An integrative view of mechanisms underlying generalized spike-and-wave epileptic seizures and its implication on optimal therapeutic treatments

Many types of epileptic seizures are characterized by generalized spike-and-wave discharges. In the past, notable effort has been devoted to understanding seizure dynamics and various hypotheses have been proposed to explain the underlying mechanisms. In this paper, by taking an integrative view of the underlying mechanisms, we demonstrate that epileptic seizures can be generated by many different combinations of synaptic strengths and intrinsic membrane properties. This integrative view has important medical implications: the specific state of a patient characterized by a set of biophysical characteristics ultimately determines the optimal therapeutic treatment. Through the same view, we further demonstrate the potentiation effect of rational polypharmacy in the treatment of epilepsy and provide a new angle to resolve the debate on polypharmacy. Our results underscore the need for personalized medicine and demonstrate that computer modeling and simulation may play an important role in assisting the clinicians in selecting the optimal treatment on an individual basis.     

Behavioral management of epileptic seizures following EEG biofeedback training of the sensorimotor rhythm

Eight severely epileptic patients, four males and four females, ranging in age from 10 to 29 years, were trained to increase 12–14 Hz EEG activity from the regions overlying the Rolandic area. This activity, the sensorimotor rhythm(SMR), has been hypothesized to be related to motor inhibitory processes(Sterman, 1974). The patients represented a crosssection of several different types of epilepsy, including grand mal, myoclonic, akinetic, focal, and psychomotor types. Three of them had varying degrees of mental retardation. SMR was detected by a combination of an analog filtering system and digital processing. Feedback, both auditory and/or visual, was provided whenever one-half second of 12–14-Hz activity was detected in the EEG. Patients were provided with additional feedback keyed by the output of a 4–7-Hz filter which indicated the presence of epileptiform spike activity, slow waves, or movement. Feedback for SMR was inhibited whenever slow-wave activity spikes or movement was also present. During the treatment period most of the patients showed varying degrees of improvement. Two of the patients who had been severely epileptic, having multiple seizures per week, have been seizure free for periods of up to 1 month. Other patients have developed the ability to block many of their seizures. Seizure intensity and duration have also decreased. Furthermore, the successful patients demonstrated an increase in the amount of SMR and an increase in amplitude of SMR during the training period. Spectral analyses for the EEGs were performed periodically. The effectiveness of SMR conditioning for the control of epileptic seizures is evaluated in terms of patient characteristics and type of seizures.     

On the prediction of epileptic seizures

In 12 epileptic patients suffering from absences 8-channel EEG was recorded by telemetry. The autoregressive model was applied to the signal and the prediction coefficients being the basis for calculation of the poles of the predictor. The location of the poles in thez- ands-planes was described as a function of time for 0.1 s steps along the pre-seizure EEG. In 10 of the 12 patients, and in 25 of the 28 recorded seizures this presentation of the poles of the predictor showed specific pattern linked with the occurrence of the siezure. The trajectory of the most mobile pole during the pre-seizure period could aid in the prediction of the seizure by several seconds.Dr. Isak Gath c/o Prof. Lehmann Neurologische Universitätsklinik CH-8091 Zürich Switzerland     

Models of epileptic seizures in immature rats

Models of basic types of epileptic seizures are elaborated not only in adult but also in immature rodents. It is important because at least half of human epilepsies starts during infancy and childhood. This paper presents a review of chemically and electrically induced models of generalized convulsive and nonconvulsive (absence) seizures as well as models of partial simple (neocortical) and complex (limbic) seizures in immature rats. These models can also serve as a tool for study the development of central nervous system and motor abilities because the level of maturation is reflected in seizure semiology. Age-dependent models of epileptic seizures (absences and flexion seizures) are discussed. Models of seizures in immature animals should be used for testing of potential antiepileptic drugs.     

Role of oxidative stress in epileptic seizures

Oxidative stress resulting from excessive free-radical release is likely implicated in the initiation and progression of epilepsy. Therefore, antioxidant therapies aimed at reducing oxidative stress have received considerable attention in epilepsy treatment. However, much evidence suggests that oxidative stress does not always have the same pattern in all seizures models. Thus, this review provides an overview aimed at achieving a better understanding of this issue. We summarize work regarding seizure models (i.e., genetic rat models, kainic acid, pilocarpine, pentylenetetrazol, and trimethyltin), oxidative stress as an etiologic factor in epileptic seizures (i.e., impairment of antioxidant systems, mitochondrial dysfunction, involvement of redox-active metals, arachidonic acid pathway activation, and aging), and antioxidant strategies for seizure treatment. Combined, this review highlights pharmacological mechanisms associated with oxidative stress in epileptic seizures and the potential for neuroprotection in epilepsy that targets oxidative stress and is supported by effective antioxidant treatment.     

