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Jindal M, Neligan A, Rajakulendran S. Early and established status epilepticus: The impact of timing of intervention, treatment escalation and dosing on outcome. Seizure 2023; 111:98-102. [PMID: 37556986 DOI: 10.1016/j.seizure.2023.07.022] [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: 05/28/2023] [Revised: 07/23/2023] [Accepted: 07/28/2023] [Indexed: 08/11/2023] Open
Abstract
OBJECTIVE We investigated the management and outcome of early and established status epilepticus including timing, dosing and selection of benzodiazepines along with the timing and efficacy of second line treatments. METHODS Retrospective single tertiary centre observational cohort study to identify all cases of SE between January 2019 and February 2022. RESULTS 252 cases were identified. Seizures terminated spontaneously in 136 (54%) cases. 116 (46%) were given benzodiazepines, of which 29 (25%) were given at least one benzodiazepine by family/carers, and 72 (62.1%) received benzodiazepines by ambulance services. Benzodiazepines terminated seizures in 83 (71.6%) cases. The commonest benzodiazepine used was buccal midazolam (35.5%). Median time to first benzodiazepine was 14.5 (6-27) minutes. There was a positive correlation between time to first benzodiazepine and time to seizure cessation, progression to second- and third-line treatment, and respiratory complications (p<0.05). 73 (62.9%) cases received a correct benzodiazepine dose. Benzodiazepine underdosing was associated with longer seizure duration (p<0.05). 33 (28.4%) cases progressed to second-line treatment where mean time to treatment was 59.4 min (±32.3 min). The commonest second-line treatment was Levetiracetam (53.8%), followed by Phenytoin (43.6%) with SE termination in 57.5% cases. 14 (12.1%) cases progressed to third-line treatment; mean time to treatment was 60.6 min (±22.24 min). Respiratory complications occurred in 17 (6.75%) cases; none due to benzodiazepines. There were two deaths in refractory SE. CONCLUSION Early administration of benzodiazepines and optimal dosing is associated with a higher rate of SE termination. Levetiracetam was the most commonly used second line treatment.
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Affiliation(s)
- Malaika Jindal
- UCL Queen Square Institute of Neurology, London, United Kingdom
| | - Aidan Neligan
- UCL Queen Square Institute of Neurology, London, United Kingdom; Homerton University Hospital NHS Foundation Trust, London, United Kingdom
| | - Sanjeev Rajakulendran
- UCL Queen Square Institute of Neurology, London, United Kingdom; National Hospital for Neurology & Neurosurgery, London WC1N 3BG United Kingdom; North Middlesex University Hospital, London, United Kingdom.
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Corrales-Hernández MG, Villarroel-Hagemann SK, Mendoza-Rodelo IE, Palacios-Sánchez L, Gaviria-Carrillo M, Buitrago-Ricaurte N, Espinosa-Lugo S, Calderon-Ospina CA, Rodríguez-Quintana JH. Development of Antiepileptic Drugs throughout History: From Serendipity to Artificial Intelligence. Biomedicines 2023; 11:1632. [PMID: 37371727 DOI: 10.3390/biomedicines11061632] [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: 05/07/2023] [Revised: 05/24/2023] [Accepted: 05/31/2023] [Indexed: 06/29/2023] Open
Abstract
This article provides a comprehensive narrative review of the history of antiepileptic drugs (AEDs) and their development over time. Firstly, it explores the significant role of serendipity in the discovery of essential AEDs that continue to be used today, such as phenobarbital and valproic acid. Subsequently, it delves into the historical progression of crucial preclinical models employed in the development of novel AEDs, including the maximal electroshock stimulation test, pentylenetetrazol-induced test, kindling models, and other animal models. Moving forward, a concise overview of the clinical advancement of major AEDs is provided, highlighting the initial milestones and the subsequent refinement of this process in recent decades, in line with the emergence of evidence-based medicine and the implementation of increasingly rigorous controlled clinical trials. Lastly, the article explores the contributions of artificial intelligence, while also offering recommendations and discussing future perspectives for the development of new AEDs.
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Affiliation(s)
- María Gabriela Corrales-Hernández
- Pharmacology Unit, Department of Biomedical Sciences, School of Medicine and Health Sciences, Universidad del Rosario, Bogotá 111221, Colombia
| | - Sebastián Kurt Villarroel-Hagemann
- Pharmacology Unit, Department of Biomedical Sciences, School of Medicine and Health Sciences, Universidad del Rosario, Bogotá 111221, Colombia
| | | | - Leonardo Palacios-Sánchez
- Neuroscience Research Group (NeURos), NeuroVitae Center for Neuroscience, School of Medicine and Health Sciences, Universidad del Rosario, Bogotá 111221, Colombia
| | - Mariana Gaviria-Carrillo
- Neuroscience Research Group (NeURos), NeuroVitae Center for Neuroscience, School of Medicine and Health Sciences, Universidad del Rosario, Bogotá 111221, Colombia
| | | | - Santiago Espinosa-Lugo
- Pharmacology Unit, Department of Biomedical Sciences, School of Medicine and Health Sciences, Universidad del Rosario, Bogotá 111221, Colombia
| | - Carlos-Alberto Calderon-Ospina
- Pharmacology Unit, Department of Biomedical Sciences, School of Medicine and Health Sciences, Universidad del Rosario, Bogotá 111221, Colombia
- Research Group in Applied Biomedical Sciences (UR Biomed), School of Medicine and Health Sciences, Universidad del Rosario, Bogotá 111221, Colombia
| | - Jesús Hernán Rodríguez-Quintana
- Fundacion CardioInfantil-Instituto de Cardiologia, Calle 163a # 13B-60, Bogotá 111156, Colombia
- Hospital Universitario Mayor Mederi, Calle 24 # 29-45, Bogotá 111411, Colombia
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Neligan A, Rajakulendran S. Has the mortality of status epilepticus changed over the past few decades? Epilepsy Behav 2023; 138:109050. [PMID: 36549100 DOI: 10.1016/j.yebeh.2022.109050] [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: 10/10/2022] [Revised: 12/02/2022] [Accepted: 12/02/2022] [Indexed: 12/24/2022]
Abstract
Earlier and more aggressive treatment of status epilepticus has long been established orthodoxy. In addition to increasing therapeutic options, it is of critical importance to understand whether or not this has translated into improved prognosis. In this review, we examine the evidence as to whether the mortality of convulsive status epilepticus changed over the past few decades. In particular, we discuss a recent systematic review and meta-analysis examining this question and its implications. We discuss potential reasons why there is no evidence of improved prognosis in terms of mortality and ways in which this may be addressed. Finally, we advocate the urgent need for accurate data on functional outcomes in non-fatal cases of status epilepticus. This paper was presented at the 8th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures held in September 2022.
