The influence of levetiracetam in cognitive performance in healthy individuals: neuropsychological, behavioral and electrophysiological approach

Levetiracetam modulates brain metabolic networks and transcriptomic signatures in the 5XFAD mouse model of Alzheimer's disease

Introduction

Subcritical epileptiform activity is associated with impaired cognitive function and is commonly seen in patients with Alzheimer's disease (AD). The anti-convulsant, levetiracetam (LEV), is currently being evaluated in clinical trials for its ability to reduce epileptiform activity and improve cognitive function in AD. The purpose of the current study was to apply pharmacokinetics (PK), network analysis of medical imaging, gene transcriptomics, and PK/PD modeling to a cohort of amyloidogenic mice to establish how LEV restores or drives alterations in the brain networks of mice in a dose-dependent basis using the rigorous preclinical pipeline of the MODEL-AD Preclinical Testing Core.

Methods

Chronic LEV was administered to 5XFAD mice of both sexes for 3 months based on allometrically scaled clinical dose levels from PK models. Data collection and analysis consisted of a multi-modal approach utilizing 18F-FDG PET/MRI imaging and analysis, transcriptomic analyses, and PK/PD modeling.

Results

Pharmacokinetics of LEV showed a sex and dose dependence in Cmax, CL/F, and AUC0-∞, with simulations used to estimate dose regimens. Chronic dosing at 10, 30, and 56 mg/kg, showed 18F-FDG specific regional differences in brain uptake, and in whole brain covariance measures such as clustering coefficient, degree, network density, and connection strength (i.e., positive and negative). In addition, transcriptomic analysis via nanoString showed dose-dependent changes in gene expression in pathways consistent 18F-FDG uptake and network changes, and PK/PD modeling showed a concentration dependence for key genes, but not for network covariance modeling.

Discussion

This study represents the first report detailing the relationships of metabolic covariance and transcriptomic network changes resulting from LEV administration in 5XFAD mice. Overall, our results highlight non-linear kinetics based on dose and sex, where gene expression analysis demonstrated LEV dose- and concentration-dependent changes, along with cerebral metabolism, and/or cerebral homeostatic mechanisms relevant to human AD, which aligned closely with network covariance analysis of 18F-FDG images. Collectively, this study show cases the value of a multimodal connectomic, transcriptomic, and pharmacokinetic approach to further investigate dose dependent relationships in preclinical studies, with translational value toward informing clinical study design.

Effect of Levetiracetam on Cognition: A Systematic Review and Meta-analysis of Double-Blind Randomized Placebo-Controlled Trials

BACKGROUND

Studies have suggested that levetiracetam may help improve cognitive function in patients with epilepsy. Recently, its efficacy in improving cognitive function was reported in patients with amnestic mild cognitive impairment, schizophrenia, and Alzheimer's disease. However, the specific cognitive domains affected and the degree of evidence supporting these effects remain unclear. This systematic review and meta-analysis aimed to explore the effects of levetiracetam on different cognitive domains.

METHODS

This meta-analysis was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. We defined our inclusion criteria for the systematic review as: (1) randomized placebo-controlled trials (RCTs) involving human subjects, (2) double-blinded RCTs, and (3) RCTs evaluating the quantitative differences in cognitive function between levetiracetam and placebo. We excluded: (1) non-RCT studies, (2) open-label studies, and (3) RCTs lacking cognitive assessments for either intervention. Two authors independently searched electronic databases, including PubMed, Embase, Cochrane CENTRAL, and ClinicalTrials.gov, from inception until 2 July 2023. The methodological quality of the included studies was assessed using the Cochrane risk of bias tool. Meta-analytic techniques were applied to examine the impact of levetiracetam on cognitive domain tests, with Hedges' g facilitating the comparison with placebo. The domains analyzed comprised multi-domain, executive function, processing speed, working memory, verbal memory/learning (verbal ML), visuospatial memory/learning (visuospatial ML), and language. We used odds ratios to compare the incidence of treatment-emergent adverse events between the groups, including somnolence, fatigue, dizziness, headache, irritability, and cognitive adverse events.

RESULTS

A random-effects model was utilized to perform a meta-analysis of 16 RCTs including 545 participants. Compared with a placebo, levetiracetam was associated with improved executive function [Hedges'g = - 0.390, 95% confidence interval (CI) = - 0.609 to - 0.172, p < 0.001, I2 = 24.0%]. Subgroup analysis showed that levetiracetam outperformed placebo in patients without epilepsy (Hedges' g = - 0.419, 95% CI = - 0.647 to - 0.191, p < 0.001, I2 = 26.2%). Meanwhile, low-dose levetiracetam showed a moderate favorable effect over placebo (Hedges' g = -0.544, 95% CI = - 1.085 to - 0.003, p = 0.049, I2 = 65.3%). In patients without epilepsy, low-dose levetiracetam was associated with improved executive function (Hedges'g = - 0.544, 95% CI = - 1.085 to - 0.003, p = 0.049, I2 = 65.3%). Concurrently, levetiracetam was associated with more frequent somnolence than a placebo (odds ratio = 4.654, 95% CI = 1.533 to 14.124, p = 0.007, I2 = 32.9%). Potential publication bias was observed in the executive function domain.

CONCLUSIONS

This exploratory study suggests that levetiracetam might improve executive function in specific populations. However, the diversity in study populations and potential publication bias warrant caution.

