinations that showed normal neurological function. NEW OR UNIQUE INFORMATION PROVIDED This case series highlights the potential benefits of a ketamine-dexmedetomidine infusion combined with mild hypothermia for the treatment of status epilepticus refractory to GABAergic therapy in dogs suffering from idiopathic epilepsy. After the dogs were weaned from the ketamine-dexmedetomidine infusion, all dogs experienced complete recovery. Thus, this case series introduces a novel approach to treat this intense condition.
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Affiliation(s)
- Daniela Gioeni
- Department of Veterinary Medicine, Università degli Studi di Milano, Milan, Italy
| | - Federica Di Cesare
- Department of Health, Animal Science and Food safety, Università degli Studi di Milano, Milan, Italy
| | - Elisa Silvia D'Urso
- Department of Veterinary Medicine, Università degli Studi di Milano, Milan, Italy
| | - Vanessa Rabbogliatti
- Department of Veterinary Medicine, Università degli Studi di Milano, Milan, Italy
| | - Giuliano Ravasio
- Department of Veterinary Medicine, Università degli Studi di Milano, Milan, Italy
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Treatment of generalized convulsive status epilepticus: An international survey in the East Mediterranean Countries. Seizure 2020; 78:96-101. [DOI: 10.1016/j.seizure.2020.03.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 03/25/2020] [Accepted: 03/27/2020] [Indexed: 12/22/2022] Open
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Yan Y, Peng X, Jing W, Wang X. How close is ketamine to routine use in refractory status epilepticus? Expert Rev Neurother 2020; 20:421-423. [PMID: 32306782 DOI: 10.1080/14737175.2020.1757433] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Yin Yan
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing Key Laboratory of Neurology, Chongqing, China
| | - Xiaoyan Peng
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing Key Laboratory of Neurology, Chongqing, China
| | - Wei Jing
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing Key Laboratory of Neurology, Chongqing, China.,Department of Neurology, Shanxi Bethune Hospital of Shanxi Aademy of Medical Sciences, Taiyuan, Shanxi, China
| | - Xuefeng Wang
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing Key Laboratory of Neurology, Chongqing, China
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Pribish A, Wood N, Kalava A. A Review of Nonanesthetic Uses of Ketamine. Anesthesiol Res Pract 2020; 2020:5798285. [PMID: 32308676 PMCID: PMC7152956 DOI: 10.1155/2020/5798285] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 02/07/2020] [Accepted: 03/05/2020] [Indexed: 12/20/2022] Open
Abstract
Ketamine, a nonselective NMDA receptor antagonist, is used widely in medicine as an anesthetic agent. However, ketamine's mechanisms of action lead to widespread physiological effects, some of which are now coming to the forefront of research for the treatment of diverse medical disorders. This paper aims at reviewing recent data on key nonanesthetic uses of ketamine in the current literature. MEDLINE, CINAHL, and Google Scholar databases were queried to find articles related to ketamine in the treatment of depression, pain syndromes including acute pain, chronic pain, and headache, neurologic applications including neuroprotection and seizures, and alcohol and substance use disorders. It can be concluded that ketamine has a potential role in the treatment of all of these conditions. However, research in this area is still in its early stages, and larger studies are required to evaluate ketamine's efficacy for nonanesthetic purposes in the general population.
