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Golub VM, Reddy DS. Post-Traumatic Epilepsy and Comorbidities: Advanced Models, Molecular Mechanisms, Biomarkers, and Novel Therapeutic Interventions. Pharmacol Rev 2022; 74:387-438. [PMID: 35302046 PMCID: PMC8973512 DOI: 10.1124/pharmrev.121.000375] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Post-traumatic epilepsy (PTE) is one of the most devastating long-term, network consequences of traumatic brain injury (TBI). There is currently no approved treatment that can prevent onset of spontaneous seizures associated with brain injury, and many cases of PTE are refractory to antiseizure medications. Post-traumatic epileptogenesis is an enduring process by which a normal brain exhibits hypersynchronous excitability after a head injury incident. Understanding the neural networks and molecular pathologies involved in epileptogenesis are key to preventing its development or modifying disease progression. In this article, we describe a critical appraisal of the current state of PTE research with an emphasis on experimental models, molecular mechanisms of post-traumatic epileptogenesis, potential biomarkers, and the burden of PTE-associated comorbidities. The goal of epilepsy research is to identify new therapeutic strategies that can prevent PTE development or interrupt the epileptogenic process and relieve associated neuropsychiatric comorbidities. Therefore, we also describe current preclinical and clinical data on the treatment of PTE sequelae. Differences in injury patterns, latency period, and biomarkers are outlined in the context of animal model validation, pathophysiology, seizure frequency, and behavior. Improving TBI recovery and preventing seizure onset are complex and challenging tasks; however, much progress has been made within this decade demonstrating disease modifying, anti-inflammatory, and neuroprotective strategies, suggesting this goal is pragmatic. Our understanding of PTE is continuously evolving, and improved preclinical models allow for accelerated testing of critically needed novel therapeutic interventions in military and civilian persons at high risk for PTE and its devastating comorbidities.
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Affiliation(s)
- Victoria M Golub
- Department of Neuroscience and Experimental Therapeutics, College of Medicine, Texas A&M University Health Science Center, Bryan, Texas
| | - Doodipala Samba Reddy
- Department of Neuroscience and Experimental Therapeutics, College of Medicine, Texas A&M University Health Science Center, Bryan, Texas
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Sun L, Liu R, Yang H, Yu T, Wu J, Wang Q. Characteristics of Epileptiform Spike-wave Discharges and Chronic Histopathology in Controlled Cortical Impact Model of Sprague-Dawley Rats. Neurochem Res 2022; 47:3615-3626. [PMID: 35103912 DOI: 10.1007/s11064-022-03542-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 01/17/2022] [Accepted: 01/24/2022] [Indexed: 10/19/2022]
Abstract
Post-traumatic epilepsy (PTE) is a serious complication that can occur following traumatic brain injury (TBI). Sustained secondary changes after TBI promote the process of PTE. Here, we aim to evaluate changes in behavior, electrocorticogram, and histomorphology in rats following chronic TBI models. We observed intensive 7-8 Hz spike-wave-discharges (SWDs) at frontal recording sites and quantified them in SD rats with different degrees of TBI and compared them with age-matched sham rats to evaluate the association between SWDs and injury severity. Notably, although SWDs were even presented in the sham group, the number and duration of events were much lower than those in the TBI groups. SWDs have numerous similarities to absence seizures, such as abrupt onset, termination, and lack of postictal suppression, which may be the nonconvulsive characteristics of PTE. Retigabine, a novel antiepileptic drug, is ineffective in reducing SWDs. In addition, we examined chronic histopathological changes in TBI rats. Rats subjected to moderate and severe TBI exhibited significantly impaired neurological function, which was accompanied by marked cortical injury, hippocampus deformation, reactive gliosis, and mossy fiber sprouting. Long-term progressive structural changes in the brain are one of the characteristics of epileptogenesis after TBI. Our study provided the potential value of epileptiform SWDs in reflecting the nonconvulsive characteristic of PTE and highlighted the vital role of chronic pathological changes, such as reactive gliosis, in promoting the epileptogenesis following TBI.
