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Ng ACH, Choudhary A, Barrett KT, Gavrilovici C, Scantlebury MH. Mechanisms of infantile epileptic spasms syndrome: What have we learned from animal models? Epilepsia 2024; 65:266-280. [PMID: 38036453 DOI: 10.1111/epi.17841] [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: 10/02/2023] [Revised: 11/27/2023] [Accepted: 11/28/2023] [Indexed: 12/02/2023]
Abstract
The devastating developmental and epileptic encephalopathy of infantile epileptic spasms syndrome (IESS) has numerous causes, including, but not limited to, brain injury, metabolic, and genetic conditions. Given the stereotyped electrophysiologic, age-dependent, and clinical findings, there likely exists one or more final common pathways in the development of IESS. The identity of this final common pathway is unknown, but it may represent a novel therapeutic target for infantile spasms. Previous research on IESS has focused largely on identifying the neuroanatomic substrate using specialized neuroimaging techniques and cerebrospinal fluid analysis in human patients. Over the past three decades, several animal models of IESS were created with an aim to interrogate the underlying pathogenesis of IESS, to identify novel therapeutic targets, and to test various treatments. Each of these models have been successful at recapitulating multiple aspects of the human IESS condition. These animal models have implicated several different molecular pathways in the development of infantile spasms. In this review we outline the progress that has been made thus far using these animal models and discuss future directions to help researchers identify novel treatments for drug-resistant IESS.
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Affiliation(s)
- Andy Cheuk-Him Ng
- Department of Pediatrics, Alberta Children's Hospital Research Institute, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Anamika Choudhary
- Department of Pediatrics, Alberta Children's Hospital Research Institute, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Karlene T Barrett
- Department of Pediatrics, Alberta Children's Hospital Research Institute, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Cezar Gavrilovici
- Department of Pediatrics, Alberta Children's Hospital Research Institute, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Morris H Scantlebury
- Department of Pediatrics, Alberta Children's Hospital Research Institute, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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2
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Riikonen R. Biochemical mechanisms in pathogenesis of infantile epileptic spasm syndrome. Seizure 2023; 105:1-9. [PMID: 36634586 DOI: 10.1016/j.seizure.2023.01.004] [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: 09/22/2022] [Revised: 01/01/2023] [Accepted: 01/05/2023] [Indexed: 01/09/2023] Open
Abstract
The molecular mechanisms leading to infantile epileptic spasm syndrome (IESS) remain obscure. The only common factor seems to be that the spasms are restricted to a limited period of infancy, during a certain maturational state. Here the current literature regarding the biochemical mechanisms of brain maturation in IESS is reviewed, and various hypotheses of the pathophysiology are put together. They include: (1) imbalance of inhibitory (NGF, IGF-1, ACTH, GABA) and excitatory factors (glutamate, nitrites) which distinguishes the different etiological subgroups, (2) abnormality of the hypothalamic pituitary adrenal (HPA) axis linking insults and early life stress, (3) inflammation (4) yet poorly known genetic and epigenetic factors, and (5) glucocorticoid and vigabatrin action on brain development, pinpointing at molecular targets of the pathophysiology from another angle. An altered maturational process may explain why so many, seemingly independent etiological factors lead to the same clinical syndrome and frequently to developmental delay. Understanding these factors can provide ideas for novel therapies.
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Affiliation(s)
- Raili Riikonen
- Children's Hospital, University of Eastern Finland and Kuopio University Hospital, Kuopio, Finland.
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3
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Barrett KT, Choudhary A, Charkhand B, Scantlebury MH. Animal Models in Epileptic Spasms and the Development of Novel Treatment Options. J Clin Neurophysiol 2022; 39:529-537. [PMID: 35323127 DOI: 10.1097/wnp.0000000000000496] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
SUMMARY The infantile spasms (IS) syndrome is a catastrophic developmental epileptic encephalopathy syndrome characterized by an age-specific expression of epileptic spasms that are associated with extremely abnormal, oftentimes described as chaotic, interictal EEG pattern known as hypsarrhythmia. Patients with IS generally have poor neurodevelopmental outcomes, in large part because of the frequent epileptic spasms and interictal EEG abnormalities. Current first-line treatments such as adrenocorticotropic hormone or vigabatrin are often ineffective and are associated with major toxic side effects. There is therefore a need for better and safer treatments for patients with IS, especially for the intractable population. Hope is on the horizon as, over the past 10 years, there has been robust progress in the development of etiology-specific animal models of IS. These models have been used to identify potential new treatments for IS and are beginning to provide some important insights into the pathophysiological substrates for this disease. In this review, we will highlight strengths and weaknesses of the currently available animal models of IS in addition to new insights into the pathophysiology and treatment options derived from these models.
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Affiliation(s)
- Karlene T Barrett
- Department of Pediatrics, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada; and
| | - Anamika Choudhary
- Department of Pediatrics, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada; and
| | - Behshad Charkhand
- Department of Pediatrics, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada; and
| | - Morris H Scantlebury
- Department of Pediatrics, Clinical Neurosciences, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
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Velíšek L, Velíšková J. Modeling epileptic spasms during infancy: Are we heading for the treatment yet? Pharmacol Ther 2020; 212:107578. [PMID: 32417271 PMCID: PMC7299814 DOI: 10.1016/j.pharmthera.2020.107578] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 05/07/2020] [Indexed: 12/22/2022]
Abstract
Infantile spasms (IS or epileptic spasms during infancy) were first described by Dr. William James West (aka West syndrome) in his own son in 1841. While rare by definition (occurring in 1 per 3200-3400 live births), IS represent a major social and treatment burden. The etiology of IS varies - there are many (>200) different known pathologies resulting in IS and still in about one third of cases there is no obvious reason. With the advancement of genetic analysis, role of certain genes (such as ARX or CDKL5 and others) in IS appears to be important. Current treatment strategies with incomplete efficacy and serious potential adverse effects include adrenocorticotropin (ACTH), corticosteroids (prednisone, prednisolone) and vigabatrin, more recently also a combination of hormones and vigabatrin. Second line treatments include pyridoxine (vitamin B6) and ketogenic diet. Additional treatment approaches use rapamycin, cannabidiol, valproic acid and other anti-seizure medications. Efficacy of these second line medications is variable but usually inferior to hormonal treatments and vigabatrin. Thus, new and effective models of this devastating condition are required for the search of additional treatment options as well as for better understanding the mechanisms of IS. Currently, eight models of IS are reviewed along with the ideas and mechanisms behind these models, drugs tested using the models and their efficacy and usefulness. Etiological variety of IS is somewhat reflected in the variety of the models. However, it seems that for finding precise personalized approaches, this variety is necessary as there is no "one-size-fits-all" approach possible for both IS in particular and epilepsy in general.
