Epileptogenesis and rational therapeutic strategies

Transient use of a systemic adenosine kinase inhibitor attenuates epilepsy development in mice

OBJECTIVE

Over one-third of all patients with epilepsy are refractory to treatment and there is an urgent need to develop new drugs that can prevent the development and progression of epilepsy. Epileptogenesis is characterized by distinct histopathologic and biochemical changes, which include astrogliosis and increased expression of the adenosine-metabolizing enzyme adenosine kinase (ADK; EC 2.7.1.20). Increased expression of ADK contributes to epileptogenesis and is therefore a target for therapeutic intervention. We tested the prediction that the transient use of an ADK inhibitor administered during the latent phase of epileptogenesis can mitigate the development of epilepsy.

METHODS

We used the intrahippocampal kainic acid (KA) mouse model of temporal lobe epilepsy, which is characterized by ipsilateral hippocampal sclerosis with granule cell dispersion and the development of recurrent hippocampal paroxysmal discharges (HPDs). KA-injected mice were treated with the ADK inhibitor 5-iodotubercidin (5-ITU, 1.6 mg/kg, b.i.d., i.p.) during the latent phase of epileptogenesis from day 3-8 after injury; the period when gradual increases in hippocampal ADK expression begin to manifest. HPDs were assessed at 6 and 9 weeks after KA administration followed by epilepsy histopathology including assessment of granule cell dispersion, astrogliosis, and ADK expression.

RESULTS

5-ITU significantly reduced the percent time in seizures by at least 80% in 56% of mice at 6 weeks post-KA. This reduction in seizure activity was maintained in 40% of 5-ITU-treated mice at 9 weeks. 5-ITU also suppressed granule cell dispersion and prevented maladaptive ADK increases in these protected mice.

SIGNIFICANCE

Our results show that the transient use of a small-molecule ADK inhibitor, given during the early stages of epileptogenesis, has antiepileptogenic disease-modifying properties, which provides the rationale for further investigation into the development of a novel class of antiepileptogenic ADK inhibitors with increased efficacy for epilepsy prevention.

Wnt/β-catenin signaling as a potential target for novel epilepsy therapies

Epilepsy is one of the most common neurological disorders, and yet many afflicted individuals are resistant to all available therapeutic treatments. Existing pharmaceutical treatments function primarily to reduce hyperexcitability and prevent seizures, but fail to influence the underlying pathophysiology of the disorder. Recently, research efforts have focused on identifying alternative mechanistic targets for anti-epileptogenic therapies that can prevent the development of chronic epilepsy. The Wnt/β-catenin pathway, one possible target, has been demonstrated to be disrupted in both acute and chronic phases of epilepsy. Wnt/β-catenin signaling can regulate many seizure-induced changes in the brain, including neurogenesis and neuronal death, as well as can influence seizure susceptibility and potentially the development of chronic epilepsy. Several genome-wide studies and in vivo knockout animal models have provided evidence for an association between disrupted Wnt/β-catenin signaling and epilepsy. Furthermore, approved pharmaceutical drugs and other small molecule compounds that target components of the β-catenin destruction complex or antagonize endogenous inhibitors of the pathway have shown to be protective following seizures. However, additional studies are needed to determine the optimal time period in which modulation of the pathway may be most beneficial. Overall, disrupted molecular networks such as Wnt/β-catenin signaling, could be a promising anti-epileptogenic target for future epilepsy therapies.

Analysis of EEG dynamics in epileptic children during carbamazepine therapy

Background: The analysis of the dynamics of background EEG characteristics on the different stages of CBZtherapy is very important for revealing the possible early predictors of benefit/adverse effects of the treatment and optimizing the anti-epileptic therapy. Objective: Evaluate the carbamazepine (CBZ) effect on the dynamics of EEG pattern in epileptic children at different stages of CBZ-monotherapy. Methods: Forty-five children (aged 3-9) with partial epilepsy were investigated. The EEG was recorded at rest and during functional tests prior to CBZ administration and three and six months after the initiation of CBZtherapy. Epileptiform graphoelements and baseline EEG activities were analyzed. Results: Following three months of CBZ-therapy an absolute power value in the low frequency bands of EEG spectrum increased while an average frequency of alpha waves decreased. During rest, CBZ reduced density of spontaneous epileptiform graphoelements and generalized epileptiform bursts. Generalized paroxysmal bursts decreased under functional tests. The EEG pattern maintained the same characteristics for six months. Deterioration of EEG pattern and clinical signs was observed in four children. Conclusion: Elevation of indices of low frequency bands, especially in occipital and parietal regions, concomitant with reduction of epileptiform elements and seizure frequency three months after initiation of therapy suggests that CBZ in appropriate doses might be continued. Otherwise, the strategy of antiepileptic therapy should be revised.

