Focal cooling for epilepsy: an alternative therapy that might actually work

A pilot protocol and review of triple neuroprotection with targeted hypothermia, controlled induced hypertension, and barbiturate infusion during emergency carotid endarterectomy for acute stroke after failed tPA or beyond 24-hour window of opportunity

An alternative to tissue plasminogen activator (tPA) failure has been a daunting challenge in ischemic stroke management. As tPA is time-dependent, delays can occur in definitive treatment while passively waiting to observe a clinical response to intravenous thrombolysis. Until today, uncertainty exists in the management strategy of wake-up stroke patients or those presenting beyond the therapeutic tPA window. Clinical dilemmas in these situations can prolong the transitional period of inertia, resulting in an adverse neurological outcome. We propose and review an innovative approach called triple neuro-protection (TNP), which encompasses three technical domains-targeted hypothermia, systemic induced hypertension, and barbiturates infusion, to protect the brain during carotid endarterectomy after failed tPA and/or beyond the 24-hour therapeutic mechanical thrombectomy window. This proposal assimilates discussion on the clinical evidence of the individual domains of TNP with our own clinical experience with TNP. Our first TNP was successfully employed in a 55-year-old man in 2015 while performing emergency carotid endarterectomy after he was referred to us 72 hours post tPA failure. The patient had a successful clinical outcome despite being in therapeutic inertia with 90–99% ipsilateral carotid stenosis and contralateral occlusion on presentation. In the last five years, we have safely used TNP in 25 selected cases with favourable clinical outcomes.

Epileptic Seizure Suppression by Focal Brain Cooling With Recirculating Coolant Cooling System: Modeling and Simulation

A focal brain cooling system for treatment of refractory epilepsy that is implantable and wearable may permit patients with this condition to lead normal daily lives. We have developed such a system for cooling of the epileptic focus by delivery of cold saline to a cooling device that is implanted cranially. The outflow is pumped for circulation and cooled by a Peltier device. Here, we describe the design of the system and evaluate its feasibility by simulation. Mathematical models were constructed based on equations of fluid dynamics and data from a cat model. Computational fluid dynamics simulations gave the following results: 1) a cooling device with a complex channel structure gives a more uniform temperature in the brain; 2) a cooling period of <10 min is required to reach an average temperature of 25.0°Cat 2 mm below the brain surface, which is the target temperature for seizure suppression. This time is short enough for cooling of the brain before seizure onset after seizure prediction by an intracranial electroencephalogram-based algorithm; and 3) battery charging would be required once every several days for most patients. These results suggest that the focal brain cooling system may be clinically applicable.

Corpus callosum low-frequency stimulation suppresses seizures in an acute rat model of focal cortical seizures

OBJECTIVE

Low-frequency fiber-tract stimulation has been shown to be effective in treating mesial temporal lobe epilepsies through activation of the hippocampal commissure in rodents and human patients. The corpus callosum is a major pathway connecting the two hemispheres of the brain; however, few experiments have documented corpus callosum stimulation. The objective is to determine the efficacy of corpus callosum stimulation at low frequencies to suppress cortical seizures.

METHODS

4-Aminopyridine was injected in the primary motor cortex of 24 rats under anesthesia. Recording electrodes were placed in the contralateral motor cortex and hippocampus. Three pairs of stimulating electrodes were inserted into the corpus callosum along its longitudinal axis. Local field potentials were recorded 1 hour before, during, and after stimulation to determine the effect of stimulation on seizure duration. Stimulation was delivered from each pair of electrodes independently in separate experiments. Furthermore, electrical stimulation was applied to the region of the corpus callosum with the highest degree of innervation of the seizure focus to compare the efficacy of different stimulation frequencies (1-30 Hz) on seizure suppression.

RESULTS

Corpus callosum stimulation was effective at suppressing seizures at 10 Hz by 76% (P < 0.05, n = 5) and at 20 Hz by 95% (P < 0.0001, n = 14). Stimulation at frequencies of 1 and 30 Hz did not have a significant effect on reducing the total time spent seizing (P > 0.9999, n = 5). Furthermore, stimulation was only effective at suppressing seizures when the pair of electrodes was placed within the section of corpus callosum containing fibers innervating the seizure focus. Secondarily generalized seizures in the hippocampus were eliminated when seizures in the cortical focus were suppressed.

