In vivo modulatory action of extracellular glutamate on the anticonvulsant effects of hippocampal dopamine and serotonin

PURPOSE: Our recent work (Clinckers et al., J Neurochem 2004;89:834-43) demonstrated that intrahippocampal perfusion of 2 nM dopamine or serotonin via a microdialysis probe offered complete protection against focal pilocarpine-induced limbic seizures and did not influence basal extracellular hippocampal glutamate levels. Ten nanomolar dopamine or serotonin perfusion, however, worsened seizures and was accompanied by significant extracellular glutamate increases to approximately 200%. The significance of these glutamate elevations in seizure generation remains unclear. The present microdialysis study investigated the modulatory role of extracellular hippocampal glutamate levels in these monoaminergic protective and proconvulsant effects. METHODS: A first group of male Wistar albino rats was perfused intrahippocampally for 240 min with 6.25 microM glutamate alone to increase extracellular levels by 200%. Other animals were perfused with anticonvulsant concentrations of monoamines throughout the experiments while receiving continuous coperfusions of 6.25 microM glutamate either before, during, and after (240 min) or only after (100 min) pilocarpine perfusion (40 min). Rats were scored for epileptic behavior, and the mean scores were compared with those of the control group. Microdialysates were analyzed for monoamine and glutamate content with microbore liquid chromatography. RESULTS: No convulsions occurred during glutamate perfusion alone. When monoamines and glutamate were coperfused before pilocarpine administration, the anticonvulsant effect of the monoamines was lost. Glutamate addition after pilocarpine administration did not affect monoaminergic seizure protection. CONCLUSIONS: These results indicate that extracellular glutamate increases per se do not necessarily induce seizures but that they can modulate the anticonvulsant effects exerted by hippocampal monoamines.     

Seizure outcome after hippocampal deep brain stimulation in a prospective cohort of patients with refractory temporal lobe epilepsy

PurposeIn this study, we present the results obtained from a series of patients with refractory temporal lobe epilepsy (r-TLE) who underwent hippocampal deep brain stimulation (Hip-DBS).MethodsNine consecutive adult patients were studied. Low-frequency and high-frequency stimulation was carried out immediately after the insertion of each electrode. Chronic continuous high-frequency stimulation was used during treatment. The mean follow-up time was 30.1 months. The mean age of the patients was 37.2 years. The MRI scan was normal in three patients; four patients had bilateral mesial temporal sclerosis (MTS), and two had unilateral MTS.ResultsThe patients with unilateral MTS received unilateral implantation and experienced a 76% and an 80% reduction in seizure frequency after Hip-DBS. All patients with normal MRI scans were implanted bilaterally. Two of these patients received unilateral activation of the electrodes and experienced a 97% and an 80% reduction in seizure frequency; the third patient had bilateral activation of the device and was a non-responder. All patients with bilateral MTS were implanted bilaterally. Three of these patients received unilateral activation of the device and experienced a 66%, a 66% and a 100% reduction in seizure frequency after Hip-DBS; one patient had bilateral electrode activation, and was a non-responder. Whenever present, generalised tonic–clonic seizures disappeared completely after Hip-DBS.ConclusionsAlthough performed on a relatively small number of patients, Hip-DBS was safe and effective in our patients with r-TLE. Seven of the nine patients were considered responders. Hip-DBS might represent a useful therapeutic option in patients with refractory temporal lobe epilepsy who were not candidates for resective surgery or have had previous failed procedures.     

Decreased hippocampal volume on MRI is associated with increased extracellular glutamate in epilepsy patients

