Deep hypothermia for the treatment of refractory status epilepticus

A peptide-neurotensin conjugate that crosses the blood-brain barrier induces pharmacological hypothermia associated with anticonvulsant, neuroprotective, and anti-inflammatory properties following status epilepticus in mice

Preclinical and clinical studies show that mild to moderate hypothermia is neuroprotective in sudden cardiac arrest, ischemic stroke, perinatal hypoxia/ischemia, traumatic brain injury, and seizures. Induction of hypothermia largely involves physical cooling therapies, which induce several clinical complications, while some molecules have shown to be efficient in pharmacologically induced hypothermia (PIH). Neurotensin (NT), a 13 amino acid neuropeptide that regulates body temperature, interacts with various receptors to mediate its peripheral and central effects. NT induces PIH when administered intracerebrally. However, these effects are not observed if NT is administered peripherally, due to its rapid degradation and poor passage of the blood-brain barrier (BBB). We conjugated NT to peptides that bind the low-density lipoprotein receptor (LDLR) to generate 'vectorized' forms of NT with enhanced BBB permeability. We evaluated their effects in epileptic conditions following peripheral administration. One of these conjugates, VH-N412, displayed improved stability, binding potential to both the LDLR and NTSR-1, rodent/human cross-reactivity and improved brain distribution. In a mouse model of kainate (KA)-induced status epilepticus (SE), VH-N412 elicited rapid hypothermia associated with anticonvulsant effects, potent neuroprotection, and reduced hippocampal inflammation. VH-N412 also reduced sprouting of the dentate gyrus mossy fibers and preserved learning and memory skills in the treated mice. In cultured hippocampal neurons, VH-N412 displayed temperature-independent neuroprotective properties. To the best of our knowledge, this is the first report describing the successful treatment of SE with PIH. In all, our results show that vectorized NT may elicit different neuroprotection mechanisms mediated by hypothermia and/or by intrinsic neuroprotective properties.

The value of hypothermia as a neuroprotective and antiepileptic strategy in patients with status epilepticus: an update of the literature

INTRODUCTION

Status epilepticus represents a significant neurological emergency, with high morbidity and mortality rates. In addition to standard care, the identification of adjuvant strategies is essential to improve the outcome.

AREAS COVERED

The authors conducted a narrative review to provide an update on the value of hypothermia as an antiseizure and neuroprotective treatment in status epilepticus.

EXPERT OPINION

The use of targeted temperature management in the treatment of hypothermia in patients with status epilepticus represents a potentially promising adjuvant strategy, supported by a substantial body of experimental evidence. However, further clinical data demonstrating its efficacy are necessary before it can be recommended for routine use in targeted patient populations, such as those with refractory or super-refractory status epilepticus.

ACVIM Consensus Statement on the management of status epilepticus and cluster seizures in dogs and cats

BACKGROUND

Seizure emergencies (ie, status epilepticus [SE] and cluster seizures [CS]), are common challenging disorders with complex pathophysiology, rapidly progressive drug-resistant and self-sustaining character, and high morbidity and mortality. Current treatment approaches are characterized by considerable variations, but official guidelines are lacking.

OBJECTIVES

To establish evidence-based guidelines and an agreement among board-certified specialists for the appropriate management of SE and CS in dogs and cats.

ANIMALS

None.

MATERIALS AND METHODS

A panel of 5 specialists was formed to assess and summarize evidence in the peer-reviewed literature with the aim to establish consensus clinical recommendations. Evidence from veterinary pharmacokinetic studies, basic research, and human medicine also was used to support the panel's recommendations, especially for the interventions where veterinary clinical evidence was lacking.

RESULTS

The majority of the evidence was on the first-line management (ie, benzodiazepines and their various administration routes) in both species. Overall, there was less evidence available on the management of emergency seizure disorders in cats in contrast to dogs. Most recommendations made by the panel were supported by a combination of a moderate level of veterinary clinical evidence and pharmacokinetic data as well as studies in humans and basic research studies.