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Affiliation(s)
- A Neligan
- Homerton University Hospital NHS Foundation Trust, Homerton Row, London E9 6SR, UK; UCL Queen Square Institute of Neurology, Queen Square, London WC1N 3BG, UK.
| | - Sanjeev Rajakulendran
- UCL Queen Square Institute of Neurology, Queen Square, London WC1N 3BG, UK; National Hospital for Neurology & Neurosurgery, Queen Square, London WC1N 3BG, UK; North Middlesex University Hospital, Sterling Way, London N18 1QX, UK
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Wijdicks EFM. Recognized, Brushed Aside, Reexamined: A Chronicled Discovery of Systemic Illness in Status Epilepticus. Neurocrit Care 2022:10.1007/s12028-022-01625-w. [PMID: 36396742 DOI: 10.1007/s12028-022-01625-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 09/30/2022] [Indexed: 11/18/2022]
Affiliation(s)
- Eelco F M Wijdicks
- Neurocritical Care Services, Saint Marys Hospital Mayo Clinic, Rochester, MN, USA.
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5
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Singh G, Chiodini P, Sander JW. Mortality associated with cysticercosis in a historical cohort from Britain. ARQUIVOS DE NEURO-PSIQUIATRIA 2022; 80:248-254. [DOI: 10.1590/0004-282x-anp-2021-0001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 05/13/2021] [Indexed: 11/22/2022]
Abstract
ABSTRACT Background: The burden of premature mortality associated with human cysticercosis is largely ignored mainly due to poor record-keeping in Taenia solium endemic regions. Objective: To document mortality and survival characteristics of an historical cohort with cysticercosis. Methods: The years of onset of symptoms and death untill 1957 were extracted from published reports of a British military cohort (n=450) examined in London in the early twentieth century. Data were entered into a Kaplan Meier survival analysis with the presence (or absence) of clinical manifestations as independent variables, which were then fitted into a Cox proportional hazards model to determine their significance. Results: Cysticercosis was responsible for 24 (52.2%) of 46 deaths in the first 15 years of follow-up in comparison to 7 (19.4%) of 36 deaths in the 20-40 years of follow-up period. In the univariate and Cox analyses, intracranial hypertension (hazard ratio [HR]: 8.26; CI: 4.71, 14.49), ocular cysticercosis (HR: 6.60; CI: 3.04, 14.33), and mental disorder (HR: 3.98; CI: 2.22, 7.13) but not epilepsy (HR: 0.66; CI: 0.20, 2.18) were associated with mortality. Over half of all deaths in the first 15 years of follow-up were attributed to cysticercosis. Conclusions: Several deaths occurred early after acquiring cysticercotic infection. Intracranial hypertension, ocular cysticercosis, and mental disorder but not epilepsy were predictors of mortality in this cohort.
