Hippocampal sclerosis revisited

Studies dating back more than 150 years reported a relationship between hippocampal sclerosis and epilepsy. Retrospective studies of patients who underwent temporal lobectomy for intractable partial epilepsy found a relationship between a history of early childhood convulsions, hippocampal sclerosis, and the development of temporal lobe epilepsy. Many believe that febrile seizures lead to hippocampal damage and this in turn predisposes the patient to the development of temporal lobe epilepsy. Studies in adult rats have shown that seizures can lead to hippocampal damage and unprovoked recurrent seizures. However, many questions remain as to the relevance of early childhood seizures to hippocampal sclerosis and temporal lobe epilepsy. Human prospective epidemiologic studies have not shown a relationship between early childhood seizures and temporal lobe epilepsy. Recent MRI studies in humans suggest that a preexisting hippocampal lesion may predispose infants to experience febrile seizures, later on hippocampal sclerosis, and possibly temporal lobe epilepsy may occur. Unlike the studies in adult rats, normal immature rats with seizures have not been shown to develop hippocampal damage or unprovoked seizures in adulthood. Furthermore, animal studies reveal that preexisting brain abnormalities can predispose to hippocampal damage following seizures early in life. This paper reviews evidence for and against the view that early childhood convulsions, hippocampal sclerosis, and temporal lobe epilepsy are related, while also exploring clinical and animal studies on how seizures can lead to hippocampal damage, and how this can result in temporal lobe epilepsy. By better understanding the cause and effect relationship between early childhood seizures and hippocampal injury in normal and abnormal brains specific treatments can be developed that target the pathogenesis of epilepsy.     

GABAergic depolarization during early cortical development and implications for anticonvulsive therapy in neonates

Epileptic seizures rank among the most frequent neurologic symptoms during the neonatal period. Accumulating data from experimental animal studies and clinical trials in humans suggest that neonatal seizures could adversely affect normal brain development and result in long-term neurologic sequelae. Unfortunately, currently used anticonvulsive drugs are often ineffective in the neonatal period. One particularity of the immature neuronal network during neonatal development is that the neurotransmitter γ-aminobutyric acid (GABA) is mainly depolarizing, rather than hyperpolarizing as commonly observed in adults. This might, in part, explain not only the higher seizure propensity of the immature neuronal network, but also the limited anticonvulsive efficacy of GABA-enhancing drugs during early postnatal life. Accordingly, pharmacologic attenuation of GABAergic depolarization has been proposed as a strategy for neonatal seizure control. However, the underlying conjecture of a depolarizing mode of GABA action has been seriously challenged recently. In the present review, we will summarize the state of knowledge regarding GABAergic depolarization in early life and discuss how these data might impact a currently tested anticonvulsive strategy.     

Neurogenesis and epilepsy in the developing brain

Multiple studies have highlighted how seizures induce different molecular, cellular, and physiologic consequences in an immature brain as compared to a mature brain. In keeping with these studies, seizures early in life alter dentate granule cell birth in different, and even opposing, fashion to adult seizure models (see Table 1 ). During the first week of rodent postnatal life, seizures decrease cell birth in the postictal period, but do not alter the maturation of newborn cells. Seizures during the second week of life have varied effects on dentate granule cell birth, either causing no change or increasing birth, and may promote a mild increase in neuronal survival. During the third and fourth weeks of life, seizures begin to increase cell birth similar to that seen in adult seizure models. Interestingly, animals that experienced seizure during the first month of life have an increase in cell birth during adulthood, opposite to the reported decrease in chronic animals experiencing a prolonged seizure as an adult. Children have more ongoing cell birth in the dentate gyrus than adults, and markers of cell division are further increased in children with refractory temporal lobe epilepsy. There are clear age-dependent differences in how seizures alter cell birth in the dentate gyrus both acutely and chronically. Future studies need to focus on how these changes in neurogenesis influence dentate gyrus function and what they imply for epileptogenesis and learning and memory impairments, so commonly found in children with temporal lobe epilepsy.  

  Table 1.  Early seizures alter cell birth in rodent dentate gyrus     

4.

