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Klein P, Friedman A, Hameed MQ, Kaminski RM, Bar-Klein G, Klitgaard H, Koepp M, Jozwiak S, Prince DA, Rotenberg A, Twyman R, Vezzani A, Wong M, Löscher W. Repurposed molecules for antiepileptogenesis: Missing an opportunity to prevent epilepsy? Epilepsia 2020; 61:359-386. [PMID: 32196665 PMCID: PMC8317585 DOI: 10.1111/epi.16450] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 01/26/2020] [Accepted: 01/27/2020] [Indexed: 12/11/2022]
Abstract
Prevention of epilepsy is a great unmet need. Acute central nervous system (CNS) insults such as traumatic brain injury (TBI), cerebrovascular accidents (CVA), and CNS infections account for 15%-20% of all epilepsy. Following TBI and CVA, there is a latency of days to years before epilepsy develops. This allows treatment to prevent or modify postinjury epilepsy. No such treatment exists. In animal models of acquired epilepsy, a number of medications in clinical use for diverse indications have been shown to have antiepileptogenic or disease-modifying effects, including medications with excellent side effect profiles. These include atorvastatin, ceftriaxone, losartan, isoflurane, N-acetylcysteine, and the antiseizure medications levetiracetam, brivaracetam, topiramate, gabapentin, pregabalin, vigabatrin, and eslicarbazepine acetate. In addition, there are preclinical antiepileptogenic data for anakinra, rapamycin, fingolimod, and erythropoietin, although these medications have potential for more serious side effects. However, except for vigabatrin, there have been almost no translation studies to prevent or modify epilepsy using these potentially "repurposable" medications. We may be missing an opportunity to develop preventive treatment for epilepsy by not evaluating these medications clinically. One reason for the lack of translation studies is that the preclinical data for most of these medications are disparate in terms of types of injury, models within different injury type, dosing, injury-treatment initiation latencies, treatment duration, and epilepsy outcome evaluation mode and duration. This makes it difficult to compare the relative strength of antiepileptogenic evidence across the molecules, and difficult to determine which drug(s) would be the best to evaluate clinically. Furthermore, most preclinical antiepileptogenic studies lack information needed for translation, such as dose-blood level relationship, brain target engagement, and dose-response, and many use treatment parameters that cannot be applied clinically, for example, treatment initiation before or at the time of injury and dosing higher than tolerated human equivalent dosing. Here, we review animal and human antiepileptogenic evidence for these medications. We highlight the gaps in our knowledge for each molecule that need to be filled in order to consider clinical translation, and we suggest a platform of preclinical antiepileptogenesis evaluation of potentially repurposable molecules or their combinations going forward.
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Affiliation(s)
- Pavel Klein
- Mid-Atlantic Epilepsy and Sleep Center, Bethesda, Maryland
| | - Alon Friedman
- Departments of Physiology and Cell Biology, and Brain and Cognitive Science, Zlotowski Center for Neuroscience, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- Departments of Medical Neuroscience and Brain Repair Center, Dalhousie University, Halifax, Canada
| | - Mustafa Q. Hameed
- Neuromodulation Program, Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Rafal M. Kaminski
- Neurosymptomatic Domains Section, Roche Pharma Research & Early Development, Roche Innovation Center, Basel, Switzerland
| | - Guy Bar-Klein