SIGNIFICANCE

Low-frequency fiber-tract stimulation of the corpus callosum suppresses both cortical and cortically induced hippocampal seizures in an acute model of focal cortical seizures. The stimulation paradigm is selective, as it is only effective when targeted to specific regions of the corpus callosum that project maximally to cortical regions generating the seizure activity. Selective placement of stimulation electrodes along the corpus callosum could be used as a patient-specific treatment for cortical epilepsies.

Development and Validation of a Brain Phantom for Therapeutic Cooling Devices

Tissue cooling has been proven as a viable therapy for multiple conditions and injuries and has been applied to the brain to treat epilepsy and concussions, leading to improved long-term outcomes. To facilitate the study of temperature reduction as a function of various cooling methods, a thermal brain phantom was developed and analyzed. The phantom is composed of a potassium-neutralized, superabsorbent copolymer hydrogel. The phantom was tested in a series of cooling trials using a cooling block and 37 deg water representing nondirectional blood flow ranging up to 6 gph, a physiologically representative range based on the prototype volume. Results were compared against a validated finite difference (FD) model. Two sets of parameters were used in the FD model: one set to represent the phantom itself and a second set to represent brain parenchyma. The model was then used to calculate steady-state cooling at a depth of 5 mm for all flow rates, for both the phantom and a model of the brain. This effort was undertaken to (1) validate the FD model against the phantom results and (2) evaluate how similar the thermal response of the phantom is to that of a perfused brain. The FD phantom model showed good agreement with the empirical phantom results. Furthermore, the empirical phantom agreed with the predicted brain response within 3.5% at physiological flow, suggesting a biofidelic thermal response. The phantom will be used as a platform for future studies of thermally mediated therapies applied to the cerebral cortex.

Epidural focal brain cooling abolishes neocortical seizures in cats and non-human primates

Focal brain cooling (FBC) is under investigation in preclinical trials of intractable epilepsy (IE), including status epilepticus (SE). This method has been studied in rodents as a possible treatment for epileptic disorders, but more evidence from large animal studies is required. To provide evidence that FBC is a safe and effective therapy for IE, we investigated if FBC using a titanium cooling plate can reduce or terminate focal neocortical seizures without having a significant impact on brain tissue. Two cats and two macaque monkeys were chronically implanted with an epidural FBC device over the somatosensory and motor cortex. Penicillin G was delivered via the intracranial cannula for induction of local seizures. Repetitive FBC was performed using a cooling device implanted for a medium-term period (FBC for 30min at least twice every week; 3 months total) in three of the four animals. The animals exhibited seizures with repetitive epileptiform discharges (EDs) after administration of penicillin G, and these discharges decreased at less than 20°C cooling with no adverse histological effects. The results of this study suggest that epidural FBC is a safe and effective potential treatment for IE and SE.

Is Using Threshold-Crossing Method and Single Type of Features Sufficient to Achieve Realistic Application of Seizure Prediction?

Objective This study aims to verify whether the simple threshold-crossing method can work well enough to achieve the realistic application of seizure prediction on the basis of a large public database, and examines how a more complex classifier can improve prediction performance. It also verified whether the combination of multiple types of features with a complex classifier can improve prediction performance. Method Phase synchronization and spectral power features were extracted from electroencephalogram recordings. The threshold-crossing method and a support vector machine (SVM) were used to identify preictal and interictal samples. Based on the type of selected features and the manner of classification, 5 different methods were conducted on 19 patients. The performances of these methods were directly compared and tested using a random predictor. In-sample optimization problems were avoided in the feature and parameter selection procedure to obtain credible results. Results The threshold-crossing method could only obtain satisfying prediction results for approximately half of the selected patients. The SVM classifier could significantly improve prediction performance compared with the threshold-crossing method for both types of features. Although the average performance was further improved when both types of features were combined with the SVM classifier, the improvement was insignificant. Conclusion A complex classifier, such as the SVM, is recommended in a realistic prediction device, although it will increase the complexity of the device. Indeed, the simple threshold-crossing method performs well enough for some of the patients. The combination of phase synchronization and spectral power features is unnecessary because of the increased computation complexity.

