Evaluation of carisbamate, a novel antiepileptic drug, in photosensitive patients: an exploratory, placebo-controlled study.

PURPOSE: Carisbamate, a novel neuromodulatory agent with antiepileptic properties, was evaluated in patients with photoparoxysmal responses to intermittent photic stimulation (IPS) in this multicenter, non-randomized, single-blind, placebo-controlled, proof-of-concept study. METHODS: Eighteen Caucasian patients (14 females, 4 males) with a mean age of 30 years (range: 16-51 years) underwent standardized IPS under three eye conditions (during eye closure, eyes closed and eyes open) at hourly intervals for up to 8h after receiving placebo (Day 1), carisbamate (Day 2) and placebo (Day 3). Carisbamate was given at single doses of 250-1000 mg. All patients received one or two concomitant antiepileptic drugs, most commonly valproate. RESULTS: Carisbamate produced a dose-dependent reduction in photosensitivity in the 13 evaluable patients, with abolishment of photoparoxysmal responses in 3 patients and clinically significant suppression of such responses in 7 additional patients. Photosensitivity was abolished or reduced in all five patients in the 1000-mg dose group. The onset of carisbamate occurred rapidly, with clinically significant suppression achieved before or near the time peak plasma drug levels were reached. The duration of action was dose-related and long-lasting, with clinically significant reductions of photosensitivity observed for up to 32 h after doses of 750 or 1000 mg. Carisbamate was generally well tolerated, with dizziness and nausea reported more frequently after active drug than placebo. CONCLUSION: This study shows that carisbamate exhibits dose-related antiepileptic effects in the photosensitivity model. Randomized, controlled studies of carisbamate in epilepsy patients inadequately controlled by their existing AED therapy are warranted.

Influence of ipsilateral transcranial magnetic stimulation on the triphasic EMG pattern accompanying fast ballistic movements in humans.

Fast ballistic flexion movements of the wrist are produced by a triphasic pattern of electromyographic (EMG) activity in flexor and extensor muscle. Whereas it is generally accepted that the primary motor cortex generates the first agonist burst (AG1), its contribution to the following antagonist burst (ANT) and second agonist burst (AG2) is unresolved. We applied single pulses of suprathreshold transcranial magnetic stimulation (TMS) at different times to the motor cortex ipsilateral to wrist flexion. This produced interhemispheric inhibition of the opposite motor cortex and a silent period in the ballistic EMG pattern that started about 30 ms after the stimulus and lasted for a further 30 ms. If the silence was timed to start within the first 30 ms of AG1, then timing of the subsequent ANT and AG2 bursts was delayed. However, if the silence began later, then the timing of the ANT burst was not changed. A similar effect on the onset latency of the AG2 was seen if the silence began in the first part of the ANT burst. The results are compatible with a model in which the triphasic pattern is not triggered as a single entity. Instead we suggest that each burst has its own trigger that occurs about 30-40 ms after the start of AG1 (or ANT). If AG1 (or ANT) is interrupted within this time period then this trigger, and hence later bursts, are delayed. If the interruption occurs after 30-40 ms it has no effect on the onset of later bursts since they have already been triggered.

Comparison of motor effects following subcortical electrical stimulation through electrodes in the globus pallidus internus and cortical transcranial magnetic stimulation.

Current concepts of transcranial magnetic stimulation (TMS) over the primary motor cortex are still under debate as to whether inhibitory motor effects are exclusively of cortical origin. To further elucidate a potential subcortical influence on motor effects, we combined TMS and unilateral subcortical electrical stimulation (SES) of the corticospinal tract. SES was performed through implanted depth electrodes in eight patients treated with deep brain stimulation (DBS) for severe dystonia. Chronaxie, conduction velocity (CV) of the stimulated fibres and poststimulus time histograms of single motor unit recordings were calculated to provide evidence of an activation of large diameter myelinated fibres by SES. Excitatory and inhibitory motor effects recorded bilaterally from the first dorsal interosseus muscle were measured after SES and focal TMS of the motor cortex. This allowed us to compare motor effects of subcortical (direct) and cortical (mainly indirect) activation of corticospinal neurons. SES activated a fast conducting monosynaptic pathway to the alpha motoneuron. Motor responses elicited by SES had significantly shorter onset latency and shorter duration of the contralateral silent period compared to TMS induced motor effects. Spinal excitability as assessed by H-reflex was significantly reduced during the silent period after SES. No ipsilateral motor effects could be elicited by SES while TMS was followed by an ipsilateral inhibition. The results suggest that SES activated the corticospinal neurons at the level of the internal capsule. Comparison of SES and TMS induced motor effects reveals that the first part of the TMS induced contralateral silent period should be of spinal origin while its later part is due to cortical inhibitory mechanisms. Furthermore, the present results suggest that the ipsilateral inhibition is predominantly mediated via transcallosal pathways.