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Affiliation(s)
- Abby Pribish
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Nicole Wood
- Department of Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Arun Kalava
- Department of Anesthesiology, University of Central Florida College of Medicine, Orlando, FL, USA
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Paulis MG, Hafez EM, El-Tahawy NF. Toxicity and postwithdrawal effects of ketamine on the reproductive function of male albino rats: Hormonal, histological, and immunohistochemical study. Hum Exp Toxicol 2020; 39:1054-1065. [PMID: 32153215 DOI: 10.1177/0960327120909857] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Ketamine is increasingly used in clinical practice, and ketamine addiction is common in young individuals. There are limited reviews on the chronic effects of ketamine on the testes. Three groups of rats received saline or ketamine 50 mg/kg/day intraperitoneally for 6 weeks with or without a subsequent 4-week drug-free period. Serum follicle-stimulating hormone, luteinizing hormone, prolactin, and testosterone levels, as well as testicular malondialdehyde concentrations, were measured. Epididymal sperm parameters were assessed. Testicular tissues were examined by hematoxylin and eosin staining and immunohistochemical staining using caspase-3 and vimentin antibodies. Chronic ketamine injection significantly decreased the levels of the examined hormones and adversely affected sperm parameters. Testicular tissue showed a significant increase in caspase-3 expression. In addition, Sertoli cell shape and position were disrupted. These effects disappeared 4 weeks after drug withdrawal. Chronic ketamine treatment has revisable hazardous effects on the rat reproductive function. There is a need to increase the knowledge of physicians and the public regarding these harmful effects of ketamine.
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Affiliation(s)
- M G Paulis
- Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Minia University, Minia, Egypt.,Internal Medicine Department, Faculty of Medicine, Mu'tah University, Mu'tah, Jordan
| | - E M Hafez
- Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Minia University, Minia, Egypt
| | - N F El-Tahawy
- Department of Histology and Cell Biology, Faculty of Medicine, Minia University, Minya, Egypt
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42
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Sedatives in neurocritical care: an update on pharmacological agents and modes of sedation. Curr Opin Crit Care 2020; 25:97-104. [PMID: 30672819 DOI: 10.1097/mcc.0000000000000592] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE OF REVIEW In this article, the specific and general indications for sedatives in the neurocritical care unit are discussed, together with an overview on current insights in sedative protocols for these patients. In addition, physiological effects of sedative agents on the central nervous system are reviewed. RECENT FINDINGS In the general ICU population, a large body of evidence supports light protocolized sedation over indiscriminate deep sedation. Unfortunately, in patients with severe acute brain injury, the evidence from randomized controlled trials is scarce to nonexistent, and practice is supported by expert opinion, physiological studies and observational or small interventional trials. The different sedatives each have different beneficial effects and side-effects. SUMMARY Extrapolating the findings from studies in the general ICU population suggests to reserve deep continuous sedation in the neuro-ICU for specific indications. Although an improved understanding of cerebral physiological changes in patients with brain injury may be helpful to guide individualized sedation, we still lack the evidence base to make broad recommendations for specific patient groups.
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43
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Huntsman RJ, Strueby L, Bingham W. Are Ketamine Infusions a Viable Therapeutic Option for Refractory Neonatal Seizures? Pediatr Neurol 2020; 103:8-11. [PMID: 31601453 DOI: 10.1016/j.pediatrneurol.2019.09.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 08/22/2019] [Accepted: 09/04/2019] [Indexed: 02/06/2023]
Abstract
Ketamine is an N-methyl-d-aspartate (NMDA) receptor antagonist that works by binding to the phencyclidine-binding site, thereby blocking influx of cations through the NMDA receptor channel. The use of ketamine to treat refractory status epilepticus in adults and older children is well documented. Maturational changes in neonatal NMDA and γ-aminobutyric acid receptor expression and function make NMDA receptor antagonists, like ketamine, attractive potential therapeutic agents for treatment of refractory seizures in the newborn. However, descriptions of its use in this age group are limited to two case reports. Concerns regarding potential ketamine-mediated neurotoxicity in the immature brain require further investigation.
