Further evidence that pathologic high-frequency oscillations are bursts of population spikes derived from recordings of identified cells in dentate gyrus

Networks through the lens of high-frequency oscillations

To date, there is no neurophysiologic or neuroimaging biomarker that can accurately delineate the epileptogenic network. High-frequency oscillations (HFO) have been proposed as biomarkers for epileptogenesis and the epileptogenic network. The pathological HFO have been associated with areas of seizure onset and epileptogenic tissue. Several studies have demonstrated that the resection of areas with high rates of pathological HFO is associated with favorable postoperative outcomes. Recent studies have demonstrated the spatiotemporal organization of HFO into networks and their potential role in defining epileptogenic networks. Our review will present the existing literature on HFO-associated networks, specifically focusing on their role in defining epileptogenic networks and their potential significance in surgical planning.

Optimizing automated detection of high frequency oscillations using visual markings does not improve SOZ localization

OBJECTIVE

High frequency oscillations (HFOs) are a biomarker of the seizure onset zone (SOZ) and can be visually or automatically detected. In theory, one can optimize an automated algorithm's parameters to maximize SOZ localization accuracy; however, there is no consensus on whether or how this should be done. Therefore, we optimized an automated detector using visually identified HFOs and evaluated the impact on SOZ localization accuracy.

METHODS

We detected HFOs in intracranial EEG from 20 patients with refractory epilepsy from two centers using (1) unoptimized automated detection, (2) visual identification, and (3) automated detection optimized to match visually detected HFOs.

RESULTS

SOZ localization accuracy based on HFO rate was not significantly different between the three methods. Across patients, visually optimized detector settings varied, and no single set of settings produced universally accurate SOZ localization. Exploratory analysis suggests that, for many patients, detection settings exist that would improve SOZ localization.

CONCLUSIONS

SOZ localization accuracy was similar for all three methods, was not improved by visually optimizing detector settings, and may benefit from patient-specific parameter optimization.

SIGNIFICANCE

Visual HFO marking is laborious, and optimizing automated detection using visual markings does not improve localization accuracy. New patient-specific detector optimization methods are needed.

The lactate receptor HCAR1: A key modulator of epileptic seizure activity

Epilepsy affects millions globally with a significant portion exhibiting pharmacoresistance. Abnormal neuronal activity elevates brain lactate levels, which prompted the exploration of its receptor, the hydroxycarboxylic acid receptor 1 (HCAR1) known to downmodulate neuronal activity in physiological conditions. This study revealed that HCAR1-deficient mice (HCAR1-KO) exhibited lowered seizure thresholds, and increased severity and duration compared to wild-type mice. Hippocampal and whole-brain electrographic seizure analyses revealed increased seizure severity in HCAR1-KO mice, supported by time-frequency analysis. The absence of HCAR1 led to uncontrolled inter-ictal activity in acute hippocampal slices, replicated by lactate dehydrogenase A inhibition indicating that the activation of HCAR1 is closely associated with glycolytic output. However, synthetic HCAR1 agonist administration in an in vivo epilepsy model did not modulate seizures, likely due to endogenous lactate competition. These findings underscore the crucial roles of lactate and HCAR1 in regulating circuit excitability to prevent unregulated neuronal activity and terminate epileptic events.

Pathological and Physiological High-frequency Oscillations on Electroencephalography in Patients with Epilepsy

High-frequency oscillations (HFOs) encompass ripples (80 Hz-200 Hz) and fast ripples (200 Hz-600 Hz), serving as a promising biomarker for localizing the epileptogenic zone in epilepsy. Spontaneous fast ripples are always pathological, while ripples may be physiological or pathological. Distinguishing physiological from pathological ripples is important not only for designating epileptogenic brain regions, but also for investigations that study ripples in the context of memory encoding, consolidation, and recall in patients with epilepsy. Many studies have sought to identify distinguishing features between pathological and physiological ripples over the past two decades. Physiological and pathological ripples differ with respect to their spatial location, cellular mechanisms, morphology, and coupling with background electroencephalographic activity. Retrospective studies have demonstrated that differentiating between pathological and physiological ripples can improve surgical outcome prediction. In this review, we summarize the characteristics, differences, and applications of pathological and physiological HFOs and discuss strategies for their clinical translation.

Pathological neurons generate ripples at the UP-DOWN transition disrupting information transfer

OBJECTIVE

To confirm and investigate why pathological high-frequency oscillations (pHFOs), including ripples (80-200 Hz) and fast ripples (200-600 Hz), are generated during the UP-DOWN transition of the slow wave and if information transmission mediated by ripple temporal coupling is disrupted in the seizure-onset zone (SOZ).

METHODS

We isolated 217 total units from 175.95 intracranial electroencephalography (iEEG) contact-hours of synchronized macro- and microelectrode recordings from 6 patients. Sleep slow oscillation (.1-2 Hz) epochs were identified in the iEEG recording. iEEG HFOs that occurred superimposed on the slow wave were transformed to phasors and adjusted by the phase of maximum firing in nearby units (i.e., maximum UP). We tested whether, in the SOZ, HFOs and associated action potentials (APs) occur more often at the UP-DOWN transition. We also examined ripple temporal correlations using cross-correlograms.

RESULTS

At the group level in the SOZ, HFO and HFO-associated AP probability was highest during the UP-DOWN transition of slow wave excitability (p < < .001). In the non-SOZ, HFO and HFO-associated AP was highest during the DOWN-UP transition (p < < .001). At the unit level in the SOZ, 15.6% and 20% of units exhibited more robust firing during ripples (Cohen's d = .11-.83) and fast ripples (d = .36-.90) at the UP-DOWN transition (p < .05 f.d.r. corrected), respectively. By comparison, also in the SOZ, 6.6% (d = .14-.30) and 8.5% (d = .33-.41) of units had significantly less firing during ripples and fast ripples at the UP-DOWN transition, respectively. Additional data shows that ripple and fast ripple temporal correlations, involving global slow waves, between the hippocampus, entorhinal cortex, and parahippocampal gyrus were reduced by >50% in the SOZ compared to the non-SOZ (N = 3).

SIGNIFICANCE

The UP-DOWN transition of slow wave excitability facilitates the activation of pathological neurons to generate pHFOs. Ripple temporal correlations across brain regions may be important in memory consolidation and are disrupted in the SOZ, perhaps by pHFO generation.

Fast ripples reflect increased excitability that primes epileptiform spikes

The neuronal circuit disturbances that drive inter-ictal and ictal epileptiform discharges remain elusive. Using a combination of extra-operative macro-electrode and micro-electrode inter-ictal recordings in six pre-surgical patients during non-rapid eye movement sleep, we found that, exclusively in the seizure onset zone, fast ripples (200-600 Hz), but not ripples (80-200 Hz), frequently occur <300 ms before an inter-ictal intra-cranial EEG spike with a probability exceeding chance (bootstrapping, P < 1e-5). Such fast ripple events are associated with higher spectral power (P < 1e-10) and correlated with more vigorous neuronal firing than solitary fast ripple (generalized linear mixed-effects model, P < 1e-9). During the intra-cranial EEG spike that follows a fast ripple, action potential firing is lower than during an intra-cranial EEG spike alone (generalized linear mixed-effects model, P < 0.05), reflecting an inhibitory restraint of intra-cranial EEG spike initiation. In contrast, ripples do not appear to prime epileptiform spikes. We next investigated the clinical significance of pre-spike fast ripple in a separate cohort of 23 patients implanted with stereo EEG electrodes, who underwent resections. In non-rapid eye movement sleep recordings, sites containing a high proportion of fast ripple preceding intra-cranial EEG spikes correlate with brain areas where seizures begin more than solitary fast ripple (P < 1e-5). Despite this correlation, removal of these sites does not guarantee seizure freedom. These results are consistent with the hypothesis that fast ripple preceding EEG spikes reflect an increase in local excitability that primes EEG spike discharges preferentially in the seizure onset zone and that epileptogenic brain regions are necessary, but not sufficient, for initiating inter-ictal epileptiform discharges.

Pathological neurons generate ripples at the UP-DOWN transition disrupting information transfer

Objective

To confirm and investigate why pathological HFOs (pHFOs), including Ripples [80-200 Hz] and fast ripples [200-600 Hz], are generated during the UP-DOWN transition of the slow wave and if pHFOs interfere with information transmission.

Methods

We isolated 217 total units from 175.95 iEEG contact-hours of synchronized macro- and microelectrode recordings from 6 patients. Sleep slow oscillation (0.1-2 Hz) epochs were identified in the iEEG recording. iEEG HFOs that occurred superimposed on the slow wave were transformed to phasors and adjusted by the phase of maximum firing in nearby units (i.e., maximum UP). We tested whether, in the seizure onset zone (SOZ), HFOs and associated action potentials (AP) occur more often at the UP-DOWN transition. We also examined ripple temporal correlations using cross correlograms.