Levetiracetam Modulates Brain Metabolic Networks and Transcriptomic Signatures in the 5XFAD Mouse Model of Alzheimer's disease

INTRODUCTION

Subcritical epileptiform activity is associated with impaired cognitive function and is commonly seen in patients with Alzheimer's disease (AD). The anti-convulsant, levetiracetam (LEV), is currently being evaluated in clinical trials for its ability to reduce epileptiform activity and improve cognitive function in AD. The purpose of the current study was to apply pharmacokinetics (PK), network analysis of medical imaging, gene transcriptomics, and PK/PD modeling to a cohort of amyloidogenic mice to establish how LEV restores or drives alterations in the brain networks of mice in a dose-dependent basis using the rigorous preclinical pipeline of the MODEL-AD Preclinical Testing Core.

METHODS

Chronic LEV was administered to 5XFAD mice of both sexes for 3 months based on allometrically scaled clinical dose levels from PK models. Data collection and analysis consisted of a multi-modal approach utilizing 18F-FDG PET/MRI imaging and analysis, transcriptomic analyses, and PK/PD modeling.

RESULTS

Pharmacokinetics of LEV showed a sex and dose dependence in Cmax, CL/F, and AUC0-∞, with simulations used to estimate dose regimens. Chronic dosing at 10, 30, and 56 mg/kg, showed 18F-FDG specific regional differences in brain uptake, and in whole brain covariance measures such as clustering coefficient, degree, network density, and connection strength (i.e. positive and negative). In addition, transcriptomic analysis via nanoString showed dose-dependent changes in gene expression in pathways consistent 18F-FDG uptake and network changes, and PK/PD modeling showed a concentration dependence for key genes, but not for network covariance modeling.

DISCUSSION

This study represents the first report detailing the relationships of metabolic covariance and transcriptomic network changes resulting from LEV administration in 5XFAD mice. Overall, our results highlight non-linear kinetics based on dose and sex, where gene expression analysis demonstrated LEV dose- and concentration- dependent changes, along with cerebral metabolism, and/or cerebral homeostatic mechanisms relevant to human AD, which aligned closely with network covariance analysis of 18F-FDG images. Collectively, this study show cases the value of a multimodal connectomic, transcriptomic, and pharmacokinetic approach to further investigate dose dependent relationships in preclinical studies, with translational value towards informing clinical study design.

Dosage, time, and polytherapy dependent effects of different levetiracetam regimens on cognitive function

OBJECTIVE

Cognitive impairment is a potential drawback of antiseizure medications. This study aimed to evaluate the impact of different levetiracetam drug regimens on cognitive function.

METHODS

A retrospective analysis identified 221 patients diagnosed with seizures who underwent cognitive screening. Patients were categorized into four groups: no medications, non-levetiracetam medications, high and low dose levetiracetam. Composite scores determined low and high levetiracetam groups whereby one point was added for each increment in dosage, duration since uptake, and concurrent anti-seizure medication. Variables known to affect cognition were recorded and classified as demographic, seizure-related, diagnosis-related, and psychopathology. Logistic regression was used to identify variables associated with cognitive scores below cut-off.

RESULTS

Multivariable analysis found being male, non-active in the community, less than 12 years of education, left temporal lobe epilepsy, high seizure frequency, and depression were associated with poor cognitive performance. In a final regression analysis, the high levetiracetam group exhibited a 4.5-fold higher likelihood of scoring below cut-off than the medication-free group (OR 4.5, CI 1.5-13.6, p<.08). Depression (OR 2.1, CI 1.1-3.9, p<.03), being male (OR 2.2, CI 1.1-4.3, p<.02), and not being active in the community (OR 3.8, 1.6-8.7, p <.003) remained significant contributors to the model. Language (p<.05), attention (p<.05), and delayed recall (p<.001) were the most affected cognitive domains.

SIGNIFICANCE

When taken in small doses, for brief periods as monotherapy, levetiracetam minimally influences cognition. At higher doses, as part of long-term seizure management, in conjunction with multiple ASMs, LEV is associated with cognitive impairment.

Associations between nesting, stereotypy, and working memory in deer mice: response to levetiracetam

BACKGROUND

Some deer mice (Peromyscus maniculatus bairdii) exhibit various phenotypes of persistent behaviors. It remains unknown if and how said phenotypes associate with early-life and adult cognitive perturbations, and whether potentially cognitive enhancing drugs might modify such associations. Here, we explored the longitudinal relationship between early-life behavioral flexibility and the expression of persistent behavior in adulthood. We also investigated how said phenotypes might associate with working memory in adulthood, and how this association might respond to chronic exposure to the putative cognitive enhancer, levetiracetam (LEV).

METHODS

76 juvenile deer mice were assessed for habit-proneness in the Barnes maze (BM) and divided into two exposure groups (n = 37-39 per group), i.e., control and LEV (75 mg/kg/day). After 56 days of uninterrupted exposure, mice were screened for nesting and stereotypical behavior, and then assessed for working memory in the T-maze.

RESULTS

Juvenile deer mice overwhelmingly utilize habit-like response strategies, regardless of LNB and HS behavior in adulthood. Further, LNB and HS are unrelated in terms of their expression, while LEV reduces the expression of LNB, but bolsters CR (but not VA). Last, an increased level of control over high stereotypical expression may facilitate improved working memory performance.

CONCLUSION

LNB, VA and CR, are divergent in terms of their neurocognitive underpinnings. Chronic LEV administration throughout the entire rearing period may be of benefit to some phenotypes, e.g., LNB, but not others (CR). We also show that an increased level of control over the expression of stereotypy may facilitate improved working memory performance.