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Affiliation(s)
- Lei Sun
- Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China.,Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, 100070, China.,China National Clinical Research Center for Neurological Diseases, Beijing, 100070, China
| | - Ru Liu
- Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China.,Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, 100070, China.,China National Clinical Research Center for Neurological Diseases, Beijing, 100070, China
| | - Huajun Yang
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, 100070, China.,Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
| | - Tingting Yu
- Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China.,Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, 100070, China.,China National Clinical Research Center for Neurological Diseases, Beijing, 100070, China
| | - Jianping Wu
- Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China. .,Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, 100070, China. .,China National Clinical Research Center for Neurological Diseases, Beijing, 100070, China. .,School of Chemistry, Chemical Engineering and Life Sciences, Wuhan University of Technology, Wuhan, 430070, China.
| | - Qun Wang
- Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China. .,China National Clinical Research Center for Neurological Diseases, Beijing, 100070, China. .,Beijing Institute for Brain Disorders, Beijing, 100069, China.
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Effects of Alpha-2 Adrenergic Agonist Mafedine on Brain Electrical Activity in Rats after Traumatic Brain Injury. Brain Sci 2021; 11:brainsci11080981. [PMID: 34439602 PMCID: PMC8392538 DOI: 10.3390/brainsci11080981] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 07/21/2021] [Accepted: 07/23/2021] [Indexed: 01/20/2023] Open
Abstract
The search for and development of new neuroprotective (or cerebroprotective) drugs, as well as suitable methods for their preclinical efficacy evaluation, are priorities for current biomedical research. Alpha-2 adrenergic agonists, such as mafedine and dexmedetomidine, are a highly appealing group of drugs capable of reducing neurological deficits which result from brain trauma and vascular events in both experimental animals and human patients. Thus, our aim was to assess the effects of mafedine and dexmedetomidine on the brain’s electrical activity in a controlled cortical-impact model of traumatic brain injury (TBI) in rats. The functional status of the animals was assessed by electrocorticography (ECoG), using ECoG electrodes which were chronically implanted in different cortical regions. The administration of intraperitoneal mafedine sodium at 2.5 mg∙kg−1 at 1 h after TBI induction, and daily for the following 6 days, restored interhemispheric connectivity in remote brain regions and intrahemispheric connections within the unaffected hemisphere at post-TBI day 7. Animals that had received mafedine sodium also demonstrated an improvement in cortical responses to photic and somatosensory stimulation. Dexmedetomidine at 25 μg∙kg−1 did not affect the brain’s electrical activity in brain-injured rats. Our results confirm the previously described neuroprotective effects of mafedine sodium and suggest that ECoG registration and analysis are a viable method evaluating drug efficacy in experimental animal models of TBI.
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Leconte C, Benedetto C, Lentini F, Simon K, Ouaazizi C, Taib T, Cho A, Plotkine M, Mongeau R, Marchand-Leroux C, Besson VC. Histological and Behavioral Evaluation after Traumatic Brain Injury in Mice: A Ten Months Follow-Up Study. J Neurotrauma 2020; 37:1342-1357. [PMID: 31830858 DOI: 10.1089/neu.2019.6679] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Traumatic brain injury (TBI) is a chronic pathology, inducing long-term deficits that remain understudied in pre-clinical studies. In this context, exploration, anxiety-like behavior, cognitive flexibility, and motor coordination were assessed until 5 and 10 months after an experimental TBI in the adult mouse, using two cohorts. In order to differentiate age, surgery, and remote gray and white matter lesions, three groups (unoperated, sham-operated, and TBI) were studied. TBI induced delayed motor coordination deficits at the pole test, 4.5 months after injury, that could be explained by gray and white matter damages in ipsilateral nigrostriatal structures (striatum, internal capsule) that were spreading to new structures between cohorts, at 5 versus 10 months after the injury. Further, TBI induced an enhanced exploratory behavior during stressful situations (active phase during actimetry test, object exploration in an open field), risk-taking behaviors in the elevated plus maze 5 months after injury, and a cognitive inflexibility in the Barnes maze that persisted until 9 months after the injury. These behavioral modifications could be related to the white and gray matter lesions observed in ipsi- and contralateral limbic structures (amygdala, hilus/cornu ammonis 4, hypothalamus, external capsule, corpus callosum, and cingular cortex) that were spreading to new structures between cohorts, at 5 months versus 10 months after the injury. The present study corroborates clinical findings on TBI and provides a relevant rodent chronic model which could help in validating pharmacological strategies against the chronic consequences of TBI.