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Affiliation(s)
- Gagandeep Singh
- Dayanand Medical College, India; University College London, UK
| | | | - Josemir W. Sander
- University College London, UK; Chalfont Centre for Epilepsy, United Kingdom; Stichting Epilepsie Instellingen Nederland, Netherlands
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Lee KL, Abiraman K, Lucaj C, Ollerhead TA, Brandon NJ, Deeb TZ, Maguire J, Moss SJ. Inhibiting with-no-lysine kinases enhances K+/Cl- cotransporter 2 activity and limits status epilepticus. Brain 2021; 145:950-963. [PMID: 34528073 DOI: 10.1093/brain/awab343] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 06/25/2021] [Accepted: 08/14/2021] [Indexed: 11/12/2022] Open
Abstract
First-in-line benzodiazepine treatment fails to terminate seizures in about 30% of epilepsy patients, highlighting a need for novel antiseizure strategies. Impaired GABAergic inhibition is key to the development of such benzodiazepine-resistant seizures, as well as the pathophysiology of status epilepticus (SE). It is emerging that reduced or impaired neuronal K+/Cl- cotransporter 2 (KCC2) activity contributes to deficits in γ-aminobutyric acid (GABA)-mediated inhibition and increased seizure vulnerability. The with-no-lysine kinase (WNK)-STE20/SPS1-related proline/alanine-rich (SPAK) kinase signaling pathway inhibits neuronal KCC2 via KCC2-T1007 phosphorylation. A selective WNK kinase inhibitor, WNK463, was recently synthesized by Novartis. Exploiting WNK463, we test the hypothesis that pharmacological WNK inhibition will enhance KCC2 activity, increase the efficacy of GABAergic inhibition, and thereby limit seizure activity in animal models. Immunoprecipitation and Western blot analysis were used to examine WNK463's effects on KCC2-T1007 phosphorylation, in vitro and in vivo. A thallium (Tl+) uptake assay was used in human embryonic kidney (HEK-293) cells expressing KCC2 to test WNK463's effects on KCC2-mediated Tl+ transport. Gramicidin-perforated- and whole-cell patch-clamp recordings in cortical rat neurons were used to examine WNK463's effects on KCC2-mediated Cl- transport. In mouse brain slices (entorhinal cortex), field recordings were utilized to examine WNK463's effects on 4-aminopyridine-induced seizure activity. Last, WNK463 was directly deliver to the mouse hippocampus in vivo and tested in a kainic acid model of diazepam-resistant SE. WNK463 significantly reduces KCC2-T1007 phosphorylation in vitro and in vivo (mice). In human embryonic kidney 293 (HEK-293) cells expressing KCC2, WNK463 greatly enhanced the rates Tl+ transport. However, the drug did not enhance Tl+ transport in cells expressing a KCC2-phospho null T1007 mutant. In cultured rat neurons, WNK463 rapidly reduced intracellular Cl- and consequently hyperpolarized the Cl- reversal potential (EGABA). In mature neurons that were artificially loaded with 30 mM Cl-, WNK463 significantly enhanced KCC2-mediated Cl- export and hyperpolarized EGABA. In a 4-aminopyridine model of acute seizures, WNK463 reduced the frequency and number of seizure-like events (SLEs). Finally, in an in vivo kainic acid (KA) model of diazepam-resistant SE, WNK463 slowed the onset and reduced the severity of KA-induced status epilepticus. Last, WNK463 prevented the development of pharmaco-resistance to diazepam in drug-treated mice. Our findings demonstrate that acute WNK463 treatment potentiates KCC2 activity in neurons and limits seizure burden in two well-established models of seizures and epilepsy. Our work suggests that agents which act to increase KCC2 activity may be useful adjunct therapeutics to alleviate diazepam-resistant SE.
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Affiliation(s)
- Kathryn L Lee
- Department of Neuroscience, Tufts University School of Medicine, Boston, MA, USA 02111
| | - Krithika Abiraman
- Department of Neuroscience, Tufts University School of Medicine, Boston, MA, USA 02111
| | - Christopher Lucaj
- Department of Neuroscience, Tufts University School of Medicine, Boston, MA, USA 02111.,AstraZeneca-Tufts Laboratory of Basic and Translational Neuroscience, Tufts University School of Medicine, Boston, MA, USA 02111
| | - Thomas A Ollerhead
- Department of Neuroscience, Tufts University School of Medicine, Boston, MA, USA 02111
| | - Nicholas J Brandon
- Neuroscience, BioPharmaceuticals R&D, AstraZeneca, Boston, MA, USA 02451
| | - Tarek Z Deeb
- Department of Neuroscience, Tufts University School of Medicine, Boston, MA, USA 02111.,AstraZeneca-Tufts Laboratory of Basic and Translational Neuroscience, Tufts University School of Medicine, Boston, MA, USA 02111
| | - Jamie Maguire
- Department of Neuroscience, Tufts University School of Medicine, Boston, MA, USA 02111
| | - Stephen J Moss
- Department of Neuroscience, Tufts University School of Medicine, Boston, MA, USA 02111.,AstraZeneca-Tufts Laboratory of Basic and Translational Neuroscience, Tufts University School of Medicine, Boston, MA, USA 02111.,Department of Neuroscience, Physiology and Pharmacology, University College London, WC16BT, UK
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Mitchell C, Chatterton Dickson L, Ramsay A, Mesalles-Naranjo O, Leonard P, Brand C, Mclellan A, Shetty J. Epidemiology and outcome of status epilepticus in children: a Scottish population cohort study. Dev Med Child Neurol 2021; 63:1075-1084. [PMID: 33929072 DOI: 10.1111/dmcn.14900] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/23/2021] [Indexed: 12/25/2022]
Abstract
AIM To describe the epidemiology and outcomes of convulsive status epilepticus (CSE) since the introduction of buccal midazolam and the change in International League Against Epilepsy definition of CSE to include seizures of at least 5 minutes. METHOD All children presenting to paediatric emergency departments with CSE (2011-2017) in Lothian, Scotland, were identified. Data, collated from electronic health records, included patient demographics, clinical characteristics, acute seizure management, and adverse outcomes (for example admission to intensive care). RESULTS Six hundred and sixty-five children were admitted with CSE who had 1228 seizure episodes (381 males, 284 females; median age 3y 8mo; age range 0-20y 11mo). CSE accounted for 0.38% (95% confidence interval 0.34-0.42) of annual attendances at emergency departments. Annual prevalence was 0.8 per 1000 children aged 0 to 14 years. Thirty-four per cent of children had recurrent CSE. Sixty-nine per cent of seizures lasted 5 to 29 minutes (median duration 10min). Buccal midazolam was given to 30% of children with CSE and had no effect on need for ventilatory support. Seventy per cent of children with CSE required hospital admission. Four per cent resulted in adverse outcome and there were only two deaths. Recurrent seizures, longer duration, and unprovoked seizures increased the odds of adverse outcome. INTERPRETATION Adverse outcomes have decreased and the use of buccal midazolam is promising. Identifying high-risk groups provides an opportunity for early intervention. These data form the basis for an extensive evaluation of acute seizure management and monitoring long-term outcomes. What this paper adds The annual prevalence of convulsive status epilepticus in Lothian, Scotland, was 0.8 per 1000 children. There was a decrease in case-fatality proportion from 3-9% to 0.2%. Use of buccal midazolam has increased, with no increase in adverse outcomes.