Pharmacotherapy in pediatric epilepsy: from trial and error to rational drug and dose selection - a long way to go

INTRODUCTION

Whereas ongoing efforts in epilepsy research focus on the underlying disease processes, the lack of a physiologically based rationale for drug and dose selection contributes to inadequate treatment response in children. In fact, limited information on the interindividual variation in pharmacokinetics and pharmacodynamics of anti-epileptic drugs (AEDs) in children drive prescription practice, which relies primarily on dose regimens according to a mg/kg basis. Such practice has evolved despite advancements in pediatric pharmacology showing that growth and maturation processes do not correlate linearly with changes in body size.

AREAS COVERED

In this review we aim to provide 1) a comprehensive overview of the sources of variability in the response to AEDs, 2) insight into novel methodologies to characterise such variation and 3) recommendations for treatment personalisation.

EXPERT OPINION

The use of pharmacokinetic-pharmacodynamic principles in clinical practice is hindered by the lack of biomarkers and by practical constraints in the evaluation of polytherapy. The identification of biomarkers and their validation as tools for drug development and therapeutics will require some time. Meanwhile, one should not miss the opportunity to integrate the available pharmacokinetic data with modeling and simulation concepts to prevent further delays in the development of personalised treatments for pediatric patients.

Antiepileptogenic effect of curcumin on kainate-induced model of temporal lobe epilepsy

CONTEXT

Temporal lobe epilepsy (TLE) is an intractable neurological disorder. Curcumin is the bioactive component of turmeric with anti-epileptic and neuroprotective potential.

OBJECTIVE

The beneficial effect of curcumin on the intrahippocampal kainate-induced model of TLE was investigated.

MATERIALS AND METHODS

Rats were divided into sham, curcumin-pretreated sham, kainate and curcumin-pretreated kainate groups. The rat model of TLE was induced by unilateral intrahippocampal injection of 4 μg of kainate. Rats received curcumin p.o. at a dose of 100 mg/kg/d starting 1 week before the surgery. Seizure activity (SE) and oxidative stress-related markers were measured. Furthermore, the Timm index for evaluation of mossy fiber sprouting (MFS) and number of Nissl-stained neurons were quantified.

RESULTS

All rats in the kainate group had SE, while 28.5% of rats showed seizures in the curcumin-pretreated kainate group. Malondialdehyde and nitrite and nitrate levels significantly increased in the kainate group (p < 0.01 and p < 0.05, respectively), and curcumin significantly lowered these parameters (p < 0.05). Superoxide dismutase activity significantly decreased in the kainate group (p < 0.05) and curcumin did not improve it. Rats in the kainate group showed a significant reduction of neurons in Cornu Ammonis 1 (CA1) (p < 0.05), CA3 (p < 0.005) and hilar (p < 0.01) regions, and curcumin significantly prevented these changes (p < 0.05-0.005). The Timm index significantly increased in the kainate group (p < 0.005), and curcumin significantly lowered this index (p < 0.01).

DISCUSSION AND CONCLUSION

Curcumin pretreatment can attenuate seizures, lower some oxidative stress markers, and prevent hippocampal neuronal loss and MFS in the kainate-induced model of TLE.

Interictal spikes, fast ripples and seizures in partial epilepsies--combining multi-level computational models with experimental data

Epileptic seizures, epileptic spikes and high-frequency oscillations (HFOs) are recognized as three electrophysiological markers of epileptogenic neuronal systems. It can be reasonably hypothesized that distinct (hyper)excitability mechanisms underlie these electrophysiological signatures. The question is 'What are these mechanisms?'. Solving this difficult question would considerably help our understanding of epileptogenic processes and would also advance our interpretation of electrophysiological signals. In this paper, we show how computational models of brain epileptic activity can be used to address this issue. With a special emphasis on the hippocampal activity recorded in various experimental models (in vivo and in vitro) as well as in epileptic patients, we confront results and insights we can get from computational models lying at two different levels of description, namely macroscopic (neural mass) and microscopic (detailed network of neurons). At each level, we show how spikes, seizures and HFOs can (or cannot) be generated depending on the model features. The replication of observed signals, the prediction of possible mechanisms as well as their experimental validation are described and discussed; as are the advantages and limitations of the two modelling approaches.