CONCLUSIONS AND CLINICAL RELEVANCE

Successful management of seizure emergencies should include an early, rapid, and stage-based treatment approach consisting of interventions with moderate to preferably high ACVIM recommendations; management of complications and underlying causes related to seizure emergencies should accompany antiseizure medications.

Ketamine as adjunct to midazolam treatment following soman-induced status epilepticus reduces seizure severity, epileptogenesis, and brain pathology in plasma carboxylesterase knockout mice

Delayed treatment of cholinergic seizure results in benzodiazepine-refractory status epilepticus (SE) that is thought, at least in part, to result from maladaptive trafficking of N-methyl-d-aspartate (NMDA) and gamma-aminobutyric acid type A (GABA_A) receptors, the effects of which may be ameliorated by combination therapy with the NMDA receptor antagonist ketamine. Our objective was to establish whether ketamine and midazolam dual therapy would improve outcome over midazolam monotherapy following soman (GD) exposure when evaluated in a mouse model that, similar to humans, lacks plasma carboxylesterase, greatly reducing endogenous scavenging of GD. In the current study, continuous cortical electroencephalographic activity was evaluated in male and female plasma carboxylesterase knockout mice exposed to a seizure-inducing dose of GD and treated with midazolam or with midazolam and ketamine combination at 40 min after seizure onset. Ketamine and midazolam combination reduced GD-induced lethality, seizure severity, and the number of mice that developed spontaneous recurrent seizure (SRS) compared with midazolam monotherapy. In addition, ketamine-midazolam combination treatment reduced GD-induced neuronal degeneration and microgliosis. These results support that combination of antiepileptic drug therapies aimed at correcting the maladaptive GABA_A and NMDA receptor trafficking reduces the detrimental effects of GD exposure. Ketamine may be a beneficial adjunct to midazolam in reducing the epileptogenesis and neuroanatomical damage that follows nerve agent exposure and pharmacoresistant SE.

Hypothermia as an adjuvant treatment in paediatric refractory or super-refractory status epilepticus

Therapeutic hypothermia is among the adjuvant therapies suggested for refractory or super-refractory status epilepticus (R/SR-SE) in paediatric patients. Experimental evidence of neuroprotective and antiseizure effects provides a strong rationale for using therapeutic hypothermia in patients with status epilepticus. Thus, hypothermia between 20°C and 33°C in animals with status epilepticus is associated not only with significantly less neuronal damage, predominantly in the hippocampal CA1, CA2, and CA3 areas, but also with increased seizure latency and decreased seizure frequency and duration. Therapeutic hypothermia has rarely been used in paediatric R/SR-SE. In the few reported cases, seizure control was markedly improved but nearly half the patients experienced recurrences after rewarming. Studies are needed to clarify the modalities and indications of therapeutic hypothermia in paediatric patients with R/SR-SE. WHAT THIS PAPER ADDS: Hypothermia at 20°C to 33°C is neuroprotective and has antiseizure effects in experimental status epilepticus. In children, antiseizure effects are marked but recurrences after rewarming are common.

Ketamine-dexmedetomidine combination and controlled mild hypothermia for the treatment of long-lasting and super-refractory status epilepticus in 3 dogs suffering from idiopathic epilepsy

OBJECTIVE

To describe the use of a ketamine-dexmedetomidine combination and mild hypothermia for the treatment of status epilepticus in 3 dogs that did not respond to GABAergic medication.

CASE SERIES SUMMARY

Three dogs, each with a diagnosis of idiopathic epilepsy, were presented to the emergency department in a state of status epilepticus. The dogs were treated unsuccessfully with benzodiazepine as a first-line therapy that was followed by IV propofol anesthesia maintained for at least 12 hours. When general anesthesia was discontinued, seizures reoccurred. All 3 dogs then received a bolus of ketamine (1 mg/kg, IV) over a period of 5 minutes that was followed by a bolus of dexmedetomidine (3 μg/kg, IV) over the same time period and then followed by a continuous infusion for 12 hours of ketamine at a constant rate of 1 mg/kg/h and dexmedetomidine at a variable rate of 3-7 μg/kg/h. Body temperature was maintained between 36.7 and 37.7°C at a state of mild hypothermia throughout treatment. The dogs recovered uneventfully over 48 hours after treatment was discontinued with no evidence of seizures. No notable alterations in physiological parameters were observed during the drug infusions. All dogs were discharged following examinations that showed normal neurological function.