Results

At the group level in the SOZ, HFO and HFO-associated AP probability was highest during the UP-DOWN transition of slow wave excitability (p<<0.001). In the non-SOZ, HFO and HFO-associated AP was highest during the DOWN-UP transition (p<<0.001). At the unit level in the SOZ, 15.6% and 20% of units exhibited more robust firing during ripples (Cohen's d=0.11-0.83) and fast ripples (d=0.36-0.90) at the UP-DOWN transition (p<0.05 f.d.r corrected), respectively. By comparison, also in the SOZ, 6.6% (d=0.14-0.30) and 8.5% (d=0.33-0.41) of units had significantly less firing during ripples and fast ripples at the UP-DOWN transition, respectively. Additional data shows ripple temporal correlations, involving global slow waves, between the hippocampus, entorhinal cortex, and parahippocampal gyrus were reduced by ~50-80% in the SOZ compared to the non-SOZ (N=3).

Significance

The UP-DOWN transition of slow wave excitability facilitates the activation of pathological neurons to generate pHFOs. The pathological neurons and pHFOs disrupt ripple temporal correlations across brain regions that transfer information and may be important in memory consolidation.

The role of superficial and deep layers in the generation of high frequency oscillations and interictal epileptiform discharges in the human cortex

Describing intracortical laminar organization of interictal epileptiform discharges (IED) and high frequency oscillations (HFOs), also known as ripples. Defining the frequency limits of slow and fast ripples. We recorded potential gradients with laminar multielectrode arrays (LME) for current source density (CSD) and multi-unit activity (MUA) analysis of interictal epileptiform discharges IEDs and HFOs in the neocortex and mesial temporal lobe of focal epilepsy patients. IEDs were observed in 20/29, while ripples only in 9/29 patients. Ripples were all detected within the seizure onset zone (SOZ). Compared to hippocampal HFOs, neocortical ripples proved to be longer, lower in frequency and amplitude, and presented non-uniform cycles. A subset of ripples (≈ 50%) co-occurred with IEDs, while IEDs were shown to contain variable high-frequency activity, even below HFO detection threshold. The limit between slow and fast ripples was defined at 150 Hz, while IEDs' high frequency components form clusters separated at 185 Hz. CSD analysis of IEDs and ripples revealed an alternating sink-source pair in the supragranular cortical layers, although fast ripple CSD appeared lower and engaged a wider cortical domain than slow ripples MUA analysis suggested a possible role of infragranularly located neural populations in ripple and IED generation. Laminar distribution of peak frequencies derived from HFOs and IEDs, respectively, showed that supragranular layers were dominated by slower (< 150 Hz) components. Our findings suggest that cortical slow ripples are generated primarily in upper layers while fast ripples and associated MUA in deeper layers. The dissociation of macro- and microdomains suggests that microelectrode recordings may be more selective for SOZ-linked ripples. We found a complex interplay between neural activity in the neocortical laminae during ripple and IED formation. We observed a potential leading role of cortical neurons in deeper layers, suggesting a refined utilization of LMEs in SOZ localization.

Oscillations in the dentate gyrus as a tool for the performance of the hippocampal functions: Healthy and epileptic brain

The dentate gyrus (DG) is part of the hippocampal formation and is essential for important cognitive processes such as navigation and memory. The oscillatory activity of the DG network is believed to play a critical role in cognition. DG circuits generate theta, beta, and gamma rhythms, which participate in the specific information processing performed by DG neurons. In the temporal lobe epilepsy (TLE), cognitive abilities are impaired, which may be due to drastic alterations in the DG structure and network activity during epileptogenesis. The theta rhythm and theta coherence are especially vulnerable in dentate circuits; disturbances in DG theta oscillations and their coherence may be responsible for general cognitive impairments observed during epileptogenesis. Some researchers suggested that the vulnerability of DG mossy cells is a key factor in the genesis of TLE, but others did not support this hypothesis. The aim of the review is not only to present the current state of the art in this field of research but to help pave the way for future investigations by highlighting the gaps in our knowledge to completely appreciate the role of DG rhythms in brain functions. Disturbances in oscillatory activity of the DG during TLE development may be a diagnostic marker in the treatment of this disease.

Evolution of interictal activity in models of mesial temporal lobe epilepsy

Interictal activity and seizures are the hallmarks of focal epileptic disorders (which include mesial temporal lobe epilepsy, MTLE) in humans and in animal models. Interictal activity, which is recorded with cortical and intracerebral EEG recordings, comprises spikes, sharp waves and high-frequency oscillations, and has been used in clinical practice to identify the epileptic zone. However, its relation with seizures remains debated. Moreover, it is unclear whether specific EEG changes in interictal activity occur during the time preceding the appearance of spontaneous seizures. This period, which is termed "latent", has been studied in rodent models of MTLE in which spontaneous seizures start to occur following an initial insult (most often a status epilepticus induced by convulsive drugs such as kainic acid or pilocarpine) and may mirror epileptogenesis, i.e., the process leading the brain to develop an enduring predisposition to seizure generation. Here, we will address this topic by reviewing experimental studies performed in MTLE models. Specifically, we will review data highlighting the dynamic changes in interictal spiking activity and high-frequency oscillations occurring during the latent period, and how optogenetic stimulation of specific cell populations can modulate them in the pilocarpine model. These findings indicate that interictal activity: (i) is heterogeneous in its EEG patterns and thus, presumably, in its underlying neuronal mechanisms; and (ii) can pinpoint to the epileptogenic processes occurring in focal epileptic disorders in animal models and, perhaps, in epileptic patients.

Diverse nature of interictal oscillations: EEG-based biomarkers in epilepsy

Interictal electroencephalogram (EEG) patterns, including high-frequency oscillations (HFOs), interictal spikes (ISs), and slow wave activities (SWAs), are defined as specific oscillations between seizure events. These interictal oscillations reflect specific dynamic changes in network excitability and play various roles in epilepsy. In this review, we briefly describe the electrographic characteristics of HFOs, ISs, and SWAs in the interictal state, and discuss the underlying cellular and network mechanisms. We also summarize representative evidence from experimental and clinical epilepsy to address their critical roles in ictogenesis and epileptogenesis, indicating their potential as electrophysiological biomarkers of epilepsy. Importantly, we put forwards some perspectives for further research in the field.

Chloride ion dysregulation in epileptogenic neuronal networks

GABA is the major inhibitory neurotransmitter in the mature CNS. When GABA_A receptors are activated the membrane potential is driven towards hyperpolarization due to chloride entry into the neuron. However, chloride ion dysregulation that alters the ionic gradient can result in depolarizing GABAergic post-synaptic potentials instead. In this review, we highlight that GABAergic inhibition prevents and restrains focal seizures but then reexamine this notion in the context of evidence that a static and/or a dynamic chloride ion dysregulation, that increases intracellular chloride ion concentrations, promotes epileptiform activity and seizures. To reconcile these findings, we hypothesize that epileptogenic pathologically interconnected neuron (PIN) microcircuits, representing a small minority of neurons, exhibit static chloride dysregulation and should exhibit depolarizing inhibitory post-synaptic potentials (IPSPs). We speculate that chloride ion dysregulation and PIN cluster activation may generate fast ripples and epileptiform spikes as well as initiate the hypersynchronous seizure onset pattern and microseizures. Also, we discuss the genetic, molecular, and cellular players important in chloride dysregulation which regulate epileptogenesis and initiate the low-voltage fast seizure onset pattern. We conclude that chloride dysregulation in neuronal networks appears to be critical for epileptogenesis and seizure genesis, but feed-back and feed-forward inhibitory GABAergic neurotransmission plays an important role in preventing and restraining seizures as well.