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Affiliation(s)
- Richard J Huntsman
- Division of Pediatric Neurology, Department of Pediatrics, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.
| | - Lannae Strueby
- Division of Neonatology, Department of Pediatrics, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - William Bingham
- Division of Neonatology, Department of Pediatrics, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
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44
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Gautam CS, Mahajan SS, Sharma J, Singh H, Singh J. Repurposing Potential of Ketamine: Opportunities and Challenges. Indian J Psychol Med 2020; 42:22-29. [PMID: 31997862 PMCID: PMC6970308 DOI: 10.4103/ijpsym.ijpsym_228_19] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 06/13/2019] [Accepted: 07/15/2019] [Indexed: 02/06/2023] Open
Abstract
Ketamine is a noncompetitive antagonist of the N-methyl-D-aspartate (NMDA) receptor which also interacts with various other receptors that account for its myriad actions. Originally approved as a general anesthetic, it is being explored to be repurposed for numerous other indications such as depressive disorders, suicidal ideation, substance-use disorders, anxiety disorders, chronic pain, refractory status epilepticus, and bronchial asthma exacerbations. Numerous trials are ongoing for the same. The nasal spray of esketamine, a more potent S (+) enantiomer of ketamine, has been approved by the United States Food and Drug Administration (USFDA) for treatment-resistant depression along with the oral antidepressants. However, there are concerns about its safety on long term use, given its psychedelic effects and potential abuse. In this review, we discuss repurposing ketamine for potential therapeutic use and about the safety concerns related to ketamine and esketamine.
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Affiliation(s)
- C. S. Gautam
- Department of Pharmacology, Government Medical College and Hospital, Chandigarh, Punjab, India
| | - Sonia S. Mahajan
- Department of Pharmacology, Government Medical College and Hospital, Chandigarh, Punjab, India
| | - Jatin Sharma
- Department of Pharmacology, Government Medical College and Hospital, Chandigarh, Punjab, India
| | - Harmanjit Singh
- Department of Pharmacology, Government Medical College and Hospital, Chandigarh, Punjab, India
| | - Jagjit Singh
- Department of Pharmacology, Government Medical College and Hospital, Chandigarh, Punjab, India
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45
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Borsato GS, Siegel JL, Rose MQ, Ojard M, Feyissa AM, Quinones-Hinojosa A, Jackson DA, Rogers ER, Freeman WD. Ketamine in seizure management and future pharmacogenomic considerations. THE PHARMACOGENOMICS JOURNAL 2019; 20:351-354. [PMID: 31772310 DOI: 10.1038/s41397-019-0120-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 11/12/2019] [Accepted: 11/14/2019] [Indexed: 11/09/2022]
Abstract
Ketamine is a noncompetitive N-methyl-D-aspartate antagonist with emerging evidence for use in medically refractory epilepsy. We describe the novel use of low-dose intravenous (IV) ketamine transitioning to enteral formulation in a patient with drug-resistant localization-related refractory epilepsy. We performed a National Library of Medicine (NLM) literature review using search terms "ketamine", "low dose", and "seizure" for similar cases, followed by an illustrative clinical case. Our NLM search engine methodology yielded 24 hits, none of which described use of low-dose ketamine for seizures. Anesthetic doses are used for status epilepticus, but we show that in a patient with postoperative worsening of his chronic seizure burden, low-dose IV ketamine can be used to avoid oversedation and intubation. We demonstrate that IV ketamine can be transitioned to oral regimen to shorten length of stay in the intensive care unit and hospital and has future CYP2B6 pharmacogenomic considerations for further dose individualization.
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Affiliation(s)
- Giovanna Soldatelli Borsato
- Pontifical Catholic University of Parana, R. Imaculada Conceição, 1155, Prado Velho, Curitiba - PR, 80215-901, Brazil
| | - Jason L Siegel
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, USA.,Department of Neurology, Mayo Clinic, Jacksonville, FL, USA.,Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Mariah Q Rose
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Michelle Ojard
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, USA
| | | | - Alfredo Quinones-Hinojosa
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL, USA.,Department of Otorhinolaryngology, Mayo Clinic, Jacksonville, FL, USA.,Department of Neuroscience, Mayo Clinic, Jacksonville, FL, USA
| | | | - Emily R Rogers
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - William D Freeman
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, USA. .,Department of Neurology, Mayo Clinic, Jacksonville, FL, USA. .,Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL, USA.