Coenzyme q10 ameliorates neurodegeneration, mossy fiber sprouting, and oxidative stress in intrahippocampal kainate model of temporal lobe epilepsy in rat

Temporal lobe epilepsy (TLE) is the most common form of epilepsy in adults and the most resistant type to treatment. Novel treatment approaches are strongly required to prevent or even reverse the cellular and molecular mechanisms of epileptogenesis. In this study, we investigated the possible neuroprotective effect of coenzyme Q10 (CoQ10) in an intrahippocampal kainate model of TLE in rat. Kainate injection caused a higher seizure severity during status epilepticus and spontaneous seizure phases, and CoQ10 pretreatment significantly attenuated its severity and incidence rate. Intrahippocampal kainate also led to elevation of malondialdehyde (MDA) and nitrite, and CoQ10 significantly attenuated the increased MDA and nitrite content. In addition, intrahippocampal kainate induced a significant degeneration of neurons in CA1, CA3, and hilar regions of the hippocampus, and CoQ10 significantly attenuated these changes in CA1 and CA3 regions. Timm's staining data showed a robust mossy fiber sprouting (MFS) in dentate gyrus of kainate-lesioned rats and CoQ10 significantly lowered MFS intensity. These data suggest that CoQ10 pretreatment could attenuate spontaneous recurrent seizures and inhibit hippocampal neuronal loss and aberrant MFS in kainate-induced model of TLE in rat, and part of its beneficial effect is due to its potential to mitigate oxidative stress.

Non-linear classification of heart rate parameters as a biomarker for epileptogenesis

PURPOSE

To characterize a biomarker for epileptogenesis based on cardiac interbeat interval characteristics.

METHODS

Electrocardiograph (ECG) and electroencephalogram (EEG) signals were recorded from freely moving rats (n = 23) before status epilepticus (SE) induced by i.p. pilocarpine (PILO) injection as baseline, and on days 1, 3 and 7 after SE. We assessed several features from cardiac interbeat intervals, including linear, non-linear and frequency parameters of interbeat intervals, and power spectra of interpolated intervals during epileptogenesis. After thresholding, the altered values were applied to a non-linear classifier. The non-linear classifier divided animals into two groups; with and without epilepsy, based on all collected data.

RESULTS

We found that none of the single altered parameters in cardiac activity emerged as a sole biomarker for epileptogenesis. However, the non-linear classifier distinguished animals that later developed from those and did not develop epilepsy. The non-linear classification was performed on preliminary findings from 23 animals; six did not develop epilepsy and the rest did. The average positive predictive value (precision rate) was 78%. This was calculated based on the average sensitivity and specificity, which were 80.6% and 35.2% respectively, for the 100 classification passes. We also showed that these numbers would have increased as the number of subjects increased.

CONCLUSION

Changes to the brain caused by status epilepticus that lead to epileptogenesis have systemic effects, and alter cardiac activity. A non-linear classifier performed on several extracted features of cardiac interbeat intervals may be useful as a biomarker to identify animals with low and high probability of developing epilepsy after status epilepticus.

Intractable epilepsy in paralimbic Word Health Organization Grade II gliomas: should the hippocampus be resected when not invaded by the tumor?

OBJECT

Beyond its oncological benefit, surgery could improve seizure control in paralimbic frontotemporoinsular or temporoinsular WHO Grade II gliomas generating intractable seizures. However, no studies have examined the impact of hippocampal resection on chronic epilepsy when the hippocampus is not invaded by Grade II gliomas. Here, the authors compared the epileptological outcomes and return to work in 2 groups of patients who underwent surgery with or without hippocampectomy for paralimbic Grade II gliomas eliciting intractable epilepsy despite no tumoral involvement of the hippocampus.

METHODS

Surgery was performed in 15 consecutive patients who were unable to work (median Karnofsky Performance Scale [KPS] Score 70) because of refractory epilepsy due to paralimbic Grade II gliomas that were not invading the hippocampus. In Group A (8 patients), the hippocampus was preserved. In Group B (7 patients), glioma removal was associated with hippocampectomy.