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Affiliation(s)
- Libor Velíšek
- Departments of Cell Biology & Anatomy, New York Medical College, Valhalla, NY, USA; Departments of Pediatrics, New York Medical College, Valhalla, NY, USA; Departments of Neurology, New York Medical College, Valhalla, NY, USA.
| | - Jana Velíšková
- Departments of Cell Biology & Anatomy, New York Medical College, Valhalla, NY, USA; Departments of Neurology, New York Medical College, Valhalla, NY, USA; Departments of Obstetrics & Gynecology, New York Medical College, Valhalla, NY, USA
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5
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Melanocortins, Melanocortin Receptors and Multiple Sclerosis. Brain Sci 2017; 7:brainsci7080104. [PMID: 28805746 PMCID: PMC5575624 DOI: 10.3390/brainsci7080104] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 08/07/2017] [Accepted: 08/08/2017] [Indexed: 02/07/2023] Open
Abstract
The melanocortins and their receptors have been extensively investigated for their roles in the hypothalamo-pituitary-adrenal axis, but to a lesser extent in immune cells and in the nervous system outside the hypothalamic axis. This review discusses corticosteroid dependent and independent effects of melanocortins on the peripheral immune system, central nervous system (CNS) effects mediated through neuronal regulation of immune system function, and direct effects on endogenous cells in the CNS. We have focused on the expression and function of melanocortin receptors in oligodendroglia (OL), the myelin producing cells of the CNS, with the goal of identifying new therapeutic approaches to decrease CNS damage in multiple sclerosis as well as to promote repair. It is clear that melanocortin signaling through their receptors in the CNS has potential for neuroprotection and repair in diseases like MS. Effects of melanocortins on the immune system by direct effects on the circulating cells (lymphocytes and monocytes) and by signaling through CNS cells in regions lacking a mature blood brain barrier are clear. However, additional studies are needed to develop highly effective MCR targeted therapies that directly affect endogenous cells of the CNS, particularly OL, their progenitors and neurons.
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van Campen JS, Jansen FE, Pet MA, Otte WM, Hillegers MHJ, Joels M, Braun KPJ. Relation between stress-precipitated seizures and the stress response in childhood epilepsy. Brain 2015; 138:2234-48. [DOI: 10.1093/brain/awv157] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Accepted: 04/14/2015] [Indexed: 11/14/2022] Open
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Galanopoulou AS, Moshé SL. Pathogenesis and new candidate treatments for infantile spasms and early life epileptic encephalopathies: A view from preclinical studies. Neurobiol Dis 2015; 79:135-49. [PMID: 25968935 DOI: 10.1016/j.nbd.2015.04.015] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Revised: 04/23/2015] [Accepted: 04/30/2015] [Indexed: 12/26/2022] Open
Abstract
Early onset and infantile epileptic encephalopathies (EIEEs) are usually associated with medically intractable or difficult to treat epileptic seizures and prominent cognitive, neurodevelopmental and behavioral consequences. EIEEs have numerous etiologies that contribute to the inter- and intra-syndromic phenotypic variability. Etiologies include structural and metabolic or genetic etiologies although a significant percentage is of unknown cause. The need to better understand their pathogenic mechanisms and identify better therapies has driven the development of animal models of EIEEs. Several rodent models of infantile spasms have emerged that recapitulate various aspects of the disease. The acute models manifest epileptic spasms after induction and include the NMDA rat model, the NMDA model with prior prenatal betamethasone or perinatal stress exposure, and the γ-butyrolactone induced spasms in a mouse model of Down syndrome. The chronic models include the tetrodotoxin rat model, the aristaless related homeobox X-linked (Arx) mouse models and the multiple-hit rat model of infantile spasms. We will discuss the main features and findings from these models on target mechanisms and emerging therapies. Genetic models have also provided interesting data on the pathogenesis of Dravet syndrome and proposed new therapies for testing. The genetic associations of many of the EIEEs have also been tested in rodent models as to their pathogenicity. Finally, several models have tested the impact of subclinical epileptiform discharges on brain function. The impact of these advances in animal modeling for therapy development will be discussed.
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Affiliation(s)
- Aristea S Galanopoulou
- Saul R. Korey Department of Neurology, Dominick P. Purpura Department of Neuroscience, Laboratory of Developmental Epilepsy, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.
| | - Solomon L Moshé
- Saul R. Korey Department of Neurology, Dominick P. Purpura Department of Neuroscience, Laboratory of Developmental Epilepsy, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA; Department of Pediatrics, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.
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Abstract
This article focuses on the inflammatory processes in patients with generalized epilepsies. We specifically review the data regarding West, Lennox-Gastaut, and Landau-Kleffner syndromes as they have generalized clinical or electroencephalogram features. There is substantial evidence for a pathogenic implication of immune mechanisms in these epilepsies. Animal models and abnormalities in both cellular and humoral immunity support this hypothesis. They also appear to be particularly responsive to immunomodulatory therapies, which has raised the speculation that an unbalanced immune system may play an important role in the pathophysiology of these epileptic syndromes. In this article, we discuss clinical and experimental data that support the potential implication of immune mediated inflammation and immune response in the mechanism of these entities.
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9
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van Campen JS, Jansen FE, de Graan PNE, Braun KPJ, Joels M. Early life stress in epilepsy: a seizure precipitant and risk factor for epileptogenesis. Epilepsy Behav 2014; 38:160-71. [PMID: 24144618 DOI: 10.1016/j.yebeh.2013.09.029] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Revised: 09/17/2013] [Accepted: 09/19/2013] [Indexed: 10/26/2022]
Abstract
Stress can influence epilepsy in multiple ways. A relation between stress and seizures is often experienced by patients with epilepsy. Numerous questionnaire and diary studies have shown that stress is the most often reported seizure-precipitating factor in epilepsy. Acute stress can provoke epileptic seizures, and chronic stress increases seizure frequency. In addition to its effects on seizure susceptibility in patients with epilepsy, stress might also increase the risk of epilepsy development, especially when the stressors are severe, prolonged, or experienced early in life. Although the latter has not been fully resolved in humans, various preclinical epilepsy models have shown increased seizure susceptibility in naïve rodents after prenatal and early postnatal stress exposure. In the current review, we first provide an overview of the effects of stress on the brain. Thereafter, we discuss human as well as preclinical studies evaluating the relation between stress, epileptic seizures, and epileptogenesis, focusing on the epileptogenic effects of early life stress. Increased knowledge on the interaction between early life stress, seizures, and epileptogenesis could improve patient care and provide a basis for new treatment strategies for epilepsy.
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Affiliation(s)
- Jolien S van Campen
- Department of Pediatric Neurology, Brain Center Rudolf Magnus, University Medical Center Utrecht, The Netherlands; Department of Neuroscience & Pharmacology, Brain Center Rudolf Magnus, University Medical Center Utrecht, The Netherlands.
| | - Floor E Jansen
- Department of Pediatric Neurology, Brain Center Rudolf Magnus, University Medical Center Utrecht, The Netherlands
| | - Pierre N E de Graan
- Department of Neuroscience & Pharmacology, Brain Center Rudolf Magnus, University Medical Center Utrecht, The Netherlands
| | - Kees P J Braun
- Department of Pediatric Neurology, Brain Center Rudolf Magnus, University Medical Center Utrecht, The Netherlands
| | - Marian Joels
- Department of Neuroscience & Pharmacology, Brain Center Rudolf Magnus, University Medical Center Utrecht, The Netherlands
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10
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Clynen E, Swijsen A, Raijmakers M, Hoogland G, Rigo JM. Neuropeptides as targets for the development of anticonvulsant drugs. Mol Neurobiol 2014; 50:626-46. [PMID: 24705860 PMCID: PMC4182642 DOI: 10.1007/s12035-014-8669-x] [Citation(s) in RCA: 85] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Accepted: 02/27/2014] [Indexed: 11/04/2022]
Abstract
Epilepsy is a common neurological disorder characterized by recurrent seizures. These seizures are due to abnormal excessive and synchronous neuronal activity in the brain caused by a disruption of the delicate balance between excitation and inhibition. Neuropeptides can contribute to such misbalance by modulating the effect of classical excitatory and inhibitory neurotransmitters. In this review, we discuss 21 different neuropeptides that have been linked to seizure disorders. These neuropeptides show an aberrant expression and/or release in animal seizure models and/or epilepsy patients. Many of these endogenous peptides, like adrenocorticotropic hormone, angiotensin, cholecystokinin, cortistatin, dynorphin, galanin, ghrelin, neuropeptide Y, neurotensin, somatostatin, and thyrotropin-releasing hormone, are able to suppress seizures in the brain. Other neuropeptides, such as arginine-vasopressine peptide, corticotropin-releasing hormone, enkephalin, β-endorphin, pituitary adenylate cyclase-activating polypeptide, and tachykinins have proconvulsive properties. For oxytocin and melanin-concentrating hormone both pro- and anticonvulsive effects have been reported, and this seems to be dose or time dependent. All these neuropeptides and their receptors are interesting targets for the development of new antiepileptic drugs. Other neuropeptides such as nesfatin-1 and vasoactive intestinal peptide have been less studied in this field; however, as nesfatin-1 levels change over the course of epilepsy, this can be considered as an interesting marker to diagnose patients who have suffered a recent epileptic seizure.