Pathophysiological basis and promise of experimental therapies for Gulf War Illness, a chronic neuropsychiatric syndrome in veterans

This article describes the pathophysiology and potential treatments for Gulf War Illness (GWI), which is a chronic neuropsychiatric illness linked to a combination of chemical exposures experienced by service personnel during the first Gulf War in 1991. However, there is currently no effective treatment for veterans with GWI. The article focuses on the current status and efficacy of existing therapeutic interventions in preclinical models of GWI, as well as potential perspectives of promising therapies. GWI stems from changes in brain and peripheral systems in veterans, leading to neurocognitive deficits, as well as physiological and psychological effects resulting from multifaceted changes such as neuroinflammation, oxidative stress, and neuronal damage. Aging not only renders veterans more susceptible to GWI symptoms, but also attenuates their immune capabilities and response to therapies. A variety of experimental models are being used to investigate the pathophysiology and develop therapies that have the ability to alleviate devastating symptoms. Over two dozen therapeutic interventions targeting neuroinflammation, mitochondrial dysfunction, neuronal injury, and neurogenesis are being tested, including agents such as curcumin, curcumin nanoparticles, monosodium luminol, melatonin, resveratrol, fluoxetine, rolipram, oleoylethanolamide, ketamine, levetiracetam, nicotinamide riboside, minocycline, pyridazine derivatives, and neurosteroids. Preclinical outcomes show that some agents have promise, including curcumin, resveratrol, and ketamine, which are being tested in clinical trials in GWI veterans. Neuroprotectants and other compounds such as monosodium luminol, melatonin, levetiracetam, oleoylethanolamide, and nicotinamide riboside appear promising for future clinical trials. Neurosteroids have been shown to have neuroprotective and disease-modifying properties, which makes them a promising medicine for GWI. Therefore, accelerated clinical studies are urgently needed to evaluate and launch an effective therapy for veterans displaying GWI.

Pharmacokinetic, pharmacodynamic, and transcriptomic analysis of chronic levetiracetam treatment in 5XFAD mice: A MODEL-AD preclinical testing core study

Introduction

Hyperexcitability and epileptiform activity are commonplace in Alzheimer's disease (AD) patients and associated with impaired cognitive function. The anti-seizure drug levetiracetam (LEV) is currently being evaluated in clinical trials for ability to reduce epileptiform activity and improve cognitive function in AD. The purpose of our studies was to establish a pharmacokinetic/pharmacodynamic (PK/PD) relationship with LEV in an amyloidogenic mouse model of AD to enable predictive preclinical to clinical translation, using the rigorous preclinical testing pipeline of the Model Organism Development and Evaluation for Late-Onset Alzheimer's Disease Preclinical Testing Core.

Methods

A multi-tier approach was applied that included quality assurance and quality control of the active pharmaceutical ingredient, PK/PD modeling, positron emission tomography/magnetic resonance imaging (PET/MRI), functional outcomes, and transcriptomics. 5XFAD mice were treated chronically with LEV for 3 months at doses in line with those allometrically scaled to the clinical dose range.

Results

Pharmacokinetics of LEV demonstrated sex differences in Cmax, AUC0-∞, and CL/F, and a dose dependence in AUC0-∞. After chronic dosing at 10, 30, 56 mg/kg, PET/MRI tracer 18F-AV45, and 18F-fluorodeoxyglucose (18F-FDG) showed specific regional differences with treatment. LEV did not significantly improve cognitive outcomes. Transcriptomics performed by nanoString demonstrated drug- and dose-related changes in gene expression relevant to human brain regions and pathways congruent with changes in 18F-FDG uptake.

Discussion

This study represents the first report of PK/PD assessment of LEV in 5XFAD mice. Overall, these results highlighted non-linear kinetics based on dose and sex. Plasma concentrations of the 10 mg/kg dose in 5XFAD overlapped with human plasma concentrations used for studies of mild cognitive impairment, while the 30 and 56 mg/kg doses were reflective of doses used to treat seizure activity. Post-treatment gene expression analysis demonstrated LEV dose-related changes in immune function and neuronal-signaling pathways relevant to human AD, and aligned with regional 18F-FDG uptake. Overall, this study highlights the importance of PK/PD relationships in preclinical studies to inform clinical study design.

Highlights

Significant sex differences in pharmacokinetics of levetiracetam were observed in 5XFAD mice.Plasma concentrations of 10 mg/kg levetiracetam dose in 5XFAD overlapped with human plasma concentration used in the clinic.Drug- and dose-related differences in gene expression relevant to human brain regions and pathways were also similar to brain region-specific changes in 18F-fluorodeoxyglucose uptake.

Perioperative levetiracetam for seizure prophylaxis in seizure-naive brain tumor patients with focus on neurocognitive functioning

Introduction

In seizure-naive brain tumor patients, the efficacy of perioperative prophylactic antiepileptic drug treatment remains controversial. In case of administration, the common preferred drug is levetiracetam (LEV) because of its favorable pharmacological profile. Research to date has not sufficiently determined how LEV affects cognition in the short term, as is the case in the perioperative period. The objective of this prospective study was to examine the neurocognitive functioning of seizure-naive brain tumor patients after receiving LEV perioperatively.