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Affiliation(s)
- Claire Leconte
- EA 4475, "Pharmacologie de la Circulation Cérébrale," Faculté de Pharmacie de Paris, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Chiara Benedetto
- EA 4475, "Pharmacologie de la Circulation Cérébrale," Faculté de Pharmacie de Paris, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Federica Lentini
- EA 4475, "Pharmacologie de la Circulation Cérébrale," Faculté de Pharmacie de Paris, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Kristin Simon
- EA 4475, "Pharmacologie de la Circulation Cérébrale," Faculté de Pharmacie de Paris, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Chahid Ouaazizi
- EA 4475, "Pharmacologie de la Circulation Cérébrale," Faculté de Pharmacie de Paris, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Toufik Taib
- EA 4475, "Pharmacologie de la Circulation Cérébrale," Faculté de Pharmacie de Paris, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Angelo Cho
- EA 4475, "Pharmacologie de la Circulation Cérébrale," Faculté de Pharmacie de Paris, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Michel Plotkine
- EA 4475, "Pharmacologie de la Circulation Cérébrale," Faculté de Pharmacie de Paris, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Raymond Mongeau
- EA 4475, "Pharmacologie de la Circulation Cérébrale," Faculté de Pharmacie de Paris, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Catherine Marchand-Leroux
- EA 4475, "Pharmacologie de la Circulation Cérébrale," Faculté de Pharmacie de Paris, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Valérie C Besson
- EA 4475, "Pharmacologie de la Circulation Cérébrale," Faculté de Pharmacie de Paris, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
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Anjum SMM, Käufer C, Hopfengärtner R, Waltl I, Bröer S, Löscher W. Automated quantification of EEG spikes and spike clusters as a new read out in Theiler's virus mouse model of encephalitis-induced epilepsy. Epilepsy Behav 2018; 88:189-204. [PMID: 30292054 DOI: 10.1016/j.yebeh.2018.09.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 07/13/2018] [Accepted: 09/16/2018] [Indexed: 12/17/2022]
Abstract
Intracerebral infection of C57BL/6 mice with Theiler's murine encephalomyelitis virus (TMEV) replicates many features of viral encephalitis-induced epilepsy in humans, including neuroinflammation, early (insult-associated) and late (spontaneous) seizures, neurodegeneration in the hippocampus, and cognitive and behavioral alterations. Thus, this model may be ideally suited to study mechanisms involved in encephalitis-induced epilepsy as potential targets for epilepsy prevention. However, spontaneous recurrent seizures (SRS) occur too infrequently to be useful as a biomarker of epilepsy, e.g., for drug studies. This prompted us to evaluate whether epileptiform spikes or spike clusters in the cortical electroencephalogram (EEG) may be a useful surrogate of epilepsy in this model. For this purpose, we developed an algorithm that allows efficient and large-scale EEG analysis of early and late seizures, spikes, and spike clusters in the EEG. While 77% of the infected mice exhibited early seizures, late seizures were only observed in 33% of the animals. The clinical characteristics of early and late seizures did not differ except that late generalized convulsive (stage 5) seizures were significantly longer than early stage 5 seizures. Furthermore, the frequency of SRS was much lower than the frequency of early seizures. Continuous (24/7) video-EEG monitoring over several months following infection indicated that the latent period to onset of SRS was 61 (range 16-91) days. Spike and spike clusters were significantly more frequent in infected mice with late seizures than in infected mice without seizures or in mock-infected sham controls. Based on the results of this study, increases in EEG spikes and spike clusters in groups of infected mice may be used as a new readout for studies on antiepileptogenic or disease-modifying drug effects in this model, because the significant increase in average spike counts in mice with late seizures obviously indicates a proepileptogenic alteration.
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Affiliation(s)
- Syed Muhammad Muneeb Anjum
- Department of Pharmacology, Toxicology, and Pharmacy, University of Veterinary Medicine Hannover, Germany; Center for Systems Neuroscience, Hannover, Germany
| | - Christopher Käufer
- Department of Pharmacology, Toxicology, and Pharmacy, University of Veterinary Medicine Hannover, Germany
| | | | - Inken Waltl
- Department of Pharmacology, Toxicology, and Pharmacy, University of Veterinary Medicine Hannover, Germany; Center for Systems Neuroscience, Hannover, Germany
| | - Sonja Bröer
- Department of Pharmacology, Toxicology, and Pharmacy, University of Veterinary Medicine Hannover, Germany
| | - Wolfgang Löscher
- Department of Pharmacology, Toxicology, and Pharmacy, University of Veterinary Medicine Hannover, Germany; Center for Systems Neuroscience, Hannover, Germany.