NEW OR UNIQUE INFORMATION PROVIDED

This case series highlights the potential benefits of a ketamine-dexmedetomidine infusion combined with mild hypothermia for the treatment of status epilepticus refractory to GABAergic therapy in dogs suffering from idiopathic epilepsy. After the dogs were weaned from the ketamine-dexmedetomidine infusion, all dogs experienced complete recovery. Thus, this case series introduces a novel approach to treat this intense condition.

Secondary hypothermia in patients with super-refractory status epilepticus managed with propofol and ketamine

BACKGROUND

Therapeutic hypothermia as a potent nonpharmacologic antiseizure therapy has been investigated experimentally in animal models and humans. Although induced hypothermia has been shown to be neuroprotective in acute convulsive status epilepticus, whether its use will translate into improved outcomes for patients with super-refractory nonconvulsive status epilepticus (SRNCSE) has been debated. No clinical data are available on the occurrence and prognostic impact of secondary hypothermia (s-HT) in patients with SRNCSE. With the possibility of core to periphery redistribution of heat with propofol and a centrally mediated dose-dependent fall in body temperature with ketamine, we aimed to investigate the incidence of s-HT events in patients with SRNCSE managed with propofol and ketamine and their impact on clinical outcomes.

METHODS

We performed a retrospective observational analysis of consecutive patients with SRNCSE managed with propofol and/or ketamine in a single-center neurological intensive care unit between December 1, 2012 and December 31, 2015. Patients were divided according to the occurrence of hypothermia (temperature < 35.0 °C) into an s-HT group and a nonhypothermia (n-HT) group. Patients who received targeted temperature management therapy were excluded. We compared the demographics, comorbidities, treatment characteristics, and outcomes between groups.

RESULTS

Ninety-nine consecutive patients with SRNCSE managed with propofol and/or ketamine were identified during the study period. Twenty patients who received targeted temperature management were excluded, leaving a total of 79 patients for analysis. Hypothermia was observed in 52% (41/79) of the study population. Ketamine was used in 63/79 patients (80%). Ketamine infusion rates were higher and of longer duration among patients who developed s-HT compared with those who did not (mean dosage: 57.35 ± 26.6 mcg/kg/min vs 37.17 ± 15 mcg/kg/min, P = 0.001; duration: 116.36 ± 81.9 h vs 88 ± 89.7 h, P = 0.048). Propofol was used in 78/79 patients (99%), with no significant differences in characteristics between groups (mean dosage: 46.44 ± 20.2 mcg/kg/min vs 36.9 ± 12.9 mcg/kg/min, P = 0.058; duration: 125.43 ± 96.4 h vs 102.3 ± 87.1 h, P = 0.215). No significant differences in demographics, comorbidities, status epilepticus duration and resolution rates, and outcomes were observed between groups.

CONCLUSION

In this single-center retrospective analysis of patients whose SRNCSE is being treated, higher doses and longer durations of ketamine were associated with the occurrence of s-HT. Further investigation is warranted to clarify the thermogenic effects of ketamine and its effect on status epilepticus outcomes.

The polarity and properties of radial glia-like neural stem cells are altered by seizures with status epilepticus: Study using an improved mouse pilocarpine model of epilepsy

