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Kirkeby K, Cockerell I, Christensen J, Hoei-Hansen CE, Holst L, Fredriksen MG, Lund C, Johannessen Landmark C. Pharmacokinetic variability of everolimus and impact of concomitant antiseizure medications in patients with tuberous sclerosis complex: A retrospective study of therapeutic drug monitoring data in Denmark and Norway. Medicine (Baltimore) 2024; 103:e39244. [PMID: 39121325 PMCID: PMC11315474 DOI: 10.1097/md.0000000000039244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 07/19/2024] [Indexed: 08/11/2024] Open
Abstract
The mTOR-inhibitor everolimus is a precision drug with antiepileptogenic properties approved for treatment of epilepsy in persons with tuberous sclerosis complex (TSC) in combination with other antiseizure medications (ASMs). However, the pharmacokinetic variability of everolimus is scarcely described, and the available information on pharmacokinetic interactions is scarce. The purpose of this study was to investigate pharmacokinetic variability of everolimus in patients with TSC, and the impact of age, sex and comedication. In this retrospective observational study we used anonymized data from medical records of patients with TSC using everolimus in Norway and Denmark, 2012 to 2020. Long-term therapeutic drug monitoring (TDM) identified inter-patient and intra-patient variability. The study included 59 patients, (36 females (61%)), median age 22 (range 3-59 years). Polytherapy was used in 50 patients (85%). The most frequently used ASMs were lamotrigine (n = 21), valproate (n = 17), and levetiracetam (n = 13). Blood concentrations of everolimus were measured in all patients. Pharmacokinetic variability of everolimus between patients was extensive, as demonstrated by a 24-fold variability from minimum-maximum concentration/dose (C/D)-ratios. The coefficient of variation (CV) for intra-patient (n = 59) and inter-patient variability (n = 47, ≥3 measurements) was 40% and 43%, respectively. The C/D-ratio of everolimus was 50% lower in 13 patients (22%) using enzyme-inducing ASMs compared to the 30 patients who did not (0.7 vs 1.4 ng/mL mg, P < .05). Age and sex were not significantly associated with changes in C/D-ratios of everolimus. Long-term TDM identified extensive variability in concentrations over time for everolimus both within and between patients, where comedication with enzyme-inducing ASMs was an important contributing factor. The findings suggest a need for TDM in patients with TSC treated with everolimus.
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Affiliation(s)
- Kjersti Kirkeby
- Department of Pharmacy, Faculty of Health Sciences, Institute of Life Sciences and Health, Oslo Metropolitan University, Oslo, Norway
| | - Ine Cockerell
- Department of Rare Disorders and Disabilities, National Centre for Rare Epilepsy-Related Disorders, Oslo University Hospital, Oslo, Norway
| | - Jakob Christensen
- Department of Neurology, Aarhus University Hospital, Affiliated Member of the European Reference Network EpiCARE, Aarhus, Denmark
| | - Christina Engel Hoei-Hansen
- Department of Pediatrics, University Hospital Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Lotte Holst
- Department of Neurology, Aarhus University Hospital, Affiliated Member of the European Reference Network EpiCARE, Aarhus, Denmark
| | - Mikkel G. Fredriksen
- Department of Pediatrics, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Caroline Lund
- Department of Rare Disorders and Disabilities, National Centre for Rare Epilepsy-Related Disorders, Oslo University Hospital, Oslo, Norway
- Department of Neurohabilitation, Oslo University Hospital, Oslo, Norway
| | - Cecilie Johannessen Landmark
- Department of Pharmacy, Faculty of Health Sciences, Institute of Life Sciences and Health, Oslo Metropolitan University, Oslo, Norway
- The National Centre for Epilepsy, Member of the ERN EpiCare, Oslo University Hospital, Oslo, Norway
- Department of Pharmacology, Section for Clinical Pharmacology, Oslo University Hospital, Oslo, Norway
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2
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Xu W, Chen H, Xiao H. mTORC2: A neglected player in aging regulation. J Cell Physiol 2024:e31363. [PMID: 38982866 DOI: 10.1002/jcp.31363] [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: 03/20/2024] [Revised: 05/21/2024] [Accepted: 06/19/2024] [Indexed: 07/11/2024]
Abstract
Mammalian target of rapamycin (mTOR) is a serine/threonine kinase that plays a pivotal role in various biological processes, through integrating external and internal signals, facilitating gene transcription and protein translation, as well as by regulating mitochondria and autophagy functions. mTOR kinase operates within two distinct protein complexes known as mTOR complex 1 (mTORC1) and mTOR complex 2 (mTORC2), which engage separate downstream signaling pathways impacting diverse cellular processes. Although mTORC1 has been extensively studied as a pro-proliferative factor and a pro-aging hub if activated aberrantly, mTORC2 received less attention, particularly regarding its implication in aging regulation. However, recent studies brought increasing evidence or clues for us, which implies the associations of mTORC2 with aging, as the genetic elimination of unique subunits of mTORC2, such as RICTOR, has been shown to alleviate aging progression in comparison to mTORC1 inhibition. In this review, we first summarized the basic characteristics of mTORC2, including its protein architecture and signaling network. We then focused on reviewing the molecular signaling regulation of mTORC2 in cellular senescence and organismal aging, and proposed the multifaceted regulatory characteristics under senescent and nonsenescent contexts. Next, we outlined the research progress of mTOR inhibitors in the field of antiaging and discussed future prospects and challenges. It is our pleasure if this review article could provide meaningful information for our readers and call forth more investigations working on this topic.