Early-life seizures in rats increase susceptibility to seizure-induced brain injury in adulthood.   总被引：14，自引：0，他引：14  

S Koh  T W Storey  T C Santos  A Y Mian  A J Cole 《Neurology》1999,53(5):915-921

BACKGROUND: Early childhood convulsions have been correlated with the finding of subsequent hippocampal neuronal loss and memory impairment in patients with intractable temporal lobe epilepsy. There is little direct evidence, however, that links early seizures with the later development of epilepsy and selective hippocampal neuronal loss. OBJECTIVE: To study the long-term effect of early seizures on later seizure-induced neuronal damage and behavior. METHODS: We used a "two hit" rat seizure mode in which systemic kainate was used to induce seizures during the second week of life (P15) and again in adulthood (P45). Memory was subsequently tested using a Morris water maze, and brains were examined for histologic evidence of injury. RESULTS: Although the first kainate-induced seizure is not associated with detectable injury or cell death, it predisposes animals to more extensive neuronal injury after kainate-induced seizures in adulthood. Moreover, although early-life kainate-induced seizures cause no impairment of spatial learning, animals that have early-life and adult kainate-induced seizures perform significantly worse than those that have seizures only as adults. CONCLUSIONS: We concluded that early-life seizures, without causing overt cellular injury, predispose the brain to the damaging effect of seizures later in life.     

5.

Maturational changes in postictal refractoriness and seizure susceptibility in developing rats     

Solomon L. Mosh  Bruce J. Albala 《Annals of neurology》1983,13(5):552-557

The ability of the central nervous system to suppress recurrent seizures as a function of age was determined in rats. Eight electrical stimulations were delivered to the amygdala at 2-minute intervals in adult and suckling rats that were previously kindled from the left amygdala. During this 16-minute period, prolonged and severe convulsions were repeatedly elicited in the 16-day-old rat pups, whereas convulsions were not always elicited in adul rats. The results suggest that immature rats are more prone to develop status epilepticus than adult rats. Subsequently, the rat pus and implanted but not stimulated littermates were allowed to grow. At maturity, all the surviving animals were kindled from the contralateral (right) amygdala. The previously kindled rats developed seizures significantly faster than did their littermates. However, their respective abilities to suppress recurrent seizures did not differ at 150 and 210 days of age, being similar to the seizure suppression abilities of naive controls and significantly greater than those evidenced in infancy. We conclude that the propensity to develop single seizures in adulthood is directly related to infant seizure history, whereas the ability to suppress multiple seizures is a dynamic process that is modified by age, being minimal early in life and enhanced with maturation independently of history of infantile convulsions.     

6.

Neonatal seizures and neonatal epileptic syndromes   总被引：2，自引：0，他引：2  

Mizrah EM 《Neurologic Clinics》2001,19(2):427-463

The neonatal period is defined as the first 28 days of life of a term infant; for premature infants the limit of this period is 44 completed weeks of the infant's conceptional age (CA)-defined as the chronological age plus gestational age (GA) at birth. The clinical and electroencephalographic (EEG) manifestations of seizures during this period are determined primarily by the development features of the immature brain at the time of seizure onset, but are also related to the type and diversity of etiologies and risk-factors for seizures neonates may face early in life. Neonatal seizures may be strikingly different from the clinical and electrical seizures of older children and adults. In addition, findings from basic science investigations suggest that immature animals are more likely to experience seizures in response to injury than more mature animals, although the developing brain is less susceptible to seizure-induced injury.     

7.

Cognitive impairment following status epilepticus and recurrent seizures during early development: support for the "two-hit hypothesis"   总被引：1，自引：0，他引：1  

Hoffmann AF  Zhao Q  Holmes GL 《Epilepsy & behavior : E&B》2004,5(6):873-877

Prolonged seizures in immature rats result in minimal behavioral consequences when the animals are studied later in life. Likewise, early-onset seizures are associated with minimal morphological changes. However, it is known that seizures early in life result in changes in the brain that make it more vulnerable to subsequent seizure-induced injury (the so-called two-hit hypothesis). Whether this heightened vulnerability occurs immediately after the first seizure is not known. In this study, immature rats were exposed to status epilepticus (SE) followed by a series of 25 flurothyl-induced seizures, SE alone, 25 flurothyl-induced seizures alone, or no seizures. Rats exposed to SE and flurothyl seizures performed significantly poorer in the water maze 2 weeks following the last seizure compared with the other groups. No histological lesions were seen in any of the four groups. This study suggests that SE renders the immature brain vulnerable to further seizure-induced injury and this enhanced vulnerability occurs very quickly after the SE.     

8.