Reduction of Hippocampal High-Frequency Activity in Wag/Rij Rats with a Genetic Predisposition to Absence Epilepsy

In temporal lobe epilepsy, high frequency oscillations serve as electroencephalographic (EEG) markers of epileptic hippocampal tissue. In contrast, absence epilepsy and other idiopathic epilepsies are known to result from thalamo-cortical abnormalities, with the hippocampus involvement considered to be only indirect. We aimed to uncover the role of the hippocampus in absence epilepsy using a genetic rat model of absence epilepsy (WAG/Rij rats), in which spike-wave discharges (SWDs) appear spontaneously in cortical EEG. We performed simultaneous recordings of local field potential from the hippocampal dentate gyrus using pairs of depth electrodes and epidural cortical EEG in freely moving rats. Hippocampal ripples (100-200 Hz) and high frequency oscillations (HFO, 50-70 Hz) were detected using GUI RIPPLELAB in MatLab (Navarrete et al., 2016). Based on the dynamics of hippocampal ripples, SWDs were divided into three clusters, which might represent different seizure types in reference to the involvement of hippocampal processes. This might underlie impairment of hippocampus-related cognitive processes in some patients with absence epilepsy. A significant reduction to nearly zero-ripple-density was found 4-8 s prior to SWD onset and during 4 s immediately after SWD onset. It follows that hippocampal ripples were not just passively blocked by the onset of SWDs, but they were affected by spike-wave seizure initiation mechanisms. Hippocampal HFO were reduced during the preictal, ictal and postictal periods in comparison to the baseline. Therefore, hippocampal HFO seemed to be blocked with spike-wave seizures. All together, this might underlie impairment of hippocampus-related cognitive processes in some patients with absence epilepsy. Further investigation of processes underlying SWD-related reduction of hippocampal ripples and HFO oscillations may help to predict epileptic attacks and explain cognitive comorbidities in patients with absence epilepsy.

Bilateral optogenetic activation of inhibitory cells favors ictogenesis

Mesial temporal lobe epilepsy (MTLE) is the most common type of focal refractory epilepsy and is characterized by recurring seizures that are often refractory to medication. Since parvalbumin-positive (PV) interneurons were recently shown to play significant roles in ictogenesis, we established here how bilateral optogenetic stimulation of these interneurons in the hippocampus CA3 regions modulates seizures, interictal spikes and high-frequency oscillations (HFOs; ripples: 80-200 Hz, fast ripples: 250-500 Hz) in the pilocarpine model of MTLE. Bilateral optogenetic stimulation of CA3 PV-positive interneurons at 8 Hz (lasting 30 s, every 2 min) was implemented in PV-ChR2 mice for 8 consecutive days starting on day 7 (n = 8) or on day 13 (n = 6) after pilocarpine-induced status epilepticus (SE). Seizure occurrence was higher in both day 7 and day 13 groups of PV-ChR2 mice during periods of optogenetic stimulation ("ON"), compared to when stimulation was not performed ("OFF") (day 7 group = p < 0.01, day 13 group = p < 0.01). In the PV-ChR2 day 13 group, rates of seizures (p < 0.05), of interictal spikes associated with fast ripples (p < 0.01), and of isolated fast ripples (p < 0.01) during optogenetic stimulations were significantly higher than in the PV-ChR2 day 7 group. Our findings reveal that bilateral activation of PV-interneurons in the hippocampus (leading to a presumptive increase in GABA signaling) favors ictogenesis. These effects may also mirror the neuropathological changes that occur over time after SE in this animal model.

Anticonvulsant Effect of Carbenoxolone on Chronic Epileptic Rats and Its Mechanism Related to Connexin and High-Frequency Oscillations

Objective

This study was designed to investigate the influence and mechanism of gap junction carbenoxolone (CBX) on dynamic changes in the spectral power of ripples and fast ripples (FRs) in the hippocampus of chronic epileptic rats.

Methods

The lithium-pilocarpine (PILO) status epilepticus (SE) model (PILO group) and the CBX pretreatment model (CBX + PILO group) were established to analyze dynamic changes in the spectral power of ripples and FRs, and the dynamic expression of connexin (CX)26, CX32, CX36, and CX43 in the hippocampus of chronic epileptic rats.

Results

Within 28 days after SE, the number of spontaneous recurrent seizures (SRSs) in the PILO group was significantly higher than that in the CBX + PILO group. The average spectral power of FRs in the PILO group was significantly higher than the baseline level at 1 and 7 days after SE. The average spectral power of FRs in the PILO group was significantly higher than that in the CBX + PILO group at 1, 7, and 14 days after SE. Seizures induced an increase in CX43 expression at 1 and 7 days after SE, but had no significant effect on CX26, CX36, or CX32. CBX pretreatment did not affect the expression of CXs in the hippocampus of normal rats, but it inhibited the expression of CX43 in epileptic rats. The number of SRSs at 2 and 4 weeks after SE had the highest correlation with the average spectral power of FRs; the average spectral power of FRs was moderately correlated with the expression of CX43.

Conclusion

The results of this study indicate that the energy of FRs may be regulated by its interference with the expression of CX43, and thus, affect seizures. Blocking the expression of CX43 thereby reduces the formation of pathological high-frequency oscillations (HFOs), making it a promising strategy for the treatment of chronic epilepsy.

Abnormal phase-amplitude coupling characterizes the interictal state in epilepsy

OBJECTIVE

 Diagnosing epilepsy still requires visual interpretation of electroencephalography and magnetoencephalography (MEG) by specialists, which prevents quantification and standardization of diagnosis. Previous studies proposed automated diagnosis by combining various features from electroencephalography and MEG, such as relative power (Power) and functional connectivity. However, the usefulness of interictal phase-amplitude coupling (PAC) in diagnosing epilepsy is still unknown. We hypothesized that resting-state PAC would be different for patients with epilepsy in the interictal state and for healthy participants such that it would improve discrimination between the groups.

METHODS

 We obtained resting-state MEG and magnetic resonance imaging in 90 patients with epilepsy during their preoperative evaluation and in 90 healthy participants. We used the cortical currents estimated from MEG and magnetic resonance imaging to calculate Power in the δ (1-3 Hz), θ (4-7 Hz), α (8-13 Hz), β (13-30 Hz), low γ (35-55 Hz), and high γ (65-90 Hz) bands and functional connectivity in the θ band. PAC was evaluated using the synchronization index (SI) for eight frequency band pairs: the phases of δ, θ, α, and β and the amplitudes of low and high γ. First, we compared the mean SI values for the patients with epilepsy and the healthy participants. Then, using features such as PAC, Power, functional connectivity, and features extracted by deep learning individually or combined, we tested whether PAC improves discrimination accuracy for the two groups.

RESULTS

 The mean SI values were significantly different for the patients with epilepsy and the healthy participants. The SI value difference was highest for θ/low γ in the temporal lobe. Discrimination accuracy was the highest, at 90%, using the combination of PAC and deep learning.

SIGNIFICANCE

 Abnormal PAC characterized the patients with epilepsy in the interictal state compared with the healthy participants, potentially improving the discrimination of epilepsy.

Drug-resistant epilepsy and the hypothesis of intrinsic severity: What about the high-frequency oscillations?

Drug‐resistant epilepsy (DRE) affects approximately one‐third of the patients with epilepsy. Based on experimental findings from animal models and brain tissue from patients with DRE, different hypotheses have been proposed to explain the cause(s) of drug resistance. One is the intrinsic severity hypothesis that posits that drug resistance is an inherent property of epilepsy related to disease severity. Seizure frequency is one measure of epilepsy severity, but frequency alone is an incomplete measure of severity and does not fully explain basic research and clinical studies on drug resistance; thus, other measures of epilepsy severity are needed. One such measure could be pathological high‐frequency oscillations (HFOs), which are believed to reflect the neuronal disturbances responsible for the development of epilepsy and the generation of spontaneous seizures. In this manuscript, we will briefly review the intrinsic severity hypothesis, describe basic and clinical research on HFOs in the epileptic brain, and based on this evidence discuss whether HFOs could be a clinical measure of epilepsy severity. Understanding the mechanisms of DRE is critical for producing breakthroughs in the development and testing of novel strategies for treatment.

Interictal spikes with and without high-frequency oscillation have different single-neuron correlates

Interictal epileptiform discharges (IEDs) are a widely used biomarker in patients with epilepsy but lack specificity. It has been proposed that there are truly epileptogenic and less pathological or even protective IEDs. Recent studies suggest that highly pathological IEDs are characterized by high-frequency oscillations (HFOs). Here, we aimed to dissect these 'HFO-IEDs' at the single-neuron level, hypothesizing that the underlying mechanisms are distinct from 'non-HFO-IEDs'. Analysing hybrid depth electrode recordings from patients with temporal lobe epilepsy, we found that single-unit firing rates were higher in HFO- than in non-HFO-IEDs. HFO-IEDs were characterized by a pronounced pre-peak increase in firing, which coincided with the preferential occurrence of HFOs, whereas in non-HFO-IEDs, there was only a mild pre-peak increase followed by a post-peak suppression. Comparing each unit's firing during HFO-IEDs to its baseline activity, we found many neurons with a significant increase during the HFO component or ascending part, but almost none with a decrease. No such imbalance was observed during non-HFO-IEDs. Finally, comparing each unit's firing directly between HFO- and non-HFO-IEDs, we found that most cells had higher rates during HFO-IEDs and, moreover, identified a distinct subset of neurons with a significant preference for this IED subtype. In summary, our study reveals that HFO- and non-HFO-IEDs have different single-unit correlates. In HFO-IEDs, many neurons are moderately activated, and some participate selectively, suggesting that both types of increased firing contribute to highly pathological IEDs.