- McKusick-Nathans Institute of Genetic Medicine, Howard Hughes Medical Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Henrik Klitgaard
- Neurosciences Therapeutic Area, UCB Pharma, Braine-l’Alleud, Belgium
| | - Mathias Koepp
- Department of Clinical and Experimental Epilepsy, University College London Institute of Neurology, London, UK
| | - Sergiusz Jozwiak
- Department of Pediatric Neurology, Warsaw Medical University, Warsaw, Poland
| | - David A. Prince
- Neurology and the Neurological Sciences, Stanford University School of Medicine, Stanford, California
| | - Alexander Rotenberg
- Neuromodulation Program, Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Annamaria Vezzani
- Department of Neuroscience, Mario Negri Institute for Pharmacological Research, Scientific Institute for Research and Health Care, Milan, Italy
| | - Michael Wong
- Department of Neurology, Washington University School of Medicine, St Louis, Missouri
| | - Wolfgang Löscher
- Department of Pharmacology, Toxicology, and Pharmacy, University of Veterinary Medicine, Hannover, Germany
- Center for Systems Neuroscience, Hannover, Germany
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Teng F, Tsien CI, Lawrence TS, Cao Y. Blood–tumor barrier opening changes in brain metastases from pre to one-month post radiation therapy. Radiother Oncol 2017; 125:89-93. [DOI: 10.1016/j.radonc.2017.08.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Revised: 06/13/2017] [Accepted: 08/05/2017] [Indexed: 12/12/2022]
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Bar-Klein G, Klee R, Brandt C, Bankstahl M, Bascuñana P, Töllner K, Dalipaj H, Bankstahl JP, Friedman A, Löscher W. Isoflurane prevents acquired epilepsy in rat models of temporal lobe epilepsy. Ann Neurol 2017; 80:896-908. [PMID: 27761920 DOI: 10.1002/ana.24804] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 09/16/2016] [Accepted: 10/10/2016] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Acquired epilepsy is a devastating long-term risk of various brain insults, including trauma, stroke, infections, and status epilepticus (SE). There is no preventive treatment for patients at risk. Attributable to the complex alterations involved in epileptogenesis, it is likely that multitargeted approaches are required for epilepsy prevention. We report novel preclinical findings with isoflurane, which exerts various nonanesthetic effects that may be relevant for antiepileptogenesis. METHODS The effects of isoflurane were investigated in two rat models of SE-induced epilepsy: intrahippocampal kainate and systemic administration of paraoxon. Isoflurane was either administered during (kainate) or after (paraoxon) induction of SE. Magnetic resonance imaging was used to assess blood-brain barrier (BBB) dysfunction. Positron emission tomography was used to visualize neuroinflammation. Long-term electrocorticographic recordings were used to monitor spontaneous recurrent seizures. Neuronal damage was assessed histologically. RESULTS In the absence of isoflurane, spontaneous recurrent seizures were common in the majority of rats in both models. When isoflurane was administered during kainate injection, duration and severity of SE were not affected, but only few rats developed spontaneous recurrent seizures. A similar antiepileptogenic effect was found when paraoxon-treated rats were exposed to isoflurane after SE. Moreover, in the latter model, isoflurane prevented BBB dysfunction and neurodegeneration, whereas isoflurane reduced neuroinflammation in the kainate model. INTERPRETATION Given that isoflurane is a widely used volatile anesthetic, and is used for inhalational long-term sedation in critically ill patients at risk to develop epilepsy, our findings hold a promising potential to be successfully translated into the clinic. Ann Neurol 2016;80:896-908.