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Affiliation(s)
- Elke Clynen
- Biomedical Research Institute BIOMED, Hasselt University, Martelarenlaan 42, 3500, Hasselt, Belgium,
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11
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Capovilla G, Moshé SL, Wolf P, Avanzini G. Epileptic encephalopathy as models of system epilepsy. Epilepsia 2013; 54 Suppl 8:34-7. [DOI: 10.1111/epi.12421] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Giuseppe Capovilla
- Department of Child Neuropsychiatry; Epilepsy Center; C. Poma Hospital; Mantua Italy
| | - Solomon L. Moshé
- Saul R. Korey Department of Neurology; Dominick P. Purpura Departments of Neuroscience and Pediatrics; Laboratory of Developmental Epilepsy; Montefiore/Einstein Epilepsy Management Center; Albert Einstein College of Medicine and Montefiore Medical Center; Bronx New York U.S.A
| | - Peter Wolf
- The Danish Epilepsy Center; Dianalund Denmark
| | - Giuliano Avanzini
- Department of Neurophysiology; IRCCS Foundation Neurological Institute “Carlo Besta”; Milan Italy
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12
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Iacobas DA, Iacobas S, Chachua T, Goletiani C, Sidyelyeva G, Velíšková J, Velíšek L. Prenatal corticosteroids modify glutamatergic and GABAergic synapse genomic fabric: insights from a novel animal model of infantile spasms. J Neuroendocrinol 2013; 25:964-79. [PMID: 23763471 PMCID: PMC3855178 DOI: 10.1111/jne.12061] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Revised: 05/25/2013] [Accepted: 06/09/2013] [Indexed: 12/16/2022]
Abstract
Prenatal exposure to corticosteroids has long-term postnatal somatic and neurodevelopmental consequences. Animal studies indicate that corticosteroid exposure-associated alterations in the nervous system include hypothalamic function. Infants with infantile spasms, a devastating epileptic syndrome of infancy with characteristic spastic seizures, chaotic irregular waves on interictal electroencephalogram (hypsarhythmia) and mental deterioration, have decreased concentrations of adrenocorticotrophic hormone (ACTH) and cortisol in cerebrospinal fluid, strongly suggesting hypothalamic dysfunction. We have exploited this feature to develop a model of human infantile spasms by using repeated prenatal exposure to betamethasone and a postnatal trigger of developmentally relevant spasms with NMDA. The spasms triggered in prenatally primed rats are more severe compared to prenatally saline-injected ones and respond to ACTH, a treatment of choice for infantile spasms in humans. Using autoradiography and immunohistochemistry, we have identified a link between the spasms in our model and the hypothalamus, especially the arcuate nucleus. Transcriptomic analysis of the arcuate nucleus after prenatal priming with betamethasone but before trigger of spasms indicates that prenatal betamethasone exposure down-regulates genes encoding several important proteins participating in glutamatergic and GABAergic transmission. Interestingly, there were significant sex-specific alterations after prenatal betamethasone in synapse-related gene expression but no such sex differences were found in prenatally saline-injected controls. A pairwise relevance analysis revealed that, although the synapse gene expression in controls was independent of sex, these genes form topologically distinct gene fabrics in males and females and these fabrics are altered by betamethasone in a sex-specific manner. These findings may explain the sex differences with respect to both normal behaviour and the occurrence and severity of infantile spasms. Changes in transcript expression and their coordination may contribute to a molecular substrate of permanent neurodevelopmental changes (including infantile spasms) found after prenatal exposure to corticosteroids.
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Affiliation(s)
- D A Iacobas
- Department of Pathology, New York Medical College, Valhalla, NY, USA
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13
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Avanzini G, Manganotti P, Meletti S, Moshé SL, Panzica F, Wolf P, Capovilla G. The system epilepsies: A pathophysiological hypothesis. Epilepsia 2012; 53:771-8. [DOI: 10.1111/j.1528-1167.2012.03462.x] [Citation(s) in RCA: 120] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Yum MS, Chachua T, Velíšková J, Velíšek L. Prenatal stress promotes development of spasms in infant rats. Epilepsia 2011; 53:e46-9. [PMID: 22191812 DOI: 10.1111/j.1528-1167.2011.03357.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
We have developed a new model of cryptogenic infantile spasms with prenatal betamethasone brain priming to increase susceptibility to development-specific spasms triggered by N-methyl-d-aspartate (NMDA). A recent clinical study linked severe prenatal stress to increased risk for development of infantile spasms. Here, we determined whether prenatal restraint stress (2 × 45 min) in rats on gestational day 15 would increase susceptibility to develop spasms on postnatal day 15. Prenatal stress significantly accelerated onset and increased number of NMDA-triggered spasms compared to handled controls. A single adrenocorticotropic hormone (ACTH or corticotropin) dose delivered acutely had no effects, whereas long-term (3 day) ACTH pretreatment significantly increased latency to onset and decreased number of spasms (an effect similar to that in the human condition). Our data support the notion that extra care should be provided during pregnancy to minimize stress.
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Affiliation(s)
- Mi-Sun Yum
- Department of Pediatrics, Asan Medical Center, Seoul, Republic of Korea
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15
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Stafstrom CE, Arnason BGW, Baram TZ, Catania A, Cortez MA, Glauser TA, Pranzatelli MR, Riikonen R, Rogawski MA, Shinnar S, Swann JW. Treatment of infantile spasms: emerging insights from clinical and basic science perspectives. J Child Neurol 2011; 26:1411-21. [PMID: 21719797 DOI: 10.1177/0883073811413129] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Infantile spasms is an epileptic encephalopathy of early infancy with specific clinical and electroencephalographic (EEG) features, limited treatment options, and a poor prognosis. Efforts to develop improved treatment options have been hindered by the lack of experimental models in which to test prospective therapies. The neuropeptide adrenocorticotropic hormone (ACTH) is effective in many cases of infantile spasms, although its mechanism(s) of action is unknown. This review describes the emerging candidate mechanisms that can underlie the therapeutic effects of ACTH in infantile spasms. These mechanisms can ultimately help to improve understanding and treatment of the disease. An overview of current treatments of infantile spasms, novel conceptual and experimental approaches to infantile spasms treatment, and a perspective on remaining clinical challenges and current research questions are presented here. This summary derives from a meeting of specialists in infantile spasms clinical care and research held in New York City on June 14, 2010.
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Affiliation(s)
- Carl E Stafstrom
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin 53705, USA.