Methods

Fortythree patients with supratentorial brain tumor scheduled for surgery received LEV three days before until six days after surgery as seizure prophylaxis. Cognitive functioning (NeuroCogFX), LEV plasma-levels, hematotoxicity, side-effects, as well as health-related quality of life (HRQoL, Qolie31), were recorded preoperatively before (Baseline) and after onset of LEV (Pre-Op), 4–6 days postoperatively (Post-Op) and 21 days postoperatively (Follow-Up).

Results

No significant changes in cognitive functioning and HRQoL were seen after onset of preoperative LEV. There was a significant improvement of NeuroCogFX total-score at Follow-Up (p = 0.004) compared to Baseline. The overall-score Qolie31 showed simultaneous improvement patterns as cognitive functioning (p < 0.001). The most frequent side effect related to study drug was somnolence (in 28.6% of patients).

Conclusions

A significant improvement of cognitive functioning, as well as an improvement in HRQoL, were detected postoperatively. This is presumably due to the debulking effect of the surgery. Nevertheless, LEV has no detrimental effect on cognitive functioning in the perioperative phase in seizure-naive brain tumor patients.

Trial registration

This study was registered prospectively (Date: 25/11/2015; EudraCT: 2015–003,916-19).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-022-02762-7.

Exposure to phenytoin associates with a lower risk of post-COVID cognitive deficits: a cohort study

Post-COVID cognitive deficits (often referred to as ‘brain fog’) are common and have large impacts on patients’ level of functioning. No specific intervention exists to mitigate this burden.

This study tested the hypothesis, inspired by recent experimental research, that post-COVID cognitive deficits can be prevented by inhibiting receptor-interacting protein kinase. Using electronic health record data, we compared the cognitive outcomes of propensity score-matched cohorts of patients with epilepsy taking phenytoin (a commonly used receptor-interacting protein kinase inhibitor) versus valproate or levetiracetam at the time of COVID-19 diagnosis. Patients taking phenytoin at the time of COVID-19 were at a significantly lower risk of cognitive deficits in the 6 months after COVID-19 infection than a matched cohort of patients receiving levetiracetam (hazard ratio 0.78, 95% confidence interval 0.63–0.97, P = 0.024) or valproate (hazard ratio 0.73, 95% confidence interval 0.58–0.93, P = 0.011). In secondary analyses, results were robust when controlling for subtype of epilepsy, and showed specificity to cognitive deficits in that similar associations were not seen with other ‘long-COVID’ outcomes such as persistent breathlessness or pain. These findings provide pharmacoepidemiological support for the hypothesis that receptor-interacting protein kinase signaling is involved in post-COVID cognitive deficits. These results should prompt empirical investigations of receptor-interacting protein kinase inhibitors in the prevention of post-COVID cognitive deficits.

Can levetiracetam improve clinical symptoms in schizophrenic patients? A randomized placebo-controlled clinical trial

INTRODUCTION

Schizophrenia is associated with persistent cognitive deficits, which worsen treatment outcomes despite increasing antipsychotic doses. This study aimed to assess the effect of levetiracetam on the severity of schizophrenia symptoms and cognitive deficits in these patients.

MATERIALS AND METHODS

In this randomized, controlled, three-blind randomized clinical trial approved by Mashhad University of Medical Sciences, Iran (IRCT20101130005280N31), forty chronic schizophrenic patients aged 18-60 years were randomly divided into two groups of levetiracetam and placebo. The levetiracetam group received levetiracetam for 8 weeks. The symptoms were evaluated by Positive and Negative Symptoms Scale (PANSS), Stroop test, Digit Span test and Wisconsin Test at baseline, 4th week, and 8th week. Data were analyzed through SPSS V. 23 software, descriptive tests and inferential statistics.

RESULTS

At the end of the study, all subscales of the PANSS questionnaire reduced significantly (P < 0.05). Also, all subscales of the cognitive tests had significant changes. The trends of digit span tests, correct number of consonants and inconsonant were increasing. While the trends related to consonant errors, inconsistent errors, consistent reaction time and nonconsistent reaction time were decreasing. The changes in the number of classes were increased while changes in preservation error were decreased.

CONCLUSION

The results showed that levetiracetam has significant effects on clinical symptoms, especially negative symptoms. Also, it impacts significantly on cognitive functions. It is recommended that it be added to the pharmacological regimen of these patients to improve their clinical symptoms, quality of life and treatment outcomes.

Spontaneous and TMS-related EEG changes as new biomarkers to measure anti-epileptic drug effects

Robust biomarkers for anti-epileptic drugs (AEDs) activity in the human brain are essential to increase the probability of successful drug development. The frequency analysis of electroencephalographic (EEG) activity, either spontaneous or evoked by transcranial magnetic stimulation (TMS-EEG) can provide cortical readouts for AEDs. However, a systematic evaluation of the effect of AEDs on spontaneous oscillations and TMS-related spectral perturbation (TRSP) has not yet been provided. We studied the effects of Lamotrigine, Levetiracetam, and of a novel potassium channel opener (XEN1101) in two groups of healthy volunteers. Levetiracetam suppressed TRSP theta, alpha and beta power, whereas Lamotrigine decreased delta and theta but increased the alpha power. Finally, XEN1101 decreased TRSP delta, theta, alpha and beta power. Resting-state EEG showed a decrease of theta band power after Lamotrigine intake. Levetiracetam increased theta, beta and gamma power, while XEN1101 produced an increase of delta, theta, beta and gamma power. Spontaneous and TMS-related cortical oscillations represent a powerful tool to characterize the effect of AEDs on in vivo brain activity. Spectral fingerprints of specific AEDs should be further investigated to provide robust and objective biomarkers of biological effect in human clinical trials.