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Affiliation(s)
- Weitong Xu
- The Lab of Aging Research, National Clinical Research Center for Geriatrics, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
| | - Honghan Chen
- The Lab of Aging Research, National Clinical Research Center for Geriatrics, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
| | - Hengyi Xiao
- The Lab of Aging Research, National Clinical Research Center for Geriatrics, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
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Chi OZ, Liu X, Fortus H, Werlen G, Jacinto E, Weiss HR. Inhibition of p70 Ribosomal S6 Kinase (S6K1) Reduces Cortical Blood Flow in a Rat Model of Autism-Tuberous Sclerosis. Neuromolecular Med 2024; 26:10. [PMID: 38570425 PMCID: PMC10990997 DOI: 10.1007/s12017-024-08780-7] [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: 01/04/2024] [Accepted: 03/04/2024] [Indexed: 04/05/2024]
Abstract
The manifestations of tuberous sclerosis complex (TSC) in humans include epilepsy, autism spectrum disorders (ASD) and intellectual disability. Previous studies suggested the linkage of TSC to altered cerebral blood flow and metabolic dysfunction. We previously reported a significant elevation in cerebral blood flow in an animal model of TSC and autism of young Eker rats. Inhibition of the mammalian target of rapamycin (mTOR) by rapamycin could restore normal oxygen consumption and cerebral blood flow. In this study, we investigated whether inhibiting a component of the mTOR signaling pathway, p70 ribosomal S6 kinase (S6K1), would yield comparable effects. Control Long Evans and Eker rats were divided into vehicle and PF-4708671 (S6K1 inhibitor, 75 mg/kg for 1 h) treated groups. Cerebral regional blood flow (14C-iodoantipyrine) was determined in isoflurane anesthetized rats. We found significantly increased basal cortical (+ 32%) and hippocampal (+ 15%) blood flow in the Eker rats. PF-4708671 significantly lowered regional blood flow in the cortex and hippocampus of the Eker rats. PF-4708671 did not significantly lower blood flow in these regions in the control Long Evans rats. Phosphorylation of S6-Ser240/244 and Akt-Ser473 was moderately decreased in Eker rats but only the latter reached statistical significance upon PF-4708671 treatment. Our findings suggest that moderate inhibition of S6K1 with PF-4708671 helps to restore normal cortical blood flow in Eker rats and that this information might have therapeutic potential in tuberous sclerosis complex and autism.
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Affiliation(s)
- Oak Z Chi
- Department of Anesthesiology and Perioperative Medicine, Rutgers Robert Wood Johnson Medical School, 125 Paterson Street, Suite 3100, New Brunswick, NJ, 08901-1977, USA.
| | - Xia Liu
- Department of Anesthesiology and Perioperative Medicine, Rutgers Robert Wood Johnson Medical School, 125 Paterson Street, Suite 3100, New Brunswick, NJ, 08901-1977, USA
| | - Harvey Fortus
- Department of Biochemistry and Molecular Biology, Rutgers Robert Wood Johnson Medical School, Piscataway, NJ, 08854, USA
| | - Guy Werlen
- Department of Biochemistry and Molecular Biology, Rutgers Robert Wood Johnson Medical School, Piscataway, NJ, 08854, USA
| | - Estela Jacinto
- Department of Biochemistry and Molecular Biology, Rutgers Robert Wood Johnson Medical School, Piscataway, NJ, 08854, USA
| | - Harvey R Weiss
- Department of Neuroscience and Cell Biology, Rutgers Robert Wood Johnson Medical School, Piscataway, NJ, 08854, USA
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4
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Seyama K, Komiyama E, Tsuchihashi H, Okura MK, Sekimoto Y, Mitsuishi Y. Stepwise Incremental Dose Schedule of Sirolimus Is Successfully Tolerated by a Patient With Lymphangioleiomyomatosis Who Was Initially Allergic to mTOR Inhibitors. Cureus 2024; 16:e58805. [PMID: 38784348 PMCID: PMC11112535 DOI: 10.7759/cureus.58805] [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] [Accepted: 04/22/2024] [Indexed: 05/25/2024] Open
Abstract
Lymphangioleiomyomatosis (LAM) is a rare disease involving the proliferation of LAM cells in the lungs and the axial lymphatic system and mechanistic target of rapamycin (mTOR) inhibitors are the only effective medicines for treating it. Patients suffering from LAM, who are allergic to mTOR inhibitors can be treated by desensitizing them to the medicine. A 39-year-old woman presented with dyspnea caused by chylous pleural effusion, ascites, and retroperitoneal lymphangioleiomyomas. She was diagnosed with LAM based on the presence of LAM cell clusters (LCCs) in chylous pleural effusion and elevated serum vascular endothelial growth factor D (VEGF-D) concentration. She was allergic to cedars and yellowtails. Although she was started on sirolimus for treating LAM, the drug had to be discontinued on day 45 because of the appearance of a skin rash on her trunk. A year later, another oral mTOR inhibitor, everolimus, was initiated but had to be discontinued because of the appearance of cutaneous reactions. Since mTOR inhibitors are the only effective molecular-target medicines for LAM, desensitization to sirolimus was attempted by initiating exposure to sirolimus at a low dose followed by stepwise dose escalation. Eventually, the patient tolerated a dose of 0.5 mg/day of sirolimus, which resulted in a trough concentration of approximately 2 ng/ml in blood, without adverse cutaneous reactions; furthermore, clinically relevant effects were observed as her LAM condition reduced and stabilized. This case study illustrates that mTOR inhibitor therapy for LAM should not be abandoned because of allergic cutaneous reactions. Physicians must find a dose that balances adverse events and therapeutic effects to ensure continued treatment for patients with LAM. Furthermore, the possible mechanisms for mTOR inhibitor-induced cutaneous reactions have been discussed.