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Riikonen RS, Jääskeläinen J, Turpeinen U. Insulin-like growth factor-1 is associated with cognitive outcome in infantile spasms. Epilepsia 2010; 51:1283-9. [DOI: 10.1111/j.1528-1167.2009.02499.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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17
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Abstract
This paper gives an account of the global evolution of (neuro-)chemistry in epileptology with an emphasis on the role of the International League Against Epilepsy (ILAE), which declared in its constitution a mission "to make the epilepsy-problem the object of special study and to make practical use of the results of such study." As Epilepsia is the scientific journal of the ILAE, the review emphasizes papers published in the journal.
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Affiliation(s)
- Clementina Van Rijn
- Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, The Netherlands
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Pranzatelli MR, Chun KY, Moxness M, Tate ED, Allison TJ. Cerebrospinal fluid ACTH and cortisol in opsoclonus-myoclonus: effect of therapy. Pediatr Neurol 2005; 33:121-6. [PMID: 16087057 DOI: 10.1016/j.pediatrneurol.2005.03.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2004] [Revised: 02/04/2005] [Accepted: 03/07/2005] [Indexed: 11/29/2022]
Abstract
Opsoclonus-myoclonus syndrome is one of a few corticotropin (ACTH)-responsive central nervous system disorders of childhood. We measured cerebrospinal fluid ACTH and cortisol in 69 children with opsoclonus-myoclonus and 25 age- and sex-matched control subjects to determine endogenous levels and look for hypothesized differential hormonal effects of ACTH and corticosteroid treatment. Cerebrospinal fluid cortisol was 10-fold higher with ACTH treatment (n = 26), but was unchanged with oral steroid treatment (n = 18) or no treatment (n = 25). It was significantly higher in children receiving daily high-dose ACTH than alternate day ACTH. In ACTH-treated children, cerebrospinal fluid and serum cortisol were highly correlated (r = 0.96, P = 0.0001), with a mean ratio of cerebrospinal fluid to serum cortisol of approximately 1:10. Cerebrospinal fluid ACTH concentration did not differ significantly between untreated opsoclonus-myoclonus and control subjects but was lower with ACTH (-29%) or steroid treatment (-36%), suggesting feedback inhibition of ACTH release. These data delineate differences in the central effects of ACTH and corticosteroid therapy, as well as between high and low ACTH doses, and support the integrity of the brain-adrenal axis in pediatric opsoclonus-myoclonus.
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Affiliation(s)
- Michael R Pranzatelli
- National Pediatric Myoclonus Center , Southern Illinois University School of Medicine, Springfield, Illinois 62794-9643, USA
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20
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Frost JD, Hrachovy RA. Pathogenesis of infantile spasms: a model based on developmental desynchronization. J Clin Neurophysiol 2005; 22:25-36. [PMID: 15689710 DOI: 10.1097/01.wnp.0000149893.12678.44] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Infantile spasms is a severe epileptic encephalopathy of infancy. The fundamental cause is unknown, although a number of predisposing conditions are recognized. In this article, the authors critically review current knowledge concerning the pathophysiologic basis of infantile spasms and propose a new model based on developmental desynchronization. It is suggested that infantile spasms may result from a particular temporal desynchronization of two or more central nervous system developmental processes, resulting in a specific disturbance of brain function. The disturbance of function is postulated to be crucially dependent on an unbalanced maturational pattern, in which certain brain systems become dysfunctional owing to divergent developmental status. An important aspect of this model is the idea that disturbed function of a specific kind can result from multiple causative factors, and so can be associated with a variety of different anatomic and/or biochemical abnormalities. Thus, this concept is compatible with the observed diversity of pathologic findings and multiplicity of etiological associations observed in infantile spasms patients.
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Affiliation(s)
- James D Frost
- Peter Kellaway Section of Neurophysiology, Department of Neurology, Baylor College of Medicine, Houston, Texas, USA.
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Abstract
The major catastrophic epileptic syndromes of childhood include infantile spasms, Lennox-Gastaut syndrome, and the progressive myoclonus epilepsies (PMEs). Although each of these syndromes manifests in an age-specific manner and is defined by distinct electroclinical features, they are all refractory to medical therapy and are invariably associated with psychomotor deficits, and in the most severe cases, either epileptic encephalopathy or progressive neurodegeneration. While much has been written about the clinical features and natural history of the catastrophic epilepsies, very little is known about the underlying pathophysiology. Progress in our understanding and treatment of these conditions has been hampered by the lack of suitable animal models in which putative mechanisms and novel targets for intervention could be rigorously studied. Nevertheless, recent clinical and basic investigations have identified certain mechanisms that may be relevant to their pathogenesis. In this review, three major hypotheses regarding the pathophysiology of infantile spasms are highlighted: the corticotropin-releasing hormone (CRH) hypothesis, the N-methyl-D-aspartate (NMDA) hypothesis, and the serotonin-kynurenine hypothesis. One or more of these mechanisms may be relevant in part to later-onset catastrophic epilepsies since infantile spasms can persist into later childhood and, like Lennox-Gastaut syndrome, well into adulthood. There is a profound need to develop more relevant animal models of the developmental encephalopathic epilepsies to truly develop better therapeutic strategies for these catastrophic disorders.
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Affiliation(s)
- Jong M Rho
- Departments of Pediatrics and Neurology, College of Medicine, University of California at Irvine Medical Center, 101 The CityDrive S., Orange, CA 92868, U.S.A.
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Hrachovy RA, Frost JD. Infantile Epileptic Encephalopathy with Hypsarrhythmia (Infantile Spasms/West Syndrome). J Clin Neurophysiol 2003; 20:408-25. [PMID: 14734931 DOI: 10.1097/00004691-200311000-00004] [Citation(s) in RCA: 131] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Infantile spasms is a unique disorder peculiar to infancy and early childhood. In this article, the clinical manifestations and electroencephalographic features of the disorder are described. The possible pathophysiologic mechanisms underlying infantile spasms and the relation of this disorder to other childhood encephalopathies are discussed. Finally, the treatment of patients with infantile spasms and their long-term outcome are briefly reviewed.
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Affiliation(s)
- Richard A Hrachovy
- Peter Kellaway Section of Neurophysiology, Department of Neurology and Division of Neuroscience, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, U.S.A.
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Abstract
Infantile spasms--seen in West's Syndrome--are often associated with cortical abnormalities. The spasms themselves, however, appear to be generated subcortically. Dr. Chugani reviews the clinical data related to the pathophysiology of infantile spasms and proposes a hypothesis which involves both cortical and subcortical mechanisms.