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Affiliation(s)
- Guy Bar-Klein
- Departments of Physiology and Cell Biology, Cognitive and Brain Sciences, the Zlotowski Center for Neuroscience, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Rebecca Klee
- Department of Pharmacology, Toxicology, and Pharmacy, University of Veterinary Medicine Hannover, Hannover, Germany.,Center for Systems Neuroscience, Hannover, Germany
| | - Claudia Brandt
- Department of Pharmacology, Toxicology, and Pharmacy, University of Veterinary Medicine Hannover, Hannover, Germany
| | - Marion Bankstahl
- Department of Pharmacology, Toxicology, and Pharmacy, University of Veterinary Medicine Hannover, Hannover, Germany.,Center for Systems Neuroscience, Hannover, Germany
| | - Pablo Bascuñana
- Department of Nuclear Medicine, Hannover Medical School, Germany
| | - Kathrin Töllner
- Department of Pharmacology, Toxicology, and Pharmacy, University of Veterinary Medicine Hannover, Hannover, Germany
| | - Hotjensa Dalipaj
- Department of Medical Neuroscience, Dalhousie University, Halifax, Canada
| | - Jens P Bankstahl
- Department of Nuclear Medicine, Hannover Medical School, Germany
| | - Alon Friedman
- Departments of Physiology and Cell Biology, Cognitive and Brain Sciences, the Zlotowski Center for Neuroscience, Ben-Gurion University of the Negev, Beer-Sheva, Israel.,Department of Medical Neuroscience, Dalhousie University, Halifax, Canada
| | - Wolfgang Löscher
- Department of Pharmacology, Toxicology, and Pharmacy, University of Veterinary Medicine Hannover, Hannover, Germany.,Center for Systems Neuroscience, Hannover, Germany
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Chi OZ, Mellender SJ, Kiss GK, Liu X, Weiss HR. Blood -brain barrier disruption was less under isoflurane than pentobarbital anesthesia via a PI3K/Akt pathway in early cerebral ischemia. Brain Res Bull 2017; 131:1-6. [PMID: 28238830 DOI: 10.1016/j.brainresbull.2017.02.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Revised: 02/19/2017] [Accepted: 02/21/2017] [Indexed: 01/07/2023]
Abstract
One of the important factors altering the degree of blood-brain barrier (BBB) disruption in cerebral ischemia is the anesthetic used. The phosphoinositide 3-kinase (PI3K)/Akt signaling pathway has been reported to be involved in modulating BBB permeability and in isoflurane induced neuroprotection. This study was performed to compare the degree of BBB disruption in focal cerebral ischemia under isoflurane vs pentobarbital anesthesia and to determine whether inhibition of PI3K/Akt would affect the disruption in the early stage of focal cerebral ischemia. Permanent middle cerebral artery (MCA) occlusion was performed in rats under 1.4% isoflurane or pentobarbital (50mg/kg i.p.) anesthesia with controlled ventilation. In half of each group LY294002, which is a PI3K/Akt inhibitor, was applied on the ischemic cortex immediately after MCA occlusion. After one hour of MCA occlusion, the transfer coefficient (Ki) of 14C-α-aminoisobutyric acid (14C-AIB) was determined to quantify the degree of BBB disruption. MCA occlusion increased the Ki both in the isoflurane and pentobarbital anesthetized rats. However, the value of Ki was lower under isoflurane (11.5±6.0μL/g/min) than under pentobarbital (18.3±7.1μL/g/min) anesthesia. The Ki of the contralateral cortex of the pentobarbital group was higher (+74%) than that of the isoflurane group. Application of LY294002 on the ischemic cortex increased the Ki (+99%) only in the isoflurane group. The degree of BBB disruption by MCA occlusion was significantly lower under isoflurane than pentobarbital anesthesia in the early stage of cerebral ischemia. Our data demonstrated the importance of choice of anesthetics and suggest that PI3K/Akt signaling pathway plays a significant role in altering BBB disruption in cerebral ischemia during isoflurane but not during pentobarbital anesthesia.
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Affiliation(s)
- Oak Z Chi
- Department of Anesthesiology, Rutgers Robert Wood Johnson Medical School, 125 Paterson Street, Suite 3100, New Brunswick, NJ, 08901-1977, USA.