An On-Site Thermoelectric Cooling Device for Cryotherapy and Control of Skin Blood Flow

Cryotherapy involves the surface application of low temperatures to enhance the healing of soft tissue injuries. Typical devices embody a remote source of chilled water that is pumped through a circulation bladder placed on the treatment site. In contrast, the present device uses thermoelectric refrigeration modules to bring the cooling source directly to the tissue to be treated, thereby achieving significant improvements in control of therapeutic temperature while having a reduced size and weight. A prototype system was applied to test an oscillating cooling and heating protocol for efficacy in regulating skin blood perfusion in the treatment area. Data on 12 human subjects indicate that thermoelectric coolers (TECs) delivered significant and sustainable changes in perfusion for both heating (increase by (±SE) 173.0 ± 66.0%, P < 0.005) and cooling (decrease by (±SE) 57.7 ± 4.2%, P < 0.0005), thus supporting the feasibility of a TEC-based device for cryotherapy with local temperature regulation.

Future of seizure prediction and intervention: closing the loop

The ultimate goal of epilepsy therapies is to provide seizure control for all patients while eliminating side effects. Improved specificity of intervention through on-demand approaches may overcome many of the limitations of current intervention strategies. This article reviews the progress in seizure prediction and detection, potential new therapies to provide improved specificity, and devices to achieve these ends. Specifically, we discuss (1) potential signal modalities and algorithms for seizure detection and prediction, (2) closed-loop intervention approaches, and (3) hardware for implementing these algorithms and interventions. Seizure prediction and therapies maximize efficacy, whereas minimizing side effects through improved specificity may represent the future of epilepsy treatments.

The Palm-Sized Cryoprobe System Based on Refrigerant Expansion and Boiling and Its Application to an Animal Model of Epilepsy

GOAL

The purpose of this study is to propose the palm-sized cryoprobe system based on a new concept and to suggest that the freezing technique could be used for treatment of epilepsy.

METHODS

We propose herein a cryoprobe system based on the boiling effect that uses a specific refrigerants with a boiling point higher than that of liquid nitrogen yet low enough to result in cell necrosis. To evaluate and verify the effectiveness of the proposed system, cooling characteristics are investigated in agar. In addition, the system is applied to a Wistar rat brain-model, in which the epileptic activities are induced in advance by a potent epileptogenic substance.

RESULTS

The design concept yielded the following benefits: 1) the selected refrigerant promotes sealing in the tank; 2) the tank can be made as compact as possible, limited only by the volume required for the refrigerant; 3) because the tank and probe units can be separated by a nonconducting, flexible, and high-pressure tube, the tank unit can be manipulated without disturbing the probe tip with mechanical vibrations and electrical noise. Although the agar experiments, we verified that the proposed system can uniquely and reproducibly create an ice ball. Moreover, in the rat experiments in vivo, it was confirmed that penicillin G-induced epileptic activities disappeared on freezing with the proposed system.

CONCLUSIONS

The palm-sized system has desired characteristics and can apply for an animal model of epilepsy.

SIGNIFICANCE

Results of in vivo experiments suggest that cryosurgery may be an effective treatment for epilepsy.

Development of an implantable flexible probe for simultaneous near-infrared spectroscopy and electrocorticography

A combination of near-infrared spectroscopy (NIRS) and electrocorticography (ECoG) provides beneficial information on cortical activity from different aspects. Integration of such multimodal measurement capability into a single apparatus and the direct measurement of cortical activity during chronic subdural implantation may be a powerful means for clinical diagnosis and neuroscience. However, an optical fiber-based NIRS probe cannot be miniaturized for implantation into the brain, and the light-scattering effect of ECoG electrodes in NIRS measurements is unknown. We describe here the development of a flexible probe, small enough for chronic subdural implantation, for simultaneous NIRS and ECoG. Two light-emitting diodes of different wavelengths and two photodiodes were mounted on a polyimide-based flexible substrate, and ECoG electrodes were formed with a design minimizing artifacts in NIRS recording. The fabricated probe measured ECoGs at sufficient spatial resolution and submicromolar changes in hemoglobin concentrations in in vivo experiments with acute implantation into a rat. Comparison of measured changes in hemoglobin concentrations for different source-detector distances reveals the reliability of the measured values and the practicality of the simulation model. The proposed intracranial multimodality probe may provide beneficial evidence for pre- and intrasurgical assessment of neurosurgery and reveal the interaction of electrophysiology and hemodynamics at high spatial resolution without artifacts due to scalp blood flow.