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Affiliation(s)
- Harry T Chugani
- Division of Pediatric Neurology and PET Center Children's Hospital of Michigan, Wayne State University, Detroit 48201, USA
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Brunson KL, Avishai-Eliner S, Baram TZ. ACTH treatment of infantile spasms: mechanisms of its effects in modulation of neuronal excitability. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2002; 49:185-97. [PMID: 12040892 PMCID: PMC3092432 DOI: 10.1016/s0074-7742(02)49013-7] [Citation(s) in RCA: 77] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The efficacy of ACTH, particularly in high doses, for rapid and complete elimination of infantile spasms (IS) has been demonstrated in prospective controlled studies. However, the mechanisms for this efficacy remain unknown. ACTH promotes the release of adrenal steroids (glucocorticoids), and most ACTH effects on the central nervous system have been attributed to activation of glucocorticoid receptors. The manner in which activation of these receptors improves IS and the basis for the enhanced therapeutic effects of ACTH--compared with steroids--for this disorder are the focus of this chapter. First, a possible "common excitatory pathway," which is consistent with the many etiologies of IS and explains the confinement of this disorder to infancy, is proposed. This notion is based on the fact that all of the entities provoking IS activate the native "stress system" of the brain. This involves increased synthesis and release of the stress-activated neuropeptide, corticotropin-releasing hormone (CRH), in limbic, seizure-prone brain regions. CRH causes severe seizures in developing experimental animals, as well as limbic neuronal injury. Steroids, given as therapy or secreted from the adrenal gland upon treatment with ACTH, decrease the production and release of CRH in certain brain regions. Second, the hypothesis that ACTH directly influences limbic neurons via the recently characterized melanocortin receptors is considered, focusing on the effects of ACTH on the expression of CRH. Experimental data showing that ACTH potently reduces CRH expression in amygdala neurons is presented. This downregulation was not abolished by experimental elimination of steroids or by blocking their receptors and was reproduced by a centrally administered ACTH fragment that does not promote steroid release. Importantly, selective blocking of melanocortin receptors prevented ACTH-induced downregulation of CRH expression, providing direct evidence for the involvement of these receptors in the mechanisms by which ACTH exerts this effect. Thus, ACTH may reduce neuronal excitability in IS by two mechanisms of action: (1) by inducing steroid release and (2) by a direct, steroid-independent action on melanocortin receptors. These combined effects may explain the robust established clinical effects of ACTH in the therapy of IS.
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Affiliation(s)
- K L Brunson
- Departments of Pediatrics, Anatomy and Neurobiology, and Neurology, University of California, Irvine, Irvine, California 92697, USA
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Brunson KL, Eghbal-Ahmadi M, Baram TZ. How do the many etiologies of West syndrome lead to excitability and seizures? The corticotropin releasing hormone excess hypothesis. Brain Dev 2001; 23:533-8. [PMID: 11701250 PMCID: PMC3107538 DOI: 10.1016/s0387-7604(01)00312-6] [Citation(s) in RCA: 77] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
West syndrome (WS) is associated with diverse etiological factors. This fact has suggested that there must be a 'final common pathway' for these etiologies, which operates on the immature brain to result in WS only at the maturational state present during infancy. Any theory for the pathogenesis of WS has to account for the unique features of this disorder. For example, how can a single entity have so many etiologies? Why does WS arise only in infancy, even when a known insult had occurred prenatally, and why does it disappear? Why is WS associated with lasting cognitive dysfunction? And, importantly, why do these seizures--unlike most others--respond to treatment by a hormone, ACTH? The established hormonal role of ACTH in human physiology is to function in the neuroendocrine cascade of the responses to all stressful stimuli, including insults to the brain. As part of this function, ACTH is known to suppress the production of corticotropin releasing hormone (CRH), a peptide that is produced in response to diverse insults and stressors.The many etiologies of WS all lead to activation of the stress response, including increased production and secretion of the stress-neurohormone CRH. CRH has been shown, in infant animal models, to cause severe seizures and death of neurons in areas involved with learning and memory. These effects of CRH are restricted to the infancy period because the receptors for CRH, which mediate its action on neurons, are most abundant during this developmental period. ACTH administration is known to inhibit production and release of CRH via a negative feedback mechanism. Therefore, the efficacy of ACTH for WS may depend on its ability to decrease the levels of the seizure-promoting stress-neurohormone CRH.This CRH-excess theory for the pathophysiology of WS is consistent not only with the profile of ACTH effects, but also with the many different 'causes' of WS, with the abnormal ACTH levels in the cerebrospinal fluid of affected infants and with the spontaneous disappearance of the seizures. Furthermore, if CRH is responsible for the seizures, and CRH-mediated neuronal injury contributes to the worsened cognitive outcome of individuals with WS, then drugs which block the actions of CRH on its receptors may provide a better therapy for this disorder.
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Affiliation(s)
- Kristen L. Brunson
- Department of Pediatrics, University of California at Irvine, Irvine, CA, 92697-4475, USA
- Department of Anatomy and Neurobiology, University of California at Irvine, Irvine, CA, 92697-4475, USA
- Department of Neurology, University of California at Irvine, Irvine, CA, 92697-4475, USA
| | - Mariam Eghbal-Ahmadi
- Department of Pediatrics, University of California at Irvine, Irvine, CA, 92697-4475, USA
- Department of Anatomy and Neurobiology, University of California at Irvine, Irvine, CA, 92697-4475, USA
- Department of Neurology, University of California at Irvine, Irvine, CA, 92697-4475, USA
| | - Tallie Z. Baram
- Department of Pediatrics, University of California at Irvine, Irvine, CA, 92697-4475, USA
- Department of Anatomy and Neurobiology, University of California at Irvine, Irvine, CA, 92697-4475, USA
- Department of Neurology, University of California at Irvine, Irvine, CA, 92697-4475, USA
- Corresponding author. Tel.: +1-949-824-1063; fax: +1-949-824-1106. (T.Z. Baram)
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Brunson KL, Khan N, Eghbal-Ahmadi M, Baram TZ. Corticotropin (ACTH) acts directly on amygdala neurons to down-regulate corticotropin-releasing hormone gene expression. Ann Neurol 2001. [DOI: 10.1002/ana.66] [Citation(s) in RCA: 91] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Baram TZ, Mitchell WG, Brunson K, Haden E. Infantile spasms: hypothesis-driven therapy and pilot human infant experiments using corticotropin-releasing hormone receptor antagonists. Dev Neurosci 1999; 21:281-9. [PMID: 10575251 PMCID: PMC3139473 DOI: 10.1159/000017407] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND RATIONALE Infantile spasms (IS) are an age-specific seizure disorder occurring in 1:2,000 infants and associated with mental retardation in approximately 90% of affected individuals. The costs of IS in terms of loss of lifetime productivity and emotional and financial burdens on families are enormous. It is generally agreed that the seizures associated with IS respond poorly to most conventional anticonvulsants. In addition, in the majority of patients, a treatment course with high-dose corticotropin (ACTH) arrests the seizures completely within days, often without recurrence on discontinuation of the hormone. However, the severe side effects of ACTH require development of better treatments for IS. Based on the rapid, all-or-none and irreversible effects of ACTH and on the established physiological actions of this hormone, it was hypothesized that ACTH eliminated IS via an established neuroendocrine feedback mechanism involving suppression of the age-specific endogenous convulsant neuropeptide corticotropin-releasing hormone (CRH). Indeed, IS typically occur in the setting of injury or insult that activate the CNS stress system, of which CRH is a major component. CRH levels may be elevated in the IS brain, and the neuropeptide is known to cause seizures in infant rats, as well as neuronal death in brain regions involved in learning and memory. If 'excess' CRH is involved in the pathogenesis of IS, then blocking CRH receptors should eliminate both seizures and the excitotoxicity of CRH-receptor-rich neurons subserving learning and memory. PATIENTS AND METHODS With FDA approval, alpha-helical CRH, a competitive antagonist of the peptide, was given as a phase I trial to 6 infants with IS who have either failed conventional treatment or who have suffered a recurrence. The study was performed at the Clinical Research Center of the Childrens Hospital, Los Angeles. The effects of alpha-helical CRH on autonomic parameters (blood pressure, pulse, temperature, respiration) were determined. In addition, immediate and short-term effects on ACTH and cortisol and on electrolytes and glucose were examined. The potential efficacy of alpha-helical CRH for IS was studied, using clinical diaries and video EEG. RESULTS alpha-Helical CRH, a peptide, did not alter autonomic or biochemical parameters. Blocking peripheral CRH receptors was evident from a transient reduction in plasma ACTH and cortisol. No evidence for the compound's penetration of the blood-brain barrier was found, since no central effects on arousal, activity or seizures and EEG patterns were observed. In addition, a striking resistance of the patients' plasma ACTH to the second infusion of alpha-helical CRH was noted. CONCLUSIONS Peptide analogs of CRH do not cross the blood-brain barrier, and their effects on peripheral stress hormones are transient and benign. Nonpeptide compouds that reach CNS receptors are required to test the hypothesis that blocking CRH receptors may ameliorate IS and its cognitive consequences.