RESULTS

No patient died or suffered a permanent deficit after surgery. Postoperatively, in Group A, no patients were seizure free (4 patients were in Engel Class II and 4 were in Class III). In Group B, all 7 patients were seizure free (Class I) (p = 0.02). Only 62.5% of patients returned to work in Group A, whereas all patients are working full time in Group B. The postsurgical median KPS score was 85 in Group A, that is, not significantly improved in comparison with the preoperative score, while the postsurgical median KPS was 95 in Group B, that is, significantly improved in comparison with the preoperative score (p = 0.03).

CONCLUSIONS

The authors' data support, for the first time, the significant impact of hippocampectomy in patients with intractable epilepsy generated by a paralimbic Grade II glioma, even if it does not invade the hippocampus. Hippocampal resection allowed seizure control in all patients, with an improvement in KPS scores, since all patients resumed their social and professional activities. Thus, the authors suggest performing a resection of the nontumoral hippocampus in addition to resection of the tumor in patients with refractory epilepsy due to paralimbic Grade II gliomas.

Efficacy of anti-inflammatory therapy in a model of acute seizures and in a population of pediatric drug resistant epileptics

Targeting pro-inflammatory events to reduce seizures is gaining momentum. Experimentally, antagonism of inflammatory processes and of blood-brain barrier (BBB) damage has been demonstrated to be beneficial in reducing status epilepticus (SE). Clinically, a role of inflammation in the pathophysiology of drug resistant epilepsies is suspected. However, the use anti-inflammatory drug such as glucocorticosteroids (GCs) is limited to selected pediatric epileptic syndromes and spasms. Lack of animal data may be one of the reasons for the limited use of GCs in epilepsy. We evaluated the effect of the CG dexamethasone in reducing the onset and the severity of pilocarpine SE in rats. We assessed BBB integrity by measuring serum S100β and Evans Blue brain extravasation. Electrophysiological monitoring and hematologic measurements (WBCs and IL-1β) were performed. We reviewed the effect of add on dexamethasone treatment on a population of pediatric patients affected by drug resistant epilepsy. We excluded subjects affected by West, Landau-Kleffner or Lennox-Gastaut syndromes and Rasmussen encephalitis, known to respond to GCs or adrenocorticotropic hormone (ACTH). The effect of two additional GCs, methylprednisolone and hydrocortisone, was also reviewed in this population. When dexamethasone treatment preceded exposure to the convulsive agent pilocarpine, the number of rats developing status epilepticus (SE) was reduced. When SE developed, the time-to-onset was significantly delayed compared to pilocarpine alone and mortality associated with pilocarpine-SE was abolished. Dexamethasone significantly protected the BBB from damage. The clinical study included pediatric drug resistant epileptic subjects receiving add on GC treatments. Decreased seizure frequency (≥50%) or interruption of status epilepticus was observed in the majority of the subjects, regardless of the underlying pathology. Our experimental results point to a seizure-reducing effect of dexamethasone. The mechanism encompasses improvement of BBB integrity. Our results also suggest that add on GCs could be of efficacy in controlling pediatric drug resistant seizures.

Prevention or modification of epileptogenesis after brain insults: experimental approaches and translational research

Diverse brain insults, including traumatic brain injury, stroke, infections, tumors, neurodegenerative diseases, and prolonged acute symptomatic seizures, such as complex febrile seizures or status epilepticus (SE), can induce "epileptogenesis," a process by which normal brain tissue is transformed into tissue capable of generating spontaneous recurrent seizures. Furthermore, epileptogenesis operates in cryptogenic causes of epilepsy. In view of the accumulating information about cellular and molecular mechanisms of epileptogenesis, it should be possible to intervene in this process before the onset of seizures and thereby either prevent the development of epilepsy in patients at risk or increase the potential for better long-term outcome, which constitutes a major clinical need. For identifying pharmacological interventions that prevent, interrupt or reverse the epileptogenic process in people at risk, two groups of animal models, kindling and SE-induced recurrent seizures, have been recommended as potentially useful tools. Furthermore, genetic rodent models of epileptogenesis are increasingly used in assessing antiepileptogenic treatments. Two approaches have been used in these different model categories: screening of clinically established antiepileptic drugs (AEDs) for antiepileptogenic or disease-modifying potential, and targeting the key causal mechanisms that underlie epileptogenesis. The first approach indicated that among various AEDs, topiramate, levetiracetam, carisbamate, and valproate may be the most promising. On the basis of these experimental findings, two ongoing clinical trials will address the antiepileptogenic potential of topiramate and levetiracetam in patients with traumatic brain injury, hopefully translating laboratory discoveries into successful therapies. The second approach has highlighted neurodegeneration, inflammation and up-regulation of immune responses, and neuronal hyperexcitability as potential targets for antiepileptogenesis or disease modification. This article reviews these areas of progress and discusses the challenges associated with discovery of antiepileptogenic therapies.