Daily rhythmic behaviors and thermoregulatory patterns are disrupted in adult female MeCP2-deficient mice

Mutations in the X-linked gene encoding Methyl-CpG-binding protein 2 (MECP2) have been associated with neurodevelopmental and neuropsychiatric disorders including Rett Syndrome, X-linked mental retardation syndrome, severe neonatal encephalopathy, and Angelman syndrome. Although alterations in the performance of MeCP2-deficient mice in specific behavioral tasks have been documented, it remains unclear whether or not MeCP2 dysfunction affects patterns of periodic behavioral and electroencephalographic (EEG) activity. The aim of the current study was therefore to determine whether a deficiency in MeCP2 is sufficient to alter the normal daily rhythmic patterns of core body temperature, gross motor activity and cortical delta power. To address this, we monitored individual wild-type and MeCP2-deficient mice in their home cage environment via telemetric recording over 24 hour cycles. Our results show that the normal daily rhythmic behavioral patterning of cortical delta wave activity, core body temperature and mobility are disrupted in one-year old female MeCP2-deficient mice. Moreover, female MeCP2-deficient mice display diminished overall motor activity, lower average core body temperature, and significantly greater body temperature fluctuation than wild-type mice in their home-cage environment. Finally, we show that the epileptiform discharge activity in female MeCP2-deficient mice is more predominant during times of behavioral activity compared to inactivity. Collectively, these results indicate that MeCP2 deficiency is sufficient to disrupt the normal patterning of daily biological rhythmic activities.

Cooling of the epileptic focus suppresses seizures with minimal influence on neurologic functions

PURPOSE

Focal brain cooling is effective for suppression of epileptic seizures, but it is unclear if seizures can be suppressed without a substantial influence on normal neurologic function. To address the issue, a thermoelectrically driven cooling system was developed and applied in free-moving rat models of focal seizure and epilepsy.

METHODS

Focal seizures limited to the unilateral forelimb were induced by local application of a penicillin G solution or cobalt powder to the unilateral sensorimotor cortex. A proportional integration and differentiation (PID)-controlled, thermoelectrically driven cooling device (weight of 11 g) and bipolar electrodes were chronically implanted on the eloquent area (on the epileptic focus) and the effects of cooling (20, 15, and 10°C) on electrocorticography, seizure frequency, and neurologic changes were investigated.

KEY FINDINGS

Cooling was associated with a distinct reduction of the epileptic discharges. In both models, cooling of epileptic foci significantly improved both seizure frequency and neurologic functions from 20°C down to 15°C. Cooling to 10°C also suppressed seizures, but with no further improvement in neurologic function. Subsequent investigation of sensorimotor function revealed significant deterioration in foot-fault tests and the receptive field size at 15°C.

SIGNIFICANCE

Despite the beneficial effects in ictal rats, sensorimotor functions deteriorated at 15°C, thereby suggesting a lower limit for the therapeutic temperature. These results provide important evidence of a therapeutic effect of temperatures from 20 to 15°C using an implantable, hypothermal device for focal epilepsy.

Wireless and batteryless biomedical microsystem for neural recording and epilepsy suppression based on brain focal cooling

This work presents a biomedical microsystem with a wireless radiofrequency (RF)-powered electronics and versatile sensors/actuators for use in nanomedicinal diagnosis and therapy. The cooling of brain tissue has the potential to reduce the frequency and severity of epilepsy. Miniaturised spiral coils as a wireless power module with low-dropout linear regulator circuit convert RF signals into a DC voltage, can be implanted without a battery in monitoring free behaviour. A thermoelectric (TE) cooler is an actuator that is employed to cool down brain tissue to suppress epilepsy. Electroencephalogram (EEG) electrodes and TE coolers are integrated to form module that is placed inside the head of a rat and fastened with a bio-compatible material. EEG signals are used to identify waveforms associated with epilepsy and are measured using readout circuits. The wireless part of the presented design achieves a low quiescent current and line/load regulation and high antenna/current efficiency with thermal protection to avoid damage to the implanted tissue. Epilepsy is suppressed by reducing the temperature to reduce the duration of this epileptic episode. Related characterisations demonstrate that the proposed design can be adopted in an effective nanomedicine microsystem.

Neuromodulation in Epilepsy

Neuromodulation strategies have been proposed to treat a variety of neurological disorders, including medication-resistant epilepsy. Electrical stimulation of both central and peripheral nervous systems has emerged as a possible alternative for patients who are not deemed to be good candidates for resective procedures. In addition to well-established treatments such as vagus nerve stimulation, epilepsy centers around the world are investigating the safety and efficacy of neurostimulation at different brain targets, including the hippocampus, thalamus, and subthalamic nucleus. Also promising are the preliminary results of responsive neuromodulation studies, which involve the delivery of stimulation to the brain in response to detected epileptiform or preepileptiform activity. In addition to electrical stimulation, novel therapeutic methods that may open new horizons in the management of epilepsy include transcranial magnetic stimulation, focal drug delivery, cellular transplantation, and gene therapy. We review the current strategies and future applications of neuromodulation in epilepsy.