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Affiliation(s)
- Clodagh Mitchell
- University of Edinburgh Medical School, Edinburgh, UK.,The Newcastle upon Tyne Hospitals NHS Foundation Trust, Freeman Hospital, Newcastle upon Tyne, UK
| | | | - Ailidh Ramsay
- University of Edinburgh Medical School, Edinburgh, UK
| | | | - Paul Leonard
- Royal Hospital for Sick Children, NHS Lothian, Edinburgh, UK
| | - Celia Brand
- Royal Hospital for Sick Children, NHS Lothian, Edinburgh, UK
| | - Ailsa Mclellan
- Royal Hospital for Sick Children, NHS Lothian, Edinburgh, UK
| | - Jay Shetty
- University of Edinburgh Medical School, Edinburgh, UK.,Royal Hospital for Sick Children, NHS Lothian, Edinburgh, UK
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Gross C. Sustainable Brain Activity and no End in Sight—What’s in It for Status Epilepticus? Epilepsy Curr 2020; 20:113-115. [PMID: 32313508 PMCID: PMC7160873 DOI: 10.1177/1535759720901509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
α-Amino-3-Hydroxy-5-Methyl-4-Isoxazolepropionic Acid Receptor Plasticity Sustains Severe, Fatal Status Epilepticus. Adotevi N, Lewczuk E, Sun H, Joshi S, Dabrowska N, Shan S, Williamson J, Kapur J. Ann Neurol. 2020;87(1):84-96. doi: 10.1002/ana.25635. Epub 2019 Nov 20. OBJECTIVE: Generalized convulsive status epilepticus is associated with high mortality. We tested whether α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptor plasticity plays a role in sustaining seizures, seizure generalization, and mortality observed during focal onset status epilepticus. We also determined whether modified AMPA receptors generated during status epilepticus could be targeted with a drug. METHODS: Electrically induced status epilepticus was characterized by electroencephalogram and behavior in GluA1 knockout mice and in transgenic mice with selective knockdown of the GluA1 subunit in hippocampal principal neurons. Excitatory and inhibitory synaptic transmission in CA1 neurons was studied using patch clamp electrophysiology. The dose-response of N, N, H,-trimethyl-5-([tricyclo(3.3.1.13,7)dec-1-ylmethyl]amino)-1-pentanaminiumbromide hydrobromide (IEM-1460), a calcium-permeable AMPA receptor antagonist, was determined. RESULTS: Global removal of the GluA1 subunit did not affect seizure susceptibility; however, it reduced susceptibility to status epilepticus. GluA1 subunit knockout also reduced mortality, severity, and duration of status epilepticus. Absence of the GluA1 subunit prevented enhancement of glutamatergic synaptic transmission associated with status epilepticus; however, γ-aminobutyric acidergic synaptic inhibition was compromised. Selective removal of the GluA1 subunit from hippocampal principal neurons also reduced mortality, severity, and duration of status epilepticus. IEM-1460 rapidly terminated status epilepticus in a dose-dependent manner. INTERPRETATION: α-Amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor plasticity mediated by the GluA1 subunit plays a critical role in sustaining and amplifying seizure activity and contributes to mortality. Calcium-permeable AMPA receptors modified during status epilepticus can be inhibited to terminate status epilepticus. Excitatory GABAergic Signalling Is Associated With Benzodiazepine Resistance in Status Epilepticus Burman RJ, Selfe JS, Lee JH, van den Berg M, Calin A, Codadu NK, Wright R, Newey SE, Parrish RR, Katz AA, Wilmshurst JM, Akerman CJ, Trevelyan AJ, Raimondo JV. Brain. 2019;142(11):3482-3501. doi:10.1093/brain/awz283. Status epilepticus is defined as a state of unrelenting seizure activity. Generalized convulsive status epilepticus is associated with a rapidly rising mortality rate, and thus constitutes a medical emergency. Benzodiazepines, which act as positive modulators of chloride (Cl−) permeable GABAA receptors, are indicated as first-line treatment, but this is ineffective in many cases. We found that 48% of children presenting with status epilepticus were unresponsive to benzodiazepine treatment, and critically, that the duration of status epilepticus at the time of treatment is an important predictor of nonresponsiveness. We therefore investigated the cellular mechanisms that underlie acquired benzodiazepine resistance, using rodent organotypic and acute brain slices. Removing Mg2+ ions leads to an evolving pattern of epileptiform activity, and eventually to a persistent state of repetitive discharges that strongly resembles clinical electroencephalogram recordings of status epilepticus. We found that diazepam loses its antiseizure efficacy and conversely exacerbates epileptiform activity during this stage of status epilepticus-like activity. Interestingly, a low concentration of the barbiturate phenobarbital had a similar exacerbating effect on status epilepticus-like activity, while a high concentration of phenobarbital was effective at reducing or preventing epileptiform discharges. We then show that the persistent status epilepticus-like activity is associated with a reduction in GABAA receptor conductance and Cl− extrusion capability. We explored the effect on intraneuronal Cl− using both gramicidin, perforated-patch clamp recordings and Cl− imaging. This showed that during status epilepticus-like activity, reduced Cl− extrusion capacity was further exacerbated by activity-dependent Cl− loading, resulting in a persistently high intraneuronal Cl−. Consistent with these results, we found that optogenetic stimulation of GABAergic interneurons in the status epilepticus-like state, actually enhanced epileptiform activity in a GABAAR dependent manner. Together our findings describe a novel potential mechanism underlying benzodiazepine-resistant status epilepticus, with relevance to how this life-threatening condition should be managed in the clinic.