Kindling in developing animals: expression of severe seizures and enhanced development of bilateral foci   总被引：9，自引：0，他引：9  

K Z Haas  E F Sperber  S L Moshé 《Brain research. Developmental brain research》1990,56(2):275-280

In adult rats, alternating stimulations between two limbic sites can result in one site kindling normally, while the other is retarded in an early non-generalized kindling stage. This phenomenon has been named kindling antagonism. In this report, we present data indicating that kindling antagonism does not occur in 16-day-old rats. Instead, 16-day-old rats receiving alternating stimulations in the amygdala and hippocampus develop progressively more severe seizures. Kindling with alternate stimulations is elicited at a much faster rate at the two foci compared to kindling from a single site, either the hippocampus or amygdala. All groups develop generalized seizures including seizure stages 6 and 7, consisting of wild jumping, running with vocalizations and tonus. These seizures appear after relatively few stimulations in the pup, in comparison to the adult. The results indicate that the immature brain is less able to suppress the generalization of seizures than the adult. The age-specific enhanced development of bilateral foci may be due to underdeveloped inhibitory systems and may underlie the propensity of the immature CNS to develop multifocal seizures.     

9.

Benign familial infantile seizures: further delineation of the syndrome     

Caraballo RH  Cersósimo RO  Amartino H  Szepetowski P  Fejerman N 《Journal of child neurology》2002,17(9):696-699

Benign familial infantile seizures are an autosomal dominant epilepsy disorder that is characterized by convulsions, with onset at age 3 to 12 months and a favorable outcome. Benign familial infantile seizures have been linked to chromosome 19q whereas infantile convulsions and choreoathetosis syndrome, in which benign familial infantile seizure is associated with paroxysmal choreoathetosis, has been linked to chromosome 16p 12-q12. Many additional families from diverse ethnic backgrounds have similar syndromes that have been linked to the chromosome 16 infantile convulsions and choreoathetosis syndrome region. Moreover, in one large pedigree with paroxysmal kinesiogenic dyskinesias only, the syndrome has also been linked to the same genomic area. Families with pure benign familial infantile seizures may be linked to chromosome 16 as well. In this study, we present a series of 19 families and 24 otherwise healthy infants with benign familial infantile seizures. Two of these families include members affected with benign familial infantile seizures and paroxysmal choreoathetosis. We included patients with normal neurologic examinations, who started having simple partial seizures, complex partial seizures, or apparently generalized seizures without recognized etiology between 2 months and 2 years of age. Neurologic studies were normal, but in all patients, there was a history of similar seizures and age at onset in either the father or the mother. Twenty-four patients (14 girls and 10 boys) were evaluated at our hospital between February 1990 and February 2001. Age at onset, sex, family history of epilepsy and/or paroxysmal dyskinesias, neurologic examination, semiology, distribution, and frequency and duration of seizures were evaluated. Electroencephalographic (EEG) and neuroradiologic studies were also performed. Seizures began between 3 and 22 months of life, with a median age of 5 1/2 months. Nine patients (37.5%) had only apparently generalized seizures, 5 patients (20.8%) had only partial seizures, and 10 patients had both partial and apparently generalized seizures (41.6%). Seizures were invariably brief, occurred during the waking state (100%), and presented mainly in clusters in 12 patients (50%). Interictal EEG was normal in 23 patients (95.8%). Sixteen patients (66.6%) had a confirmed history of convulsions in family members other than parents. Twenty-two patients became seizure free after 30 months of life. Two brothers in the same family had brief paroxysmal episodes of choreoathetosis in the hemibody triggered by stress while awake at 15 and 17 years old, respectively. One of them had paroxysmal choreoathetosis only, and the other was associated with benign familial infantile seizures. One father had brief spontaneous episodes of paroxysmal choreoathetosis when awake at age 18 years. All of them had a good response to antiepilepsy drugs, and neurologic examination and EEG and neuroradiologic studies were normal. Benign familial infantile seizure is a genetic epilepsy syndrome with autosomal dominant inheritance. It may be associated with paroxysmal choreoathetosis (infantile convulsions and choreoathetosis syndrome), which has been linked to the chromosome 16 infantile convulsions and choreoathetosis syndrome region. Patients in families with infantile convulsions and choreoathetosis syndrome could display either benign familial infantile seizures or paroxysmal choreoathetosis or both. It is likely that the disease in families with pure benign familial infantile seizures may be linked to the infantile convulsions and choreoathetosis region as well. We cannot exclude the possibility that the youngest patients may develop choreoathetosis or other dyskinesias later in life.     

10.

Effects of seizures on brain development: lessons from the laboratory   总被引：6，自引：0，他引：6  

Holmes GL 《Pediatric neurology》2005,33(1):1-11

Both clinical and laboratory studies demonstrate that seizures early in life can result in permanent behavioral abnormalities and enhance epileptogenicity. In experimental rodent models, the consequences of seizures are dependent upon age, etiology, seizure duration, and frequency. Recurrent seizures in immature rats result in long-term adverse effects on learning and memory. These behavioral changes are paralleled by changes in brain connectivity, dendritic morphology, excitatory and inhibitory receptor subunits, ion channels, and neurogenesis. These changes can occur in the absence of cell loss. Although impaired cognitive function and brain changes have been well documented after early onset seizures, the mechanisms of seizure-induced injury remain unclear. Recent studies have demonstrated abnormalities in single cell function that parallel behavioral changes.     