Characterizing the electrophysiological abnormalities in visually reviewed normal EEGs of drug-resistant focal epilepsy patients

Routine scalp EEG is essential in the clinical diagnosis and management of epilepsy. However, a normal scalp EEG (based on expert visual review) recorded from a patient with epilepsy can cause delays in diagnosis and clinical care delivery. Here, we investigated whether normal EEGs might contain subtle electrophysiological clues of epilepsy. Specifically, we investigated (i) whether there are indicators of abnormal brain electrophysiology in normal EEGs of epilepsy patients, and (ii) whether such abnormalities are modulated by the side of the brain generating seizures in focal epilepsy. We analysed awake scalp EEG recordings of age-matched groups of 144 healthy individuals and 48 individuals with drug-resistant focal epilepsy who had normal scalp EEGs. After preprocessing, using a bipolar montage of eight channels, we extracted the fraction of spectral power in the alpha band (8-13 Hz) relative to a wide band of 0.5-40 Hz within 10-s windows. We analysed the extracted features for (i) the extent to which people with drug-resistant focal epilepsy differed from healthy subjects, and (ii) whether differences within the drug-resistant focal epilepsy patients were related to the hemisphere generating seizures. We then used those differences to classify whether an EEG is likely to have been recorded from a person with drug-resistant focal epilepsy, and if so, the epileptogenic hemisphere. Furthermore, we tested the significance of these differences while controlling for confounders, such as acquisition system, age and medications. We found that the fraction of alpha power is generally reduced (i) in drug-resistant focal epilepsy compared to healthy controls, and (ii) in right-handed drug-resistant focal epilepsy subjects with left hemispheric seizures compared to those with right hemispheric seizures, and that the differences are most prominent in the frontal and temporal regions. The fraction of alpha power yielded area under curve values of 0.83 in distinguishing drug-resistant focal epilepsy from healthy and 0.77 in identifying the epileptic hemisphere in drug-resistant focal epilepsy patients. Furthermore, our results suggest that the differences in alpha power are greater when compared with differences attributable to acquisition system differences, age and medications. Our findings support that EEG-based measures of normal brain function, such as the normalized spectral power of alpha activity, may help identify patients with epilepsy even when an EEG does not contain any epileptiform activity, recorded seizures or other abnormalities. Although alpha abnormalities are unlikely to be disease-specific, we propose that such abnormalities may provide a higher pre-test probability for epilepsy when an individual being screened for epilepsy has a normal EEG on visual assessment.

Cognitive dysfunction in Nigerian women with epilepsy on carbamazepine and levetiracetam monotherapy

BACKGROUND

This study aims to identify the determinants of cognitive dysfunction and compare the effect of CPZ and LTC on cognition in WWE.

METHODS

An observational study involving 87 consenting adult WWE aged between 16 and 40 years on LTC or CZP monotherapy. At enrollment, an interviewer-based questionnaire was used to obtain demographic and clinical information from participants. The diagnosis of epilepsy was mainly clinical and supported by electroencephalographic (EEG) features and classified based on recommendation by the 2017 International League Against Epilepsy (ILAE). Zung Self-Reporting Depression Scale (ZSRDS) was used to assess the mood of participants. The Community Screening Interview for Dementia (CSID) was used to assess various cognition domains. The National Hospital Seizure Severity Scale (NHS-3) was used to assess disease severity.

RESULTS

There were statistical differences between the CZP and LTC groups in all domains of cognition assessed except for orientation. The total CSID scores of the LTC group were 59.2 (4.9) as opposed to CZP group, 57.2 (5.0); p: .005. Those with focal onset seizures had lower median total CSID score (58; IQR: 54-62) when compared to those with generalized onset seizures (62; IQR: 58-62), p: .012. There was a significant correlation between ZSRD score and NHS-3 score; rho: 0.30, p: .007. Bivariate analysis shows statistically significant correlation between total CSID score and ZSRDS (rho: -0.65), BMI (rho: 0.22), and NHSS-3 score (rho: -0.36), respectively. However, the effect of AED on CSID scores was lost after multivariate quantile regression with only ZSRDS retaining significance.

CONCLUSION

Depression, seizure severity, type and structural etiology were associated with cognitive impairment among WWE. However, on regression model, only depression was statistically significant. The presence of more risks for cognitive impairment in the CZP group limits possible conclusion of LTC superiority.

Seizures and Epilepsy After Stroke: Epidemiology, Biomarkers and Management

Stroke is the leading cause of seizures and epilepsy in older adults. Patients who have larger and more severe strokes involving the cortex, are younger, and have acute symptomatic seizures and intracerebral haemorrhage are at highest risk of developing post-stroke epilepsy. Prognostic models, including the SeLECT and CAVE scores, help gauge the risk of epileptogenesis. Early electroencephalogram and blood-based biomarkers can provide information additional to the clinical risk factors of post-stroke epilepsy. The management of acute versus remote symptomatic seizures after stroke is markedly different. The choice of an ideal antiseizure medication should not only rely on efficacy but also consider adverse effects, altered pharmacodynamics in older adults, and the influence on the underlying vascular co-morbidity. Drug-drug interactions, particularly those between antiseizure medications and anticoagulants or antiplatelets, also influence treatment decisions. In this review, we describe the epidemiology, risk factors, biomarkers, and management of seizures after an ischaemic or haemorrhagic stroke. We discuss the special considerations required for the treatment of post-stroke epilepsy due to the age, co-morbidities, co-medication, and vulnerability of stroke survivors.