Purpose: Temporal lobe epilepsy (TLE) is associated with smaller hippocampal volume and with elevated extracellular (EC) glutamate levels. We investigated the relationship between the hippocampal volume and glutamate in refractory TLE patients.
Methods: We used quantitative MRI volumetrics to measure the hippocampal volume and zero-flow microdialysis to measure the interictal glutamate, glutamine, and GABA levels in the epileptogenic hippocampus of 17 patients with medication-resistant epilepsy undergoing intracranial EEG evaluation. The relationships between hippocampal volume, neurochemical levels, and relevant clinical factors were examined.
Results: Increased EC glutamate in the epileptogenic hippocampus was significantly related to smaller ipsilateral (R²= 0.75, p < 0.0001), but not contralateral hippocampal volume when controlled for glutamine and GABA levels, and for clinical factors known to influence hippocampal volume. Glutamate in the atrophic hippocampus was significantly higher (p = 0.008, n = 9), with the threshold for hippocampal atrophy estimated as 5 μM. GABA and glutamine levels in the atrophic and nonatrophic hippocampus were comparable. Decreased hippocampal volume was related to higher seizure frequency (p = 0.008), but not to disease duration or febrile seizure history. None of these clinical factors were related to the neurochemical levels.
Conclusions: We provide evidence for a significant association between increased EC glutamate and decreased ipsilateral epileptogenic hippocampal volume in TLE. Future work will be needed to determine whether the increase in glutamate has a causal relationship with hippocampal atrophy, or whether another, yet unknown factor results in both. This work has implications for the understanding and treatment of epilepsy as well as other neurodegenerative disorders associated with hippocampal atrophy.     

Memory function during low intensity hippocampal electrical stimulation in patients with temporal lobe epilepsy

Hippocampal memory dysfunction is a main symptom of mesiotemporal lobe epilepsy (TLE). It may increase after temporal lobectomy for seizure relief. The aim of this study was to assess the ability of psychometry during hippocampal electrical stimulation to predict post-operative memory deficits and thereby to contribute to lateralization of the epileptogenic zone. A computerized memory test was performed during low intensity hippocampal stimulation in nine patients with TLE during invasive presurgical evaluation. The following results were obtained: speech dominant hippocampal stimulation induced subtle verbal memory deficits in patients with the epileptogenic zone in the speech dominant hemisphere and normal baseline memory performance. Verbal memory deficits could not be induced in patients with the epileptogenic zone in the speech dominant hemisphere and pre-existing memory deficits, or if the seizure origin was contralateral to speech dominance. Thus it was possible to lateralize the epileptogenic zone in patients with normal baseline memory performance by revealing hippocampal dysfunction only during electrical stimulation. Post-operative psychometric testing demonstrated that the individual risk for impairment of verbal memory performance following temporal lobectomy could be predicted correctly. In conclusion, psychometry during hippocampal stimulation may allow prediction of memory deficits following temporal lobectomy and improve determination of the epileptogenic zone.     

Electrical stimulation of the anterior nucleus of thalamus for treatment of refractory epilepsy

Purpose: We report a multicenter, double‐blind, randomized trial of bilateral stimulation of the anterior nuclei of the thalamus for localization‐related epilepsy. Methods: Participants were adults with medically refractory partial seizures, including secondarily generalized seizures. Half received stimulation and half no stimulation during a 3‐month blinded phase; then all received unblinded stimulation. Results: One hundred ten participants were randomized. Baseline monthly median seizure frequency was 19.5. In the last month of the blinded phase the stimulated group had a 29% greater reduction in seizures compared with the control group, as estimated by a generalized estimating equations (GEE) model (p = 0.002). Unadjusted median declines at the end of the blinded phase were 14.5% in the control group and 40.4% in the stimulated group. Complex partial and “most severe” seizures were significantly reduced by stimulation. By 2 years, there was a 56% median percent reduction in seizure frequency; 54% of patients had a seizure reduction of at least 50%, and 14 patients were seizure‐free for at least 6 months. Five deaths occurred and none were from implantation or stimulation. No participant had symptomatic hemorrhage or brain infection. Two participants had acute, transient stimulation‐associated seizures. Cognition and mood showed no group differences, but participants in the stimulated group were more likely to report depression or memory problems as adverse events. Discussion: Bilateral stimulation of the anterior nuclei of the thalamus reduces seizures. Benefit persisted for 2 years of study. Complication rates were modest. Deep brain stimulation of the anterior thalamus is useful for some people with medically refractory partial and secondarily generalized seizures.     