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Affiliation(s)
- T Z Baram
- Department of Anatomy/Neurobiology, University of California at Irvine, CA 92697-4475, USA.
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28
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Abstract
Corticotrophin (adrenocorticotropic hormone, ACTH) and beta-endorphin levels of the cerebrospinal fluid (CSF) were determined in 16 infants with the West syndrome during individualized ACTH treatment. Prior to treatment, the levels of CSF ACTH were significantly higher in infants with cryptogenic spasms, normal perinatal events, or normal development than in infants with symptomatic spasms or delayed development. The CSF beta-endorphin levels did not differ among the groups. At response, the infants could be divided into three groups: (1) short-course, low-dose responders with a substantial CSF ACTH decline, (2) long-course, high-dose responders with no such effect (but with a tendency towards an upward incline), and (3) non-responders with no significant CSF ACTH changes. The changes in CSF beta-endorphin were somewhat similar to the changes in CSF ACTH, but the greater variability did not allow statistical significance.
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Affiliation(s)
- H Heiskala
- Children's Hospital, Department of Child Neurology, University of Helsinki, Finland
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Riikonen RS. How do cryptogenic and symptomatic infantile spasms differ? Review of biochemical studies in Finnish patients. J Child Neurol 1996; 11:383-8. [PMID: 8877606 DOI: 10.1177/088307389601100508] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Infants with cryptogenic infantile spasms seem to differ from those with symptomatic spasms in having a higher cerebrospinal fluid corticotropin content, different levels of corticotropin release after exogenous vasopressin, higher serum levels of progesterone, higher dehydroepiandrosterone: androstenedione ratio (during corticotropin therapy), a higher cerebrospinal fluid gamma-aminobutyric acid content, and higher cerebrospinal fluid nerve growth factor concentrations. It remains to be seen whether the biochemical differences between the two groups are specific or only happen to correlate with the early brain damage. However, these differences would explain many pathophysiologic features of infantile spasms.
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Affiliation(s)
- R S Riikonen
- Department of Child Neurology, Children's Hospital, University of Helsinki, Finland
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Baram TZ, Mitchell WG, Hanson RA, Snead OC, Horton EJ. Cerebrospinal fluid corticotropin and cortisol are reduced in infantile spasms. Pediatr Neurol 1995; 13:108-10. [PMID: 8534274 PMCID: PMC3498461 DOI: 10.1016/0887-8994(95)00121-u] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Infantile spasms respond to ACTH, and levels of the hormone in cerebrospinal fluid of untreated infants with this disorder were found to be lower than in age-matched controls. In this study we analyzed cerebrospinal fluid cortisol and ACTH using improved immunoassays in a larger cohort of infants with infantile spasms. Analysis of 20 patients and 15 age-matched controls revealed significantly lower levels of both ACTH and cortisol in the cerebrospinal fluid. These data, combined with the efficacy of ACTH and glucocorticoids for infantile spasms, support an involvement of the brain-adrenal-axis in this disorder.
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Affiliation(s)
- T Z Baram
- Department of Neurology, University of Southern California, Los Angeles, USA
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31
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Pranzatelli MR. Putative neurotransmitter abnormalities in infantile spasms: cerebrospinal fluid neurochemistry and drug effects. J Child Neurol 1994; 9:119-29. [PMID: 7911815 DOI: 10.1177/088307389400900204] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The neuropharmacologic basis of infantile spasms and the mechanism by which adrenocorticotropic hormone (ACTH) exerts its therapeutic effects are unknown. This is a critical review of cerebrospinal fluid neurotransmitters or their metabolites in infantile spasms before and during treatment with ACTH, and of clinical drug trials with drugs acting on neurotransmission. Cerebrospinal fluid studies have shown lower gamma-aminobutyric acid (GABA), ACTH, and 5-hydroxyindoleacetic acid concentrations in patients with infantile spasms compared to controls, elevated lysine and glutamate, variable or no differences in homovanillic acid, 3-methoxy-4-hydroxyphenylglycol, norepinephrine, corticotropin-releasing hormone, and beta-endorphin. Chronic treatment with ACTH in infantile spasms reduces cerebrospinal fluid GABA, beta-endorphin, and somatostatin, increases norepinephrine and tyrosine, and has variable or no effect on homovanillic acid, 3-methoxy-4-hydroxyphenylglycol, 5-hydroxyindoleacetic acid, histamine, and tryptophan. Small therapeutic trials with drugs that act through different neurotransmitters such as methysergide, alpha-methylparatyrosine, various benzodiazepine agonists, and vigabatrin lend some support to a role for GABA and monoamines in infantile spasms. These data, though promising, provide only a hint of potential neurotransmitter disturbances, and more basic and clinical data are needed.
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Affiliation(s)
- M R Pranzatelli
- Department of Neurology, George Washington University, Washington, DC
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Devinsky O, Emoto S, Nadi NS, Theodore WH. Cerebrospinal fluid levels of neuropeptides, cortisol, and amino acids in patients with epilepsy. Epilepsia 1993; 34:255-61. [PMID: 8095891 DOI: 10.1111/j.1528-1157.1993.tb02407.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
We measured lumbar cerebrospinal fluid (CSF) levels of somatostatin, cholecystokinin, neurotensin, atrial natriuretic factor, vasoactive inhibitory peptide, neuropeptide Y, adrenocorticotrophic hormone, corticotropin releasing hormone, beta-endorphin, metenkephalin, cortisol, alanine, glycine, aspartate, glutamate, taurine, and gamma-aminobutyric acid in 25 inpatients with epilepsy at known interictal and postictal times and in 11 neurologically normal volunteers. There were no significant differences between interictal or postictal complex partial seizures (CPS), postictal generalized tonic-clonic seizures (GTC), and control CSF neuropeptide, cortisol, and amino acid (AA) levels. However, there were nonsignificant trends for CSF levels of several neuropeptides to be increased after CPS and GTC as compared with interictal baseline levels. There were significant correlations between levels of certain CSF neuropeptides or (AAs) and serum antiepileptic drug (AED) levels. Several correlations were noted between CSF levels of AAs, including a correlation between the excitatory neurotransmitters aspartate and glutamate identified only after CPS.
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Affiliation(s)
- O Devinsky
- Clinical Epilepsy Section, NINDS, NIH, Bethesda, Maryland
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33
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Baram TZ. Pathophysiology of massive infantile spasms: perspective on the putative role of the brain adrenal axis. Ann Neurol 1993; 33:231-6. [PMID: 8388675 PMCID: PMC3786774 DOI: 10.1002/ana.410330302] [Citation(s) in RCA: 116] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Massive infantile spasms are an age-specific seizure syndrome of infancy. Uniquely, the spasms respond to hormonal manipulation using adrenocorticotropic hormone (ACTH) or glucocorticoids. A hypothesis explaining the efficacy of hormonal therapy, age-specificity, multiple causative factors, and spontaneous resolution of infantile spasms is presented. Corticotropin-releasing hormone (CRH), an excitant neuropeptide suppressed by ACTH/steroids, is implicated. Evidence for the age-specific convulsant properties of CRH is presented, and a putative scenario in which a stress-induced enhancement of endogenous CRH-mediated seizures is discussed. Clinical testing of the CRH-excess theory and its therapeutic implications are suggested.