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Meaden CW, Barnes S. Ketamine Implicated in New Onset Seizure. Clin Pract Cases Emerg Med 2019; 3:401-404. [PMID: 31763599 PMCID: PMC6861038 DOI: 10.5811/cpcem.2019.9.44271] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 08/20/2019] [Accepted: 09/10/2019] [Indexed: 11/30/2022] Open
Abstract
Ketamine is used widely in emergency departments for a variety of purposes, including procedural sedation and pain management. A major benefit of using ketamine is the rapid onset and lack of respiratory depression. The known side effects include emergence reactions, hallucinations, hypertension, dizziness, nausea, and vomiting. Recent studies have shown the benefit of ketamine for refractory status epilepticus; however, this application of the drug is still being studied. We present a case where ketamine likely induced a seizure in a patient on whom it was used as a single agent in procedural sedation. Seizure is not a known side effect of ketamine in patients without a seizure history. Given the eagerness over additional uses for ketamine, this novel case of a seizure following procedural sedation with ketamine should be of interest to emergency providers.
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Affiliation(s)
- Christopher W Meaden
- St. Joseph's University Medical Center, Department of Emergency Medicine, Paterson, New Jersey
| | - Stacey Barnes
- St. Joseph's University Medical Center, Department of Emergency Medicine, Paterson, New Jersey
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Nelson SE, Varelas PN. Status Epilepticus, Refractory Status Epilepticus, and Super-refractory Status Epilepticus. Continuum (Minneap Minn) 2019; 24:1683-1707. [PMID: 30516601 DOI: 10.1212/con.0000000000000668] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE OF REVIEW Status epilepticus, refractory status epilepticus, and super-refractory status epilepticus can be life-threatening conditions. This article presents an overview of the three conditions and discusses their management and outcomes. RECENT FINDINGS Status epilepticus was previously defined as lasting for 30 minutes or longer but now is more often defined as lasting 5 minutes or longer. A variety of potential causes exist for status epilepticus, refractory status epilepticus, and super-refractory status epilepticus, but all three ultimately involve changes at the cellular and molecular level. Management of patients with status epilepticus generally requires several studies, with EEG of utmost importance given the pathophysiologic changes that can occur during the course of status epilepticus. Status epilepticus is treated with benzodiazepines as first-line antiepileptic drugs, followed by phenytoin, valproic acid, or levetiracetam. If status epilepticus does not resolve, these are followed by an IV anesthetic and then alternative therapies based on limited data/evidence, such as repetitive transcranial magnetic stimulation, therapeutic hypothermia, immunomodulatory agents, and the ketogenic diet. Scores have been developed to help predict the outcome of status epilepticus. Neurologic injury and outcome seem to worsen as the duration of status epilepticus increases, with outcomes generally worse in super-refractory status epilepticus compared to status epilepticus and sometimes also to refractory status epilepticus. SUMMARY Status epilepticus can be a life-threatening condition associated with multiple complications, including death, and can progress to refractory status epilepticus and super-refractory status epilepticus. More studies are needed to delineate the best management of these three entities.
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48
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Shelkar GP, Pavuluri R, Gandhi PJ, Ravikrishnan A, Gawande DY, Liu J, Stairs DJ, Ugale RR, Dravid SM. Differential effect of NMDA receptor GluN2C and GluN2D subunit ablation on behavior and channel blocker-induced schizophrenia phenotypes. Sci Rep 2019; 9:7572. [PMID: 31110197 PMCID: PMC6527682 DOI: 10.1038/s41598-019-43957-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 04/25/2019] [Indexed: 12/18/2022] Open
Abstract
The GluN2C- and GluN2D-containing NMDA receptors are distinct from GluN2A- and GluN2B-containing receptors in many aspects including lower sensitivity to Mg2+ block and lack of desensitization. Recent studies have highlighted the unique contribution of GluN2C and GluN2D subunits in various aspects of neuronal and circuit function and behavior, however a direct comparison of the effect of ablation of these subunits in mice on pure background strain has not been conducted. Using knockout-first strains for the GRIN2C and GRIN2D produced on pure C57BL/6N strain, we compared the effect of partial or complete ablation of GluN2C and GluN2D subunit on various behaviors relevant to mental disorders. A large number of behaviors described previously in GluN2C and GluN2D knockout mice were reproduced in these mice, however, some specific differences were also observed possibly representing strain effects. We also examined the response to NMDA receptor channel blockers in these mouse strains and surprisingly found that unlike previous reports GluN2D knockout mice were not resistant to phencyclidine-induced hyperlocomotion. Interestingly, the GluN2C knockout mice showed reduced sensitivity to phencyclidine-induced hyperlocomotion. We also found that NMDA receptor channel blocker produced a deficit in prepulse inhibition which was prevented by a GluN2C/2D potentiator in wildtype and GluN2C heterozygous mice but not in GluN2C knockout mice. Together these results demonstrate a unique role of GluN2C subunit in schizophrenia-like behaviors.
