Brainstem triggers absence seizures in human generalized epilepsy

The cooccurrence of interictal discharges and seizures in pediatric sleep-disordered breathing

Studies in the literature data have shown that the prevalence of obstructive sleep apnea (OSA) in children with epilepsy is high and that treatment for OSA leads to a reduction in the number of seizures; by contrast, few studies have demonstrated an increased prevalence of interictal epileptiform discharges (IEDs) or epilepsy in children with sleep-disordered breathing (SDB). The aim of the present study was to confirm the high prevalence of IEDs or epilepsy in a large sample of children with SDB and to collect follow-up data. Children were recruited prospectively and underwent their first video-polysomnography (video-PSG) for SDB in a teaching hospital sleep center. Of the 298 children who fulfilled the diagnostic criteria for sleep-disordered breathing, 48 (16.1%) children were found to have IEDs, three of these 48 children were also found to have nocturnal seizures (two females diagnosed with rolandic epilepsy and a male diagnosed with frontal lobe epilepsy). Only 11 subjects underwent a second video-PSG after 6months; at the second video-PSG, the IEDs had disappeared in six subjects, who also displayed a reduced AHI and an increased mean overnight saturation. Thirty-eight of the 250 children without IEDs underwent a second video-PSG after 6months. Of these 250 children, four, who did not display any improvement in the respiratory parameters and were found to experience numerous stereotyped movements during sleep, were diagnosed with nocturnal frontal lobe epilepsy. Our study confirms the high prevalence of IEDs in children with SDB. Follow-up data indicate that they may recede over time, accompanied by an improvement of sleep respiratory parameters.

Top of the basilar syndrome in a young adult initially presenting with a convulsive seizure

A 23-year-old man was admitted to our hospital due to loss of consciousness and a generalized convulsive seizure. He was diagnosed as having primary epilepsy and treated with antiepileptic drugs. Emergency CT scan of the head showed no abnormality. However, MRI scan of the head several days after admission revealed fresh infarctions caused by occlusion of the basilar artery, i.e., "top of the basilar" syndrome. This case indicates the need for precise differential diagnosis of convulsive seizure in an emergency situation. It should also be borne in mind that basilar occlusion with 'onset seizure' can occur even in young adults who have no risk factors for stroke.

Functional neuroimaging of spike-wave seizures

Generalized spike-wave seizures are typically brief events associated with dynamic changes in brain physiology, metabolism, and behavior. Functional magnetic resonance imaging (fMRI) provides a relatively high spatiotemporal resolution method for imaging cortical-subcortical network activity during spike-wave seizures. Patients with spike-wave seizures often have episodes of staring and unresponsiveness which interfere with normal behavior. Results from human fMRI studies suggest that spike-wave seizures disrupt specific networks in the thalamus and frontoparietal association cortex which are critical for normal attentive consciousness. However, the neuronal activity underlying imaging changes seen during fMRI is not well understood, particularly in abnormal conditions such as seizures. Animal models have begun to provide important fundamental insights into the neuronal basis for fMRI changes during spike-wave activity. Work from these models including both fMRI and direct neuronal recordings suggest that, in humans, specific cortical-subcortical networks are involved in spike-wave, while other regions are spared. Regions showing fMRI increases demonstrate correlated increases in neuronal activity in animal models. The mechanisms of fMRI decreases in spike-wave will require further investigation. A better understanding of the specific brain regions involved in generating spike-wave seizures may help guide efforts to develop targeted therapies aimed at preventing or reversing abnormal excitability in these brain regions, ultimately leading to a cure for this disorder.

Ictal nystagmus in a newborn baby after birth asphyxia

Ictal nystagmus (IN) is an uncommon phenomenon characterized by rhythmic saccadic eye movements occurring during epileptic seizures. We report a newborn baby with severe birth asphyxia, undergoing long-term video EEG monitoring with electro-oculogram (EOG), who showed irregular IN when eye movements crossed the midline from left to right and vice versa, resulting in large amplitude of the nystagmoid movements. The nystagmus was followed 15 to 29 seconds later by ictal discharges in the occipital regions. MRI of the brain showed features suggestive of periventricular leukomalacia. This interesting combination of findings suggests a complex mechanism for IN of cortical or subcortical ictal rhythms, which results in (a) the generation of subcortical electrical discharges in the pons and midbrain, causing nystagmoid eye movements, and (b) subsequent occipital spiking. We conclude that this clinical manifestation supports the existence of functioning cortical-subcortical connections between the brainstem ocular motor centers and the occipital cortex at birth.

Vinpocetine prevents 4-aminopyridine-induced changes in the EEG, the auditory brainstem responses and hearing

OBJECTIVE

The purpose of the present study was to investigate if the sodium channel blocker and memory enhancer, vinpocetine, was capable to overcome the epileptic cortical activity, the abnormalities in the later waves of the auditory brainstem responses (ABRs) and the hearing loss induced by 4-AP at a convulsing dose in the guinea pig in vivo.