The role of remaining presynaptic terminals in the hippocampal CA1 after selective neuronal death: ischemia-induced glutamate efflux

Following selective neuronal death, numerous presynaptic terminals maintain their structural integrity in the brain region. The role that these remaining presynaptic terminals play in the brain region showing selective neuronal death is not known. In the present study, we investigated the possibility that brief transient ischemia induces an excessive release of glutamate from the remaining presynaptic terminals, which then spreads by diffusion. The glutamate could act as an excitotoxin and be a pathogenic factor in the local injured brain region. Transient ischemia of 3.5 min duration was used in the gerbil as a pretreatment to obtain hippocampal CA1 in which most of postsynaptic neurons were eliminated but numerous presynaptic terminals remained normal. At 10–14 days after the pretreatment, brain microdialysis experiments were performed in vivo in the CA1 to measure the levels of extracellular glutamate induced by 5 min ischemia. Prior to 5 min ischemia the basal concentration of glutamate in the CA1 was the same as that observed in gerbils that had been subjected to sham pretreatment. During 5 min ischemia, no significant increase in glutamate was induced in the CA1 which showed selective neuronal death. However, a massive increase in glutamate was induced in the CA1 of the sham-pretreated gerbils. These results suggest that the remaining presynaptic terminals are unlikely to play a pathogenic role in the CA1 after selective neuronal death has occurred. Received: 6 June 1995 / Revised, accepted: 4 August 1995     

Deep brain stimulation of the subthalamic nucleus as adjunct treatment for refractory epilepsy

PURPOSE: We studied the efficacy and safety of bilateral subthalamic deep brain stimulation (DBS) for refractory partial-onset epilepsy in two cases. METHODS: This was an open treatment pilot study for subjects who had failed numerous medications and had seizure injuries. Seizure counts and adverse events were collected during a 3-4 month baseline, and for 26-32 months after DBS surgery, with AEDs held constant. RESULTS: Case 1, age 45, with bitemporal seizures, had about half the seizure frequency but still fell with injuries. Case 2, age 46, with left frontal encephalomalacia, had a frequency reduction of about one-third, but a more meaningful reduction of seizure severity and injuries. CONCLUSIONS: Subthalamic DBS partly reduced partial-onset seizures, but the quality of life was more affected by seizure-related injuries.     

High and low frequency electrical stimulation in non-lesional temporal lobe epilepsy

In patients with pharmacologically intractable epilepsy who are not eligible for surgery, deep brain stimulation is currently under evaluation as an alternative treatment. Optimal stimulation parameters, including high (HFS) versus low frequency (LFS) stimulation, are not well defined. Here, we report the effects of HFS (130 pulses per second, pps) and LFS (5pps) of the principal epileptogenic focus, in three patients with non-lesional temporal lobe epilepsy. HFS, but not LFS, was associated with a reduction of the interictal discharges and absence of seizures. HFS may be beneficial in patients with non-lesional temporal lobe epilepsy who are not surgical candidates.     

迷走神经刺激术治疗药物难治性癫痫的价值

尽管目前癫痫的药物治疗已取得较大进展,但仍有20％～30％的患者对癫痫药物治疗反应差,部分癫痫发作难以有效控制,即所谓的药物难治性癫痫。癫痫病灶切除术是治疗药物难治性癫痫的有效方法,但并非所有患者均能找到确切病灶,而且部分患者手术后效果不佳。1988年,迷走神经刺激术(vagus nerve stimulation,VNS)开始应用于治疗药物难治性部分性癫痫,为药物难治性癫痫提供了一种新的治疗方法。     

迷走神经刺激术治疗药物难治性癫痫的初步研究

目的 探讨迷走神经刺激术治疗药物难治性癫痫的方法及效果. 方法 回顾性分析上海交通大学医学院附属仁济医院神经外科自2007年1月至2011年1月收治的14例药物难治性、全身性癫痫患者临床资料,其中脑炎后继发癫痫6例,外伤后继发癫痫3例,原因不明5例,所有患者均行左侧迷走神经刺激术治疗.术后3周内开机,初始刺激参数为:刺激电流0.25 mA,频率30 Hz,刺激时间30 s,间歇时间5 min,脉宽500 μs.刺激电流强度以0.25 mA为一调整单位逐渐递增,并综合其他参数调控以到达满意疗效. 结果 随访3月以上,14例患者术后发作频率平均减少63.6％,其中3例发作频率减少＜50％,11例发作频率减少≥50％,6例发作频率减少＞80％,2例发作停止.5例患者使用磁铁后发作控制得到改善. 结论 迷走神经刺激术是一种治疗药物难治性癫痫有效、安全的方法,对全身性癫痫发作患者同样有效.     