Polycystic ovarian syndrome in Nigerian women with epilepsy on carbamazepine/levetiracetam monotherapy

OBJECTIVE

The study is aimed at comparing effects of older drugs like carbamazepine (CBZ) and newer agent like levetiracetam (LEV) on polycystic ovarian syndrome (PCOS) in women with epilepsy (WWE).

METHODS

An interviewer-based questionnaire was used to obtain relevant clinical information from 50 WWE on CBZ and LEV monotherapy, respectively, and 50 age-matched controls. The diagnosis of epilepsy was clinical with electroencephalographic features taken into consideration and the seizures classified using the 2017 International League Against Epilepsy classification. The diagnosis of PCOS was based on the European Society for Human Reproduction and Embryology/American Society for Reproductive Medicine.

RESULTS

The frequency of PCOS and its subcomponent were higher among WWE compare to controls. PCOS was present in 22 (44%) of LEV group compare to 8 (16%) CBZ group. The frequency of its subcomponent was higher among those on LEV except for comparable effect with regard to oligomenorrhea. The levels of the sex steroid hormone were comparable in both groups of WWE except luteal phase luteinizing hormone, which was lower among the LEV group (P .001). The follicular phase estradiol level was lower (P .021), and follicle-stimulating hormone level was about 2-fold higher (P .03) among WWE compare to controls. The mean value testosterone was significantly lower among controls compared to WWE.

CONCLUSIONS

The increased frequency of PCOS and its subcomponent and the unsatisfactory effect of LEV compared to CBZ on reproductive endocrine function underscore the need for routine reproductive endocrine evaluation to improve overall quality of life.

Event-related potential (P300): the effects of levetiracetam in cognitive performance

BACKGROUND

The current study is a reanalysis in the time domain of EEG data collection in healthy adults during an oddball paradigm using levetiracetam (LEV) vs. placebo acute administration. Specifically, the event-related potential (ERP) technique provides a tool for exploring the EEG responses to a specific event/stimulus. One of the ERP components widely studied is the P300 component, which is associated with the last stage of information processing and a general measurement of "cognitive efficiency."

METHODS

The sample was composed of thirteen healthy right-handed individuals randomized to participate under two conditions: LEV and placebo. Electrophysiological measures were collected before and after drug intake. We explored the oddball paradigm, which is commonly used with healthy individuals to investigate the stages of information processing.

RESULTS

The electrophysiological results showed a main effect of condition on P300 amplitude for the frontal (F3, Fz, F4), central (C3, Cz, C4), and parietal electrodes (P3, Pz, P4). The post hoc comparisons (Scheffé's test) demonstrated the significant differences between electrodes. Regarding P300 latency, all regions represented a main effect of condition. A P300 latency reduction was observed during LEV condition compared with placebo.

CONCLUSION

Our study observed the ERP component-P300-through the variation of its amplitude and latency to evaluate a supposed higher CNS efficiency when participants were under the LEV effect. Our findings sustain this premise, mainly due to reducing in P300 latency for the LEV condition, supporting the neural efficiency hypothesis.

Unskilled shooters improve both accuracy and grouping shot having as reference skilled shooters cortical area: An EEG and tDCS study

Transcranial direct current stimulation (tDCS) has been used as a non-invasive method for enhanced motor and cognitive abilities. However, no previous study has investigated if the tDCS application in unskilled shooters on cortical sites, selected based on the cortical activity of skilled shooters, improves the accuracy and shot grouping. Sixty participants were selected, which included 10 skilled shooters and 50 unskilled shooters. After we identified the right dorsolateral prefrontal cortex (DLPFC) as the area with the highest activity in skilled shooters, we applied anodal tDCS over the right DLPFC in the unskilled shooters under two conditions: sham-tDCS (placebo) and real-tDCS (anodal tDCS). We also analyzed electroencephalography. Our results indicated that anodal tDCS application enhanced the shot accuracy (p = 0.001). Furthermore, the beta power in the EEG recording was higher in the left DLPFC, left and right parietal cortex (p = 0,001) after applying anodal tDCS, while the low-gamma power was higher in the right DLPFC in sham-tDCS (p = 0.001) and right parietal cortex after anodal-tDCS (p = 0.001). Our findings indicate that anodal tDCS can improve accuracy and shot grouping when applied over the unskilled shooters' right DLPFC. Furthermore, beta and low-gamma bands are influenced by anodal tDCS over the right DLPFC, which may be predictive of skill improvement.