METHODS

EEG and ABR recordings before and at specific times within 2h after the injection of 4-AP (2 mg/kg, i.p.) were taken in animals pre-injected i.p. with vehicle or with vinpocetine (2 mg/kg) 1 h before 4-AP. The amplitude and latency of the ABR waves induced by a monoaural stimulus of high intensity (100 dB nHL) at 4 and 8 kHz pure tone frequencies and the ABR threshold were determined in the animals exposed to the different experimental conditions.

RESULTS

Vinpocetine inhibited the EEG changes induced by 4-AP for the ictal and post-ictal periods as well as the alterations in amplitude and latency of P3 and P4 and the increase in the ABR threshold induced by 4-AP.

CONCLUSIONS

Vinpocetine prevents the retro-cochlear alterations and the hearing decline that accompany the epileptic cortical activity.

SIGNIFICANCE

Vinpocetine could be a promising alternative for the treatment of epilepsy.

Vinpocetine inhibits the epileptic cortical activity and auditory alterations induced by pentylenetetrazole in the guinea pig in vivo

Here we investigate the effect of the neuroprotective drug, vinpocetine on the epileptic cortical activity, on the alterations of the later waves of brainstem auditory evoked potentials (BAEPs) and on the hearing decline induced by the convulsing agent, pentylenetetrazole (PTZ). Vinpocetine at doses from 2 to 10 mg/kg inhibits the tonic-clonic convulsions induced by PTZ (100 mg/kg). Vinpocetine injected at a dose of 2 mg/kg 4 h before PTZ completely prevents the characteristic electroencephalogram (EEG) changes induced by PTZ for the ictal and post-ictal periods. Vinpocetine also abolished the PTZ-induced changes in the amplitude and latency of the later waves of the BAEPs in response to pure tone burst monoaural stimuli (frequency 8 or 4 kHz intensity 100 dB), and the PTZ-induced increase in the BAEP threshold. These results show the antiepileptic potential of vinpocetine and indicate the capability of vinpocetine to prevent the changes in the BAEP waves associated with the hearing loss observed during generalized epilepsy.

Widespread activation of the brainstem preceding the recruiting rhythm in human epilepsies

The excitability change of the brainstem was investigated before and during the conspicuous epileptic discharge in six patients with generalized convulsive seizures. The discharge consisted of a short duration of recruiting rhythm, which was considered equivalent to the seizure discharge on electroencephalogram. The excitability of the brainstem was measured with the parameters (amplitude and area) of component waves (wave-III and -V) of brainstem auditory evoked potentials. The theoretical background of the analysis is that brainstem auditory evoked potentials are 'far-field' potentials, by which they convey the information on the activity change of the brainstem even during the paroxysmal discharge within the cortex. The excitability of both the ventral (parameters of wave-III) and the dorsal brainstem (parameters of wave-V) exhibited a synchronized change (activation-inactivation). They were enhanced from -2.4+/-0.4 s, reaching the maxima before the onset of the seizure discharge, and decayed corresponding to the emergence of the recruiting rhythm. The results suggest the possibility that the widespread (ventral and dorsal) and synchronized activation of the brainstem triggers the seizure discharge in human generalized epilepsy. During the widespread activation of the brainstem, both the thalamus and the cortex probably undergo a suppressed inhibitory state through the cholinergic activation, precipitating the seizure discharge.

Effects of pentylenetetrazole and 4-aminopyridine on the auditory brainstem response (ABR) and on the hearing sensitivity in the guinea pig in vivo

For exploring a possible connection between the reduced hearing sensitivity and certain abnormalities in the auditory brainstem responses (ABRs) in generalized epilepsy, the effects of two convulsing agents, namely pentylenetetrazole (PTZ) and of 4-aminopyridine (4-AP), on: (1). the cortical activity (EEG), (2). the hearing threshold and (3). the amplitudes and latencies of the ABR waves evoked by a stimulus of high intensity (100 dB) were investigated in guinea pigs. All animals injected (i.p.) with 100mg/kg PTZ or with 2mg/kg 4-AP developed generalized seizures, followed by characteristic EEG patterns for the post-ictal period, that were accompanied by a marked reduction of the hearing sensitivity (as indicated by the elevated threshold of the ABR), as well as by retro-cochlear changes (as judged by the changes in the later ABR waves in response to 100 dB). For instance, both convulsing agents decreased the amplitude and increased the latency of P4, that is the wave component of the ABRs generated in the lateral superior olivary nucleus and while PTZ increased the latency of P3, the wave component of the ABRs generated in the medial superior olivary nucleus, 4-AP dramatically increased its amplitude. Comparison of recordings taken at specific times for the duration of the post-ictal period (i.e. within about 1h for PTZ and 2h for 4-AP) reveals that the extent of the changes on the EEG matches with the increase in the auditory threshold and with the extent of the changes on the later waves of the ABR elicited by 100 dB. These data indicate that changes in the activity of the lateral and the medial nuclei of the superior olivary complex (SOC) accompany the hearing loss and the post-ictal epileptic cortical activity.