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Brigo F, Lattanzi S, Trinka E, Nardone R, Bragazzi NL, Ruggieri M, Vecchio I, Martini M. 'Infantile convulsions' in the early nineteenth century. Abnormal brain blood flow and leeches, teething and gums' scarification and food and purgatives: the historical contribution of John Clarke (1760-1815). Childs Nerv Syst 2018; 34:1271-1278. [PMID: 29557512 DOI: 10.1007/s00381-018-3769-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 02/26/2018] [Indexed: 11/26/2022]
Abstract
In this article, we discuss on the role of the British physician and midwifery practitioner John Clarke (1760-1815) in the characterisation of the various types of seizures and epilepsy and related phenomena ('convulsions') occurring in children. In his unfinished work Commentaries on Some of the Most Important Diseases of Children (1815), Clarke discussed the pathophysiology of convulsions and was the first to describe, 12 years before the French neurologist Louis Francois Bravais (1801-1843) and more than 30 years before the Irish-born physician Robert Bentley Todd (1809-1860), the postictal paresis. He believed that convulsions originated from changes in pressure within the ventricles as a consequence of abnormal blood flow to the cerebral vessels. In keeping with the theories of his time (e.g. Baumes 1789, 1805; Brachet 1824), Clarke believed that teething was a major cause of 'infantile convulsions'. His proposed remedies ranged from scarification of the gums to ammonia, application of leeches, cold water, and purgatives. The use of antispasmodics, quite popular at the time, was instead questioned. In his Practical Observations on the Convulsions of Infants (1826), the London practitioner and midwifery John North (1790-1873) deeply criticised Clarke's view that convulsions arise inevitably as a consequence of organic brain lesions. North inferred that the results of autopsies of children who had died of convulsions revealed no brain damages, and claimed that cerebral irritation could also occur as the effect of distant lesions. Other Clarke's contemporaries (e.g. Jean Baptiste Timothée Baumes-1756-1828) inferred that all convulsions reflected a hereditary diathesis, which rendered children (especially those with softer and limper nervous and muscular tissues!) extremely sensitive to all sorts of provocation that could trigger convulsions, including bad digestion (more pronounced at the time of teething), loud noise, and bright light. Although almost every aspect of Clarke's view on convulsions was subsequently proved wrong, his (and his contemporaries') work provides fascinating insights into the theories and therapies of seizures, which were popular at the dawn of modern neurology.
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Affiliation(s)
- Francesco Brigo
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
- Department of Neurology, Franz Tappeiner Hospital, Merano, Italy
| | - Simona Lattanzi
- Unit of Neurology, Department of Clinical and Experimental Medicine, Università Politecnica delle Marche, Ancona, Italy
| | - Eugen Trinka
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria
- Center for Cognitive Neuroscience, Salzburg, Austria
- Public Health, Health Services Research and HTA, University for Health Sciences, Medical Informatics and Technology, Hall i.T, Austria
| | - Raffaele Nardone
- Department of Neurology, Franz Tappeiner Hospital, Merano, Italy
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria
| | - Nicola Luigi Bragazzi
- School of Public Health, Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Martino Ruggieri
- Unit of Rare Diseases of the Nervous System in Childhood, Department of Clinical and Experimental Medicine, Section of Pediatrics and Child Neuropsychiatry, AOU "Policlinico-Vittorio Emanuele", University of Catania, Via S. Sofia, 78, 95128, Catania, Italy.
| | - Ignazio Vecchio
- Department of Clinical and Experimental Medicine, Section of History of Medicine, University of Catania, Catania, Italy
| | - Mariano Martini
- Department of Health Sciences, Section of Medical History and Ethics, University of Genoa, Genoa, Italy
- Unesco Chair "Anthropology of Health-Biosphere and Healing System", University of Genoa, Genoa, Italy
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Brigo F, Trinka E, Lattanzi S, Bragazzi NL, Nardone R, Martini M. A brief history of typical absence seizures - Petit mal revisited. Epilepsy Behav 2018; 80:346-353. [PMID: 29402631 DOI: 10.1016/j.yebeh.2018.01.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 01/05/2018] [Accepted: 01/06/2018] [Indexed: 11/25/2022]
Abstract
In this article, we have traced back the history of typical absence seizures, from their initial clinical description to the more recent nosological position. The first description of absence seizures was made by Poupart in 1705 and Tissot in 1770. In 1824, Calmeil introduced the term "absences", and in 1838, Esquirol for the first time used the term petit mal. Reynolds instead used the term "epilepsia mitior" (milder epilepsy) and provided a comprehensive description of absence seizures (1861). In 1854, Delasiauve ranked absences as the seizure type with lower severity and introduced the concept of idiopathic epilepsy. Otto Binswanger (1899) discussed the role of cortex in the pathophysiology of "abortive seizures", whereas William Gowers (1901) emphasized the importance of a detailed clinical history to identify nonmotor seizures or very mild motor phenomena which otherwise may go unnoticed or considered not epileptic. At the beginning of the 20th Century, the term pyknolepsy was introduced, but initially was not universally considered as a type of epilepsy; it was definitely recognized as an epileptic entity only in 1945, based on electroencephalogram (EEG) recordings. Hans Berger, the inventor of the EEG, made also the first EEG recording of an atypical absence (his results were published only in 1933), whereas the characteristic EEG pattern was reported by neurophysiologists of the Harvard Medical School in 1935. The discovery of EEG made it also possible to differentiate absence seizures from so called "psychomotor" seizures occurring in temporal lobe epilepsy. Penfield and Jasper (1938) considered absences as expression of "centrencephalic epilepsy". Typical absences seizures are now classified by the International League Against Epilepsy among generalized nonmotor (absence) seizures.