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Affiliation(s)
- Kuniaki Seyama
- Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, Tokyo, JPN
| | - Etsuko Komiyama
- Dermatology, Juntendo University Faculty of Medicine and Graduate School of Medicine, Tokyo, JPN
| | - Hitoshi Tsuchihashi
- Dermatology, Juntendo University Faculty of Medicine and Graduate School of Medicine, Tokyo, JPN
| | - Makiko K Okura
- Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, Tokyo, JPN
| | - Yasuhito Sekimoto
- Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, Tokyo, JPN
| | - Yoichiro Mitsuishi
- Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, Tokyo, JPN
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Lee DJW, Hodzic Kuerec A, Maier AB. Targeting ageing with rapamycin and its derivatives in humans: a systematic review. THE LANCET. HEALTHY LONGEVITY 2024; 5:e152-e162. [PMID: 38310895 DOI: 10.1016/s2666-7568(23)00258-1] [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: 08/29/2023] [Revised: 11/22/2023] [Accepted: 11/24/2023] [Indexed: 02/06/2024] Open
Abstract
Rapamycin and its derivatives (rapalogs) are inhibitors of mTOR, a major regulator of the ageing process. We aimed to summarise the effects of rapamycin and its derivatives on the severity of ageing-related physiological changes and disease in adults. A search across five databases yielded 18 400 unique articles, resulting in 19 included studies. Rapamycin and its derivatives improved physiological parameters associated with ageing in the immune, cardiovascular, and integumentary systems of healthy individuals or individuals with ageing-related diseases. Overall, no significant effects on the endocrine, muscular, or neurological systems were found. The effects of rapamycin or its derivatives on the respiratory, digestive, renal, and reproductive systems were not assessed. No serious adverse events attributed to rapamycin and its derivatives were reported in healthy individuals; however, there were increased numbers of infections and increases in total cholesterol, LDL cholesterol, and triglycerides in individuals with ageing-related diseases. Future studies should assess the remaining unexamined systems and test the effects of long-term exposure to rapamycin and its derivatives.
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Affiliation(s)
- Deborah J W Lee
- Healthy Longevity Translational Research Program, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Ajla Hodzic Kuerec
- Healthy Longevity Translational Research Program, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Centre for Healthy Longevity, @AgeSingapore National University Health System, Singapore
| | - Andrea B Maier
- Healthy Longevity Translational Research Program, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Centre for Healthy Longevity, @AgeSingapore National University Health System, Singapore; Department of Human Movement Sciences, @AgeAmsterdam, Amsterdam Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, Netherlands.
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6
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Almacellas Barbanoj A, Graham RT, Maffei B, Carpenter JC, Leite M, Hoke J, Hardjo F, Scott-Solache J, Chimonides C, Schorge S, Kullmann DM, Magloire V, Lignani G. Anti-seizure gene therapy for focal cortical dysplasia. Brain 2024; 147:542-553. [PMID: 38100333 PMCID: PMC10834237 DOI: 10.1093/brain/awad387] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 10/17/2023] [Accepted: 10/31/2023] [Indexed: 12/17/2023] Open
Abstract
Focal cortical dysplasias are a common subtype of malformation of cortical development, which frequently presents with a spectrum of cognitive and behavioural abnormalities as well as pharmacoresistant epilepsy. Focal cortical dysplasia type II is typically caused by somatic mutations resulting in mammalian target of rapamycin (mTOR) hyperactivity, and is the commonest pathology found in children undergoing epilepsy surgery. However, surgical resection does not always result in seizure freedom, and is often precluded by proximity to eloquent brain regions. Gene therapy is a promising potential alternative treatment and may be appropriate in cases that represent an unacceptable surgical risk. Here, we evaluated a gene therapy based on overexpression of the Kv1.1 potassium channel in a mouse model of frontal lobe focal cortical dysplasia. An engineered potassium channel (EKC) transgene was placed under control of a human promoter that biases expression towards principal neurons (CAMK2A) and packaged in an adeno-associated viral vector (AAV9). We used an established focal cortical dysplasia model generated by in utero electroporation of frontal lobe neural progenitors with a constitutively active human Ras homolog enriched in brain (RHEB) plasmid, an activator of mTOR complex 1. We characterized the model by quantifying electrocorticographic and behavioural abnormalities, both in mice developing spontaneous generalized seizures and in mice only exhibiting interictal discharges. Injection of AAV9-CAMK2A-EKC in the dysplastic region resulted in a robust decrease (∼64%) in the frequency of seizures. Despite the robust anti-epileptic effect of the treatment, there was neither an improvement nor a worsening of performance in behavioural tests sensitive to frontal lobe function. AAV9-CAMK2A-EKC had no effect on interictal discharges or behaviour in mice without generalized seizures. AAV9-CAMK2A-EKC gene therapy is a promising therapy with translational potential to treat the epileptic phenotype of mTOR-related malformations of cortical development. Cognitive and behavioural co-morbidities may, however, resist an intervention aimed at reducing circuit excitability.