Scalp-HFO indexes are biomarkers for the lateralization and localization of the epileptogenic zone in preoperative assessment

During the noninvasive evaluation phase for refractory epilepsy, the localization of the epileptogenic zone (EZ) is essential for the surgical protocols. Confirmation of laterality is required when the preoperative evaluation limits the EZ to bilateral anterior temporal lobes or bilateral frontal lobes. High-frequency oscillations (HFOs) are considered to be promising biological markers for the EZ. However, a large number of studies on HFOs stem from intracranial research. There were few quantitative measures for scalp HFOs, so we proposed a new method to quantify and analyze scalp HFOs. This method was called the "scalp-HFO index" (HI) and calculated in both the EZ and non-EZ. The calculation was based on the numbers and spectral power of scalp HFOs automatically detected. We labeled the brain lobes involved in the EZ as regions of interest (ROIs). The HIs based on the ripple numbers (n-HI) and spectral power (s-HI) were significantly higher in the ROI than in the contra-ROI (P = 0.012, P = 0.003), indicating that HIs contributed to the lateralization of EZ. The sensitivity and specificity of n-HI for the localization of the EZ were 90% and 79.58%, respectively, suggesting that n-HI was valuable in localizing the EZ. HI may contribute to the implantation strategy of invasive electrodes. However, few scalp HFOs were recorded when the EZ was located in the medial cortex region.NEW & NOTEWORTHY We proposed the scalp-high-frequency oscillation (HFO) index (HI) as a quantitative assessment method for scalp HFOs to locate the epileptogenic zone (EZ). Our results showed that the HI in regions of interest (ROIs) was significantly higher than in contra-ROIs. Sensitivity and specificity of HI based on ripple rates (n-HI) for EZ localization were 90% and 79.58%, respectively. If the n-HI of the brain region was >1.35, it was more likely to be an epileptogenic region. Clinical application of HIs as an indicator may facilitate localization of the EZ.

The pilocarpine model of mesial temporal lobe epilepsy: Over one decade later, with more rodent species and new investigative approaches

Fundamental work on the mechanisms leading to focal epileptic discharges in mesial temporal lobe epilepsy (MTLE) often rests on the use of rodent models in which an initial status epilepticus (SE) is induced by kainic acid or pilocarpine. In 2008 we reviewed how, following systemic injection of pilocarpine, the main subsequent events are the initial SE, the latent period, and the chronic epileptic state. Up to a decade ago, rats were most often employed and they were frequently analysed only behaviorally. However, the use of transgenic mice has revealed novel information regarding this animal model. Here, we review recent findings showing the existence of specific neuronal events during both latent and chronic states, and how optogenetic activation of specific cell populations modulate spontaneous seizures. We also address neuronal damage induced by pilocarpine treatment, the role of neuroinflammation, and the influence of circadian and estrous cycles. Updating these findings leads us to propose that the rodent pilocarpine model continues to represent a valuable tool for identifying the basic pathophysiology of MTLE.

Microscale dynamics of electrophysiological markers of epilepsy

OBJECTIVE

Interictal discharges (IIDs) and high frequency oscillations (HFOs) are established neurophysiologic biomarkers of epilepsy, while microseizures are less well studied. We used custom poly(3,4-ethylenedioxythiophene) polystyrene sulfonate (PEDOT:PSS) microelectrodes to better understand these markers' microscale spatial dynamics.

METHODS

Electrodes with spatial resolution down to 50 µm were used to record intraoperatively in 30 subjects. IIDs' degree of spread and spatiotemporal paths were generated by peak-tracking followed by clustering. Repeating HFO patterns were delineated by clustering similar time windows. Multi-unit activity (MUA) was analyzed in relation to IID and HFO timing.

RESULTS

We detected IIDs encompassing the entire array in 93% of subjects, while localized IIDs, observed across < 50% of channels, were seen in 53%. IIDs traveled along specific paths. HFOs appeared in small, repeated spatiotemporal patterns. Finally, we identified microseizure events that spanned 50-100 µm. HFOs covaried with MUA, but not with IIDs.

CONCLUSIONS

Overall, these data suggest that irritable cortex micro-domains may form part of an underlying pathologic architecture which could contribute to the seizure network.

SIGNIFICANCE

These results, supporting the possibility that epileptogenic cortex comprises a mosaic of irritable domains, suggests that microscale approaches might be an important perspective in devising novel seizure control therapies.

High-Frequency Oscillations on Interictal Epileptiform Discharges in Routinely Acquired Scalp EEG: Can It Be Used as a Prognostic Marker?

Introduction

Despite all the efforts for optimizing epilepsy management in children over the past decades, there is no clear consensus regarding whether to treat or not to treat epileptiform discharges (EDs) after a first unprovoked seizure or the optimal duration of therapy with anti-seizure medication (ASM). It is therefore highly needed to find markers on scalp electroencephalogram (EEG) that can help identify pathological EEG discharges that require treatment.

Aim of the study

This retrospective study aimed to identify whether the coexistence of ripples/high-frequency oscillations (HFOs) with interictal EDs (IEDs) in routinely acquired scalp EEG is associated with a higher risk of seizure recurrence and could be used as a prognostic marker.

Methods

100 children presenting with new onset seizure to Children’s Medical Center- Dallas during 2015–2016, who were not on ASM and had focal EDs on an awake and sleep EEG recorded with sample frequency of 500 HZ, were randomly identified by database review. EEGs were analyzed blinded to the data of the patients. HFOs were visually identified using review parameters including expanded time base and adjusted filter settings.

Results

The average age of patients was 6.3 years (±4.35 SD). HFOs were visually identified in 19% of the studied patients with an inter-rater reliability of 99% for HFO negative discharges and 78% agreement for identification of HFOs. HFOs were identified more often in the younger age group; however, they were identified in 11% of patients >5 years old. They were more frequently associated with spikes than with sharp waves and more often with higher amplitude EDs. Patients with HFOs were more likely to have a recurrence of seizures in the year after the first seizure (P < 0.05) and to continue to have seizures after 2 years (P < 0.0001). There was no statistically significant difference between the two groups with regards to continuing ASM after 2 years.

Conclusion

Including analysis for HFOs in routine EEG interpretation may increase the yield of the study and help guide the decision to either start or discontinue ASM. In the future, this may also help to identify pathological discharges with deleterious effects on the growing brain and set a new target for the management of epilepsy.

Causal relationship of CA3 back-projection to the dentate gyrus and its role in CA1 fast ripple generation

BACKGROUND

Pathophysiological evidence from temporal lobe epilepsy models highlights the hippocampus as the most affected structure due to its high degree of neuroplasticity and control of the dynamics of limbic structures, which are necessary to encode information, conferring to it an intrinsic epileptogenicity. A loss in this control results in observable oscillatory perturbations called fast ripples, in epileptic rats those events are found in CA1, CA3, and the dentate gyrus (DG), which are the principal regions of the trisynaptic circuit of the hippocampus. The present work used Granger causality to address which relationships among these three regions of the trisynaptic circuit are needed to cause fast ripples in CA1 in an in vivo model. For these purposes, male Wistar rats (210-300 g) were injected with a single dose of pilocarpine hydrochloride (2.4 mg/2 µl) into the right lateral ventricle and video-monitored 24 h/day to detect spontaneous and recurrent seizures. Once detected, rats were implanted with microelectrodes in these regions (fixed-recording tungsten wire electrodes, 60-μm outer diameter) ipsilateral to the pilocarpine injection. A total of 336 fast ripples were recorded and probabilistically characterized, from those fast ripples we made a subset of all the fast ripple events associated with sharp-waves in CA1 region (n = 40) to analyze them with Granger Causality.

RESULTS

Our results support existing evidence in vitro in which fast ripple events in CA1 are initiated by CA3 multiunit activity and describe a general synchronization in the theta band across the three regions analyzed DG, CA3, and CA1, just before the fast ripple event in CA1 have begun.

CONCLUSION

This in vivo study highlights the causal participation of the CA3 back-projection to the DG, a connection commonly overlooked in the trisynaptic circuit, as a facilitator of a closed-loop among these regions that prolongs the excitatory activity of CA3. We speculate that the loss of inhibitory drive of DG and the mechanisms of ripple-related memory consolidation in which also the CA3 back-projection to DG has a fundamental role might be underlying processes of the fast ripples generation in CA1.