Adaptive prediction of epileptic seizures from intracranial recordings

Previous work has demonstrated that some dynamic properties of intracranial EEG signals are indicative of epileptic seizures and hence could be used for prediction in order to realize counter measures. However, most previous studies only investigated predictability via offline analysis of EEG signals as compared to actually predicting seizures in a setting applicable to implantable devices. Here we address this problem, which calls for simple and fast online methods, and based on previous offline analyses we hypothesize that prediction can be further improved when using multiple features to detect the preictal patterns. We propose a simple adaptive online method (an evolving neuro-fuzzy model) to adaptively learn such combined features. The classifier starts out with a simple structure and patient-independent parameters and then grows into a personal seizure predictor as recursive methods tune the model structure and parameters. We apply the adaptive classifier to a publicly available database of intracranial recordings from 21 patients and demonstrate that seizure prediction is improved with our online method as compared to offline non-adaptive techniques. We show that our method is robust with respect to those few model parameters, which are not adapted. Moreover, as we report the performance on data from a publicly available seizure database, our results can serve as a yardstick for future method developments.     

A model of cell firing patterns during epileptic seizures

A simplified model is presented of the dynamics of excitatory and inhibitory neurons in the cerebral cortex. A key feature of the model is that neurons may cease to fire when strongly depolarized (spike inactivation). Computer simulations for different parameters reveal five classes of solutons: a) steady states in which neither excitatory nor inhibitory cells are active, b) steady states in which one or both types of cells fire repetitively, c) states in which one type of cell fluctuates rapidly between bursts of action potentials and inactivity due to strong depolarization, d) rhythmic activity in which both types of cells fire in unison followed by a period of spike inactivation and e) states similar to d but in which the inhibitory cells never produce action potentials. Solutions b, c, d, and e qualitatively resemble the different firing patterns observed during experimental seizures. It is shown that changes in those parameters that are functions of potassium concentration can induce changes in the type of solution. It is therefore proposed that the increase in extracellular potassium concentration during seizures may be responsible for the progressive changes observed in firing patterns and particularly for the transition from tonic to clonic patterns. A method is also outlined for testing the predictions of the model.     

Ion mechanisms of hyperpolarizing afterpotentials accompanying epileptic discharges in neocortical neurons

Hyperpolarizing afterpotentials of penicillin-induced (local application) paroxysmal depolarizing shifts (PDS) in neurons of the sensorimotor cortex of the cat were studied. The pattern of membrane conductance changes within different segments of hyperpolarization and the data on the role of various ion currents in its generation allow us to conclude that hyperpolarizing afterpotentials accompanying PDS are of a composite nature and include the following components: (i) the initial component provided by an increased membrane permeability to chloride ions (presumably a synaptic GABA_A response); (ii) the second component resulting predominantly from a potassium current and representing presumably a GABA_B response; and (iii) the final component comprising mainly a calcium-activated potassium current. These components are present in all neurons, are not clearly demarcated as separate waves, and partially overlap with each other, thus forming a prolonged hyperpolarizing deflection of the potential.     

Incidence of seizures and EEG abnormalities among offspring of epileptic patients

Summary The marriage rate of epileptic patients was 62% in males und 78% in females. Compared with the rates in the general population, the male patients had a 15% lower rate, but there was no difference in females. There were 263 patients with at least one offspring selected for the study. There were 243 sons and 272 daughters (506 total, 1.9 per patient). Distribution by types of seizure was awakening grand mal, absence or myoclonic petit mal in 24%, grand mal with no aura in 21%, grand mal during sleep in 23%, diffuse grand mal in 7%, grand mal with aura in 13%, psychomotor seizure in 9%, and focal seizure in 3%. The probands were composed of 79% idiopathic and 21% symptomatic in pathogenetic classification. An epileptic EEG abnormality was demonstrated in 22% of male and 44% of female probands.The incidence of seizures among offspring was 2.4% (4.2% age-corrected) in a narrow sense (epilepsy) and 9.1% in a broad sense including febrile convulsions. The latter morbidity was 11.0% for the idiopathic and 3.2% for the symptomatic group; 11.0% for female and 6.9% for male probands; 10.2% for sons and 8.1% for daughters. The figure was higher for the probands with the age range at onset of seizure of 0–4 years (20.6%) and 20–29 years (12.6%) than for those with other age ranges; higher for those with awakening grand mal, absence, myoclonic petit mal, or grand mal with no aura than for those with other types of seizure; and higher for those with family history of epilepsy than those without it.Possible correlation of types of seizure between probands and offspring was demonstrated. Thirty-seven percent of offspring exhibited epileptic EEG abnormalities, and the ratio of epileptic EEG abnormalities to clinical manifestation is about 4:1.Possible existence of familial aggregation of EEG abnormalities and of two kinds of families with large or small epileptic predisposition was indicated.The importance of the role of hereditary and environmental factors in epileptic pathogenesis is proved, and the results of an investigation of congenital malformation among offspring of epileptic mothers are presented. These results were considered to be useful for genetic counseling of epileptic patients.     