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Affiliation(s)
- T Z Baram
- Department of Neurology, University of Southern California, Los Angeles
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Airaksinen E, Tuomisto L, Riikonen R. The concentrations of GABA, 5-HIAA and HVA in the cerebrospinal fluid of children with infantile spasms and the effects of ACTH treatment. Brain Dev 1992; 14:386-90. [PMID: 1283505 DOI: 10.1016/s0387-7604(12)80345-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Children with infantile spasms (IS) are generally treated with ACTH although little is known of the biochemical basis of the symptoms and the mechanism of this therapy. We have measured the concentrations of gamma-aminobutyric acid (GABA), homovanillic acid (HVA) and 5-hydroxyindoleacetic acid (5-HIAA) in the CSF of IS children, followed the effect of ACTH treatment on these parameters and correlated CSF GABA values with the cause of IS, cranial CT findings and antiepileptic treatment. While significant differences in GABA concentrations were found between the children with IS and those with febrile seizures or nonconvulsive symptoms, these could be accounted for by age, not the disease present. The CSF GABA level was highest in the IS children with normal CT, cryptogenic cause and no antiepileptic treatment, and lowest in those with abnormal CT, symptomatic cause and antiepileptic treatment. The basal level of CSF 5-HIAA in the IS children was higher than that in the nonconvulsive children, but HVA levels did not differ. ACTH therapy did not change the CSF levels of GABA, 5-HIAA and HVA significantly.
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Affiliation(s)
- E Airaksinen
- Department of Paediatrics, University of Kuopio, Finland
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35
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Baram TZ, Mitchell WG, Snead OC, Horton EJ, Saito M. Brain-adrenal axis hormones are altered in the CSF of infants with massive infantile spasms. Neurology 1992; 42:1171-5. [PMID: 1318521 PMCID: PMC3139472 DOI: 10.1212/wnl.42.6.1171] [Citation(s) in RCA: 69] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Massive infantile spasms (MIS), a seizure disorder unique to infants, is considered an age-dependent response of the immature brain to various insults and stressors. The seizures improve with ACTH and glucocorticoids, both major components of the brain-adrenal axis. We hypothesized that CNS levels of these hormones are abnormal in infants with MIS and studied CSF from 14 infants with MIS and 13 age-matched controls by analysis for corticotropin-releasing hormone (CRH), ACTH, cortisol, and interleukin-1-beta. ACTH levels in CSF of patients were significantly lower than those of controls, but differences in cortisol levels between patients and controls were not statistically significant. CRH levels in both groups were similar and fluctuated diurnally. These results indicate an alteration of specific CNS components of the brain-adrenal axis in MIS.
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Affiliation(s)
- T Z Baram
- Department of Neurology, University of Southern California, Los Angeles
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36
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Holmes GL. Effect of non-sex hormones on neuronal excitability, seizures, and the electroencephalogram. Epilepsia 1991; 32 Suppl 6:S11-8. [PMID: 1659981 DOI: 10.1111/j.1528-1157.1991.tb05886.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Several of the non-sex hormones have been found to be useful in the treatment of seizures. These hormones have an effect on seizures, and seizures have an effect on these hormones. Adrenocorticotropic hormone (ACTH) and corticosteroid drugs have been found to be useful in the treatment of infantile spasms and other seizure disorders. Unfortunately, there is no clear consensus regarding superiority of ACTH versus prednisone in regard to efficacy and long-term benefits, dosage, or duration of treatment. There is also considerable debate regarding reasons why ACTH and prednisone are useful in infantile spasms, their mechanism of action, and their long-term effects on brain development. Thyrotropin-releasing hormone also has been used in the treatment of infantile spasms and other seizure types in children, with modest success. As with ACTH and prednisone, the mechanisms of action remain unclear.
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Affiliation(s)
- G L Holmes
- Department of Neurology, Harvard Medical School, Children's Hospital, Boston, Massachusetts 02115
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37
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Abstract
Cerebrospinal fluid (CSF) from 7 patients with infantile spasms (mean age: 6.7 months) was collected before and after treatment with adrenocorticotropic hormone (ACTH). The concentration of neurotransmitter metabolites was analyzed using high-performance liquid chromatography and compared to the metabolite concentration in the CSF from 7 age-matched controls (mean age: 6.1 months). Pretreatment levels of CSF 5-hydroxyindoleacetic acid (5-HIAA), homovanillic acid, 3-methoxy-4-hydroxyphenyl glycol (MHPG), and kynurenine were significantly lower in infantile spasm patients compared to controls. Following treatment, marked increases in 5-HIAA and decreases in kynurenine levels were observed in the CSF of the 5 infants whose seizures were eliminated or reduced by ACTH. In the 2 nonresponders 5-HIAA levels decreased. The level of MHPG was reduced slightly in 5 infants, including the 2 nonresponders, and was increased in 2 responders. CSF homovanillic acid levels increased in 4 infantile spasm infants and decreased in 3 following ACTH. These data demonstrate that the presence of seizures in infantile spasms is associated with a significant decrease in serotonergic activity and that elimination of seizures by ACTH is accompanied by increased serotonin turnover. The simultaneous increase of 5-HIAA and decrease of kynurenine, an alternate metabolite of tryptophan, suggests an underlying disturbance of tryptophan metabolism in infantile spasms. The possibility that elimination of seizures by ACTH may be related to decreased production of certain kynurenine metabolites, particularly quinolinic acid, is discussed.
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Affiliation(s)
- P J Langlais
- Department of Psychology, San Diego State University, CA 92182
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Iannetti P, Fabbri A, Meloni G, Moleti ML, Ulisse S, Mandelli F, Isidori A, Imperato C. Immunoreactive beta-endorphin levels in cerebrospinal fluid of children with acute lymphoblastic leukemia: relationship with glucocorticoid therapy and neurological complications. J Endocrinol Invest 1989; 12:623-9. [PMID: 2531180 DOI: 10.1007/bf03350022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Neurological disorders, such as seizures, are not infrequently associated with anti-leukemic therapy. It has been hypothesized that a disrupted peptidergic transmission between neurons could be the cellular basis of the neurological dysfunction. Since endogenous opioids have been recently found to alter neuronal function and possess anticonvulsant properties, the cerebrospinal fluid (CSF) immunoreactive beta-endorphin levels in children with Acute Lymphoblastic Leukemia (ALL) during chemotherapy and cranial irradiation have been studied. Twenty-seven children, 2 at low, 20 at medium and 5 with high risk ALL, undergoing prophylactic treatment for meningeal leukemia, entered the study. Sequential lumbar punctures with introduction of MTX combined with oral prednisone therapy were performed; each lumbar puncture sample was collected and assayed for immunoreactive beta-endorphin. All the patients studied showed a biphasic profile of the peptide with the minimum levels reached during the induction (days 14-28) and the maximum levels detected at the end of the intensification chemotherapy (days 49-55). In the 3 groups the beta-endorphin decrease corresponded to the period of prednisone therapy; the increase was concomitant with the suspension of oral glucocorticoids. 3 patients showed tonic-clonic seizures which coincided with the lowest cerebrospinal fluid beta-endorphin levels and, in the follow-up, 13 out of 27 patients displayed EEG abnormalities. From these findings a relationship between cerebrospinal fluid beta-endorphin concentrations and neuronal excitability in patients with ALL can be suggested. It is also evidenced that oral glucocorticoid therapy has profound inhibitory effects on central beta-endorphin levels.