New-onset refractory status epilepticus (NORSE)

New-onset refractory status epilepticus and its subcategory febrile infection-related epilepsy syndrome are rare devastating clinical presentations in those without pre-existing relevant history, often in schoolchildren or young adults, without a clear cause on initial investigations. A cause is later identified in up to half of adults, but in many fewer children. Patients often require protracted intensive care and are at significant risk of dying. Functional disability is common and subsequent chronic epilepsy is the norm, but some people do have good outcomes, even after prolonged status epilepticus. Patients need prompt investigations and treatment. Anaesthetic and antiseizure medications are supplemented by other treatment modalities, including the ketogenic diet. Despite limited evidence, it is appropriate to try to modify the presumed underlying pathogenesis with immune modulation early, with a more recent focus on using interleukin inhibitors. Optimising management will require concerted multicentre international efforts.

Detection of high-frequency oscillations in electroencephalography: A scoping review and an adaptable open-source framework

PURPOSE

High frequency oscillations (HFOs) are putative biomarkers of epileptogenicity. These electrophysiological phenomena can be effectively detected in electroencephalography using automated methods. Nonetheless, the implementation of these methods into clinical practice remains challenging as significant variability exists between algorithms and their characterizations of HFOs. Here, we perform a scoping review of the literature pertaining to automated HFO detection methods. In addition, we propose a framework for defining and detecting HFOs based on a simplified single-stage time-frequency based detection algorithm with clinically-familiar parameters.

METHODS

Several databases (OVID Medline, Web of Science, PubMed) were searched for articles presenting novel, automated HFO detection methods. Details related to the algorithm and various stages of data acquisition, pre-processing, and analysis were abstracted from included studies.

RESULTS

From the 261 records screened, 57 articles presented novel, automated HFO detection methods and were included in the scoping review. These algorithms were categorized into 3 groups based on their most salient features: energy thresholding, time-frequency analysis, and data mining/machine learning. Algorithms were optimized for specific datasets and suffered from low specificity. A framework for user-constrained inputs is proposed to circumvent some of the weaknesses of highly performant detectors.

CONCLUSIONS

Further efforts are required to optimize and validate existing automated HFO detection methods for clinical utility. The proposed framework may be applied to understand and standardize the variations in HFO definitions across institutions.

Evolution of interictal spiking during the latent period in a mouse model of mesial temporal lobe epilepsy

Interictal spikes and high-frequency oscillations (HFOs, ripples: 80–200 ​Hz, fast ripples: 250–500 ​Hz) occur in epileptic patients and in animal models of mesial temporal lobe epilepsy (MTLE). In this study, we explored how type 1 and type 2 interictal spikes as well as ripples and fast ripples evolve during the latent period in the hippocampus of pilocarpine-treated mice. Depth EEG recordings were obtained from the hippocampus CA3 subfield of adult male mice (n ​= ​5, P60–P100) starting one day before pilocarpine-induced status epilepticus up to the first spontaneous seizure, the so-called latent period. We found that rates of type 1 (n ​= ​1 655) and type 2 (n ​= ​2 309) interictal spikes were significantly lower during the late phase of the latent period compared to its early and mid phase (p ​< ​0.001). However, rates of type 1 spikes associated with ripples (n ​= ​266) or fast ripples (n ​= ​106), as well as rates of type 2 interictal spikes associated with ripples (n ​= ​233), were significantly higher during the late phase compared to the early and mid phases (p ​< ​0.05). Our findings reveal that an increase of type 1 interictal spikes co-occurring with ripples or fast ripples and an increase of type 2 interictal spikes co-occurring with ripples mark the end of the latent period. We propose that changes in the occurrence of interictal spike associated with HFOs represent a biomarker of epileptogenicity in this mouse model of MTLE.

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We studied interictal spike types in a model of mesial temporal lobe epilepsy.

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Type 1 and type 2 spike rates were lower in the late phase of the latent period.

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Rates of type 1 spikes with ripples or fast ripples were higher in the late phase.

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Rates of type 2 spikes with fast ripples were also higher during the late phase.

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These changes in interictal spike types mark the end of the latent period.

Neurosteroids and Focal Epileptic Disorders

Neurosteroids are a family of compounds that are synthesized in principal excitatory neurons and glial cells, and derive from the transformation of cholesterol into pregnenolone. The most studied neurosteroids—allopregnanolone and allotetrahydrodeoxycorticosterone (THDOC)—are known to modulate GABA_A receptor-mediated transmission, thus playing a role in controlling neuronal network excitability. Given the role of GABA_A signaling in epileptic disorders, neurosteroids have profound effects on seizure generation and play a role in the development of chronic epileptic conditions (i.e., epileptogenesis). We review here studies showing the effects induced by neurosteroids on epileptiform synchronization in in vitro brain slices, on epileptic activity in in vivo models, i.e., in animals that were made epileptic with chemoconvulsant treatment, and in epileptic patients. These studies reveal that neurosteroids can modulate ictogenesis and the occurrence of pathological network activity such as interictal spikes and high-frequency oscillations (80–500 Hz). Moreover, they can delay the onset of spontaneous seizures in animal models of mesial temporal lobe epilepsy. Overall, this evidence suggests that neurosteroids represent a new target for the treatment of focal epileptic disorders.

The subiculum and its role in focal epileptic disorders

The subicular complex (hereafter referred as subiculum), which is reciprocally connected with the hippocampus and rhinal cortices, exerts a major control on hippocampal outputs. Over the last three decades, several studies have revealed that the subiculum plays a pivotal role in learning and memory but also in pathological conditions such as mesial temporal lobe epilepsy (MTLE). Indeed, subicular networks actively contribute to seizure generation and this structure is relatively spared from the cell loss encountered in this focal epileptic disorder. In this review, we will address: (i) the functional properties of subicular principal cells under normal and pathological conditions; (ii) the subiculum role in sustaining seizures in in vivo models of MTLE and in in vitro models of epileptiform synchronization; (iii) its presumptive role in human MTLE; and (iv) evidence underscoring the relationship between subiculum and antiepileptic drug effects. The studies reviewed here reinforce the view that the subiculum represents a limbic area with relevant, as yet unexplored, roles in focal epilepsy.

High frequency oscillations in epileptic and non-epileptic human hippocampus during a cognitive task

Hippocampal high-frequency electrographic activity (HFOs) represents one of the major discoveries not only in epilepsy research but also in cognitive science over the past few decades. A fundamental challenge, however, has been the fact that physiological HFOs associated with normal brain function overlap in frequency with pathological HFOs. We investigated the impact of a cognitive task on HFOs with the aim of improving differentiation between epileptic and non-epileptic hippocampi in humans. Hippocampal activity was recorded with depth electrodes in 15 patients with focal epilepsy during a resting period and subsequently during a cognitive task. HFOs in ripple and fast ripple frequency ranges were evaluated in both conditions, and their rate, spectral entropy, relative amplitude and duration were compared in epileptic and non-epileptic hippocampi. The similarity of HFOs properties recorded at rest in epileptic and non-epileptic hippocampi suggests that they cannot be used alone to distinguish between hippocampi. However, both ripples and fast ripples were observed with higher rates, higher relative amplitudes and longer durations at rest as well as during a cognitive task in epileptic compared with non-epileptic hippocampi. Moreover, during a cognitive task, significant reductions of HFOs rates were found in epileptic hippocampi. These reductions were not observed in non-epileptic hippocampi. Our results indicate that although both hippocampi generate HFOs with similar features that probably reflect non-pathological phenomena, it is possible to differentiate between epileptic and non-epileptic hippocampi using a simple odd-ball task.