Regulation of cell death and epileptogenesis by the mammalian target of rapamycin (mTOR): a double-edged sword?

Identification of cell signaling mechanisms mediating seizure-related neuronal death and epileptogenesis is important for developing more effective therapies for epilepsy. The mammalian target of rapamycin (mTOR) pathway has recently been implicated in regulating neuronal death and epileptogenesis in rodent models of epilepsy. In particular, kainate-induced status epilepticus causes abnormal activation of the mTOR pathway, and the mTOR inhibitor, rapamycin, can decrease the development of neuronal death and chronic seizures in the kainate model. Here, we discuss the significance of these findings and extend them further by identifying upstream signaling pathways through which kainate status epilepticus activates the mTOR pathway and by demonstrating limited situations where rapamycin may paradoxically increase mTOR activation and worsen neuronal death in the kainate model. Thus, the regulation of seizure-induced neuronal death and epileptogenesis by mTOR is complex and may have dual, opposing effects depending on the physiological and pathological context. Overall, these findings have important implications for designing potential neuroprotective and antiepileptogenic therapies that modulate the mTOR pathway.

Antiepileptic drug monotherapy: the initial approach in epilepsy management

Antiepileptic drug (AED) monotherapy is the preferred initial management approach in epilepsy care, since most patients may be successfully managed with the first or second monotherapy utilized. This article reviews the rationale and evidence supporting preferential use of monotherapy when possible and guidelines for initiating and successfully employing AED monotherapy. Suggested approaches to consider when patients fail monotherapy include substituting a new AED monotherapy, initiating chronic maintenance AED polytherapy, or pursuit of non-pharmacologic treatments such as epilepsy surgery or vagus nerve stimulation. Reducing AED polytherapy to monotherapy frequently reduces the burden of adverse effects and may also improve seizure control. AED monotherapy remains the optimal approach for managing most patients with epilepsy.

Selection of antiepileptic drugs in adults

Epilepsy affects approximately 50 million people worldwide, with an annual incidence of 50 to 70 cases per 100,000 population. The condition can strike at any time of life, with an immediate impact on everyday activities and routine. Key to optimal management is swift referral to an epilepsy specialist, appropriate investigation, and timely institution of antiepileptic drug therapy. In the past 20 years, the explosion of 13 new agents into the marketplace has greatly increased the potential for therapeutic intervention. This article explores the rationale for treatment selection in adults with epilepsy.

Mammalian target of rapamycin (mTOR) inhibition as a potential antiepileptogenic therapy: From tuberous sclerosis to common acquired epilepsies

Most current treatments for epilepsy are symptomatic therapies that suppress seizures but do not affect the underlying course or prognosis of epilepsy. The need for disease-modifying or "antiepileptogenic" treatments for epilepsy is widely recognized, but no such preventive therapies have yet been established for clinical use. A rational strategy for preventing epilepsy is to target primary signaling pathways that initially trigger the numerous downstream mechanisms mediating epileptogenesis. The mammalian target of rapamycin (mTOR) pathway represents a logical candidate, because mTOR regulates multiple cellular functions that may contribute to epileptogenesis, including protein synthesis, cell growth and proliferation, and synaptic plasticity. The importance of the mTOR pathway in epileptogenesis is best illustrated by tuberous sclerosis complex (TSC), one of the most common genetic causes of epilepsy. In mouse models of TSC, mTOR inhibitors prevent the development of epilepsy and underlying brain abnormalities associated with epileptogenesis. Accumulating evidence suggests that mTOR also participates in epileptogenesis due to a variety of other causes, including focal cortical dysplasia and acquired brain injuries, such as in animal models following status epilepticus or traumatic brain injury. Therefore, mTOR inhibition may represent a potential antiepileptogenic therapy for diverse types of epilepsy, including both genetic and acquired epilepsies.