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Affiliation(s)
- Amanda Almacellas Barbanoj
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, University College London, London WC1N 3BG, UK
| | - Robert T Graham
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, University College London, London WC1N 3BG, UK
| | - Benito Maffei
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, University College London, London WC1N 3BG, UK
| | - Jenna C Carpenter
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, University College London, London WC1N 3BG, UK
| | - Marco Leite
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, University College London, London WC1N 3BG, UK
| | - Justin Hoke
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, University College London, London WC1N 3BG, UK
| | - Felisia Hardjo
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, University College London, London WC1N 3BG, UK
| | - James Scott-Solache
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, University College London, London WC1N 3BG, UK
| | - Christos Chimonides
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, University College London, London WC1N 3BG, UK
| | - Stephanie Schorge
- Department of Neuroscience, Physiology and Pharmacology, University College London, London WC1E 6BT, UK
| | - Dimitri M Kullmann
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, University College London, London WC1N 3BG, UK
| | - Vincent Magloire
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, University College London, London WC1N 3BG, UK
| | - Gabriele Lignani
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, University College London, London WC1N 3BG, UK
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7
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Mammadova D, Vecko J, Hofmann M, Schüssler SC, Deiters L, Canda A, Wieland AK, Gollwitzer S, Hamer H, Trollmann R. A single-center observational study on long-term neurodevelopmental outcomes in children with tuberous sclerosis complex. Orphanet J Rare Dis 2023; 18:349. [PMID: 37946245 PMCID: PMC10637019 DOI: 10.1186/s13023-023-02959-0] [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: 11/14/2022] [Accepted: 10/25/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND Tuberous sclerosis complex (TSC) is a rare multisystem disorder caused by mutations in the TSC1 or TSC2 gene. More than 90% of patients with TSC develop neurological and/or neuropsychiatric manifestations. The aim of the present study was to determine the developmental and cognitive long-term outcomes of pediatric TSC patients. METHODS This cross-sectional, monocenter study included pediatric TSC patients who received multidisciplinary long-term care with a last visit between 2005 and 2019. Neurological manifestations and cognitive development (BSID, K-ABC) were analyzed in relation to age and type of mutation. RESULTS Thirty-five patients aged 13.5 ± 7.8 years were included in the study. Diagnosis was confirmed genetically in 65.7% of patients (TSC1, 26.1%; TSC2, 65.2%; NMI, 8.7%). Mean age at diagnosis was 1.3 ± 3.5 years; 74.3% of the patients had been diagnosed within the first year of life due to seizures (62.9%) or/and cardiac rhabdomyomas (28.6%). The most common TSC manifestations included structural brain lesions (cortical tubers, 91.4%; subependymal nodules, 82.9%), epilepsy (85.7%), and cardiac rhabdomyomas (62.9%). Mean age at seizure onset was 1.5 ± 2.3 years, with onset in 80.0% of patients within the first two years of life. Infantile spasms, which were the first seizure type in 23.3% of the patients, developed earlier (0.6 ± 0.4 years) than focal seizures (1.8 ± 2.5 years). Refractory epilepsy was present in 21 (70.0%) patients, mild or severe intellectual impairment in 66.6%, and autism spectrum disorders in 11.4%. Severe cognitive impairment (33.3%) was significantly associated with epilepsy type and age at seizure onset (p < 0.05). CONCLUSIONS The results emphasized the phenotypic variability of pediatric-onset TSC and the high rate of neurological and neuropsychiatric morbidity. Early-onset refractory epilepsy was associated with impaired cognitive development. Children of all ages with TSC require multidisciplinary long-term care and individual early-intervention programs.
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Affiliation(s)
- D Mammadova
- Department of Pediatric and Adolescent Medicine, Pediatric Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Loschgestr. 15, 91054, Erlangen, Germany
| | - J Vecko
- Department of Pediatric and Adolescent Medicine, Pediatric Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Loschgestr. 15, 91054, Erlangen, Germany
| | - M Hofmann
- Department of Pediatric and Adolescent Medicine, Pediatric Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Loschgestr. 15, 91054, Erlangen, Germany
| | - S C Schüssler
- Department of Pediatric and Adolescent Medicine, Pediatric Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Loschgestr. 15, 91054, Erlangen, Germany
| | - L Deiters
- Department of Pediatric and Adolescent Medicine, Pediatric Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Loschgestr. 15, 91054, Erlangen, Germany
| | - A Canda
- Department of Pediatric and Adolescent Medicine, Pediatric Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Loschgestr. 15, 91054, Erlangen, Germany
| | - A K Wieland
- Department of Pediatric and Adolescent Medicine, Pediatric Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Loschgestr. 15, 91054, Erlangen, Germany
- Center of Rare Diseases Erlangen (ZSEER), Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - S Gollwitzer
- Department of Neurology, Epilepsy Center, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
- Center of Rare Diseases Erlangen (ZSEER), Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - H Hamer
- Department of Neurology, Epilepsy Center, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
- Center of Rare Diseases Erlangen (ZSEER), Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Regina Trollmann
- Department of Pediatric and Adolescent Medicine, Pediatric Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Loschgestr. 15, 91054, Erlangen, Germany.