Toward feedback controlled deep brain stimulation: Dynamics of glutamate release in the subthalamic nucleus in rats

Deep brain stimulation (DBS) is an effective symptomatic treatment in Parkinson's disease. High frequency stimulation (HFS) of the subthalamic nucleus elicits neurotransmitter release in multiple nuclei. Therefore, we tested the hypothesis that neurotransmitter release during HFS may be used to provide feedback control of the intensity and pattern of HFS. We studied the dynamic relationship between extracellular glutamate levels and HFS in and around the STN in anesthetized rats. We used a pseudorandom binary sequence (PRBS) of stimulation in the STN, the independent forcing function, while measuring extracellular glutamate in the same nucleus, the dependent variable. The PRBS consisted of 90 s periods during which stimulation (100 μA, 150 Hz, 10% duty cycle) was either off or on. The stimulation and extracellular glutamate levels were fitted using an autoregressive exogenous model (ARX) to determine the transfer function between HFS and the extracellular glutamate concentration in the STN. The ARX model fit the dynamics of extracellular glutamate levels well (correlation coefficients ranged from 0.74 to 0.99; n = 11). The transfer function accurately predicted extracellular glutamate levels in the STN even when the pattern of HFS was modified. We used the transfer function to develop a feedback controlled stimulation algorithm. Feedback controlled HFS maintained extracellular glutamate concentrations at any predefined level, but only intermittent HFS was required. We conclude that the transfer function between HFS and neurotransmitter levels in the brain can be used to design DBS protocols that generate specific temporal patterns of glutamate release in the STN.     

Bilateral hippocampal stimulation for intractable temporal lobe epilepsy: Impact on seizures and memory

The effect of continuous electrical stimulation of the hippocampus bilaterally on seizures and memory was assessed in two subjects with seizures from both mesial temporal lobes who were not candidates for resective epilepsy surgery. A double blind, randomized, controlled, cross‐over trial design was utilized. Two electrodes with four contacts each were implanted along the axis of the hippocampus bilaterally. Simultaneous stimulation of all electrodes contacts was either on or off during each 3‐month interval. Seizure frequency decreased by 33% in the two patients during stimulation and remained lower by 25% for the 3 months after stimulation was turned off before returning to baseline (p < 0.01). No consistent change in objective or subjective measures of memory occurred. No other adverse effects occurred. Seizure frequency is reduced both during and for a period after bilateral hippocampal stimulation, but the overall impact in this study is not as robust as has been previously reported.     

Multitask preoperative language mapping in epilepsy surgery: A combination of navigated transcranial magnetic stimulation and extra-operative electrical cortical stimulation

Navigated transcranial magnetic stimulation (nTMS) is increasingly applied in language mapping. However, the application mode and task selection of nTMS are not standardized. The aim of this study was to assessed the necessity and validity of multitask nTMS language mapping by comparing results with extraoperative electrical cortical stimulation (eoECS). In this study, sixteen epilepsy surgery patients were examined by nTMS and eoECS language mapping, and the two results were compared. The mapping results were validated with pre- to postoperative language assessments. Compared with eoECS, nTMS showed the overall sensitivity of 82.4%, specificity of 95.1%, positive predictive value of 66.7%, and negative predictive value of 97.8%. Spontaneous speech was the most sensitive task in the frontal area, naming was the sensitive task in both frontal and temporal areas. The false responses were mainly located in the perisylvian region. Multitask nTMS helps to reduce missing language relevant cortex preoperatively. Selecting spontaneous speech and naming tasks in frontal area, comprehension and naming tasks in temporal and posterior language area would strike the balance between the validity and efficiency of the mapping procedure. These results manifested the necessity of applying multitask in nTMS language mapping. Our study highlighted the importance of the nTMS evaluation mode and task selection for epilepsy patients.     