Developing Antiepileptogenic Drugs for Acquired Epilepsy: Targeting the Mammalian Target of Rapamycin (mTOR) Pathway

While current medications for epilepsy are primarily symptomatic treatments that suppress seizures, one of the main goals of future drug development in epilepsy is the identification of antiepileptogenic or disease-modifying therapies that can completely prevent epilepsy or slow its progression. A rational antiepileptogenic strategy is to target primary cell signaling pathways that initially trigger the downstream mechanisms causing epileptogenesis. Recent work implicates the mammalian target of rapamycin (mTOR) pathway as mediating epileptogenesis in a genetic epilepsy, Tuberous Sclerosis Complex (TSC), and suggests that mTOR inhibitors, such as rapamycin, may have antiepileptogenic properties for epilepsy in TSC. As mTOR regulates multiple cellular functions that may contribute to epileptogenesis in general, including ion channel expression, synaptic plasticity, and programmed cell death, mTOR inhibitors might also represent an effective antiepileptogenic therapy for other, more common types of epilepsy, such as acquired epilepsies due to brain injuries. Here, we describe evidence from a recently-published study that mTOR mediates epileptogenesis in a popular animal model of acquired limbic epilepsy due to brain injury following kainate-induced status epilepticus, and that rapamycin has antiepileptogenic effects in this model. Furthermore, putative pathways and mechanisms upstream and downstream from mTOR involved in epileptogenesis in the kainite model are considered, identifying possible additional therapeutic targets. Finally, the potential translational applications of this and other animal model data for developing antiepileptogenic therapies for people with acquired epilepsy due to brain injury are discussed.

The mammalian target of rapamycin signaling pathway mediates epileptogenesis in a model of temporal lobe epilepsy

Understanding molecular mechanisms mediating epileptogenesis is critical for developing more effective therapies for epilepsy. We recently found that the mammalian target of rapamycin (mTOR) signaling pathway is involved in epileptogenesis, and mTOR inhibitors prevent epilepsy in a mouse model of tuberous sclerosis complex. Here, we investigated the potential role of mTOR in a rat model of temporal lobe epilepsy initiated by status epilepticus. Acute kainate-induced seizures resulted in biphasic activation of the mTOR pathway, as evident by an increase in phospho-S6 (P-S6) expression. An initial rise in P-S6 expression started approximately 1 h after seizure onset, peaked at 3-6 h, and returned to baseline by 24 h in both hippocampus and neocortex, reflecting widespread stimulation of mTOR signaling by acute seizure activity. After resolution of status epilepticus, a second increase in P-S6 was observed in hippocampus only, which started at 3 d, peaked 5-10 d, and persisted for several weeks after kainate injection, correlating with the development of chronic epileptogenesis within hippocampus. The mTOR inhibitor rapamycin, administered before kainate, blocked both the acute and chronic phases of seizure-induced mTOR activation and decreased kainate-induced neuronal cell death, neurogenesis, mossy fiber sprouting, and the development of spontaneous epilepsy. Late rapamycin treatment, after termination of status epilepticus, blocked the chronic phase of mTOR activation and reduced mossy fiber sprouting and epilepsy but not neurogenesis or neuronal death. These findings indicate that mTOR signaling mediates mechanisms of epileptogenesis in the kainate rat model and that mTOR inhibitors have potential antiepileptogenic effects in this model.

Towards a non-invasive interictal application of hypothermia for treating seizures: a feasibility and pilot study

OBJECTIVES

To evaluate the feasibility and safety of head-neck cooling in conscious normal volunteers (10) and patients with medically refractory epilepsy (5) without causing shivering.

PATIENTS AND METHODS

We used a non-invasive head-neck cooling system (CoolSystems Inc., Lincoln, CA, USA). The tympanic temperature (TT) and intestinal temperature (IT) were measured as two measurements of 'core temperature' (CT), and multi-site external temperatures, several physiologic variables and EEG were monitored. Seizure counts over 4-week precooling, treatment and follow-up phases were compared.

RESULTS

All 15 participants completed all the cooling sessions without significant complaints. At the end of 60 min of cooling, scalp temperature fell on average by 12.2 degrees C (P < 0.001), TT by 1.67 degrees C (P < 0.001), and IT by 0.12 degrees C (P = NS). Average weekly seizure frequency decreased from 2.7 to 1.7 events per patient per week (MANOVA: P < 0.05).

CONCLUSIONS

Non-invasive head-neck cooling is safe and well-tolerated. Initial pilot data in patients suggest that additional therapeutic studies are warranted.