Temperature Modulation of Slow and Fast Cortical Rhythms

In the local cortical network, spontaneous emergent activity self-organizes in rhythmic patterns. These rhythms include a slow one (<1 Hz), consisting in alternation of up and down states, and also faster rhythms (10–80 Hz) generated during up states. Varying the temperature in the bath between 26 and 41°C resulted in a strong modulation of the emergent network activity. Up states became shorter for warmer temperatures and longer with cooling, whereas down states were shortest at physiological (36–37°C) temperature. The firing rate during up states was robustly modulated by temperature, increasing with higher temperatures. The sparse firing rate during down states hardly varied with temperature, thus resulting in a progressive merging of up and down states for temperatures around 30°C. Below 30°C and down to 26°C the firing lost rhythmicity, becoming progressively continuous. The slope of the down-to-up transitions, which reflects the speed of recruitment of the local network, was progressively steeper for higher temperatures, whereas wave-propagation speed exhibited only a moderate increase. Fast rhythms were particularly sensitive to temperature. Broadband high-frequency fluctuations in the local field potential were maximal for recordings at 36–38°C. Overall, we found that maintaining cortical slices at physiological temperature is critical for the generated activity to be analogous to that in vivo. We also demonstrate that changes in activity with temperature were not secondary to oxygenation changes. Temperature variation sets the in vitro cortical network at different functional regimes, allowing the exploration of network activity generation and control mechanisms.

Optical suppression of experimental seizures in rat brain slices

PURPOSE

To determine if a small ultraviolet emitting diode (UV LED) could release sufficient gamma-aminobutyric acid (GABA) from a caged precursor to suppress paroxysmal activity in rat brain slices.

METHODS

Electrophysiologic recordings were obtained from rat brain slices bathed with caged GABA: 4-[[(2H-benzopyran-2-one-7-amino-4-methoxy)carbonyl]amino]butanoic acid (BC204), at concentrations between 3 and 30 microm. Seizure-like activity was induced by perfusing slices with extracellular medium lacking magnesium and containing 4-aminopyridine (4-AP; 100 microm). A small, high-power UV LED was used to uncage BC204 and determine whether an increase in ambient GABA could alter normal or paroxysmal activity in the slice.

RESULTS

UV LED illumination, in the absence of BC204, had no effect on CA1 population spikes or seizure-like activity. The light did induce a small temperature elevation (<0.15 degrees C) over the current intensities and exposure durations used in these experiments. In the presence of BC204, UV light decreased the CA1 population spike and seizure-like activity. The BC204 effect can be best accounted for by release of GABA: The reduction of population spikes and seizure-like activity was blocked by the GABA antagonist picrotoxin, and BC204 illumination produced a membrane polarization that reversed at the expected potential for GABA(A) receptors.

DISCUSSION

These experiments establish that illumination of a low concentration of caged GABA with a tiny UV LED can release sufficient GABA to attenuate seizure-like activity in brain slices. Because our seizure model is very severe, it is probable that this technique would have a robust effect in human focal epilepsy.

Commentary: physical approaches for the treatment of epilepsy: electrical and magnetic stimulation and cooling

Physical approaches for the treatment of epilepsy currently under study or development include electrical or magnetic brain stimulators and cooling devices, each of which may be implanted or applied externally. Some devices may stimulate peripheral structures, whereas others may be implanted directly into the brain. Stimulation may be delivered chronically, intermittently, or in response to either manual activation or computer-based detection of events of interest. Physical approaches may therefore ultimately be appropriate for seizure prophylaxis by causing a modification of the underlying substrate, presumably with a reduction in the intrinsic excitability of cerebral structures, or for seizure termination, by interfering with the spontaneous discharge of pathological neuronal networks. Clinical trials of device-based therapies are difficult due to ethical issues surrounding device implantation, problems with blinding, potential carryover effects that may occur in crossover designs if substrate modification occurs, and subject heterogeneity. Unresolved issues in the development of physical treatments include optimization of stimulation parameters, identification of the optimal volume of brain to be stimulated, development of adequate power supplies to stimulate the necessary areas, and a determination that stimulation itself does not promote epileptogenesis or adverse long-term effects on normal brain function.