In the adult mouse hippocampus, new neurons are produced by radial glia-like (RGL) neural stem cells in the subgranular zone, which extend their apical processes toward the molecular layer, and express the astrocyte marker glial fibrillary acidic protein, but not the astrocyte marker S100β. In rodent models of epilepsy, adult hippocampal neurogenesis was reported to be increased after acute and mild seizures, but to be decreased by chronic and severe epilepsy. In the present study, we investigated how the severity of seizures affects neurogenesis and RGL neural stem cells in acute stages of epilepsy, using an improved mouse pilocarpine model in which pilocarpine-induced hypothermia was prevented by maintaining body temperature, resulting in a high incidence rate of epileptic seizures and low rate of mortality. In mice that experienced seizures without status epilepticus (SE), the number of proliferating progenitors and immature neurons were significantly increased, whereas no changes were observed in RGL cells. In mice that experienced seizures with SE, the number of proliferating progenitors and immature neurons were unchanged, but the number of RGL cells with an apical process was significantly reduced. Furthermore, the processes of the majority of RGL cells extended inversely toward the hilus, and about half of the aberrant RGL cells expressed S100β. These results suggest that seizures with SE lead to changes in the polarity and properties of RGL neural stem cells, which may direct them toward astrocyte differentiation, resulting in the reduction of neural stem cells producing new granule cells. This also suggests the possibility that cell polarity of RGL stem cells is important for maintaining the stemness of adult neural stem cells.

Delayed midazolam dose effects against soman in male and female plasma carboxylesterase knockout mice

Chemical warfare nerve agent exposure leads to status epilepticus that may progress to epileptogenesis and severe brain pathology when benzodiazepine treatment is delayed. We evaluated the dose-response effects of delayed midazolam (MDZ) on toxicity induced by soman (GD) in the plasma carboxylesterase knockout (Es1^-/- ) mouse, which, similar to humans, lacks plasma carboxylesterase. Initially, we compared the median lethal dose (LD₅₀ ) of GD exposure in female Es1^-/- mice across estrous with male mice and observed a greater LD₅₀ during estrus compared with proestrus or with males. Subsequently, male and female GD-exposed Es1^-/- mice treated with a dose range of MDZ 40 min after seizure onset were evaluated for survivability, seizure activity, and epileptogenesis. GD-induced neuronal loss and microglial activation were evaluated 2 weeks after exposure. Similar to our previous observations in rats, delayed treatment with MDZ dose-dependently increased survival and reduced seizure severity in GD-exposed mice, but was unable to prevent epileptogenesis, neuronal loss, or gliosis. These results suggest that MDZ is beneficial against GD exposure, even when treatment is delayed, but that adjunct therapies to enhance protection need to be identified. The Es1^-/- mouse GD exposure model may be useful to screen for improved medical countermeasures against nerve agent exposure.

Pharmacotherapy for Pediatric Convulsive Status Epilepticus

Convulsive status epilepticus (CSE) is one of the most common pediatric neurological emergencies. Ongoing seizure activity is a dynamic process and may be associated with progressive impairment of gamma-aminobutyric acid (GABA)-mediated inhibition due to rapid internalization of GABA_A receptors. Further hyperexcitability may be caused by AMPA (alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid) and NMDA (N-methyl-D-aspartic acid) receptors moving from subsynaptic sites to the synaptic membrane. Receptor trafficking during prolonged seizures may contribute to difficulties treating seizures of longer duration and may provide some of the pathophysiological underpinnings of established and refractory SE (RSE). Simultaneously, a practice change toward more rapid initiation of first-line benzodiazepine (BZD) treatment and faster escalation to second-line non-BZD treatment for established SE is in progress. Early administration of the recommended BZD dose is suggested. For second-line treatment, non-BZD anti-seizure medications (ASMs) include valproate, fosphenytoin, or levetiracetam, among others, and at this point there is no clear evidence that any one of these options is better than the others. If seizures continue after second-line ASMs, RSE is manifested. RSE treatment consists of bolus doses and titration of continuous infusions under continuous electro-encephalography (EEG) guidance until electrographic seizure cessation or burst-suppression. Ultimately, etiological workup and related treatment of CSE, including broad spectrum immunotherapies as clinically indicated, is crucial. A potential therapeutic approach for future studies may entail consideration of interventions that may accelerate diagnosis and treatment of SE, as well as rational and early polytherapy based on synergism between ASMs by utilizing medications targeting different mechanisms of epileptogenesis and epileptogenicity.