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Missault S, Anckaerts C, Blockx I, Deleye S, Van Dam D, Barriche N, De Pauw G, Aertgeerts S, Valkenburg F, De Deyn PP, Verhaeghe J, Wyffels L, Van der Linden A, Staelens S, Verhoye M, Dedeurwaerdere S. Neuroimaging of Subacute Brain Inflammation and Microstructural Changes Predicts Long-Term Functional Outcome after Experimental Traumatic Brain Injury. J Neurotrauma 2018; 36:768-788. [PMID: 30032713 DOI: 10.1089/neu.2018.5704] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
There is currently a lack of prognostic biomarkers to predict the different sequelae following traumatic brain injury (TBI). The present study investigated the hypothesis that subacute neuroinflammation and microstructural changes correlate with chronic TBI deficits. Rats were subjected to controlled cortical impact (CCI) injury, sham surgery, or skin incision (naïve). CCI-injured (n = 18) and sham-operated rats (n = 6) underwent positron emission tomography (PET) imaging with the translocator protein 18 kDa (TSPO) radioligand [18F]PBR111 and diffusion tensor imaging (DTI) in the subacute phase (≤3 weeks post-injury) to quantify inflammation and microstructural alterations. CCI-injured, sham-operated, and naïve rats (n = 8) underwent behavioral testing in the chronic phase (5.5-10 months post-injury): open field and sucrose preference tests, two one-week video-electroencephalogram (vEEG) monitoring periods, pentylenetetrazole (PTZ) seizure susceptibility tests, and a Morris water maze (MWM) test. In vivo imaging revealed pronounced neuroinflammation, decreased fractional anisotropy, and increased diffusivity in perilesional cortex and ipsilesional hippocampus of CCI-injured rats. Behavioral analysis revealed disinhibition, anhedonia, increased seizure susceptibility, and impaired learning in CCI-injured rats. Subacute TSPO expression and changes in DTI metrics significantly correlated with several chronic deficits (Pearson's |r| = 0.50-0.90). Certain specific PET and DTI parameters had good sensitivity and specificity (area under the receiver operator characteristic [ROC] curve = 0.85-1.00) to distinguish between TBI animals with and without particular behavioral deficits. Depending on the investigated behavioral deficit, PET or DTI data alone, or the combination, could very well predict the variability in functional outcome data (adjusted R2 = 0.54-1.00). Taken together, both TSPO PET and DTI seem promising prognostic biomarkers to predict different chronic TBI sequelae.
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Affiliation(s)
- Stephan Missault
- 1 Experimental Laboratory of Translational Neuroscience and Otolaryngology, Faculty of Medicine and Health Sciences, Faculty of Medicine and Health Sciences, University of Antwerp , Wilrijk, Belgium .,2 Bio-Imaging Lab, Faculty of Pharmaceutical, Biomedical and Veterinary Sciences, Faculty of Medicine and Health Sciences, University of Antwerp , Wilrijk, Belgium
| | - Cynthia Anckaerts
- 2 Bio-Imaging Lab, Faculty of Pharmaceutical, Biomedical and Veterinary Sciences, Faculty of Medicine and Health Sciences, University of Antwerp , Wilrijk, Belgium
| | - Ines Blockx
- 2 Bio-Imaging Lab, Faculty of Pharmaceutical, Biomedical and Veterinary Sciences, Faculty of Medicine and Health Sciences, University of Antwerp , Wilrijk, Belgium
| | - Steven Deleye
- 3 Molecular Imaging Center Antwerp, Faculty of Medicine and Health Sciences, Faculty of Medicine and Health Sciences, University of Antwerp , Wilrijk, Belgium
| | - Debby Van Dam
- 4 Laboratory of Neurochemistry and Behavior, Institute Born-Bunge, University of Antwerp, Wilrijk, Belgium; Department of Neurology and Alzheimer Research Center, University of Groningen and University Medical Center Groningen (UMCG) , Groningen, The Netherlands
| | - Nora Barriche
- 1 Experimental Laboratory of Translational Neuroscience and Otolaryngology, Faculty of Medicine and Health Sciences, Faculty of Medicine and Health Sciences, University of Antwerp , Wilrijk, Belgium
| | - Glenn De Pauw
- 1 Experimental Laboratory of Translational Neuroscience and Otolaryngology, Faculty of Medicine and Health Sciences, Faculty of Medicine and Health Sciences, University of Antwerp , Wilrijk, Belgium
| | - Stephanie Aertgeerts
- 1 Experimental Laboratory of Translational Neuroscience and Otolaryngology, Faculty of Medicine and Health Sciences, Faculty of Medicine and Health Sciences, University of Antwerp , Wilrijk, Belgium