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Affiliation(s)
- P Iannetti
- Istituto di Clinica Pediatrica, Università di Roma, La Sapienza, Italy
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Genazzani AR, Zappella M, Nalin A, Hayek Y, Facchinetti F. Reduced cerebrospinal fluid B-endorphin levels in Rett syndrome. Childs Nerv Syst 1989; 5:111-3. [PMID: 2544265 DOI: 10.1007/bf00571121] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Cerebrospinal fluid (CSF) levels of B-endorphin (B-EP), B-lipotropin (B-LPH) and ACTH were measured in nine girls with Rett syndrome with features of autistic behavior (3.7-12.1 years of age) and in ten children with chronic leukemia (control group). The peptides were measured by radioimmunoassay, either directly in the sample (ACTH) or after Sephadex G-75 column chromatography, in order to eliminate interfering substances (B-LPH and B-EP). The CSF B-EP patient levels (20.8 +/- 13.1 fmol/ml, means +/- SD) were significantly lower than in age-matched controls (69.1 +/- 32.6, P less than 0.01), whereas the B-LPH and ACTH levels were in the control range. No correlations were found between the clinical findings and CSF neuropeptide concentrations. These data demonstrate a decrease in central opiate activity in girls with Rett syndrome.
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Affiliation(s)
- A R Genazzani
- Department of Obstetrics and Gynecology, University of Modena, Italy
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Pranzatelli MR, Eng B. Chronic ACTH treatment: influence on 5-HT2 receptors and behavioral supersensitivity induced by 5,7-dihydroxytryptamine lesions. Peptides 1989; 10:5-8. [PMID: 2546129 DOI: 10.1016/0196-9781(89)90066-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
The capacity of the serotonin (5-HT) precursor 5-HIP to induce the ACTH-responsive myoclonic-convulsive disorder infantile spasms in patients with Down's syndrome has been cited as evidence for altered serotonergic neurotransmission in infantile spasms. Since there is no animal model of infantile spasms, the suitability of behavioral supersensitivity (myoclonus) evoked by 5-HTP in rats with 5,7-dihydroxytryptamine (DHT) lesions as a model was tested by determining the effect of chronic treatment with ACTH (40 IU/kg) on 5-HTP-evoked myoclonus. In rats treated with DHT as adults, ACTH administration did not alter the "serotonergic behaviors," such as myoclonus, induced by 30 mg/kg 5-hydroxytryptophan (5-HTP), but induced a small significant increase in Bmax of neocortical 5-HT2 sites of the DHT group, with no change in rats without lesions. In rats treated with DHT as neonates, there was also no significant difference in behaviors evoked by several doses of 5-HTP. These data suggest that ACTH minimally modifies the effects on 5-HT receptors of DHT lesions, but the intracisternal DHT model is not a suitable model for infantile spasms because chronic ACTH was not antimyoclonic.
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Affiliation(s)
- M R Pranzatelli
- Department of Neurology, College of Physicians and Surgeons, Columbia University New York, NY 10032
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Nalin A, Petraglia F, Genazzani AR, Frigieri G, Facchinetti F. Lack of clinical-EEG effects of naloxone injection on infantile spasms. Childs Nerv Syst 1988; 4:365-6. [PMID: 3245947 DOI: 10.1007/bf00270612] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
In a previous study we found depressed ACTH and normal beta-endorphin values in the cerebrospinal fluid of patients with West's syndrome, whereas normal peptide levels were present in infants with secondary Infantile spasms. This prompted us to study the effects of naloxone administration in children with West's syndrome. After informed consent was obtained from the parents, the effects of naloxone administration on clinical and EEG findings were evaluated in five infants 5-9 months old (3 males, 2 females) with cryptogenic infantile spasms and hypsarrhythmia. The infants were studied at the onset of symptomatology before therapy. An average of 5-10 groups of spasms were present per day. Naloxone (12 micrograms/kg body weight) was administered as an intravenous bolus in two cases, as a slow venous drip in another two cases, and intramuscularly in the last case. EEG and polygraphic monitoring were performed for 2 h. Naloxone did not induce any acute behavioral changes and the number of seizures remained unchanged after treatment. These data reject the possibility that endogenous opioids tonically modulate infantile spasms. Further studies are required to ascertain the involvement of POMC peptides in West's syndrome.
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Affiliation(s)
- A Nalin
- Department of Pediatrics, University of Modena, Italy
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42
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Abstract
To determine if the mechanism of action of clinical and investigational antiepileptic and antimyoclonic drugs or neuropeptides involves direct actions at serotonin (5-HT) receptors, the activity of various compounds in vitro at 5-HT1 (with subtypes) and 5-HT2 sites was measured in adult rat brainstem, spinal cord, and neocortex. Adrenocorticotropic hormone (ACTH1-39) noncompetitively inhibited specific binding at 5-HT1, 5-HT1A, and 5-HT2 sites in brainstem and neocortex [concentrations required to displace 50% of ligand binding (IC50S) 4-8 X 10(-5) M]. ACTH1-24, ACTH1-17, and ACTH4-10 were sequentially less active, and ACTH34-39 and corticosterone were inactive. D-Ala2, Leu5-enkephalinamide, but not D-Ala2, Met5-enkephalinamide, also displaced spinal and neocortical 5-HT2 sites (IC50 6 X 10(-5) M). Piracetam, glycine, and the clinical antiepileptics valproate, phenacemide, phenytoin, carbamazepine, phenobarbital, diazepam, clonazepam, nitrazepam, and ethosuximide did not displace serotonergic radioligands, but melacimide showed some activity at 5-HT1 sites (IC50 7-9 X 10(-5) M). Anticonvulsant inactivity at 5-HT receptors in vitro correlates with the lack of antimyoclonic activity in 5-HT lesion myoclonic models but not with antimyoclonic efficacy in humans. These data indicate that acute effects of these anticonvulsants cannot be attributed to direct action at the 5-HT receptor recognition site in the rat. In contrast, ACTH showed mild in vitro displacement and regional specificity but only at micromolar concentrations.
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Affiliation(s)
- M R Pranzatelli
- Department of Neurology, College of Physicians and Surgeons of Columbia University, New York, NY 10032
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Riikonen R, Santavuori P, Meretoja O, Sainio K, Neuvonen PJ, Tokola RA. Can barbiturate anaesthesia cure infantile spasms? Brain Dev 1988; 10:300-4. [PMID: 3239696 DOI: 10.1016/s0387-7604(88)80060-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Five patients with infantile spasms and hypsarrhythmia and one with Lennox-Gastaut syndrome were treated with brief thiopentone anaesthesia as the primary treatment of infantile spasms. Thiopentone (30 mg/kg) was given intravenously and burst suppression was reached in EEG in three patients by this dose. The results were disappointing. In three patients a transient beneficial effect on spasms and hypsarrhythmia was seen, but all patients relapsed. Three other patients had anaesthesia for surgery. The spasms ceased and hypsarrhythmia disappeared dramatically, and the effect was permanent. The possible mechanisms of the therapeutic effect are discussed. It seems advisable to give anaesthesia and surgery prior to steroid treatment in any case where the both are needed.
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Affiliation(s)
- R Riikonen
- Children's Hospital, University of Helsinki, Finland
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