Loss of Protection by Antiepileptic Drugs in Lipopolysaccharide-primed Pilocarpine-induced Status Epilepticus is Mediated via Inflammatory Signalling

The evidences from various studies show the association of peripheral and neuronal inflammation with complex pathophysiology of status epilepticus (SE). In this view, the present work attempted to develop a model of neuronal inflammation mediated SE by combining both epileptic and inflammatory components of the disease and also to mimic SE co-morbid with systemic inflammation by peripheral administration of the lipopolysaccharide (LPS) 2 h prior to the pilocarpine (PILO) induction in C57BL/6 mice. We evaluated the anti-convulsant and neuroprotective effects of 7-day prophylactic treatment with three conventional anti-epileptic drugs (Sodium valproate, SVP 300 mg/kg p.o.; Carbamazepine CBZ 100 mg/kg p.o.; Levetiracetam; LEV 200 mg/kg p.o.) of widespread clinical use. Morris water maze and Rota rod tests were carried out 24-h post-exposure to evaluate the neurobehavioral co-morbidities associated with neuroinflammation-mediated status epilepticus. Upon priming with LPS, the loss of protection against PILO-induced seizures was observed by SVP and CBZ, however, LEV showed protection by delaying the seizures. Dramatic elevation in the seizure severity and neuronal loss demonstrated the possible pro-convulsant effect of LPS in the PILO model. Also, the decreased cytokine levels by the AEDs showed their association with NF-κB, IL-1β, IL-6, TNF-α and TGF-β pathways in PILO model. The loss of protective activities of SVP and CBZ in LPS+PILO model was due to increased cytokine levels associated with over-activation of neuroinflammatory pathways, however, partial efficacy of LEV is possibly due to association of other neuroinflammatory mechanisms. The current work provides direct evidence of the contribution of increased peripheral and neuronal inflammation in seizures via regulation of inflammatory pathways in the brain.

Levetiracetam induction of theta frequency oscillations in rodent hippocampus in vitro

Levetiracetam (LEV) has been demonstrated to improve cognitive function. Hippocampal theta rhythm (4-12 Hz) is associated with a variety of cognitively related behaviors, such as exploration in both humans and animal models. We investigated the effects of LEV on the theta rhythm in the rat hippocampal CA3 in hippocampal slices in vitro. We found that LEV increased the theta power in a dose-dependent manner. The increase in theta power can be blocked by GABA_A receptor (GABA_AR) or NMDA receptor (NMDAR) antagonists but not by AMPA receptor antagonist, indicating the involvement of GABA_AR and NMDAR in the induction of theta activity. Interestingly, LEV enhancement of theta power can be also blocked by taurine or GABA-A agonist THIP, indicating that LEV induction of theta may be related to the indirect boosting of GABA action via reduction of extrasynaptic GABA_AR activation. Furthermore, the increased theta power can be partially reduced by the mACh receptor (mAChR) antagonist atropine but not by nACh receptor antagonists, suggesting that mAChR activation provides excitatory input into local network responsible for LEV-induced theta. Our study demonstrated that LEV induced a novel theta oscillation in vitro, which may have implications in the treatment of the neuronal disorders with impaired theta oscillation and cognitive function.

Effects of Levetiracetam Compared to Valproate on Cognitive Functions of Patients with Epilepsy

OBJECTIVE

This study compared the effect of levetiracetam (LEV) as monotherapy to sodium valproate (VPA) as monotherapy on cognitive functions in patients with epilepsy.

METHODS

This was a comparative prospective study on 50 patients with newly diagnosed epilepsy started on antiseizure medications. Patients were selected from the neurology-outpatient clinics at Minia University Hospital, Minia, Egypt. They were divided into two groups: group treated with LEV and group treated with VPA. All patients were subjected to cognitive function assessment using reaction-time tests, trail-making tests, and Wisconsin card-sorting test before treatment and 3 months after treatment.

RESULTS

Both groups of patients showed reduction in seizure frequency. However, patients on LEV showed significant improvement in measured cognitive functions 3 months after starting treatment, while patients in the VPA group showed significant impairment in measured cognitive functions 3 months after starting treatment.

CONCLUSION

Both groups of patients showed reduction in seizure frequency. However, patients on LEV showed significant improvement in measured cognitive functions 3 months after starting treatment, while patients in the VPA group showed significant impairment in measured cognitive functions 3 months after starting treatment.

Anxiety-like features and spatial memory problems as a consequence of hippocampal SV2A expression

The Synaptic Vesicle Protein 2A (SV2A) is a transmembrane protein whose presence is reduced both in animal models and in patients with chronic epilepsy. Besides its implication in the epileptic process, the behavioural consequences of the changes in its expression remain unclear. The purpose of our research is to better understand the possible role(s) of this protein through the phenotype of cKO (Grik4 Cre+/-, SV2A lox/lox) mice, male and female, which present a specific decrease of SV2A expression levels in the hippocampal glutamatergic neurons but without any epileptic seizures. In this study, we compare the cKO mice with cHZ (Grik4 Cre+/-, SV2A lox/+) and WT (Grik4 Cre+/+, SV2A lox/lox) mice through a battery of tests, used to evaluate different features: the anxiety-related features (Elevated Plus Maze), the locomotor activity (Activity Chambers), the contextual fear-related memory (Contextual Fear Conditioning), and the spatial memory (Barnes Maze). Our results showed statistically significant differences in the habituation to a new environment, an increase in the anxiety levels and spatial memory deficit in the cHZ and cKO groups, compared to the WT group. No statistically significant differences due to the genotype appeared in the spontaneous locomotor activity or the fear-linked memory. However, sexual differences were observed in this last feature. These results highlight not only an important role of the SV2A protein in the cognitive and anxiety problems typically encountered in epileptic patients, but also a possible role in the symptomatology of other neurodegenerative diseases, such as the Alzheimer’s disease.