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.

Epilepsy and nonlinear dynamics

This overview summarizes findings obtained from analyzing electroencephalographic (EEG) recordings from epilepsy patients with methods from the theory of nonlinear dynamical systems. The last two decades have shown that nonlinear time series analysis techniques allow an improved characterization of epileptic brain states and help to gain deeper insights into the spatial and temporal dynamics of the epileptic process. Nonlinear EEG analyses can help to improve the evaluation of patients prior to neurosurgery, and with an unequivocal identification of precursors of seizures, they can be of great value in the development of seizure warning and prevention techniques.

Technology insight: neuroengineering and epilepsy-designing devices for seizure control

Despite substantial innovations in antiepileptic drug therapy over the past 15 years, the proportion of patients with uncontrolled epilepsy has not changed, highlighting the need for new treatment strategies. New implantable antiepileptic devices, which are currently under development and in pivotal clinical trials, hold great promise for improving the quality of life of millions of people with epileptic seizures worldwide. A broad range of strategies to stop seizures is currently being investigated, with various modes of control and intervention. The success of novel antiepileptic devices rests upon collaboration between neuroengineers, physicians and industry to adapt new technologies for clinical use. The initial results with these technologies are exciting, but considerable development and controlled clinical trials will be required before these treatments earn a place in our standard of clinical care.

Focal Increases in Perfusion and Decreases in Hemoglobin Oxygenation Precede Seizure Onset in Spontaneous Human Epilepsy

PURPOSE

Optical recording of intrinsic signals provides the highest combined spatial and temporal resolution with broad spatial sampling for measuring cerebral blood volume (CBV) and hemoglobin oxygenation in cerebral cortex. Few opportunities arise to apply this laboratory method to record spontaneous seizures in unanesthetized human brain during neurosurgery. We report such a rare opportunity in a man with recurrent focal epilepsy arising from a cavernous malformation.

METHODS

We recorded intrinsic optical signals (IOS) from human cortex intraoperatively during spontaneous seizures arising from brain surrounding a small cavernous malformation in an awake patient using only local anesthesia with simultaneous electrocorticography. The IOS was recorded at two wavelengths, one an isosbestic point for hemoglobin to measure CBV (570 nm) and the other at a wavelength more sensitive to deoxygenated hemoglobin (Hbr) (610 nm). A modified Beer-Lambert calculation was used on two separate but similar seizures to approximate changes in Hbr, CBV as well as oxygenated hemoglobin (HbO(2)).

RESULTS

Electrographically recorded seizures (n = 3) elicited a focal increase in both Hbr and CBV that lasted for the duration of the seizure, indicating that perfusion was inadequate to meet metabolic demand. Remarkably, these hemodynamic changes preceded the onset of the seizures by approximately 20 s and occurred focally over the known location of the lesion and the seizure onsets.

DISCUSSION

These findings demonstrate that the hemoglobin becomes deoxygenated in spite of large increase in CBV during spontaneous human focal seizures and that optically recorded hemodynamic events can be used both to predict and localize human focal epilepsy. Such data may someday be useful to assist in the presurgical evaluation of patients considered for epilepsy surgery and to predict the timing and location of seizure onsets.

Etiology and management of refractory epilepsies

The epilepsies are an important, common and diverse group of symptom complexes characterized by recurrent spontaneous seizures. Although many patients with epilepsy have their seizures controlled effectively by antiepileptic drugs (AEDs), about one-third of patients continue to have seizures, despite trying a range of AEDs. Such patients bear the heaviest burden of epilepsy, with increased morbidity and risk of premature mortality. Our current understanding of the refractory epilepsies--the most common of which are focal--is limited; even their definition is problematic. Standard treatments for refractory epilepsies include optimization of existing AED regimens, trials of further AEDs, and, for some patients, therapeutic resective neurosurgery. Recent basic research has explored possible underlying causes of refractory epilepsy, and two main hypotheses have emerged to account for the failure of AED treatment. According to one hypothesis, AEDs might fail because of alterations in the properties of their usual targets. Alternatively, they might fail because multidrug transporter mechanisms limit concentrations of the drugs at their targets. The refractory epilepsies can be viewed as offering remarkable insights into biological processes in the epilepsies, and their effective treatment remains an important aim; treatment would potentially bring much-needed relief to hundreds of thousands of patients across the world.