神经导航经颅磁刺激在癫痫术前语言区评估中的应用

目的探讨神经导航经颅磁刺激(n TMS)在术前皮质语言区评估中的临床应用价值。方法选取14例接受颅内硬膜下电极埋置术的癫痫患者,在神经导航引导下,采用4~10Hz重复经颅磁刺激(r TMS),对患者语言区进行定侧、定位分析。通过与颅内电极皮质电刺激(ECS)语言功能定位结果进行比较,评估nT MS在术前语言区定位中的临床应用价值。结果在14例患者中,nT MS诱发出明确语言停顿或明显语言干扰的患者12例,2例未出现明显语言干扰现象。术前nT MS诱发出语言障碍的12例患者,在ECS过程中均出现明确语言功能障碍。提高刺激强度可以提高诱发语言干扰的几率,频率4~6Hz刺激在语言区定位中,可以较好地兼顾患者的耐受性和刺激效果。结论对于不适合接受ECS等有创性评估的患者,术前nT MS可以提供有价值的语言功能定位信息。     

Cerebral neurons of transgenic ALS mice are vulnerable to glutamate release stimulation but not to increased extracellular glutamate due to transport blockade

Mechanisms of motor neuron loss in amyotrophic lateral sclerosis (ALS) are unknown, but it has been postulated that excitotoxicity due to excessive glutamatergic neurotransmission by decreased efficiency of glutamate transport may be involved in both familial (FALS) and sporadic ALS. Using microdialysis in vivo, we tested the effects of the glutamate transport inhibitor L-trans-pyrrolidine-2,4-dicarboxylate (PDC) and of 4-aminopyridine (4-AP), which stimulates glutamate release from nerve endings, in the hippocampus and motor cortex of wild type (WT) and transgenic SOD1/G93A mice, an established model of FALS. Perfusion of 4-AP induced convulsions, expression of the inducible stress-marker heat-shock protein 70 (HSP70) and hippocampal neuronal loss. These effects were similar in both WT and G93A mice, and, in both groups, they were prevented by the previous systemic administration of the NMDA receptor antagonist MK-801. In contrast, perfusion of PDC resulted in a large and long-lasting (2 h) increase of extracellular glutamate, but no convulsions, neuronal damage or HSP70 expression were observed in either the WT or the G93A mice. Our results demonstrate that SOD1 G93A mutation does not enhance the vulnerability to endogenous glutamate-mediated excitotoxicity in brain, neither by blocking glutamate transport nor by stimulating its release. Therefore, these data do not support the possibility that glutamate transport deficiency may be an important factor of brain neuronal degeneration in familial ALS.     

Suppression of hippocampal epileptic seizures in the kainate rat by Poisson distributed stimulation

Purpose: Hippocampal deep brain stimulation (DBS) is an experimental therapy for patients with pharmacoresistant temporal lobe epilepsy (TLE). Despite the successful clinical application of DBS, the optimal stimulation parameters are undetermined. We evaluate the efficacy of a new form of DBS, using continuous stimuli with Poisson distributed intervals (Poisson distributed stimulation, PDS) in the kainate (KA) rat model, a validated model for human TLE. Methods: Status epilepticus was elicited by injection of KA (i.p.). After development of spontaneous seizures, rats were implanted with hippocampal DBS‐ and depth electroencephalography (EEG) electrodes. After baseline EEG monitoring, one group of rats (n = 13) was treated with PDS and a second (n = 11) received regular high frequency stimulation (HFS) at 130 Hz. Stimulation intensity was 100 μA below the threshold for induction of epileptiform EEG activity. Results: Stimulation intensity was significantly lower for PDS (156 ± 20 μA) than HFS (207 ± 23 μA; p < 0.02). Seven (54%) of 13 rats treated with PDS and 5 (45%) of 11 rats treated with HFS experienced a significant reduction in seizure frequency. In PDS‐improved rats, seizure frequency was reduced to 33% (p < 0.01) of baseline value and in HFS‐improved rats to 50% (p < 0.01). After termination of PDS, seizure rate returned to baseline value. Discussion: Continuous hippocampal PDS significantly reduces the number of spontaneous seizures. Compared to regular HFS, there is a slightly larger number of improved rats and a larger efficacy at a considerably lower stimulus intensity. The first two observations leave room for optimization, whereas a lower intensity is beneficial for battery life.     