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Affiliation(s)
- Gajanan P Shelkar
- Department of Pharmacology, Creighton University, Omaha, NE, 68178, USA
| | | | - Pauravi J Gandhi
- Department of Pharmacology, Creighton University, Omaha, NE, 68178, USA
| | | | - Dinesh Y Gawande
- Department of Pharmacology, Creighton University, Omaha, NE, 68178, USA
| | - Jinxu Liu
- Department of Pharmacology, Creighton University, Omaha, NE, 68178, USA
| | | | - Rajesh R Ugale
- Department of Pharmaceutical Sciences, R.T.M. Nagpur University, Nagpur, Maharashtra, 440033, India
| | - Shashank M Dravid
- Department of Pharmacology, Creighton University, Omaha, NE, 68178, USA.
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Gaínza-Lein M, Fernández IS, Ulate-Campos A, Loddenkemper T, Ostendorf AP. Timing in the treatment of status epilepticus: From basics to the clinic. Seizure 2019; 68:22-30. [DOI: 10.1016/j.seizure.2018.05.021] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Revised: 05/18/2018] [Accepted: 05/29/2018] [Indexed: 02/07/2023] Open
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50
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Effects of ketamine on EEG in baboons with genetic generalized epilepsy. Epilepsy Res 2019; 154:50-54. [PMID: 31048260 DOI: 10.1016/j.eplepsyres.2019.04.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 04/12/2019] [Accepted: 04/17/2019] [Indexed: 11/21/2022]
Abstract
Ketamine, a noncompetitive N-methyl-D-aspartate receptor (NMDAR) antagonist, used as an anesthetic has been reported to induce seizures both in humans and baboons predisposed to epilepsy. In this study, we aimed to characterize the acute effects of ketamine on scalp (sc-EEG) and intracranial EEG (ic-EEG) in the baboon, which offers a natural model of genetic generalized epilepsy (GGE). We evaluated the electroclinical response to ketamine in three epileptic baboons. The raw EEG data were analyzed within 10 min of intramuscular ketamine (5-6 mg/kg) administration. Earliest EEG changes occurred after 30 s in sc-EEG and after 15 s in ic-EEG of ketamine administration. These initial changes involved increased paroxysmal fast activity (PFA) followed by slowing, the latter emerging first occipitally, and then spreading more anteriorly. Generalized spike-and-wave discharges (GSWDs) were evident on both sc-EEG and ic-EEG within two minutes, but focal occipital discharges were already increased on ic-EEG after 15 s. Occipital slowing emerged on ic-EEG after 30 s, before spreading fronto-centrally and orbito-frontally. By 60-120 seconds post-injection, ic-EEG demonstrated a parieto-occipital burst suppression (BS), which was not noted on sc-EEG. Ketamine waves and seizures, especially if the latter were subclinical, also appeared earlier on ic-EEG. This study highlights the anesthetic and proconvulsant effects of ketamine originate in the occipital lobes before fronto-central regions. We speculate that NMDAR concentration difference in cortical regions, such as the occipital and frontal cortices, are mainly involved in the expression of ketamine's EEG effects, both physiological and epileptic.
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