| | - Femke Valkenburg
- 4 Laboratory of Neurochemistry and Behavior, Institute Born-Bunge, University of Antwerp, Wilrijk, Belgium; Department of Neurology and Alzheimer Research Center, University of Groningen and University Medical Center Groningen (UMCG) , Groningen, The Netherlands
| | - Peter Paul De Deyn
- 4 Laboratory of Neurochemistry and Behavior, Institute Born-Bunge, University of Antwerp, Wilrijk, Belgium; Department of Neurology and Alzheimer Research Center, University of Groningen and University Medical Center Groningen (UMCG) , Groningen, The Netherlands
| | - Jeroen Verhaeghe
- 3 Molecular Imaging Center Antwerp, Faculty of Medicine and Health Sciences, Faculty of Medicine and Health Sciences, University of Antwerp , Wilrijk, Belgium
| | - Leonie Wyffels
- 3 Molecular Imaging Center Antwerp, Faculty of Medicine and Health Sciences, Faculty of Medicine and Health Sciences, University of Antwerp , Wilrijk, Belgium .,5 Department of Nuclear Medicine, University Hospital Antwerp , Edegem, Belgium
| | - Annemie Van der Linden
- 2 Bio-Imaging Lab, Faculty of Pharmaceutical, Biomedical and Veterinary Sciences, Faculty of Medicine and Health Sciences, University of Antwerp , Wilrijk, Belgium
| | - Steven Staelens
- 3 Molecular Imaging Center Antwerp, Faculty of Medicine and Health Sciences, Faculty of Medicine and Health Sciences, University of Antwerp , Wilrijk, Belgium
| | - Marleen Verhoye
- 2 Bio-Imaging Lab, Faculty of Pharmaceutical, Biomedical and Veterinary Sciences, Faculty of Medicine and Health Sciences, University of Antwerp , Wilrijk, Belgium
| | - Stefanie Dedeurwaerdere
- 6 Laboratory of Experimental Hematology, Faculty of Medicine and Health Sciences, University of Antwerp , Wilrijk, Belgium
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Brady RD, Casillas-Espinosa PM, Agoston DV, Bertram EH, Kamnaksh A, Semple BD, Shultz SR. Modelling traumatic brain injury and posttraumatic epilepsy in rodents. Neurobiol Dis 2018; 123:8-19. [PMID: 30121231 DOI: 10.1016/j.nbd.2018.08.007] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Revised: 07/25/2018] [Accepted: 08/13/2018] [Indexed: 12/14/2022] Open
Abstract
Posttraumatic epilepsy (PTE) is one of the most debilitating and understudied consequences of traumatic brain injury (TBI). It is challenging to study the effects, underlying pathophysiology, biomarkers, and treatment of TBI and PTE purely in human patients for a number of reasons. Rodent models can complement human PTE studies as they allow for the rigorous investigation into the causal relationship between TBI and PTE, the pathophysiological mechanisms of PTE, the validation and implementation of PTE biomarkers, and the assessment of PTE treatments, in a tightly controlled, time- and cost-efficient manner in experimental subjects known to be experiencing epileptogenic processes. This article will review several common rodent models of TBI and/or PTE, including their use in previous studies and discuss their relative strengths, limitations, and avenues for future research to advance our understanding and treatment of PTE.
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Affiliation(s)
- Rhys D Brady
- Departments of Neuroscience and Medicine, Central Clinical School, Monash University, VIC 3004, Australia; Department of Medicine, The Royal Melbourne Hospital, The University of Melbourne, VIC 3052, Australia.
| | - Pablo M Casillas-Espinosa
- Departments of Neuroscience and Medicine, Central Clinical School, Monash University, VIC 3004, Australia; Department of Medicine, The Royal Melbourne Hospital, The University of Melbourne, VIC 3052, Australia.
| | - Denes V Agoston
- Anatomy, Physiology & Genetics, Uniformed Services University, Bethesda, MD 20814, USA
| | - Edward H Bertram
- Department of Neurology, University of Virginia, P.O. Box 800394, Charlottesville, VA 22908-0394, USA
| | - Alaa Kamnaksh
- Anatomy, Physiology & Genetics, Uniformed Services University, Bethesda, MD 20814, USA
| | - Bridgette D Semple
- Departments of Neuroscience and Medicine, Central Clinical School, Monash University, VIC 3004, Australia; Department of Medicine, The Royal Melbourne Hospital, The University of Melbourne, VIC 3052, Australia
| | - Sandy R Shultz
- Departments of Neuroscience and Medicine, Central Clinical School, Monash University, VIC 3004, Australia; Department of Medicine, The Royal Melbourne Hospital, The University of Melbourne, VIC 3052, Australia
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