- Center of Rare Diseases Erlangen (ZSEER), Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany.
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8
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Auvin S, Galanopoulou AS, Moshé SL, Potschka H, Rocha L, Walker MC. Revisiting the concept of drug-resistant epilepsy: A TASK1 report of the ILAE/AES Joint Translational Task Force. Epilepsia 2023; 64:2891-2908. [PMID: 37676719 PMCID: PMC10836613 DOI: 10.1111/epi.17751] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 08/08/2023] [Accepted: 08/16/2023] [Indexed: 09/08/2023]
Abstract
Despite progress in the development of anti-seizure medications (ASMs), one third of people with epilepsy have drug-resistant epilepsy (DRE). The working definition of DRE, proposed by the International League Against Epilepsy (ILAE) in 2010, helped identify individuals who might benefit from presurgical evaluation early on. As the incidence of DRE remains high, the TASK1 workgroup on DRE of the ILAE/American Epilepsy Society (AES) Joint Translational Task Force discussed the heterogeneity and complexity of its presentation and mechanisms, the confounders in drawing mechanistic insights when testing treatment responses, and barriers in modeling DRE across the lifespan and translating across species. We propose that it is necessary to revisit the current definition of DRE, in order to transform the preclinical and clinical research of mechanisms and biomarkers, to identify novel, effective, precise, pharmacologic treatments, allowing for earlier recognition of drug resistance and individualized therapies.
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Affiliation(s)
- Stéphane Auvin
- Institut Universitaire de France, Paris, France
- Paediatric Neurology, Assistance Publique - Hôpitaux de Paris, EpiCARE ERN Member, Robert-Debré Hospital, Paris, France
- University Paris-Cité, Paris, France
| | - Aristea S Galanopoulou
- Saul R. Korey Department of Neurology, Isabelle Rapin Division of Child Neurology, Dominick P. Purpura Department of Neuroscience, Albert Einstein College of Medicine, and Montefiore/Einstein Epilepsy Center, Bronx, New York, USA
| | - Solomon L Moshé
- Saul R. Korey Department of Neurology, Isabelle Rapin Division of Child Neurology, Dominick P. Purpura Department of Neuroscience, Albert Einstein College of Medicine, and Montefiore/Einstein Epilepsy Center, Bronx, New York, USA
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Heidrun Potschka
- Institute of Pharmacology, Toxicology, and Pharmacy, Ludwig-Maximilians-University (LMU), Munich, Germany
| | - Luisa Rocha
- Pharmacobiology Department, Center for Research and Advanced Studies (CINVESTAV), Mexico City, Mexico
| | - Matthew C Walker
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, UK
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9
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Aitken P, Stanescu I, Boddington L, Mahon C, Fogarasi A, Liao YH, Ivars M, Moreno-Artero E, Trauner D, DeRoos ST, Jancic J, Nikolic M, Balážová P, Price HN, Hadzsiev K, Riney K, Stapleton S, Tollefson MM, Bauer D, Pinková B, Atkinson H. A novel rapamycin cream formulation improves facial angiofibromas associated with tuberous sclerosis complex: a double-blind randomized placebo-controlled trial. Br J Dermatol 2023; 189:520-530. [PMID: 37463422 DOI: 10.1093/bjd/ljad243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 07/03/2023] [Accepted: 07/13/2023] [Indexed: 07/20/2023]
Abstract
BACKGROUND Facial angiofibromas (FAs) are a major feature of tuberous sclerosis complex (TSC). Topical rapamycin can successfully treat FAs. A new stabilized cream formulation that protects rapamycin from oxidation has been developed in 0.5% and 1% concentrations. OBJECTIVES To assess the efficacy and safety of a novel, stabilized topical rapamycin cream formulation. METHODS This multicentre double-blind randomized placebo-controlled dose-response phase II/III study with a parallel design included participants aged 6-65 years with FAs of mild or moderate severity according to the Investigator's Global Assessment (IGA) scale. Participants were randomized to one of three treatment arms: topical rapamycin 0.5%, topical rapamycin 1% or placebo. Treatment was applied once daily for 26 weeks. Safety and efficacy measures were assessed at days 14, 56, 98, 140 and 182. The primary endpoint was the percentage of participants achieving IGA scores of 'clear' or 'almost clear' after 26 weeks of treatment. Secondary measures included Facial Angiofibroma Severity Index (FASI) and participant- and clinician-reported percentage-based improvement. Safety measures included the incidence of treatment-emergent adverse events and blood rapamycin concentration changes over time. RESULTS Participants (n = 107) were randomized to receive either rapamycin 1% (n = 33), rapamycin 0.5% (n = 36) or placebo (n = 38). All treated participants were included in the final analysis. The percentage of participants with a two-grade IGA improvement was greater in the rapamycin 0.5% treatment group (11%) and rapamycin 1% group (9%) than in the placebo group (5%). However, this was not statistically significant [rapamycin 0.5%: odds ratio (OR) 1.71, 95% confidence interval (CI) 0.36-8.18 (P = 0.50); rapamycin 1%: OR 1.68, 95% CI 0.33-8.40 (P = 0.53)]. There was a statistically significant difference in the proportion of participants treated with rapamycin cream that achieved at least a one-grade improvement in IGA [rapamycin 0.5%: 56% (OR 4.73, 95% CI 1.59-14.10; P = 0.005); rapamycin 1%: 61% (OR 5.14, 95% CI 1.70-15.57; P = 0.004); placebo: 24%]. Skin adverse reactions were more common in patients following rapamycin application (64%) vs. placebo (29%). CONCLUSIONS Both rapamycin cream formulations (0.5% and 1%) were well tolerated, and either strength could lead to clinical benefit in the treatment of FA.