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Affiliation(s)
- Francesco Brigo
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Italy; Department of Neurology, Franz Tappeiner Hospital, Merano, Italy.
| | - Eugen Trinka
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria; Center for Cognitive Neuroscience, Salzburg, Austria; Public Health, Health Services Research and HTA, University for Health Sciences, Medical Informatics and Technology, Hall i.T., Austria
| | - Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | | | - Raffaele Nardone
- Department of Neurology, Franz Tappeiner Hospital, Merano, Italy; Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria
| | - Mariano Martini
- Department of Health Sciences, Section of History of Medicine and Ethics, University of Genoa, Genoa, Italy
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11
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Do Val-da Silva RA, Peixoto-Santos JE, Kandratavicius L, De Ross JB, Esteves I, De Martinis BS, Alves MNR, Scandiuzzi RC, Hallak JEC, Zuardi AW, Crippa JA, Leite JP. Protective Effects of Cannabidiol against Seizures and Neuronal Death in a Rat Model of Mesial Temporal Lobe Epilepsy. Front Pharmacol 2017; 8:131. [PMID: 28367124 PMCID: PMC5355474 DOI: 10.3389/fphar.2017.00131] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 03/02/2017] [Indexed: 11/30/2022] Open
Abstract
The present study reports the behavioral, electrophysiological, and neuropathological effects of cannabidiol (CBD), a major non-psychotropic constituent of Cannabis sativa, in the intrahippocampal pilocarpine-induced status epilepticus (SE) rat model. CBD was administered before pilocarpine-induced SE (group SE+CBDp) or before and after SE (group SE+CBDt), and compared to rats submitted only to SE (SE group), CBD, or vehicle (VH group). Groups were evaluated during SE (behavioral and electrophysiological analysis), as well as at days one and three post-SE (exploratory activity, electrophysiological analysis, neuron density, and neuron degeneration). Compared to SE group, SE+CBD groups (SE+CBDp and SE+CBDt) had increased SE latency, diminished SE severity, increased contralateral afterdischarge latency and decreased relative powers in delta (0.5–4 Hz) and theta (4–10 Hz) bands. Only SE+CBDp had increased vertical exploratory activity 1-day post SE and decreased contralateral relative power in delta 3 days after SE, when compared to SE group. SE+CBD groups also showed decreased neurodegeneration in the hilus and CA3, and higher neuron density in granule cell layer, hilus, CA3, and CA1, when compared to SE group. Our findings demonstrate anticonvulsant and neuroprotective effects of CBD preventive treatment in the intrahippocampal pilocarpine epilepsy model, either as single or multiple administrations, reinforcing the potential role of CBD in the treatment of epileptic disorders.
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Affiliation(s)
- Raquel A Do Val-da Silva
- Department of Neurosciences and Behavioral Sciences, Ribeirao Preto Medical School, University of São Paulo São Paulo, Brazil
| | - Jose E Peixoto-Santos
- Department of Neurosciences and Behavioral Sciences, Ribeirao Preto Medical School, University of São Paulo São Paulo, Brazil
| | - Ludmyla Kandratavicius
- Department of Neurosciences and Behavioral Sciences, Ribeirao Preto Medical School, University of São PauloSão Paulo, Brazil; National Institute of Science and Technology for Translational Medicine, Conselho Nacional de Desenvolvimento Cientifico e TecnologicoBrasília, Brazil
| | - Jana B De Ross
- Department of Neurosciences and Behavioral Sciences, Ribeirao Preto Medical School, University of São Paulo São Paulo, Brazil
| | - Ingrid Esteves
- Department of Neurosciences and Behavioral Sciences, Ribeirao Preto Medical School, University of São Paulo São Paulo, Brazil
| | - Bruno S De Martinis
- National Institute of Science and Technology for Translational Medicine, Conselho Nacional de Desenvolvimento Cientifico e TecnologicoBrasília, Brazil; Department of Chemistry, Faculty of Philosophy, Science and Languages of Ribeirao Preto, University of São PauloSão Paulo, Brazil
| | - Marcela N R Alves
- Department of Chemistry, Faculty of Philosophy, Science and Languages of Ribeirao Preto, University of São Paulo São Paulo, Brazil
| | - Renata C Scandiuzzi
- Department of Neurosciences and Behavioral Sciences, Ribeirao Preto Medical School, University of São Paulo São Paulo, Brazil
| | - Jaime E C Hallak
- Department of Neurosciences and Behavioral Sciences, Ribeirao Preto Medical School, University of São PauloSão Paulo, Brazil; National Institute of Science and Technology for Translational Medicine, Conselho Nacional de Desenvolvimento Cientifico e TecnologicoBrasília, Brazil
| | - Antonio W Zuardi
- Department of Neurosciences and Behavioral Sciences, Ribeirao Preto Medical School, University of São PauloSão Paulo, Brazil; National Institute of Science and Technology for Translational Medicine, Conselho Nacional de Desenvolvimento Cientifico e TecnologicoBrasília, Brazil
| | - Jose A Crippa
- Department of Neurosciences and Behavioral Sciences, Ribeirao Preto Medical School, University of São PauloSão Paulo, Brazil; National Institute of Science and Technology for Translational Medicine, Conselho Nacional de Desenvolvimento Cientifico e TecnologicoBrasília, Brazil
| | - Joao P Leite
- Department of Neurosciences and Behavioral Sciences, Ribeirao Preto Medical School, University of São PauloSão Paulo, Brazil; National Institute of Science and Technology for Translational Medicine, Conselho Nacional de Desenvolvimento Cientifico e TecnologicoBrasília, Brazil
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12
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McCarren HS, McDonough JH. Anticonvulsant discovery through animal models of status epilepticus induced by organophosphorus nerve agents and pesticides. Ann N Y Acad Sci 2016; 1374:144-50. [DOI: 10.1111/nyas.13092] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Hilary S. McCarren
- Pharmacology Department U.S. Army Medical Research Institute of Chemical Defense Aberdeen Proving Ground Maryland
| | - John H. McDonough
- Pharmacology Department U.S. Army Medical Research Institute of Chemical Defense Aberdeen Proving Ground Maryland
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13