| | - Scott J Mellender
- Department of Anesthesiology, Rutgers Robert Wood Johnson Medical School, 125 Paterson Street, Suite 3100, New Brunswick, NJ, 08901-1977, USA
| | - Geza K Kiss
- Department of Anesthesiology, Rutgers Robert Wood Johnson Medical School, 125 Paterson Street, Suite 3100, New Brunswick, NJ, 08901-1977, USA
| | - Xia Liu
- Department of Anesthesiology, Rutgers Robert Wood Johnson Medical School, 125 Paterson Street, Suite 3100, New Brunswick, NJ, 08901-1977, USA
| | - Harvey R Weiss
- Department of Neuroscience and Cell Biology, Rutgers Robert Wood Johnson Medical School, 675 Hoes Lane West, Piscataway, NJ, 08854, USA
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Almutairi MMA, Gong C, Xu YG, Chang Y, Shi H. Factors controlling permeability of the blood-brain barrier. Cell Mol Life Sci 2016; 73:57-77. [PMID: 26403789 PMCID: PMC11108286 DOI: 10.1007/s00018-015-2050-8] [Citation(s) in RCA: 180] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 09/15/2015] [Accepted: 09/17/2015] [Indexed: 12/27/2022]
Abstract
As the primary protective barrier for neurons in the brain, the blood-brain barrier (BBB) exists between the blood microcirculation system and the brain parenchyma. The normal BBB integrity is essential in protecting the brain from systemic toxins and maintaining the necessary level of nutrients and ions for neuronal function. This integrity is mediated by structural BBB components, such as tight junction proteins, integrins, annexins, and agrin, of a multicellular system including endothelial cells, astrocytes, pericytes, etc. BBB dysfunction is a significant contributor to the pathogeneses of a variety of brain disorders. Many signaling factors have been identified to be able to control BBB permeability through regulating the structural components. Among those signaling factors are inflammatory mediators, free radicals, vascular endothelial growth factor, matrix metalloproteinases, microRNAs, etc. In this review, we provide a summary of recent progress regarding these structural components and signaling factors, relating to their roles in various brain disorders. Attention is also devoted to recent research regarding impact of pharmacological agents such as isoflurane on BBB permeability and how iron ion passes across BBB. Hopefully, a better understanding of the factors controlling BBB permeability helps develop novel pharmacological interventions of BBB hyperpermeability under pathological conditions.
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Affiliation(s)
- Mohammed M A Almutairi
- Department of Pharmacology and Toxicology, School of Pharmacy, University of Kansas, 1251 Wescoe Hall Drive, Malott Hall 5044, Lawrence, KS, 66045, USA
| | - Chen Gong
- Department of Pharmacology and Toxicology, School of Pharmacy, University of Kansas, 1251 Wescoe Hall Drive, Malott Hall 5044, Lawrence, KS, 66045, USA
| | - Yuexian G Xu
- Department of Anesthesiology, School of Medicine, University of Kansas, Kansas City, KS, 66160, USA
| | - Yanzhong Chang
- Laboratory of Molecular Iron Metabolism, College of Life Science, Hebei Normal University, Shijiazhuang, 050016, China
| | - Honglian Shi
- Department of Pharmacology and Toxicology, School of Pharmacy, University of Kansas, 1251 Wescoe Hall Drive, Malott Hall 5044, Lawrence, KS, 66045, USA.
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Gavins FNE, Smith HK. Cell tracking technologies for acute ischemic brain injury. J Cereb Blood Flow Metab 2015; 35:1090-9. [PMID: 25966948 PMCID: PMC4640284 DOI: 10.1038/jcbfm.2015.93] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Revised: 04/07/2015] [Accepted: 04/09/2015] [Indexed: 02/06/2023]
Abstract
Stem cell therapy has showed considerable potential in the treatment of stroke over the last decade. In order that these therapies may be optimized, the relative benefits of growth factor release, immunomodulation, and direct tissue replacement by therapeutic stem cells are widely under investigation. Fundamental to the progress of this research are effective imaging techniques that enable cell tracking in vivo. Direct analysis of the benefit of cell therapy includes the study of cell migration, localization, division and/or differentiation, and survival. This review explores the various imaging tools currently used in clinics and laboratories, addressing image resolution, long-term cell monitoring, imaging agents/isotopes, as well as safety and costs associated with each technique. Finally, burgeoning tracking techniques are discussed, with emphasis on multimodal imaging.