Modulatory effect of opioid ligands on status epilepticus and the role of nitric oxide pathway

Epilepsy is a chronic disorder that causes unprovoked, recurrent seizures. Status epilepticus (SE) is a medical emergency associated with significant morbidity and mortality. Morphine has been the cornerstone of pain controlling medicines for a long time. In addition to the analgesic and opioid responses, morphine has also revealed anticonvulsant effects in different epilepsy models including pentylenetetrazole (PTZ)-induced seizures threshold. Some authors suggest that nitric oxide (NO) pathway interactions of morphine explain the reason for its pro or anticonvulsant activities. To induce SE, injection of a single dose of lithium chloride (127 mg/kg, intraperitoneal (i.p.)) 20 h before pilocarpine (60 mg/kg, i.p.) was used. Administration of morphine (15 mg/kg, i.p.) inhibited the SE and decreased the mortality in rats when injected 30 min before pilocarpine. On the other hand, injection of L-NG-nitro arginine methyl ester (L-NAME, a nonselective NO synthase (NOS) blocker; 10 mg/kg, i.p.), 7-nitroindazole (7-NI, a neuronal NOS (nNOS) blocker; 30 mg/kg, i.p.), and aminoguanidine (AG, an inducible NOS (iNOS) blocker; 50 mg/kg, i.p.) 15 min before morphine, significantly reversed inhibitory effect of morphine on SE. Subsequently, measurement of nitrite metabolite levels in the hippocampus of SE-induced rats displayed high levels of nitrite metabolite for the control group. However, after injection of morphine in SE-induced rats, nitrite metabolite levels reduced. In conclusion, these findings demonstrated that NO pathway (both nNOS and iNOS) interactions are involved in the anticonvulsant effects of morphine on the SE signs and mortality rate induced by lithium-pilocarpine in rats.

Hypothermia as a treatment in status epilepticus: A narrative review

Status epilepticus (SE) is associated with high mortality and morbidity rates, notably in its refractory and super-refractory forms. This narrative review discusses recent data on the potential benefits of targeted temperature management. In studies of patients with cerebral injury due to various factors, therapeutic hypothermia had variable effects on survival and functional outcomes. Sources of this variability may include the underlying etiology, whether hypothermia was used for prophylaxis or treatment, the degree and duration of hypothermia, and the hypothermia application modalities. Data from animal studies strongly suggest benefits from therapeutic hypothermia in SE. In humans, beneficial effects have been described in anecdotal case reports and small case series, but the level of evidence is low. A randomized controlled trial found no evidence that moderate hypothermia (32-34 °C) was neuroprotective in critically ill patients with convulsive SE. Nevertheless, some promising effects were noted, suggesting that therapeutic hypothermia might have a role as an adjuvant to anticonvulsant drug therapy in patients with refractory or super-refractory SE. This article is part of a Special Issue entitled "Status Epilepticus". This article is part of the Special Issue "Proceedings of the 7th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures".

Neurosteroid and benzodiazepine combination therapy reduces status epilepticus and long-term effects of whole-body sarin exposure in rats

OBJECTIVE

Our objective was to evaluate the protective efficacy of the neurosteroid pregnanolone (3α-hydroxy-5β pregnan-20-one), a GABAA receptor-positive allosteric modulator, as an adjunct to benzodiazepine therapy against the chemical warfare nerve agent (CWNA) sarin (GB), using whole-body exposure, an operationally relevant route of exposure to volatile GB.

METHODS

Rats implanted with telemetry transmitters for the continuous measurement of cortical electroencephalographic (EEG) activity were exposed for 60 minutes to 3.0 LCt50 of GB via whole-body exposure. At the onset of toxic signs, rats were administered an intramuscular injection of atropine sulfate (2 mg/kg) and the oxime HI-6 (93.6 mg/kg) to increase survival rate and, 30 minutes after seizure onset, treated subcutaneously with diazepam (10 mg/kg) and intravenously with pregnanolone (4 mg/kg) or vehicle. Animals were evaluated for GB-induced status epilepticus (SE), spontaneous recurrent seizures (SRS), impairment in spatial memory acquisition, and brain pathology, and treatment groups were compared.