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Abstract
Status epilepticus (SE) represents the most severe form of epilepsy. It is one of the most common neurologic emergencies, with an incidence of up to 61 per 100,000 per year and an estimated mortality of 20 %. Clinically, tonic-clonic convulsive SE is divided into four subsequent stages: early, established, refractory, and super-refractory. Pharmacotherapy of status epilepticus, especially of its later stages, represents an "evidence-free zone," due to a lack of high-quality, controlled trials to inform clinical decisions. This comprehensive narrative review focuses on the pharmacotherapy of SE, presented according to the four-staged approach outlined above, and providing pharmacological properties and efficacy/safety data for each antiepileptic drug according to the strength of scientific evidence from the available literature. Data sources included MEDLINE and back-tracking of references in pertinent studies. Intravenous lorazepam or intramuscular midazolam effectively control early SE in approximately 63-73 % of patients. Despite a suboptimal safety profile, intravenous phenytoin or phenobarbital are widely used treatments for established SE; alternatives include valproate, levetiracetam, and lacosamide. Anesthetics are widely used in refractory and super-refractory SE, despite the current lack of trials in this field. Data on alternative treatments in the later stages are limited. Valproate and levetiracetam represent safe and effective alternatives to phenobarbital and phenytoin for treatment of established SE persisting despite first-line treatment with benzodiazepines. To date there are no class I data to support recommendations for most antiepileptic drugs for established, refractory, and super-refractory SE. Limiting the methodologic heterogeneity across studies is required and high-class randomized, controlled trials to inform clinicians about the best treatment in established and refractory status are needed.
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Affiliation(s)
- Eugen Trinka
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University Salzburg, Ignaz Harrerstrasse 79, 5020, Salzburg, Austria,
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14
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Neligan A. The importance of treatment protocols for the management of status epilepticus. Pract Neurol 2014; 14:134-5. [DOI: 10.1136/practneurol-2013-000765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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15
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Shorvon S. The historical evolution of, and the paradigms shifts in, the therapy of convulsive status epilepticus over the past 150 years. Epilepsia 2013; 54 Suppl 6:64-7. [DOI: 10.1111/epi.12281] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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16
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Deeb TZ, Maguire J, Moss SJ. Possible alterations in GABAA receptor signaling that underlie benzodiazepine-resistant seizures. Epilepsia 2012; 53 Suppl 9:79-88. [PMID: 23216581 PMCID: PMC4402207 DOI: 10.1111/epi.12037] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Benzodiazepines have been used for decades as first-line treatment for status epilepticus (SE). For reasons that are not fully understood, the efficacy of benzodiazepines decreases with increasing duration of seizure activity. This often forces clinicians to resort to more drastic second- and third-line treatments that are not always successful. The antiseizure properties of benzodiazepines are mediated by γ-aminobutyric acid type A (GABA(A) ) receptors. Decades of research have focused on the failure of GABAergic inhibition after seizure onset as the likely cause of the development benzodiazepine resistance during SE. However, the details of the deficits in GABA(A) signaling are still largely unknown. Therefore, it is necessary to improve our understanding of the mechanisms of benzodiazepine resistance so that more effective strategies can be formulated. In this review we discuss evidence supporting the role of altered GABA(A) receptor function as the major underlying cause of benzodiazepine-resistant SE in both humans and animal models. We specifically address the prevailing hypothesis, which is based on changes in the number and subtypes of GABA(A) receptors, as well as the potential influence of perturbed chloride homeostasis in the mature brain.
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Affiliation(s)
- Tarek Z Deeb
- Department of Neuroscience, Tufts University School of Medicine, Boston, Massachusetts 02111, USA
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17
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Hamil NE, Cock HR, Walker MC. Acute down-regulation of adenosine A1 receptor activity in status epilepticus. Epilepsia 2011; 53:177-88. [DOI: 10.1111/j.1528-1167.2011.03340.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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18
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Shorvon S. Super-refractory status epilepticus: an approach to therapy in this difficult clinical situation. Epilepsia 2011; 52 Suppl 8:53-6. [PMID: 21967364 DOI: 10.1111/j.1528-1167.2011.03238.x] [Citation(s) in RCA: 94] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Super-refractory status epilepticus (SE) is a stage of refractory SE characterized by unresponsiveness to initial anesthetic therapy. It is a new concept that has been the focus of recent basic and therapeutic work, and is defined as "SE that continues or recurs 24 hours or more after the onset of anesthesia, including those cases in which SE recurs on the reduction or withdrawl of anesthesia." It is encountered typically, but not exclusively, in two quite distinctive clinical situations: (1) in patients with severe acute brain injury, and (2) in patients with no history of epilepsy in whom status epilepticus develops out of the blue with no overt cause. There are a variety of treatments used, almost entirely based on open observational studies or case reports. Therapy includes anesthesia, antiepileptic drug therapy, hypothermia and ICU therapy, other medical, immunological, and physical therapies. In this review, the range of possible therapies is outlined and an approach to therapy is discussed.