Ictogenesis: the origin of seizures in humans. A new look at an old theory

Seizure (ictal) behavior in humans has been observed and recorded since ancient times. A satisfactory solution to this vexing problem continues to elude medical science. Antiepileptic drug (AED) therapy fails to control seizures in 20% of patients with primary generalized epilepsy and 35% of patients with partial epilepsy and has many side effects, including death. This paper cites evidence from the current literature that supports a plausible hypothesis of seizure genesis that was published in 1942, but somehow escaped recognition. It presents a concept that challenges contemporary thinking and may provide the basis for a much needed paradigm shift in the understanding of the nature of seizures and an approach to their management. The theory views a seizure as a natural reflex defense response to a lethal threat to the brain. Although capable of inflicting bodily injury due to falls, drowning, etc., the seizure is not considered inherently harmful to the brain and may be associated with beneficial circulatory changes. Efforts to control and prevent seizures should be directed away from pharma-chemical suppression towards developing methods and bioactive agents that promote neuroplasticity, neurogenesis, and an optimized physiological milieu within the brain.

Infantile spasms versus myoclonus: is there a connection?

Infantile spasms (IS) is usually classified as a form of "myoclonic epilepsy," but the nosology of this whole group of disorders is unclear. Evidence suggests that the spasms are subcortically mediated, but can be modified by input from the cortex, which is believed to be abnormally excitable and disorganized. The latter features may give rise to hypsarrhythmia. The whole issue of myoclonus rests on the phenotype of IS and precise measurements of the length of electromyographic (EMG) bursts. Based on scant EMG data, it would appear that the bursts during flexor spasms are too long for epileptic myoclonus. The nature of tonic spasms of even longer duration is not myoclonic. However, the infrequent spontaneous myoclonic jerks, which can occur without spasms, and head nodding could represent positive and negative myoclonus, respectively. Data can be collected easily through techniques such as back-averaging to resolve the issue of classification and localization of motor phenomena.

The role of subcortical structures in human epilepsy

Like normal cerebral function, epileptic seizures involve widespread network interactions between cortical and subcortical structures. Although the cortex is often emphasized as the site of seizure origin, accumulating evidence points to a crucial role for subcortical structures in behavioral manifestations, propagation, and, in some cases, initiation of epileptic seizures. Extensive previous studies have shown the importance of subcortical structures in animal seizure models, but corresponding human studies have been relatively few. We review the existing evidence supporting the importance of the thalamus, basal ganglia, hypothalamus, cerebellum, and brain stem in human epilepsy. We also propose a "network inhibition hypothesis" through which focal cortical seizures disrupt function in subcortical structures (such as the medial diencephalon and pontomesencephalic reticular formation), leading secondarily to widespread inhibition of nonseizing cortical regions, which may in turn be responsible for behavioral manifestations such as loss of consciousness during complex partial seizures.

Brainstem activates paroxysmal discharge in human generalized epilepsy

In nine patients with generalized epilepsy of convulsive seizures, the excitability change of the brainstem was evaluated over the course of the interictal paroxysmal discharge (poly spike-and-wave complex, poly SWC). The evaluation was carried out by a sequential analysis of brainstem auditory evoked potentials (BAEPs) before and during one sequence of poly SWC. The characteristics of BAEPs, i.e. far-field evoked potentials, allowed the evaluation of the excitability change in the brainstem, which was not influenced by the cortical activity. The excitability in the ventral brainstem, measured with the parameters of wave-III, showed a biphasic fluctuation (deceleration--acceleration) before the onset of poly SWC (minima at -0.7+/-0.4 s). On the other hand, the excitability in the dorsal brainstem, measured with the parameters of wave-V, showed no significant difference over the course of poly SWC. The results suggest that the biphasic excitability change in the ventral brainstem is conveyed to the cortex through the ascending activating system. The excitability acceleration preceded by deceleration in the ventral brainstem probably synchronizes the cortical activity profoundly enough to produce poly SWC through the activation of intralaminar thalamic neurons.

Dual control of the brainstem on the spindle oscillation in humans

In human subjects, the excitability change of the brainstem was investigated over the course of the spindle oscillation. The investigation was carried out by a sequential analysis of brainstem auditory evoked potentials (BAEPs) with reference to one sequence of spindle oscillation. The method was based on the characteristics of BAEPs, i.e. far-field evoked potential. The brainstem revealed two types of excitability change: one in the lower ventral brainstem (wave-III components), and the other in the upper dorsal brainstem (wave-V components). The excitability in the dorsal brainstem showed an oscillation with one cycle period of about 1.5 s, whereas in the ventral brainstem, the excitability showed a long-range biphasic (decaying-growing) fluctuation. Both excitability changes in the brainstem preceded the spindle oscillation, and the phase was reversed during the emerging period of spindle oscillation. The results suggest a primary triggering mechanism of the brainstem for the spindle oscillation, which is independent of preceding cortical drives (K-complexes) upon the thalamus. The difference of the excitability change between the spindle oscillation and the paroxysmal discharge (spike-and-wave complex) was also discussed.