Cross sectional study of reporting of epileptic seizures to general practitioners

ObjectiveComparison of reporting of recent epileptic seizures by patients to a doctor and anonymously.DesignCross sectional study of patients with epilepsy by comparison of paired questionnaires.SettingRural and urban general practices in Norfolk. Participants122 patients aged over 16 years and able to self complete a questionnaire who were recruited by 31 general practitioners when attending for review of their epilepsy.Results18 patients failed to report a seizure in the past year to their general practitioner (uncontrolled epilepsy). 40% (24/60) of people with epilepsy who anonymously reported a seizure in the past year held a driving licence, but only six revealed this to their general practitioner. The unemployment rate was 34%, substantially higher than the 9% in the general population. Measures of anxiety, depression, and stigmatisation were higher in patients with uncontrolled epilepsy.ConclusionsA significant proportion of patients with epilepsy underreport their seizures. Recognition of underreporting is important if patients are to benefit from adequate and appropriate treatment. General practitioners'' ability to treat epilepsy is hampered by their role in regulating the rights of epileptic patients to hold a driving licence or access certain occupations.

Key messages

• People with epilepsy may be reluctant to report seizures to their general practitioners as epilepsy affects their eligibility for a driving licence and access to various employment and leisure activities
• In this study about a sixth of patients anonymously reported seizures in the past year which they had not revealed to their general practitioner
• 40% of patients who anonymously reported a seizure in the past year held a driving licence, but only a quarter of these admitted this to their general practitioner
• People who had had seizures in the past year were significantly more depressed and felt more stigmatised than those who had not had a seizure
• Underreporting of seizures has important consequences for treatment, and doctors need to put more effort into explaining this to patients

     

2,4-Dimethoxyphenylsemicarbazones with anticonvulsant activity against three animal models of seizures: synthesis and pharmacological evaluation

Various 2,4-dimethoxyphenylsemicarbazones were synthesized starting from 2,4-dimethoxyaniline via a phenylcarbamate intermediate. The structures were confirmed by spectral and elemental analyses. The anticonvulsant activity of the synthesized compounds was established after intraperitoneal administration in three seizure models in mice which include maximal electroshock seizure, subcutaneous pentylenetetrazole, and subcutaneous strychnine-induced seizure screens. Nine compounds exhibited protection in all the three seizure models, and N1-(2,4-dimethoxyphenyl)-N4-(propan-2-one)semicarbazone (17) emerged as the most active compound with no neurotoxicity. These compounds were found to elevate gamma-aminobutyric acid (GABA) levels in the midbrain and medulla oblongata regions equipotent to clobazam.     

Effect of penicillin G-induced epileptic seizures on hemorheological parameters in rats

Normally, cerebral blood flow (CBF) is quantitatively coupled to cerebral metabolic rate like other tissues and maintained basically by altering vascular geometry and appropriate perfusion pressure. However, the rheological properties of the blood are important factors for effective tissue perfusion. Although a lot of studies have reported that hemorheological parameters are affected by a wide range of pathophysiological conditions, to our knowledge no research related to the effects of epileptic seizures on hemorheological parameters has been carried out. Thus, the aim of this study was to explore possible changes in rheological parameters including red blood cell (RBC) deformability, rigidity and aggregation, whole blood and plasma viscosity during epileptic seizures induced by penicillin G in rats. Eighteen female albino rats were divided into three groups that included sham operated controls (Group S), epileptic group (Group E), intraperitoneal penicillin group (Group IPP). Epilepsy was induced by intracortical injections of penicillin G. Hemorheological studies had been carried out 3 h after the induction of epilepsy. Among the studied hemorheological parameters, only RBC deformability was found to be different in the E group compared to S group. Epileptic seizures led to an increase in RBC deformability in the E group. In conclusion, these results suggest that in addition to an increase in CBF, RBC deformability may also improve to better match brain metabolic demands during seizures.