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Affiliation(s)
| | | | | | - Caroline Mahon
- Dermatology Department, Christchurch Hospital, Christchurch, New Zealand
| | | | - Yi-Hua Liao
- Department of Dermatology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Marta Ivars
- Dermatology Department, Clínica Universidad de Navarra, Madrid, Spain
| | | | - Doris Trauner
- University of California San Diego Health Sciences, Department of Neurosciences, San Diego, CA, USA
| | | | - Jasna Jancic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- Clinic of Neurology and Psychiatry for Children and Youth, Belgrade, Serbia
| | - Milos Nikolic
- University of Belgrade School of Medicine, Department of Dermatovenereology, University Clinical Center of Serbia, Belgrade, Serbia
| | - Patrícia Balážová
- Department of Pediatric Neurology, Faculty of Medicine, Comenius University, National Institute of Children's Diseases, Bratislava, Slovakia
| | - Harper N Price
- Division of Dermatology, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Kinga Hadzsiev
- Department of Medical Genetics, Medical School, University of Pécs, Pécs, Hungary
| | - Kate Riney
- Neurosciences Unit, Queensland Children's Hospital, South Brisbane, QLD, Australia
- Faculty of Medicine, University of Queensland, St Lucia, QLD, Australia
| | | | - Megha M Tollefson
- Departments of Dermatology and Pediatrics, Mayo Clinic and Mayo Clinic Children's Center, MN, USA
| | - Derek Bauer
- University of Virginia, Charlottesville, VA, USA
| | - Blanka Pinková
- Department of Paediatric Dermatology, Faculty Hospital, Brno, Czech Republic
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Previtali R, Prontera G, Alfei E, Nespoli L, Masnada S, Veggiotti P, Mannarino S. Paradigm shift in the treatment of tuberous sclerosis: Effectiveness of everolimus. Pharmacol Res 2023; 195:106884. [PMID: 37549757 DOI: 10.1016/j.phrs.2023.106884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 08/03/2023] [Accepted: 08/03/2023] [Indexed: 08/09/2023]
Abstract
Tuberous sclerosis complex (TSC) is an autosomal dominant disease characterised by abnormal cell proliferation and differentiation that affects multiple organs and can lead to the growth of hamartomas. Tuberous sclerosis complex is caused by the disinhibition of the protein mTOR (mammalian target of rapamycin). In the past, various therapeutic approaches, even if only symptomatic, have been attempted to improve the clinical effects of this disease. While all of these therapeutic strategies are useful and are still used and indicated, they are symptomatic therapies based on the individual symptoms of the disease and therefore not fully effective in modifying long-term outcomes. A new therapeutic approach is the introduction of allosteric inhibitors of mTORC1, which allow restoration of metabolic homeostasis in mutant cells, potentially eliminating most of the clinical manifestations associated with Tuberous sclerosis complex. Everolimus, a mammalian target of the rapamycin inhibitor, is able to reduce hamartomas, correcting the specific molecular defect that causes Tuberous sclerosis complex. In this review, we report the findings from the literature on the use of everolimus as an effective and safe drug in the treatment of TSC manifestations affecting various organs, from the central nervous system to the heart.
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Affiliation(s)
- Roberto Previtali
- Pediatric Neurology Unit, Buzzi Children's Hospital, Milan, Italy; Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Giorgia Prontera
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Enrico Alfei
- Pediatric Neurology Unit, Buzzi Children's Hospital, Milan, Italy
| | - Luisa Nespoli
- Pediatric Cardiology Unit, Department of Pediatric, Buzzi Children's Hospital, Milan, Italy
| | - Silvia Masnada
- Pediatric Neurology Unit, Buzzi Children's Hospital, Milan, Italy
| | - Pierangelo Veggiotti
- Pediatric Neurology Unit, Buzzi Children's Hospital, Milan, Italy; Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Savina Mannarino
- Pediatric Cardiology Unit, Department of Pediatric, Buzzi Children's Hospital, Milan, Italy.