Brivaracetam in the treatment of epilepsy: a review of clinical trial data

Brivaracetam (BRV), an analog of levetiracetam (LEV), was discovered during a target-based rational drug discovery program that aimed to identify potent synaptic vesicle protein 2A (SV2A) ligands. Among the 12,000 compounds screened in vitro, BRV was found to have 15-30 times greater affinity for SV2A and faster brain permeability than LEV. Although preclinical and post-marketing studies suggest broad spectrum of efficacy, BRV is currently only approved as monotherapy and adjunctive therapy of focal-onset seizures in patients age 4 years and older. This review examines the use of BRV as add-on (5-200 mg/day) therapy for epilepsy with a particular emphasis on the six regulatory randomized clinical trialsinvolving 2399 participants. Participants receiving BRV add-on at doses of 50-200 mg/day were more likely to experience a 50% or greater reduction in seizure frequency (pooled risk ratio [RR]) 1.79 with 95% CI of 1.51-2.12) than those receiving placebo. Participants receiving BRV were also more likely to attain seizure freedom (57 [3.3%] vs 4 [0.5%]; RR 4.74, 95% CI 2.00-11.25) than those receiving placebo. In addition, BRV demonstrated a favorable safety profile similar to placebo across all BRV doses. Treatment emergent adverse events significantly associated with BRV were irritability, fatigue, somnolence, and dizziness. Post-hoc analysis of regulatory trials, post-marketing studies, and indirect comparison meta-analyses demonstrated equivalent efficacy and better tolerability of BRV when compared to other antiseizure drugs. Further, these studies appear to suggest that behavioral adverse events are likely to be less frequent and less severe with BRV than LEV. Therefore, switching to BRV may be considered for patients who have seizure control with LEV, but who cannot tolerate its behavioral adverse effects. In this setting, immediate switch from LEV to BRV at a 10:1-15:1 ratio without titration is feasible. Further research is needed to examine the long-term tolerability and efficacy of BRV as well as its role in the treatment of other types of epilepsies, particularly dementia-related epilepsy and brain tumor-related epilepsy.

Antiepileptic Drug of Levetiracetam Decreases Centrotemporal Spike-Associated Activation in Rolandic Epilepsy

The objective was to study the modulation effects of levetiracetam on the fMRI activation/deactivation patterns associated with centrotemporal spikes (CTS) in Rolandic epilepsy. Forty patients with Rolandic epilepsy, including levetiracetam-medicated patients (n = 20) and drug-naive patients (n = 20), were studied. Single and sequential hemodynamic response functions-based EEG-fMRI analysis was performed to detect dynamic activation/deactivation associated with CTS. Comparisons of spatiotemporal features of activation/deactivation were performed between the two groups. Both the groups (CTS were detected in 12 cases of levetiracetam-medicated group, and 11 cases of drug-naive group) showed CTS-associated activation in the Rolandic cortex, whereas activation strength, time-to-peak delay, and overall activation were diminished in the levetiracetam-medicated group. Moreover, the drug-naive group showed deactivation in the regions engaged in higher cognition networks compared with the levetiracetam-medicated group. Levetiracetam inhibits CTS-associated activation intensity and alters the temporal pattern of this activation in the epileptogenic regions, and it also affects the brain deactivation related to higher cognition networks. The findings sheds a light on the pharmocological mechanism of levetiracetam therapy on Rolandic epilepsy.

Repetitive Transcranial Magnetic Stimulation changes absolute theta power during cognitive/motor tasks

Repetitive Transcranial Magnetic Stimulation (rTMS) studies are used to test motor imagery hypothesis. Motor Imagery (MI) represents conscious access to contents of movement intention, generally executed unconsciously during motor preparation. The main objective of this study was to investigate electrophysiological changes, which occurred before and after low-frequency rTMS application when we compared three different tasks: execution, action observation and motor imagery of finger movement. We hypothesize that absolute theta power over frontal regions would change between sensorimotor integration tasks and after 1 Hz of rTMS application. Eleven healthy, right-handed volunteers of both sexes (5 males, 6 females; mean age 28 ± 5 years), with no history of psychiatric or neurological disorders, participated in the experiment. After performing the tasks randomly, subjects were submitted to 15 min of low-frequency rTMS applied on Superior Parietal Cortex (SPC) and performed the tasks again. All tasks were executed simultaneously with Eletroencephalography (EEG) signals recording. Our results clarified the specificity of each sub-region during MI activity. Frontopolar cortex presented involvement with motor process and showed main effect for task and moment. Inferior frontal gyrus presented involvement with long-term memory retrieval and showed interaction between task and moment in the left hemisphere while the right hemisphere showed a main effect for task and moment. The lack of the main effect for conditions on the anterior frontal cortex collaborates with the hypothesis that in this region an integrated circuit of performance monitoring exists.

Levetiracetam efficacy on frontal lobe dysfunctions and anger rumination in patients with epilepsy

This study compared the frontal lobe functioning and anger rumination between patients with epilepsy and healthy individuals. The second objective was to examine the efficacy of levetiracetam therapy on frontal lobe dysfunctions and anger rumination in patients with epilepsy. Participants (50 patients with epilepsy and 50 healthy individuals) completed the Frontal Assessment Battery (FAB) and Anger Rumination Scale (ARS). The patients had two testing sessions: pre- and post-levetiracetam therapies. The results showed that patients with epilepsy had frontal lobe dysfunctions in contrast with healthy individuals. Patients with epilepsy had higher anger rumination than healthy individuals. Compared with baseline performance, frontal lobe dysfunctions and anger rumination were significantly reduced after three months of levetiracetam therapy in patients with epilepsy. It is concluded that levetiracetam therapy may be beneficial in improving frontal lobe functioning and anger rumination thought pattern in patients with epilepsy. However, further studies are required to confirm this evidence.