Kurtosis and skewness of high-frequency brain signals are altered in paediatric epilepsy

Intracranial studies provide solid evidence that high-frequency brain signals are a new biomarker for epilepsy. Unfortunately, epileptic (pathological) high-frequency signals can be intermingled with physiological high-frequency signals making these signals difficult to differentiate. Recent success in non-invasive detection of high-frequency brain signals opens a new avenue for distinguishing pathological from physiological high-frequency signals. The objective of the present study is to characterize pathological and physiological high-frequency signals at source levels by using kurtosis and skewness analyses. Twenty-three children with medically intractable epilepsy and age-/gender-matched healthy controls were studied using magnetoencephalography. Magnetoencephalographic data in three frequency bands, which included 2–80 Hz (the conventional low-frequency signals), 80–250 Hz (ripples) and 250–600 Hz (fast ripples), were analysed. The kurtosis and skewness of virtual electrode signals in eight brain regions, which included left/right frontal, temporal, parietal and occipital cortices, were calculated and analysed. Differences between epilepsy and controls were quantitatively compared for each cerebral lobe in each frequency band in terms of kurtosis and skewness measurements. Virtual electrode signals from clinical epileptogenic zones and brain areas outside of the epileptogenic zones were also compared with kurtosis and skewness analyses. Compared to controls, patients with epilepsy showed significant elevation in kurtosis and skewness of virtual electrode signals. The spatial and frequency patterns of the kurtosis and skewness of virtual electrode signals among the eight cerebral lobes in three frequency bands were also significantly different from that of the controls (2–80 Hz, P < 0.001; 80–250 Hz, P < 0.00001; 250–600 Hz, P < 0.0001). Compared to signals from non-epileptogenic zones, virtual electrode signals from epileptogenic zones showed significantly altered kurtosis and skewness (P < 0.001). Compared to normative data from the control group, aberrant virtual electrode signals were, for each patient, more pronounced in the epileptogenic lobes than in other lobes(kurtosis analysis of virtual electrode signals in 250–600 Hz; odds ratio = 27.9; P < 0.0001). The kurtosis values of virtual electrode signals in 80–250 and 250–600 Hz showed the highest sensitivity (88.23%) and specificity (89.09%) for revealing epileptogenic lobe, respectively. The combination of virtual electrode and kurtosis/skewness measurements provides a new quantitative approach to distinguishing pathological from physiological high-frequency signals for paediatric epilepsy. Non-invasive identification of pathological high-frequency signals may provide novel important information to guide clinical invasive recordings and direct surgical treatment of epilepsy.

Ripples Have Distinct Spectral Properties and Phase-Amplitude Coupling With Slow Waves, but Indistinct Unit Firing, in Human Epileptogenic Hippocampus

Ripple oscillations (80-200 Hz) in the normal hippocampus are involved in memory consolidation during rest and sleep. In the epileptic brain, increased ripple and fast ripple (200-600 Hz) rates serve as a biomarker of epileptogenic brain. We report that both ripples and fast ripples exhibit a preferred phase angle of coupling with the trough-peak (or On-Off) state transition of the sleep slow wave in the hippocampal seizure onset zone (SOZ). Ripples on slow waves in the hippocampal SOZ also had a lower power, greater spectral frequency, and shorter duration than those in the non-SOZ. Slow waves in the mesial temporal lobe modulated the baseline firing rate of excitatory neurons, but did not significantly influence the increased firing rate associated with ripples. In summary, pathological ripples and fast ripples occur preferentially during the On-Off state transition of the slow wave in the epileptogenic hippocampus, and ripples do not require the increased recruitment of excitatory neurons.

Pathological high frequency oscillations associate with increased GABA synaptic activity in pediatric epilepsy surgery patients

Pathological high-frequency oscillations (HFOs), specifically fast ripples (FRs, >250 Hz), are pathognomonic of an active epileptogenic zone. However, the origin of FRs remains unknown. Here we explored the correlation between FRs recorded with intraoperative pre-resection electrocorticography (ECoG) and spontaneous synaptic activity recorded ex vivo from cortical tissue samples resected for the treatment of pharmacoresistant epilepsy. The cohort included 47 children (ages 0.22-9.99 yr) with focal cortical dysplasias (CD types I and II), tuberous sclerosis complex (TSC) and non-CD pathologies. Whole-cell patch clamp recordings were obtained from pyramidal neurons and interneurons in cortical regions that were positive or negative for pathological HFOs, defined as FR band oscillations (250-500 Hz) at ECoG. The frequency of spontaneous excitatory and inhibitory postsynaptic currents (sEPSCs and IPSCs, respectively) was compared between HFO+ and HFO- regions. Regardless of pathological substrate, regions positive for FRs displayed significantly increased frequencies of sIPSCs compared with regions negative for FRs. In contrast, the frequency of sEPSCs was similar in both regions. In about one third of cases (n = 17), pacemaker GABA synaptic activity (PGA) was observed. In the vast majority (n = 15), PGA occurred in HFO+ areas. Further, fast-spiking interneurons displayed signs of hyperexcitability exclusively in HFO+ areas. These results indicate that, in pediatric epilepsy patients, increased GABA synaptic activity is associated with interictal FRs in the epileptogenic zone and suggest an active role of GABAergic interneurons in the generation of pathological HFOs. Increased GABA synaptic activity could serve to dampen excessive excitability of cortical pyramidal neurons in the epileptogenic zone, but it could also promote neuronal network synchrony.

Paradoxical effects of optogenetic stimulation in mesial temporal lobe epilepsy

OBJECTIVE

To establish the effects induced by long-term, unilateral stimulation of parvalbumin (PV)-positive interneurons on seizures, interictal spikes, and high-frequency oscillations (80-500Hz) occurring after pilocarpine-induced status epilepticus (SE)-a proven model of mesial temporal lobe epilepsy (MTLE)-in transgenic mice expressing or not expressing ChR2.

METHODS

PV-ChR2 (n = 6) and PV-Cre (n = 6) mice were treated with pilocarpine to induce SE. Three hours after SE onset, unilateral optogenetic stimulation (450nm, 25mW, 20-millisecond pulses delivered at 8Hz for 30 seconds every 2 minutes) of CA3 PV-positive interneurons was implemented for 14 continuous days in both groups.

RESULTS

Rates of seizures (p < 0.01), interictal spikes (p < 0.001), and interictal spikes with fast ripples (250-500Hz) (p < 0.001) were lower in PV-ChR2 than in PV-Cre mice. Ripples (80-200Hz) occurring outside of interictal spikes had higher rates in the PV-ChR2 group (p < 0.01), whereas isolated fast ripples had lower rates (p < 0.01). However, seizure probability was higher during optogenetic stimulation in PV-ChR2 compared to PV-Cre animals (p < 0.05).

INTERPRETATION

Our findings show that the unilateral activation of CA3 PV-positive interneurons exerts anti-ictogenic effects associated with decreased rates of interictal spikes and fast ripples in this MTLE model. However, PV-positive interneuron stimulation can paradoxically trigger seizures in epileptic animals, supporting the notion that γ-aminobutyric acid type A signaling can also initiate ictogenesis. ANN NEUROL 2019;86:714-728.

Therapy for acute nerve agent poisoning: An update

Purpose of review

Acute nerve agent poisoning was last reviewed in the neurology literature in 2004. As neurologists may expect to be called upon by non-neurologist colleagues as local experts, it is timely to update the 2004 review.

Recent findings

Acute antidotal therapy for nerve agent poisoning has been rendered simpler and faster by the FDA approval and introduction of the dual-dose autoinjector. Although there are no truly new fielded antidotes, midazolam recently received FDA approval for treatment against seizures, and will replace diazepam in most acute situations when the FDA approves it in the autoinjector form. Information on acute therapy is much more easily accessed in real time now than in 2004, thanks to efforts by the National Library of Medicine and the American College of Medical Toxicology.

Summary

Since 2004, there have been changes in antidotal therapy and a robust expansion in familiarity with nerve agent management principles in the civilian sector. These advances are somewhat offset by the increased use of nerve agents for nefarious purposes.

Redaction of false high frequency oscillations due to muscle artifact improves specificity to epileptic tissue

OBJECTIVE

High Frequency Oscillations (HFOs) are a promising biomarker of epilepsy. HFOs are typically acquired on intracranial electrodes, but contamination from muscle artifacts is still problematic in HFO analysis. This paper evaluates the effect of myogenic artifacts on intracranial HFO detection and how to remove them.

METHODS

Intracranial EEG was recorded in 31 patients. HFOs were detected for the entire recording using an automated algorithm. When available, simultaneous scalp EEG was used to identify periods of muscle artifact. Those markings were used to train an automated scalp EMG detector and an intracranial EMG detector. Specificity to epileptic tissue was evaluated by comparison with seizure onset zone and resected volume in patients with good outcome.

RESULTS

EMG artifacts are frequent and produce large numbers of false HFOs, especially in the anterior temporal lobe. The scalp and intracranial EMG detectors both had high accuracy. Removing false HFOs improved specificity to epileptic tissue.

CONCLUSIONS

Evaluation of HFOs requires accounting for the effect of muscle artifact. We present two tools that effectively mitigate the effect of muscle artifact on HFOs.

SIGNIFICANCE

Removing muscle artifacts improves the specificity of HFOs to epileptic tissue. Future HFO work should account for this effect, especially when using automated algorithms or when scalp electrodes are not present.