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Affiliation(s)
- Simon Shorvon
- UCL Institute of Neurology, University College London, Queen Square, London, United Kingdom.
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20
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Ding YX, Zou LP, Ma MS, Wang Y, Meng LL, Fang F, Ding CH. Retrospective analysis of the effectiveness of first-line antiepileptic drugs for generalized onset and unclassified epileptic seizures in Chinese children. Childs Nerv Syst 2011; 27:279-84. [PMID: 20689955 DOI: 10.1007/s00381-010-1255-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2010] [Accepted: 07/26/2010] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND PURPOSE Based on the time until treatment failure, we retrospectively analyzed 389 children to compare the long-term effectiveness of first-line antiepileptic drugs (AEDs) in children with generalized onset or unclassified epileptic seizures. METHODS Analyses were based on time until treatment failure and time until remission. RESULTS In terms of time until treatment failure, the failure rates of topiramate and carbamazepine were higher than that of sodium valproate (p < 0.05). For time until 1-year remission, sodium valproate was found to be significantly better than either topiramate or carbamazepine (p < 0.05). For the subgroup with generalized onset epilepsy, sodium valproate was much better than either topiramate or carbamazepine (p < 0.05). No significant differences were found between topiramate and carbamazepine (p = 0.319). For unclassified epileptic seizures, no significant differences were found among the three AEDs. CONCLUSION Sodium valproate should be the drug of choice for patients with children with generalized onset, and no significant differences were found among the three AEDs in unclassified epileptic seizures.
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Affiliation(s)
- Ying-Xue Ding
- Department of Pediatrics, Chinese PLA General Hospital, Beijing, China
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21
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Rejdak K, Nieoczym D, Czuczwar M, Kiś J, Wlaź P, Turski WA. Orphenadrine induces secondarily generalized convulsive status epilepticus in rats. Brain Res Bull 2011; 84:389-93. [PMID: 21272614 DOI: 10.1016/j.brainresbull.2011.01.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2011] [Accepted: 01/17/2011] [Indexed: 10/18/2022]
Abstract
The current study was aimed to assess the convulsant potency of orphenadrine (ORPH) in rats together with a screen of different conventional antiepileptic drugs (AEDs) on their efficacy to suppress it. ORPH was administered intraperitoneally (i.p.) in doses of 50-80 mg/kg in male Wistar rats. The latency to first seizure, the number of seizure episodes and the duration of overt status epilepticus (SE) as well as the incidence of deaths was scored with simultaneous electroencephalographic (EEG) recordings. Subsequently, the effects of conventional AEDs on ORPH-evoked (80 mg/kg) seizure incidence were studied. ORPH dose-dependently induced seizures in increasing number of animals, reaching 100% at a dose of 80 mg/kg, associated with low mortality and no drug-related neurotoxicity. Epileptic attacks started as complex partial fits consisting of stereotyped behavior, limb movements, head shaking and myoclonic twitches of the body. Subsequently, an overt generalized convulsive SE appeared, lasting for approximately 2h. Among conventional AEDs: carbamazepine, ethosuximide and phenytoin had no effect while valproate (p<0.001), diazepam (p<0.01), and phenobarbital (p<0.001) dose-dependently suppressed seizure activity. All the above characteristics make the new model, a useful, easy to perform experimental tool to study the pathophysiology of SE as well as the effects of new AEDs.
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Affiliation(s)
- Konrad Rejdak
- Department of Neurology, Medical University of Lublin, 8 Jaczewskiego Str., Lublin, Poland.
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Shorvon SD. Drug treatment of epilepsy in the century of the ILAE: the second 50 years, 1959-2009. Epilepsia 2009; 50 Suppl 3:93-130. [PMID: 19298435 DOI: 10.1111/j.1528-1167.2009.02042.x] [Citation(s) in RCA: 95] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The drug therapy of epilepsy evolved enormously in this 50 year period. Advances in therapeutics included the incorporation of pharmacokinetics into clinical practice, enormous advances in neurochemistry, a trend to antiepileptic drug monotherapy, better drug assessment, better understanding of therapeutic outcomes, and the recognition of the large epilepsy treatment gap in many countries. An unprecedented range of new drugs was introduced in this period. Before 1989, these included carbamazepine, valproate, ethosuximide, and the benzodiazepines. Since 1989, 13 more new drugs have been licensed and marketed and there are others in the pipeline. The International League Against Epilepsy and its leading figures have played an important role in these developments. In this period, too, there has been a rapid expansion in research and development within the pharmaceutical industry and a rise in the value of the antiepileptic drug market. In parallel, governmental regulation of pharmaceuticals has greatly increased. To what extent the overall prognosis of epilepsy has improved as a result of these activities is an interesting and perplexing question.
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Affiliation(s)
- Simon D Shorvon
- UCL Institute of Neurology, University College London, London, United Kingdom.
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