Stabilizing dendritic structure as a novel therapeutic approach for epilepsy

People with epilepsy often experience long-term cognitive dysfunction and other neurological deficits, including memory loss, learning disabilities and neurobehavioral disorders, which may exhibit a progressive course correlating with worsening seizure control. Furthermore, a third of epilepsy patients have seizures that are intractable to all available treatments. Thus, novel therapies for seizures and the neurological comorbidities of epilepsy are desperately needed. As most current treatments are merely symptomatic therapies that suppress seizures, epilepsy researchers have recently realized the critical need for novel therapeutic strategies targeting the underlying mechanisms of epileptogenesis and seizure-related brain injury. Yet, to date, few such antiepileptogenic therapies have emerged or are even in developmental stages. Although many seizure medications modulate the functional or physiological activity of neurons, the methods for stabilizing the structure of neurons are relatively unexplored therapeutic strategies for epilepsy. Human pathological studies and animal models of epilepsy demonstrate obvious structural abnormalities in dendrites of neurons, which could contribute to neuronal dysfunction, epileptogenesis and cognitive/neurological deficits in epilepsy patients. This dendritic injury may be caused by activity-dependent breakdown of cytoskeletal elements, such as actin. Mechanistically targeted approaches to limit seizure-related structural changes in dendrites may represent a novel therapeutic strategy for treating epilepsy and its complications.

Antiepileptic drugs in non-epilepsy disorders: relations between mechanisms of action and clinical efficacy

Antiepileptic drugs (AEDs) are used extensively to treat multiple non-epilepsy disorders, both in neurology and psychiatry. This article provides a review of the clinical efficacy of AEDs in non-epilepsy disorders based on recently published preclinical and clinical studies, and attempts to relate this efficacy to the mechanism of action of AEDs and pathophysiological processes associated with the disorders. Some newer indications for AEDs have been established, while others are under investigation. The disorders where AEDs have been demonstrated to be of clinical importance include neurological disorders, such as essential tremor, neuropathic pain and migraine, and psychiatric disorders, including anxiety, schizophrenia and bipolar disorder. Many of the AEDs have various targets of action in the synapse and have several proposed relevant mechanisms of action in epilepsy and in other disorders. Pathophysiological processes disturb neuronal excitability by modulating ion channels, receptors and intracellular signalling pathways, and these are targets for the pharmacological action of various AEDs. Attention is focused on the glutamatergic and GABAergic synapses. In psychiatric conditions such as schizophrenia and bipolar disorder, AEDs such as valproate, carbamazepine and lamotrigine appear to have clear roles based on their effect on intracellular pathways. On the other hand, some AEDs, e.g. topiramate, have efficacy for nonpsychiatric disorders including migraine, possibly by enhancing GABAergic and reducing glutamatergic neurotransmission. AEDs that seem to enhance GABAergic neurotransmission, e.g. tiagabine, valproate, gabapentin and possibly levetiracetam, may have a role in treating neurological disorders such as essential tremor, or anxiety disorders. AEDs with effects on voltage-gated sodium or calcium channels may be advantageous in treating neuropathic pain, e.g. gabapentin, pregabalin, carbamazepine, oxcarbazepine, lamotrigine and valproate. Co-morbid conditions associated with epilepsy, such as mood disorders and migraine, may often respond to treatment with AEDs. Other possible disorders where AEDs may be of clinical importance include cancer, HIV infection, drug and alcohol abuse, and also in neuroprotection. A future challenge is to evaluate the second-generation AEDs in non-epilepsy disorders and to design clinical trials to study their effects in such disorders in paediatric patients. Differentiation between the main mechanisms of action of the AEDs needs more consideration in drug selection for tailored treatment of the various non-epilepsy disorders.

Emerging drugs for epilepsy and other treatment options

Epilepsies are amongst the most frequent chronic neurological conditions. Patients suffer from spontaneously recurring seizures because of sudden extensive electrical gray matter discharges. Although the current drug therapy allows many patients at least some degree of a satisfying course of the disease, a substantial number of patients remain without adequate seizure control. Reasons are either refractoriness to anticonvulsant drugs or intolerable drug-related side effects. Epilepsy surgery should be considered in these cases as possible treatment option. Nevertheless, a considerable rate of patients will not be suitable candidates or continue to have seizures despite surgery. Therefore there is a substantial need for better antiepileptic drugs. The aim of this review is to highlight currently emerging different treatment approaches which may ameliorate the perspectives of patients with difficult-to-treat epilepsies.