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11
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Sokolov AM, Aurich M, Bordey A. In Utero Electroporated Neurons for Medium-Throughput Screening of Compounds Regulating Neuron Morphology. eNeuro 2023; 10:ENEURO.0160-23.2023. [PMID: 37620147 PMCID: PMC10464655 DOI: 10.1523/eneuro.0160-23.2023] [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: 05/15/2023] [Revised: 07/27/2023] [Accepted: 07/27/2023] [Indexed: 08/26/2023] Open
Abstract
Several neurodevelopmental disorders are associated with increased mTOR activity that results in pathogenic neuronal dysmorphogenesis (i.e., soma and dendrite overgrowth), leading to circuit alterations associated with epilepsy and neurologic disabilities. Although an mTOR analog is approved for the treatment of epilepsy in one of these disorders, it has limited efficacy and is associated with a wide range of side effects. There is a need to develop novel agents for the treatment of mTOR-pathway related disorders. Here, we developed a medium-throughput phenotypic assay to test drug efficacy on neurite morphogenesis of mouse neurons in a hyperactive mTOR condition. Our assay involved in utero electroporation (IUE) of a selective population of cortical pyramidal neurons with a plasmid encoding the constitutively active mTOR activator, Rheb, and tdTomato. Labeled neurons from the somatosensory cortex (SSC) were cultured onto 96-well plates and fixed at various days in vitro or following Torin 1 treatment. Automated systems were used for image acquisition and neuron morphologic measurements. We validated our automated approach using traditional manual methods of neuron morphologic assessment. Both automated and manual analyses showed increased neurite length and complexity over time, and decreased neurite overgrowth and soma size with Torin 1. These data validate the accuracy of our automated approach that takes hours compared with weeks when using traditional manual methods. Taken together, this assay can be scaled to screen 32 compounds simultaneously in two weeks, highlighting its robustness and efficiency for medium-throughput screening of candidate therapeutics on a defined population of wild-type or diseased neurons.
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Affiliation(s)
- Aidan M Sokolov
- Departments of Neurosurgery, and Cellular and Molecular Physiology, Wu Tsai Institute, Yale University School of Medicine, New Haven, CT 06520-8082
| | - Mariana Aurich
- Departments of Neurosurgery, and Cellular and Molecular Physiology, Wu Tsai Institute, Yale University School of Medicine, New Haven, CT 06520-8082
| | - Angélique Bordey
- Departments of Neurosurgery, and Cellular and Molecular Physiology, Wu Tsai Institute, Yale University School of Medicine, New Haven, CT 06520-8082
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Wirrell EC, Riney K, Specchio N, Zuberi SM. How have the recent updated epilepsy classifications impacted on diagnosis and treatment? Expert Rev Neurother 2023; 23:969-980. [PMID: 37676056 DOI: 10.1080/14737175.2023.2254937] [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: 07/19/2023] [Accepted: 08/30/2023] [Indexed: 09/08/2023]
Abstract
INTRODUCTION Epilepsies are a diverse group of disorders which differ regarding prognosis for seizure control and associated comorbidities. Accurate classification is critical to choose the highest yield investigations and best therapeutic options and to provide the most accurate prognoses regarding the expected degree of seizure control, possible remission, and risk of associated comorbidities to patients and their families. This article reviews the recent updates in epilepsy classification to illustrate how accurate classification impacts care for persons with epilepsy. AREAS COVERED The authors discuss the ILAE 2017 Classification of the Epilepsies along with the modification of the classification for neonatal seizures and epilepsies. They also discuss the ILAE position papers on Epilepsy syndromes in neonates and infants and children of variable age and the Idiopathic Generalized Epilepsies. EXPERT OPINION Accurate epilepsy classification allows selection of the highest yield investigations, choice of optimal therapies, and accurate prognostication of seizures (likelihood of response to antiseizure treatments and likelihood of remission with age), as well as comorbidities (likelihood, type, and severity). As we move into the era of disease modifying therapy, early accurate identification of underlying causes with timely introduction of specific treatments will be crucial to lessen the severity of epilepsy, with improved seizure control and attenuation of associated comorbidities.
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Affiliation(s)
- Elaine C Wirrell
- Divisions of Child and Adolescent Neurology and Epilepsy, Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Kate Riney
- Neurosciences Unit, Queensland Children's Hospital, Australia and Faculty of Medicine, University of St Lucia, Brisbane, Queensland, Australia
| | - Nicola Specchio
- Clinical and Experimental Neurology, Bambino Gesu Children's Hospital, IRCCS, Full Member of European Reference Network on Rare and Complex Epilepsies (EpiCARE), Rome, Italy
| | - Sameer M Zuberi
- School of Health and Wellbeing, University of Glasgow, Glasgow, UK
- Royal Hospital for Children, Glasgow, UK
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13
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Auvin S, Baulac S. mTOR-therapy and targeted treatment opportunities in mTOR-related epilepsies associated with cortical malformations. Rev Neurol (Paris) 2023; 179:337-344. [PMID: 36906459 DOI: 10.1016/j.neurol.2022.12.007] [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: 10/27/2022] [Revised: 12/08/2022] [Accepted: 12/13/2022] [Indexed: 03/11/2023]
Abstract
Dysregulation of the mTOR pathway is now well documented in several neurodevelopmental disorders associated with epilepsy. Mutations of mTOR pathway genes are involved in tuberous sclerosis complex (TSC) as well as in a range of cortical malformations from hemimegalencephaly (HME) to type II focal cortical dysplasia (FCD II), leading to the concept of "mTORopathies" (mTOR pathway-related malformations). This suggests that mTOR inhibitors (notably rapamycin (sirolimus), and everolimus) could be used as antiseizure medication. In this review, we provide an overview of pharmacological treatments targeting the mTOR pathway for epilepsy based on lectures from the ILAE French Chapter meeting in October 2022 in Grenoble. There is strong preclinical evidence for the antiseizure effects of mTOR inhibitors in TSC and cortical malformation mouse models. There are also open studies on the antiseizure effects of mTOR inhibitors, as well as one phase III study showing the antiseizure effect of everolimus in TSC patients. Finally, we discuss to which extent mTOR inhibitors might have properties beyond the antiseizure effect on associated neuropsychiatric comorbidities. We also discuss a new way of treatment on the mTOR pathways.