Early-life seizures in rats increase susceptibility to seizure-induced brain injury in adulthood.

BACKGROUND: Early childhood convulsions have been correlated with the finding of subsequent hippocampal neuronal loss and memory impairment in patients with intractable temporal lobe epilepsy. There is little direct evidence, however, that links early seizures with the later development of epilepsy and selective hippocampal neuronal loss. OBJECTIVE: To study the long-term effect of early seizures on later seizure-induced neuronal damage and behavior. METHODS: We used a "two hit" rat seizure mode in which systemic kainate was used to induce seizures during the second week of life (P15) and again in adulthood (P45). Memory was subsequently tested using a Morris water maze, and brains were examined for histologic evidence of injury. RESULTS: Although the first kainate-induced seizure is not associated with detectable injury or cell death, it predisposes animals to more extensive neuronal injury after kainate-induced seizures in adulthood. Moreover, although early-life kainate-induced seizures cause no impairment of spatial learning, animals that have early-life and adult kainate-induced seizures perform significantly worse than those that have seizures only as adults. CONCLUSIONS: We concluded that early-life seizures, without causing overt cellular injury, predispose the brain to the damaging effect of seizures later in life.     

Maturational changes in postictal refractoriness and seizure susceptibility in developing rats

The ability of the central nervous system to suppress recurrent seizures as a function of age was determined in rats. Eight electrical stimulations were delivered to the amygdala at 2-minute intervals in adult and suckling rats that were previously kindled from the left amygdala. During this 16-minute period, prolonged and severe convulsions were repeatedly elicited in the 16-day-old rat pups, whereas convulsions were not always elicited in adul rats. The results suggest that immature rats are more prone to develop status epilepticus than adult rats. Subsequently, the rat pus and implanted but not stimulated littermates were allowed to grow. At maturity, all the surviving animals were kindled from the contralateral (right) amygdala. The previously kindled rats developed seizures significantly faster than did their littermates. However, their respective abilities to suppress recurrent seizures did not differ at 150 and 210 days of age, being similar to the seizure suppression abilities of naive controls and significantly greater than those evidenced in infancy. We conclude that the propensity to develop single seizures in adulthood is directly related to infant seizure history, whereas the ability to suppress multiple seizures is a dynamic process that is modified by age, being minimal early in life and enhanced with maturation independently of history of infantile convulsions.     

Neonatal seizures and neonatal epileptic syndromes

The neonatal period is defined as the first 28 days of life of a term infant; for premature infants the limit of this period is 44 completed weeks of the infant's conceptional age (CA)-defined as the chronological age plus gestational age (GA) at birth. The clinical and electroencephalographic (EEG) manifestations of seizures during this period are determined primarily by the development features of the immature brain at the time of seizure onset, but are also related to the type and diversity of etiologies and risk-factors for seizures neonates may face early in life. Neonatal seizures may be strikingly different from the clinical and electrical seizures of older children and adults. In addition, findings from basic science investigations suggest that immature animals are more likely to experience seizures in response to injury than more mature animals, although the developing brain is less susceptible to seizure-induced injury.     

Cognitive impairment following status epilepticus and recurrent seizures during early development: support for the "two-hit hypothesis"

Prolonged seizures in immature rats result in minimal behavioral consequences when the animals are studied later in life. Likewise, early-onset seizures are associated with minimal morphological changes. However, it is known that seizures early in life result in changes in the brain that make it more vulnerable to subsequent seizure-induced injury (the so-called two-hit hypothesis). Whether this heightened vulnerability occurs immediately after the first seizure is not known. In this study, immature rats were exposed to status epilepticus (SE) followed by a series of 25 flurothyl-induced seizures, SE alone, 25 flurothyl-induced seizures alone, or no seizures. Rats exposed to SE and flurothyl seizures performed significantly poorer in the water maze 2 weeks following the last seizure compared with the other groups. No histological lesions were seen in any of the four groups. This study suggests that SE renders the immature brain vulnerable to further seizure-induced injury and this enhanced vulnerability occurs very quickly after the SE.     