Novel anticonvulsant drugs

Principles of complex mechanisms of action of anticonvulsants including latest reports concerning new antiepileptic drugs (AED) are considered. Different aspects of new anticonvulsant drugs (2nd generation) from preclinical and clinical testing, pharmacokinetics, and mono or combination therapy in children and adults are summarized. In the following condensed synopsis pharmacological and clinical characteristics of gabapentin (GBP), lamotrigine (LTG), levetiracetam (LEV), oxcarbazepine (OXC), pregabalin (PGB) and tiagabine (TGB) as well as topiramate (TPM) and zonisamide (ZNS) are discussed. In addition to the mechanisms of action, pharmacokinetics, interactions, indications and dosages as well as side effects are considered. Important data concerning the effect and tolerability of anticonvulsant drugs can be obtained from controlled studies. In comparison to drugs of the first generation (phenobarbital [PB], primidon [PRD], phenytoin [PHT], carbamazepine [CBZ] and valproic acid [VPA]) the potential for interactions and side effects due to enzyme induction or inhibition is reduced by most of the anticonvulsant drugs of the second generation. New anticonvulsant drugs increase the spectrum of treatment and represent further steps with regard to the optimization of an individual therapy of the epilepsies.

Novel antiseizure drug mechanisms

The amount of new knowledge being generated regarding brain mechanisms in general, and epileptic mechanisms in particular, is enormous. Anticonvulsant drugs are ineffective in approximately a third of people with epilepsy. To our knowledge, strategies for preventing epilepsy after an initial insult are nonexistent. In this review, we briefly examine some recent novel concepts for preventing seizures, which might lead to enhanced anticonvulsant drug therapy. We start with some known seizure mechanisms that have yet to yield widely used anticonvulsant drugs, including potassium channels, chloride cotransporters, extracellular space constriction, gap junctions and magnesium. Pharmacoresistance is then discussed, focusing on the upregulation of drug-resistance proteins (a concept with significant therapeutic appeal) and the drug-target hypothesis. Two further areas that hold great promise for future therapeutics are sex hormones and inflammatory processes. The genetics of epilepsy are currently being elaborated, providing potential novel anticonvulsant targets. Prevention being better than a cure, we discuss epileptogenesis and its treatment. Given the astounding progress of neuroscience research, one hopes for many new therapeutics for our intractable epileptic patients.

ABCB1 polymorphisms influence the response to antiepileptic drugs in Japanese epilepsy patients

OBJECTIVES

The efflux transporter P-glycoprotein encoded by the ATP-binding cassette (ABC)B1 gene may play a role in drug-resistant epilepsy by limiting gastrointestinal absorption and brain access of antiepileptic drugs (AEDs). Our objective was to investigate the effect of ABCB1 polymorphisms on AED responsiveness and on the pharmacokinetics of carbamazepine (CBZ) in epileptic patients with the indication for CBZ therapy.

METHODS

The ABCB1 T-129C, C1236T, G2677T/A and C3435T polymorphisms were genotyped in 210 Japanese epileptics who had been prescribed AEDs, including CBZ, for longer than 2 years. Haplotype and diplotype frequencies were estimated by expectation-maximization algorithm. Drug resistance was determined by the presence of seizures. Association of the polymorphisms with the risk of drug resistance was estimated by logistic regression analysis and the odds ratios (ORs) were adjusted for the clinical factors affecting the outcome of AED therapy. CBZ concentrations to the dose (C/D) ratios were compared among the ABCB1 polymorphisms.

RESULTS

Drug-resistant patients were more likely to have the T allele (OR [95% confidence interval (CI)], 2.02 [1.14-3.58]) and the TT genotype at C3435T (OR [95% CI], 3.64 [1.16-11.39]), and the TT genotype at G2677T/A (OR vs the GG genotype [95% CI], 3.43 [1.01-11.72]). The frequency of the T-T-T haplotype at C1236T, G2677T/A and C3435T was significantly higher (OR [95% CI], 1.84 [1.03-3.30]), and the CC-GG-CC diplotype was lower (OR [95% CI], 0.09 [0.01-0.85]) in the drug-resistant patients than in the drug-responsive patients. None of the ABCB1 polymorphisms were observed to influence the C/D ratios of CBZ.

CONCLUSION

We demonstrated that ABCB1 polymorphisms may influence the AED responsiveness without significant changes in the plasma concentrations of CBZ. Our findings were the inverse of previous results in European epileptics, thus the influence of ABCB1 polymorphisms on the AED responsiveness and/or the P-glycoprotein activity may vary among races.