RESULTS

Delayed dual therapy with pregnanolone and diazepam reduced time in SE in GB-exposed rats compared to those treated with delayed diazepam monotherapy. The combination therapy of pregnanolone with diazepam also prevented impairment in the Morris water maze and reduced the neuronal loss and neuronal degeneration, evaluated at one and three months after exposure.

SIGNIFICANCE

Neurosteroid administration as an adjunct to benzodiazepine therapy offers an effective means to treat benzodiazepine-refractory SE, such as occurs following delayed treatment of GB exposure. This study is the first to present data on the efficacy of delayed pregnanolone and diazepam dual therapy in reducing seizure activity, performance deficits and brain pathology following an operationally relevant route of exposure to GB and supports the use of a neurosteroid as an adjunct to standard anticonvulsant therapy for the treatment of CWNA-induced SE.

A New Vision for Therapeutic Hypothermia in the Era of Targeted Temperature Management: A Speculative Synthesis

Three decades of animal studies have reproducibly shown that hypothermia is profoundly cerebroprotective during or after a central nervous system (CNS) insult. The success of hypothermia in preclinical acute brain injury has not only fostered continued interest in research on the classic secondary injury mechanisms that are prevented or blunted by hypothermia but has also sparked a surge of new interest in elucidating beneficial signaling molecules that are increased by cooling. Ironically, while research into cold-induced neuroprotection is enjoying newfound interest in chronic neurodegenerative disease, conversely, the scope of the utility of therapeutic hypothermia (TH) across the field of acute brain injury is somewhat controversial and remains to be fully defined. This has led to the era of Targeted Temperature Management, which emphasizes a wider range of temperatures (33–36°C) showing benefit in acute brain injury. In this comprehensive review, we focus on our current understandings of the novel neuroprotective mechanisms activated by TH, and discuss the critical importance of developmental age germane to its clinical efficacy. We review emerging data on four cold stress hormones and three cold shock proteins that have generated new interest in hypothermia in the field of CNS injury, to create a framework for new frontiers in TH research. We make the case that further elucidation of novel cold responsive pathways might lead to major breakthroughs in the treatment of acute brain injury, chronic neurological diseases, and have broad potential implications for medicines of the distant future, including scenarios such as the prevention of adverse effects of long-duration spaceflight, among others. Finally, we introduce several new phrases that readily summarize the essence of the major concepts outlined by this review—namely, Ultramild Hypothermia, the “Responsivity of Cold Stress Pathways,” and “Hypothermia in a Syringe.”

Advancements in the critical care management of status epilepticus

PURPOSE OF REVIEW

Status epilepticus has a high morbidity and mortality. There are little definitive data to guide management; however, new recent data continue to improve understanding of management options of status epilepticus. This review examines recent advancements regarding the critical care management of status epilepticus.

RECENT FINDINGS

Recent studies support the initial treatment of status epilepticus with early and aggressive benzodiazepine dosing. There remains a lack of prospective randomized controlled trials comparing different treatment regimens. Recent data support further study of intravenous lacosamide as an urgent-control therapy, and ketamine and clobazam for refractory status epilepticus. Recent data support the use of continuous EEG to help guide treatment for all patients with refractory status epilepticus and to better understand epileptic activity that falls on the ictal-interictal continuum. Recent data also improve our understanding of the relationship between periodic epileptic activity and brain injury.

SUMMARY

Many treatments are available for status epilepticus and there are much new data guiding the use of specific agents. However, there continues to be a lack of prospective data supporting specific regimens, particularly in cases of refractory status epilepticus.