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Affiliation(s)
- S Auvin
- Service de neurologie pédiatrique, EpiCARE ERN membre, Hôpital Robert Debré, AP-HP, Paris, France; Université Paris-Cité, Inserm NeuroDiderot, Paris, France; Institut Universitaire de France (IUF), Paris, France.
| | - S Baulac
- Sorbonne Université, Institut du Cerveau - Paris Brain Institute - ICM, Inserm, CNRS, Hôpital de la Pitié Salpêtrière, 75013 Paris, France
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14
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Advances in the genetics and neuropathology of tuberous sclerosis complex: edging closer to targeted therapy. Lancet Neurol 2022; 21:843-856. [DOI: 10.1016/s1474-4422(22)00213-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 03/09/2022] [Accepted: 05/11/2022] [Indexed: 12/23/2022]
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15
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Liu T, Chen F, Zhai F, Liang S. Progress of clinical research studies on tuberous sclerosis complex-related epilepsy in China. Acta Neurol Scand 2022; 146:743-751. [PMID: 36000491 DOI: 10.1111/ane.13692] [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: 06/30/2022] [Revised: 07/31/2022] [Accepted: 08/11/2022] [Indexed: 11/29/2022]
Abstract
Tuberous sclerosis complex (TSC) is an autosomal dominant neurocutaneous syndrome, with 75.6%-83.5% and 54.1% patients presenting with epilepsy and drug-resistant epilepsy (DRE), respectively. Clinical studies on TSC, particularly surgical interventions, have achieved rapid and substantial progress. The TSC-Task Force Committee of the China Association Against Epilepsy (CAAE-TFTSC) was founded in 2012, and annual academic conferences on the surgical treatment of TSC-related epilepsy have been held since 2013. 'China experts' consensus on surgical treatment of TSC-related epilepsy' was published in 2019. This review focuses on surgical treatment, including resective surgery, neuromodulations, corpus callosotomy and mini-invasive ablations, as well as studies on phenotype, genotype and anti-seizure therapies of mammalian target of rapamycin inhibitor, vigabatrin and ketogenic diet in patients with TSC-related DRE in China.
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Affiliation(s)
- Tinghong Liu
- Functional Neurosurgery Department, National Children's Health Center of China, Beijing Children's Hospital, Capital Medical University, Beijing, China.,Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing, China
| | - Feng Chen
- Functional Neurosurgery Department, National Children's Health Center of China, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Feng Zhai
- Functional Neurosurgery Department, National Children's Health Center of China, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Shuli Liang
- Functional Neurosurgery Department, National Children's Health Center of China, Beijing Children's Hospital, Capital Medical University, Beijing, China.,Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing, China
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16
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Erratum. Epilepsia 2022; 63:1606. [PMID: 35482576 DOI: 10.1111/epi.17267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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17
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van Vliet EA, Marchi N. Neurovascular unit dysfunction as a mechanism of seizures and epilepsy during aging. Epilepsia 2022; 63:1297-1313. [PMID: 35218208 PMCID: PMC9321014 DOI: 10.1111/epi.17210] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 02/23/2022] [Accepted: 02/23/2022] [Indexed: 11/30/2022]
Abstract
The term neurovascular unit (NVU) describes the structural and functional liaison between specialized brain endothelium, glial and mural cells, and neurons. Within the NVU, the blood‐brain barrier (BBB) is the microvascular structure regulating neuronal physiology and immune cross‐talk, and its properties adapt to brain aging. Here, we analyze a research framework where NVU dysfunction, caused by acute insults or disease progression in the aging brain, represents a converging mechanism underlying late‐onset seizures or epilepsy and neurological or neurodegenerative sequelae. Furthermore, seizure activity may accelerate brain aging by sustaining regional NVU dysfunction, and a cerebrovascular pathology may link seizures to comorbidities. Next, we focus on NVU diagnostic approaches that could be tailored to seizure conditions in the elderly. We also examine the impending disease‐modifying strategies based on the restoration of the NVU and, more in general, the homeostatic control of anti‐ and pro‐inflammatory players. We conclude with an outlook on current pre‐clinical knowledge gaps and clinical challenges pertinent to seizure onset and conditions in an aging population.
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Affiliation(s)
- Erwin A van Vliet
- Amsterdam UMC, University of Amsterdam, dept. of (Neuro)pathology, Amsterdam, the Netherlands.,University of Amsterdam, Swammerdam Institute for Life Sciences, Center for Neuroscience, Amsterdam, the Netherlands
| | - Nicola Marchi
- Cerebrovascular and Glia Research, Department of Neuroscience, Institute of Functional Genomics, University of Montpellier, CNRS, INSERM, Montpellier, France
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