Middle short gyrus of the insula implicated in speech production: Intracerebral electric stimulation of patients with epilepsy

Purpose: Different lines of evidence have suggested an involvement of the insular cortex in speech production. These have included results from lesion studies, functional imaging techniques, and electrical stimulation of the human insular cortex during invasive evaluation of epileptic patients. Methods: We evaluated 25 patients who had drug refractory focal epilepsy with at least one electrode stereotactically implanted in the insular cortex. Results: Eight responses to insular cortex electrical stimulation were reported by five patients as speech arrest (five responses) and a lowering of voice intensity (three responses). Conclusions: Data from this study implicate the middle short gyrus of the insula in the production of speech and show the importance of intrainsular electrode implantation during invasive pre‐resection evaluation by stereo‐electroencephalography (SEEG) when speech arrest occurs early in seizure semiology.     

Analysis of EEG data from weak-field magnetic stimulation of mesial temporal lobe epilepsy patients

Ten patients suffering from mesial temporal lobe epilepsy were exposed to weak, DC magnetic field stimulation following computer-controlled protocols established in previous studies. Poisson statistical analysis of the ten patients undergoing semi-invasive (foramen ovale) electrode monitoring reveals that for at least one experimental protocol, application of DC magnetic fields alters interictal epileptiform spike activity in five of ten patients. Similar results also have been observed in the analysis of both human and rat brains by employing weak, alternating magnetic field stimulation. Further study is necessary in order to optimize the magnetic field exposure protocol.     

Controlling seizures is not controlling epilepsy: a parametric study of deep brain stimulation for epilepsy

Pharmacological inhibition and high-frequency stimulation (HFS) of the substantia nigra pars reticulata (SNr) suppress seizures in different animal models of epilepsy. The aim of the present study was to determine the optimal parameters of HFS to control spontaneous seizures in a genetic model of absence epilepsy in the rat. Single SNr stimulation that was bilateral, bipolar and monophasic at 60 Hz frequency and with 60-micros pulse width was optimal. However, when used for repeated stimulations, long-term suppression did not occur and even the number of seizures increased. A delay of at least 60 s between stimulations was necessary to be fully effective. Although single HFS of the SNr can be used to suppress ongoing seizures, repeated HFS is ineffective and could even aggravate seizures in our model. Thus investigations of accurate stimulation procedures are still needed.     

7-Nitroindazole, a selective inhibitor of nNOS, increases hippocampal extracellular glutamate concentration in status epilepticus induced by kainic acid in rats

The glutamate extracellular concentration is controlled by metabolic and neuronal pathways via release and uptake mechanisms. Stimulation of glutamate receptors induces neuronal nitric oxide (NO) release, which in turn modulates glutamate transmission. In this study, the influence of neuronally derived NO on hippocampal glutamate extracellular concentration was investigated in conditions of intense metabolic activation, i.e., during status epilepticus induced by systemic kainic acid (KA). Glutamate, arginine and citrulline concentrations were measured by microdialysis coupled to HPLC. Experiments were performed in conscious rats implanted with a microdialysis probe within the hippocampal CA3 area. Three groups were used: (1) rats treated with KA i.p. (12 mg/kg) and vehicle locally, via the microdialysis probe (n = 9); (2) rats given KA i.p. and a selective inhibitor of neuronal NO synthase, 7-nitroindazole (7-NI, 1.25 mM) locally (n = 13); (3) rats treated with saline i.p. and 7-NI locally (n = 7). Infusion of 7-NI or vehicle was performed throughout the second hour of status epilepticus. In groups 1 and 3, no significant modifications of extracellular glutamate, arginine and citrulline concentrations were measured. In group 2, the local application of 7-NI in the hippocampus during status epilepticus significantly increased extracellular glutamate and arginine concentrations, whereas citrulline concentration remained constant. The concomitant increases of extracellular glutamate and arginine concentrations under local 7-NI perfusion in seizure conditions, suggest that glutamate and arginine are linked in a common metabolic pathway and/or that glutamate is involved in the cross-talk between glia and neurons. A cerebrovascular effect of 7-NI which triggers glutamate release may also occur.