In vivo study indicating loss of intracortical inhibition in tumor-associated epilepsy.

Transcranial magnetic stimulation was performed in 2 patients with focal motor seizures in the right hand caused by a circumscribed tumor process affecting the left precentral gyrus. In both cases, paired-pulse transcranial magnetic stimulation showed a loss of intracortical inhibition for interstimulus intervals of 2 to 4msec that was replaced by an enormous facilitation in the lesioned hand motor cortex. The uniform impairment of inhibitory mechanisms in epileptogenic tumors with different histologies suggests a common, nonspecific cause of tumor-related epileptogenesis.

Spatial reorganization of cortical motor output maps of stump muscles in human upper-limb amputees.

Spatial changes of the motor cortical representation of the biceps brachii muscle (stump muscle) were studied in ten patients with long-standing amputations at the level of the forearm. Motor output maps were established by focal transcranial magnetic stimulation on a skull surface grid overlying the motor cortex. Characteristics of the motor output map were its spatial extension (number of effective stimulation sites), the maximal response amplitude and the center of gravity (COG) of the spatial distribution of response amplitudes. The extension of the stump muscle motor maps was increased (ratio: 1.5+/-0.3 versus 1.0+/-0.3 in control group; P<0.05) and the stump muscle motor responses were much larger (ratio: 2.6+/-0.6 versus 1.0+/-0.5 in the control group; P<0.05). The COG of the stump muscle map was significantly shifted laterally by, on average, 6.0+/-7.7 mm (range, -3.4-21 mm; P<0.05), either reflecting gross changes of local cortical excitability or structural anatomic reorganization.

Changes in visual cortex excitability in blind subjects as demonstrated by transcranial magnetic stimulation.

Any attempt to restore visual functions in blind subjects with pregeniculate lesions provokes the question of the extent to which deafferented visual cortex is still able to generate conscious visual experience. As a simple approach to assessing activation of the visual cortex, subjects can be asked to report conscious subjective light sensations (phosphenes) elicited by focal transcranial magnetic stimulation (TMS) over the occiput. We hypothesized that such induction of phosphenes can be used as an indicator of residual function of the visual cortex and studied 35 registered blind subjects after partial or complete long-term (>10 years) deafferentation of the visual cortex due to pregeniculate lesions. TMS was applied over the visual cortex in 10 blind subjects with some residual vision (visual acuity <20/400; Group 1), 15 blind subjects with very poor residual vision (only perception of movement or light; Group 2), 10 blind subjects without any residual vision (Group 3) and 10 healthy controls. A stimulation mapping procedure was performed on a 1 x 1 cm skull surface grid with 130 stimulation points overlying the occipital skull. We analysed the occurrence of phosphenes at each stimulation point with regard to frequency and location of phosphenes in the visual field. Previous experiments have shown that repetitive TMS reliably elicits brief flashes of white or coloured patches of light. Therefore, stimulation was performed with short trains of seven consecutive 15 Hz stimuli applied with an intensity of 1.3 times the motor threshold. Under such conditions, phosphenes occurred in 100% of subjects in Group 1, in 60% of Group 2 and in 20% of Group 3. Phosphene thresholds were normal, but the number of effective stimulation sites was significantly reduced in Groups 2 and 3. The results indicate that in blind subjects there is alteration in TMS-induced activation of the deafferented visual cortex or processes engaged in bringing the artificial cortex input to consciousness. The ability to elicit phosphenes is reduced in subjects with a high degree of visual deafferentation, especially in those without previous visual experience.