Unit firing and oscillations at seizure onset in epileptic rodents

Epileptic seizures result from a variety of pathophysiological processes, evidenced by different electrographic ictal onset patterns, as seen on direct brain recordings. The two most common electrographic patterns of focal ictal onset in patients are hypersynchronous (HYP) and low-voltage fast (LVF). Whereas LVF ictal onsets were believed to result from disinhibition; based on similarities with absence seizures, focal HYP ictal onsets were believed to result from increased synchronizing inhibition. Recent findings, however, suggest the differences between these seizure onset types are more complicated and, in some cases, the opposite of these concepts are true. The following review presents evidence that a reduction of tonic inhibition on small pathologically interconnected neuron (PIN) clusters generating pathological high-frequency oscillations (pHFOs), which reflect abnormal synchronously bursting neurons may be the cause of HYP ictal onsets. Increased inhibition preceding LVF ictal onsets are discussed in other reviews in this issue. We postulate that neuronal cell loss following epileptogenic insults can result in structural reorganization, giving rise to small PIN clusters, which generate pHFOs. These clusters have a heterogeneous distribution and are spatially stable over time. Studies have demonstrated that a transient reduction in tonic inhibition causes these clusters to increase in size. This could result in consolidation and synchronization of pHFOs until a critical mass leads to propagation of HYP ictal discharges. Viewed within a network neuroscience framework, local disturbances such as PIN clusters are likely to contribute to large-scale brain network alterations: a better understanding of these epileptogenic networks promises to elucidate mechanisms of ictogenesis, epileptogenesis, and certain comorbidities of epilepsy.

High-frequency oscillations and focal seizures in epileptic rodents

High-pass filtering (> 80 Hz) of EEG signals has enabled neuroscientists to analyze high-frequency oscillations (HFOs; i.e., ripples: 80-200 Hz and fast ripples: 250-500 Hz) in epileptic patients presenting with focal seizures and in animal models mimicking this condition. Evidence obtained from these studies indicate that HFOs mirror pathological network activity that may initiate and sustain ictogenesis and epileptogenesis. HFOs are observed in temporal lobe regions of epileptic animals during interictal periods but they also occur before seizure onset and during the ictal period, suggesting that they can pinpoint to the mechanisms of seizure generation. Accordingly, ripples and fast ripples predominate during two specific seizure onset patterns termed low-voltage fast and hypersynchronous, respectively. In this review we will: (i) summarize these experimental studies; (ii) consider the evolution of HFOs over time during epileptogenesis; (iii) address data obtained with optogenetic stimulating procedures both in vitro and in vivo, and (iv) take into account the impact of anti-epileptic drugs on HFOs. We expect these findings to contribute to understanding the neuronal mechanisms leading to ictogenesis and epileptogenesis thus leading to the development of mechanistically targeted anti-epileptic strategies.

Docosanoids and elovanoids from omega-3 fatty acids are pro-homeostatic modulators of inflammatory responses, cell damage and neuroprotection

The functional significance of the selective enrichment of the omega-3 essential fatty acid docosahexaenoic acid (DHA; 22C and 6 double bonds) in cellular membrane phospholipids of the nervous system is being clarified by defining its specific roles on membrane protein function and by the uncovering of the bioactive mediators, docosanoids and elovanoids (ELVs). Here, we describe the preferential uptake and DHA metabolism in photoreceptors and brain as well as the significance of the Adiponectin receptor 1 in DHA retention and photoreceptor cell (PRC) survival. We now know that this integral membrane protein is engaged in DHA retention as a necessary event for the function of PRCs and retinal pigment epithelial (RPE) cells. We present an overview of how a) NPD1 selectively mediates preconditioning rescue of RPE and PR cells; b) NPD1 restores aberrant neuronal networks in experimental epileptogenesis; c) the decreased ability to biosynthesize NPD1 in memory hippocampal areas of early stages of Alzheimer's disease takes place; d) NPD1 protection of dopaminergic circuits in an in vitro model using neurotoxins; and e) bioactivity elicited by DHA and NPD1 activate a neuroprotective gene-expression program that includes the expression of Bcl-2 family members affected by Aβ42, DHA, or NPD1. In addition, we highlight ELOVL4 (ELOngation of Very Long chain fatty acids-4), specifically the neurological and ophthalmological consequences of its mutations, and their role in providing precursors for the biosynthesis of ELVs. Then we outline evidence of ELVs ability to protect RPE cells, which sustain PRC integrity. In the last section, we present a summary of the protective bioactivity of docosanoids and ELVs in experimental ischemic stroke. The identification of early mechanisms of neural cell survival mediated by DHA-synthesized ELVs and docosanoids contributes to the understanding of cell function, pro-homeostatic cellular modulation, inflammatory responses, and innate immunity, opening avenues for prevention and therapeutic applications in neurotrauma, stroke and neurodegenerative diseases.

Nonictal EEG biomarkers for diagnosis and treatment

There are no reliable nonictal biomarkers for epilepsy, electroencephalography (EEG) or otherwise, but efforts to identify biomarkers that would predict the development of epilepsy after a potential epileptogenic insult, diagnose the existence of epilepsy, or assess the effects of antiseizure or antiepileptogenic interventions are relying heavily on electrophysiology. The most promising EEG biomarkers to date are pathologic high‐frequency oscillations (pHFOs), brief EEG events in the range of 100 to 600 Hz, which are believed to reflect summated action potentials from synchronously bursting neurons. Studies of patients with epilepsy, and experimental animal models, have been based primarily on direct brain recording, which makes pHFOs potentially useful for localizing the epileptogenic zone for surgical resection, but application for other diagnostic and therapeutic purposes is limited. Consequently, recent efforts have involved identification of HFOs recorded with scalp electrodes, and with magnetoencephalography, which may reflect the same pathophysiologic mechanisms as pHFOs recorded directly from the brain. The search is also on for other EEG changes that might serve as epilepsy biomarkers, and candidates include arcuate rhythms, which may reflect repetitive pHFOs, reduction in theta rhythm, which correlates with epileptogenesis in several rodent models of epilepsy, and shortened sleep spindles that correlate with ictogenesis.

Midazolam-Resistant Seizures and Brain Injury after Acute Intoxication of Diisopropylfluorophosphate, an Organophosphate Pesticide and Surrogate for Nerve Agents

Organophosphates (OP) such as the pesticide diisopropylfluorophosphate (DFP) and the nerve agent sarin are lethal chemicals that induce seizures, status epilepticus (SE), and brain damage. Midazolam, a benzodiazepine modulator of synaptic GABA-A receptors, is currently considered as a new anticonvulsant for nerve agents. Here, we characterized the time course of protective efficacy of midazolam (0.2-5 mg/kg, i.m.) in rats exposed to DFP, a chemical threat agent and surrogate for nerve agents. Behavioral and electroencephalogram (EEG) seizures were monitored for 24 hours after DFP exposure. The extent of brain injury was determined 3 days after DFP exposure by unbiased stereologic analyses of valid markers of neurodegeneration and neuroinflammation. Seizures were elicited within ∼8 minutes after DFP exposure that progressively developed into persistent SE lasting for hours. DFP exposure resulted in massive neuronal injury or necrosis, neurodegeneration of principal cells and interneurons, and neuroinflammation as evident by extensive activation of microglia and astrocytes in the hippocampus, amygdala, and other brain regions. Midazolam controlled seizures, neurodegeneration, and neuroinflammation when given early (10 minutes) after DFP exposure, but it was less effective when given at 40 minutes or later. Delayed therapy (≥40 minutes), a simulation of the practical therapeutic window for first responders or hospital admission, was associated with reduced seizure protection and neuroprotection. These results strongly reaffirm that the DFP-induced seizures and brain damage are progressively resistant to delayed treatment with midazolam, confirming the benzodiazepine refractory SE after OP intoxication. Thus, novel anticonvulsants superior to midazolam or adjunct therapies that enhance its efficacy are needed for effective treatment of refractory SE.

Epilepsy

Epilepsy affects all age groups and is one of the most common and most disabling neurological disorders. The accurate diagnosis of seizures is essential as some patients will be misdiagnosed with epilepsy, whereas others will receive an incorrect diagnosis. Indeed, errors in diagnosis are common, and many patients fail to receive the correct treatment, which often has severe consequences. Although many patients have seizure control using a single medication, others require multiple medications, resective surgery, neuromodulation devices or dietary therapies. In addition, one-third of patients will continue to have uncontrolled seizures. Epilepsy can substantially impair quality of life owing to seizures, comorbid mood and psychiatric disorders, cognitive deficits and adverse effects of medications. In addition, seizures can be fatal owing to direct effects on autonomic and arousal functions or owing to indirect effects such as drowning and other accidents. Deciphering the pathophysiology of epilepsy has advanced the understanding of the cellular and molecular events initiated by pathogenetic insults that transform normal circuits into epileptic circuits (epileptogenesis) and the mechanisms that generate seizures (ictogenesis). The discovery of >500 genes associated with epilepsy has led to new animal models, more precise diagnoses and, in some cases, targeted therapies.