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Affiliation(s)
- Felicity NE Gavins
- Molecular and Cellular Physiology Department, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Helen K Smith
- Molecular and Cellular Physiology Department, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
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Dittmar MS, Petermichl W, Lindner R, Sinner B, Graf BM, Schlachetzki F, Gruber M. In Vitro Induction of Endothelial Apoptosis of the Post-Hypoxic Blood-Brain Barrier by Isoflurane but Not by Sevoflurane and Midazolam. PLoS One 2015; 10:e0130408. [PMID: 26091107 PMCID: PMC4475016 DOI: 10.1371/journal.pone.0130408] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 05/20/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The effects of anesthetics on the injured brain continue to be the subject of controversial discussion. Since isoflurane has recently been shown to induce apoptosis of cerebral endothelial cells, this study compared different anesthetic compounds regarding their potential to induce cerebro-vascular apoptosis. METHODS The in vitro model of the blood-brain barrier used in this study consisted of astrocyte-conditioned human umbilical vein endothelial cells (AC-HUVEC) has been used. After 24 h of deep hypoxia and reoxygenation or control treatment, AC-HUVEC were exposed to 0, 0.5, 1.0, or 2.0 times the minimum alveolar concentration of isoflurane or sevoflurane, or 0, 75, 150, or 300 nM of midazolam for 2 h. After 24 h, AC-HUVEC were harvested, and the degree of apoptosis was assessed by means of Western blots for the Bax and Bcl-2 ratio and, for controls and the highest concentration groups, terminal deoxynucleotidyl-mediated dUTP-biotin nick end labeling (TUNEL). RESULTS Without hypoxic pretreatment, 2.0 MAC of isoflurane slightly increased TUNEL intensity compared to control and sevoflurane, but without any significant changes in the Bax and Bcl-2 ratio. After hypoxic pretreatment, exposure to isoflurane led to a multifold increase in the Bax and Bcl-2 ratio in a dose dependent manner, which was also significantly higher than the ratio observed in the 2 MAC sevoflurane group. TUNEL intensity in the post-hypoxic 2 MAC isoflurane group was increased by a factor of 11 vs. control and by 40 vs. sevoflurane. Sevoflurane and midazolam did not significantly alter these markers of apoptosis, when compared to the control group. CONCLUSIONS Isoflurane administered after hypoxia elevates markers of apoptosis in endothelial cells transdifferentiated to the cerebro-vascular endothelium. Endothelial apoptosis may be a previously underestimated mechanism of anesthetic neurotoxicity. Administration of high concentrations of isoflurane in experimental settings may have negative effects on the blood-brain barrier.
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Affiliation(s)
- Michael S. Dittmar
- Department of Anesthesiology, Regensburg University Medical Center, Regensburg, Germany
- * E-mail:
| | - Walter Petermichl
- Department of Anesthesiology, Regensburg University Medical Center, Regensburg, Germany
| | - Regina Lindner
- Department of Anesthesiology, Regensburg University Medical Center, Regensburg, Germany
| | - Barbara Sinner
- Department of Anesthesiology, Regensburg University Medical Center, Regensburg, Germany
| | - Bernhard M. Graf
- Department of Anesthesiology, Regensburg University Medical Center, Regensburg, Germany
| | - Felix Schlachetzki
- Department of Neurology, Bezirksklinikum Regensburg, University of Regensburg, Regensburg, Germany
| | - Michael Gruber
- Department of Anesthesiology, Regensburg University Medical Center, Regensburg, Germany
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Winter C, Bell C, Whyte T, Cardinal J, Macfarlane D, Rose S. Blood–brain barrier dysfunction following traumatic brain injury: correlation of Ktrans(DCE-MRI) and SUVR (99mTc-DTPA SPECT) but not serum S100B. Neurol Res 2015; 37:599-606. [DOI: 10.1179/1743132815y.0000000018] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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