The role of genetic background in susceptibility to chemical warfare nerve agents across rodent and non-human primate models

Genetics likely play a role in various responses to nerve agent exposure, as genetic background plays an important role in behavioral, neurological, and physiological responses to environmental stimuli. Mouse strains or selected lines can be used to identify susceptibility based on background genetic features to nerve agent exposure. Additional genetic techniques can then be used to identify mechanisms underlying resistance and sensitivity, with the ultimate goal of developing more effective and targeted therapies. Here, we discuss the available literature on strain and selected line differences in cholinesterase activity levels and response to nerve agent-induced toxicity and seizures. We also discuss the available cholinesterase and toxicity literature across different non-human primate species. The available data suggest that robust genetic differences exist in cholinesterase activity, nerve agent-induced toxicity, and chemical-induced seizures. Available cholinesterase data suggest that acetylcholinesterase activity differs across strains, but are limited by the paucity of carboxylesterase data in strains and selected lines. Toxicity and seizures, two outcomes of nerve agent exposure, have not been fully evaluated for genetic differences, and thus further studies are required to understand baseline strain and selected line differences.

Prolonged Localized Mild Hypothermia Does Not Affect Seizure Activity After Intracerebral Hemorrhage in Rats

Intracerebral hemorrhage (ICH) is a devastating stroke with high morbidity and mortality. Post-ICH seizures are a common complication, potentially increasing brain injury and the risk of delayed epilepsy. Mild therapeutic hypothermia (HYPO, ∼33°C) is neuroprotective against several brain insults, such as ischemia, while also mitigating seizure incidence and severity in some instances. Therefore, we tested whether brain-selective HYPO reduced electrographic seizure activity after a collagenase-induced striatal ICH in rats. Animals were injected unilaterally with 0.14 U of bacterial collagenase, implanted with a unilateral brain cooling device, and a probe to bilaterally record electroencephalographic (EEG) activity. Cooling began 6 hours after collagenase infusion and was maintained for 48 hours, followed by rewarming over 6 hours. Our protocol did not affect EEG activity in naïve rats, nor did it increase bleeding after ICH (∼50 μL). Epileptiform activity commonly occurred in untreated ICH rats (∼60% of animals), but HYPO did not affect the incidence, timing, total duration of seizures, or the peaks occurring during epileptiform activity. However, longer average duration was detected on the ipsilateral side to stroke in the HYPO group (p < 0.05). Cooling did not affect neurological deficits (e.g., circling), measured 7 and 14 days after ICH, or lesion volume (∼35 mm(3)). In addition, there was no relationship among endpoints (e.g., seizures and lesion size). In summary, HYPO failed to reduce seizure activity after ICH, which fits with our separate findings that cooling does not mitigate thrombin and iron-mediated secondary injury mechanisms thought to cause seizures after ICH. Additional research is needed to identify better HYPO protocols and the use of cotreatments to maximize the benefit of HYPO to ICH patients.

Neuroprotective effects of deep hypothermia in refractory status epilepticus

Objective

Pharmacoresistance develops quickly during repetitive seizures, and refractory status epilepticus (RSE) remains a therapeutic challenge. The outcome of RSE is poor, with high mortality and morbidity. New treatments are needed. Deep hypothermia (20°C) is used clinically during reconstructive cardiac surgery and neurosurgery, and has proved safe and effective in those indications. We tested the hypothesis that deep hypothermia reduces RSE and its long‐term consequences.

Methods

We used a model of SE induced by lithium and pilocarpine and refractory to midazolam. Several EEG measures were recorded in both hypothermic (n = 17) and normothermic (n = 20) animals. Neuronal injury (by Fluoro‐Jade B), cell‐mediated inflammation, and breakdown of the blood–brain barrier (BBB) (by immunohistochemistry) were studied 48 h following SE onset.

Results

Normothermic rats in RSE seized for 4.1 ± 1.1 h, and at 48 h they displayed extensive neuronal injury in many brain regions, including hippocampus, dentate gyrus, amygdala, entorhinal and pyriform cortices, thalamus, caudate/putamen, and the frontoparietal neocortex. Deep hypothermia (20°C) of 30 min duration terminated RSE within 12 min of initiation of hypothermia, reduced EEG power and seizure activity upon rewarming, and eliminated SE‐induced neuronal injury in most animals. Normothermic rats showed widespread breakdown of the BBB, and extensive macrophage infiltration in areas of neuronal injury, which were completely absent in animals treated with hypothermia.

Interpretation

These results suggest that deep hypothermia may open a new therapeutic avenue for the treatment of RSE and for the prevention of its long‐term consequences.