Detection of fast (40-150 Hz) oscillations from the ictal scalp EEG data of myoclonic seizures in pediatric patients

OBJECTIVE

We explored fast (40-150 Hz) oscillations (FOs) from the ictal scalp electroencephalogram (EEG) data of myoclonic seizures in pediatric patients to obtain insight into the pathophysiological mechanisms involved in the generation of myoclonic seizures.

SUBJECTS AND METHODS

The participants were 21 children (11 boys, 10 girls; age ranging from 5 months to 17 years 2 months) with myoclonic seizures associated with generalized (poly)spike-wave bursts in the ictal EEG data. The patients had heterogeneous etiologies and epilepsy diagnoses. In the ictal data, we detected FOs that clearly showed oscillatory morphology in filtered EEG traces and an outstanding spectral blob in time-frequency analysis.

RESULTS

We identified FOs in 61 (88.4%) of all 69 myoclonic seizures. Every patient had at least one myoclonic seizure-associated FO. The observed FOs were embedded in the spike component of (poly)spike-wave discharges, and they had a focal distribution with frontal predominance. They ranged in frequency from 41.0 to 123.0 Hz and involved both the gamma and ripple bands, and their spectral peak frequencies were higher in the group of patients with a genetic background free of apparent fundamental brain pathology than in the group of other patients (p = 0.019).

CONCLUSION

FOs were found to represent at least part of the cortical pathophysiological process in the generation of myoclonic seizures that should involve the thalamocortical network system.

Spatiotemporal changes in regularity of gamma oscillations contribute to focal ictogenesis

In focal ictogenesis, gamma oscillations (30–70 Hz) recorded by electroencephalography (EEG) are related to the epileptiform synchronization of interneurons that links the seizure onset zone (SOZ) to the surrounding epileptogenic zone. We hypothesized that the synchronization of interneurons could be detected as changes in the regularity of gamma oscillation rhythmicity. We used multiscale entropy (MSE) analysis, which can quantify the regularity of EEG rhythmicity, to investigate how the regularity of gamma oscillations changes over the course of a seizure event. We analyzed intracranial EEG data from 13 pediatric patients with focal cortical dysplasia. The MSE analysis revealed the following characteristic changes of MSE score (gamma oscillations): (1) during the interictal periods, the lowest MSE score (the most regular gamma oscillations) was always found in the SOZ; (2) during the preictal periods, the SOZ became more similar to the epileptogenic zone as the MSE score increased in the SOZ (gamma oscillations became less regular in the SOZ); and (3) during the ictal periods, a decreasing MSE score (highly regular gamma oscillations) propagated over the epileptogenic zone. These spatiotemporal changes in regularity of gamma oscillations constitute an important demonstration that focal ictogenesis is caused by dynamic changes in interneuron synchronization.

High frequency activity overriding cortico-cortical evoked potentials reflects altered excitability in the human epileptic focus

OBJECTIVE

We aimed to clarify that high frequency activity (HFA) of cortico-cortical evoked potentials (CCEPs), elicited by single pulse electrical stimulation (SPES), reflects cortical excitability.

METHODS

We recruited 16 patients with refractory partial epilepsy who had chronic subdural electrode implantation for presurgical evaluation. A repetitive SPES was given to (1) the seizure onset zone (SOZ) and (2) the control cortices (non-seizure onset zone: nSOZ). CCEPs were recorded from the neighboring cortices within SOZ and nSOZ. We applied short-time Fourier transform to obtain the induced responses for the timing of early (<50ms after SPES) and late CCEP components and analyzed the logarithmic power change for ripple (<200Hz) and fast ripple (>200Hz) bands.

RESULTS

Twenty-one clear CCEPs were recorded for both the SOZ and nSOZ. The HFA power of early CCEPs in SOZ significantly increased compared to that in nSOZ in both frequency bands, particularly in mesial temporal lobe epilepsy (MTLE).

CONCLUSION

Similar to the features of spontaneous pathological HFOs, the power of stimulus-induced HFAs in SOZ were greater than that outside SOZ, particularly in MTLE.

SIGNIFICANCE

HFA overriding CCEPs can be a surrogate marker of cortical excitability in epileptic focus.

Update on the mechanisms and roles of high-frequency oscillations in seizures and epileptic disorders

High-frequency oscillations (HFOs) are a type of brain activity that is recorded from brain regions capable of generating seizures. Because of the close association of HFOs with epileptogenic tissue and ictogenesis, understanding their cellular and network mechanisms could provide valuable information about the organization of epileptogenic networks and how seizures emerge from the abnormal activity of these networks. In this review, we summarize the most recent advances in the field of HFOs and provide a critical evaluation of new observations within the context of already established knowledge. Recent improvements in recording technology and the introduction of optogenetics into epilepsy research have intensified experimental work on HFOs. Using advanced computer models, new cellular substrates of epileptic HFOs were identified and the role of specific neuronal subtypes in HFO genesis was determined. Traditionally, the pathogenesis of HFOs was explored mainly in patients with temporal lobe epilepsy and in animal models mimicking this condition. HFOs have also been reported to occur in other epileptic disorders and models such as neocortical epilepsy, genetically determined epilepsies, and infantile spasms, which further support the significance of HFOs in the pathophysiology of epilepsy. It is increasingly recognized that HFOs are generated by multiple mechanisms at both the cellular and network levels. Future studies on HFOs combining novel high-resolution in vivo imaging techniques and precise control of neuronal behavior using optogenetics or chemogenetics will provide evidence about the causal role of HFOs in seizures and epileptogenesis. Detailed understanding of the pathophysiology of HFOs will propel better HFO classification and increase their information yield for clinical and diagnostic purposes.

High-frequency oscillations and mesial temporal lobe epilepsy

The interest of epileptologists has recently shifted from the macroscopic analysis of interictal spikes and seizures to the microscopic analysis of short events in the EEG that are not visible to the naked eye but are observed once the signal has been filtered in specific frequency bands. With the use of new technologies that allow multichannel recordings at high sampling rates and the development of computer algorithms that permit the automated analysis of extensive amounts of data, it is now possible to extract high-frequency oscillations (HFOs) between 80 and 500Hz from the EEG; HFOs have been further categorised as ripples (80-200Hz) and fast ripples (250-500Hz). Within the context of epileptic disorders, HFOs should reflect the pathological activity of neural networks that sustain seizure generation, and could serve as biomarkers of epileptogenesis and ictogenesis. We review here the presumptive cellular mechanisms of ripples and fast ripples in mesial temporal lobe epilepsy. We also focus on recent findings regarding the occurrence of HFOs during epileptiform activity observed in in vitro models of epileptiform synchronization, in in vivo models of mesial temporal lobe epilepsy and in epileptic patients. Finally, we address the effects of anti-epileptic drugs on HFOs and raise some questions and issues related to the definition of HFOs.

Non-harmonicity in high-frequency components of the intra-operative corticogram to delineate epileptogenic tissue during surgery

OBJECTIVE

We aimed to test the potential of auto-regressive model residual modulation (ARRm), an artefact-insensitive method based on non-harmonicity of the high-frequency signal, to identify epileptogenic tissue during surgery.

METHODS

Intra-operative electrocorticography (ECoG) of 54 patients with refractory focal epilepsy were recorded pre- and post-resection at 2048Hz. The ARRm was calculated in one-minute epochs in which high-frequency oscillations (HFOs; fast ripples, 250-500Hz; ripples, 80-250Hz) and spikes were marked. We investigated the pre-resection fraction of HFOs and spikes explained by the ARRm (h²-index). A general ARRm threshold was set and used to compare the ARRm to surgical outcome in post-resection ECoG (Pearson X²).

RESULTS

ARRm was associated strongest with the number of fast ripples in pre-resection ECoG (h²=0.80, P<0.01), but also with ripples and spikes. An ARRm threshold of 0.47 yielded high specificity (95%) with 52% sensitivity for channels with fast ripples. ARRm values >0.47 were associated with poor outcome at channel and patient level (both P<0.01) in post-resection ECoG.

CONCLUSIONS

The ARRm algorithm might enable intra-operative delineation of epileptogenic tissue.

SIGNIFICANCE

ARRm is the first unsupervised real-time analysis that could provide an intra-operative, 'on demand' interpretation per electrode about the need to remove underlying tissue to optimize the chance of seizure freedom.