Kindling in developing animals: expression of severe seizures and enhanced development of bilateral foci

In adult rats, alternating stimulations between two limbic sites can result in one site kindling normally, while the other is retarded in an early non-generalized kindling stage. This phenomenon has been named kindling antagonism. In this report, we present data indicating that kindling antagonism does not occur in 16-day-old rats. Instead, 16-day-old rats receiving alternating stimulations in the amygdala and hippocampus develop progressively more severe seizures. Kindling with alternate stimulations is elicited at a much faster rate at the two foci compared to kindling from a single site, either the hippocampus or amygdala. All groups develop generalized seizures including seizure stages 6 and 7, consisting of wild jumping, running with vocalizations and tonus. These seizures appear after relatively few stimulations in the pup, in comparison to the adult. The results indicate that the immature brain is less able to suppress the generalization of seizures than the adult. The age-specific enhanced development of bilateral foci may be due to underdeveloped inhibitory systems and may underlie the propensity of the immature CNS to develop multifocal seizures.     

Benign familial infantile seizures: further delineation of the syndrome

Benign familial infantile seizures are an autosomal dominant epilepsy disorder that is characterized by convulsions, with onset at age 3 to 12 months and a favorable outcome. Benign familial infantile seizures have been linked to chromosome 19q whereas infantile convulsions and choreoathetosis syndrome, in which benign familial infantile seizure is associated with paroxysmal choreoathetosis, has been linked to chromosome 16p 12-q12. Many additional families from diverse ethnic backgrounds have similar syndromes that have been linked to the chromosome 16 infantile convulsions and choreoathetosis syndrome region. Moreover, in one large pedigree with paroxysmal kinesiogenic dyskinesias only, the syndrome has also been linked to the same genomic area. Families with pure benign familial infantile seizures may be linked to chromosome 16 as well. In this study, we present a series of 19 families and 24 otherwise healthy infants with benign familial infantile seizures. Two of these families include members affected with benign familial infantile seizures and paroxysmal choreoathetosis. We included patients with normal neurologic examinations, who started having simple partial seizures, complex partial seizures, or apparently generalized seizures without recognized etiology between 2 months and 2 years of age. Neurologic studies were normal, but in all patients, there was a history of similar seizures and age at onset in either the father or the mother. Twenty-four patients (14 girls and 10 boys) were evaluated at our hospital between February 1990 and February 2001. Age at onset, sex, family history of epilepsy and/or paroxysmal dyskinesias, neurologic examination, semiology, distribution, and frequency and duration of seizures were evaluated. Electroencephalographic (EEG) and neuroradiologic studies were also performed. Seizures began between 3 and 22 months of life, with a median age of 5 1/2 months. Nine patients (37.5%) had only apparently generalized seizures, 5 patients (20.8%) had only partial seizures, and 10 patients had both partial and apparently generalized seizures (41.6%). Seizures were invariably brief, occurred during the waking state (100%), and presented mainly in clusters in 12 patients (50%). Interictal EEG was normal in 23 patients (95.8%). Sixteen patients (66.6%) had a confirmed history of convulsions in family members other than parents. Twenty-two patients became seizure free after 30 months of life. Two brothers in the same family had brief paroxysmal episodes of choreoathetosis in the hemibody triggered by stress while awake at 15 and 17 years old, respectively. One of them had paroxysmal choreoathetosis only, and the other was associated with benign familial infantile seizures. One father had brief spontaneous episodes of paroxysmal choreoathetosis when awake at age 18 years. All of them had a good response to antiepilepsy drugs, and neurologic examination and EEG and neuroradiologic studies were normal. Benign familial infantile seizure is a genetic epilepsy syndrome with autosomal dominant inheritance. It may be associated with paroxysmal choreoathetosis (infantile convulsions and choreoathetosis syndrome), which has been linked to the chromosome 16 infantile convulsions and choreoathetosis syndrome region. Patients in families with infantile convulsions and choreoathetosis syndrome could display either benign familial infantile seizures or paroxysmal choreoathetosis or both. It is likely that the disease in families with pure benign familial infantile seizures may be linked to the infantile convulsions and choreoathetosis region as well. We cannot exclude the possibility that the youngest patients may develop choreoathetosis or other dyskinesias later in life.     

Effects of seizures on brain development: lessons from the laboratory

Both clinical and laboratory studies demonstrate that seizures early in life can result in permanent behavioral abnormalities and enhance epileptogenicity. In experimental rodent models, the consequences of seizures are dependent upon age, etiology, seizure duration, and frequency. Recurrent seizures in immature rats result in long-term adverse effects on learning and memory. These behavioral changes are paralleled by changes in brain connectivity, dendritic morphology, excitatory and inhibitory receptor subunits, ion channels, and neurogenesis. These changes can occur in the absence of cell loss. Although impaired cognitive function and brain changes have been well documented after early onset seizures, the mechanisms of seizure-induced injury remain unclear. Recent studies have demonstrated abnormalities in single cell function that parallel behavioral changes.