NKCC1 transporter facilitates seizures in the developing brain.

During development, activation of Cl(-)-permeable GABA(A) receptors (GABA(A)-R) excites neurons as a result of elevated intracellular Cl(-) levels and a depolarized Cl(-) equilibrium potential (E(Cl)). GABA becomes inhibitory as net outward neuronal transport of Cl(-) develops in a caudal-rostral progression. In line with this caudal-rostral developmental pattern, GABAergic anticonvulsant compounds inhibit motor manifestations of neonatal seizures but not cortical seizure activity. The Na(+)-K(+)-2Cl(-) cotransporter (NKCC1) facilitates the accumulation of Cl(-) in neurons. The NKCC1 blocker bumetanide shifted E(Cl) negative in immature neurons, suppressed epileptiform activity in hippocampal slices in vitro and attenuated electrographic seizures in neonatal rats in vivo. Bumetanide had no effect in the presence of the GABA(A)-R antagonist bicuculline, nor in brain slices from NKCC1-knockout mice. NKCC1 expression level versus expression of the Cl(-)-extruding transporter (KCC2) in human and rat cortex showed that Cl(-) transport in perinatal human cortex is as immature as in the rat. Our results provide evidence that NKCC1 facilitates seizures in the developing brain and indicate that bumetanide should be useful in the treatment of neonatal seizures.

Activity- and age-dependent modulation of GABAergic neurotransmission by system A-mediated glutamine uptake.

GABAergic neurotransmission adapts to maintain normal brain function in a wide range of activity states through multiple mechanisms; pre-synaptic control of quantal size has only recently gained recognition as one of those mechanisms. GABA synthesis from glutamate is coupled with vesicular packaging, and therefore the supply of glutamate can affect inhibitory synaptic strength. Because System A transporters supply glutamine to neurons, where it is converted to glutamate, we hypothesized that regulation of the activity of these transporters could alter glutamine uptake and provide a mechanism to link supply to demand for neurotransmitter GABA. In immature and mature rat hippocampus, after a period of hyperexcitability, we observed a System A-dependent enhancement of inhibitory synaptic strength along with an increase in System A activity in synaptosomes under the same conditions. Under resting conditions, System A's contribution of glutamine to synaptic GABA diminished with age, correlating with reduced SNAT1/SAT1 expression and, even more so, with its activity on synaptic membranes. We conclude that System A activity is highly regulated, by depolarization and developmental cues, to dynamically modulate GABAergic transmission. Our evidence suggests that SNAT1/SAT1 is the transporter that plays a critical role in dynamically modulating inhibition in response to metabolic demands.

Glutamate spillover augments GABA synthesis and release from axodendritic synapses in rat hippocampus.

Tight coupling between gamma-aminobutyric acid (GABA) synthesis and vesicle filling suggests that the presynaptic supply of precursor glutamate could dynamically regulate inhibitory synapses. Although the neuronal glutamate transporter excitatory amino acid transporter 3 (EAAT3) has been proposed to mediate such a metabolic role, highly efficient astrocytic uptake of synaptically released glutamate normally maintains low-extracellular glutamate levels. We examined whether axodendritic inhibitory synapses in stratum radiatum of hippocampal area CA1, which are closely positioned among excitatory glutamatergic synapses, are regulated by synaptic glutamate release via presynaptic uptake. Under conditions of spatially and temporally coordinated release of glutamate and GABA within pyramidal cell dendrites, blocking glial glutamate uptake enhanced quantal release of GABA in a transporter-dependent manner. These physiological findings correlated with immunohistochemical studies revealing expression of EAAT3 by interneurons and uptake of D-asparate into putative axodendritic inhibitory terminals only when glial uptake was blocked. These results indicate that spillover of glutamate between adjacent excitatory and inhibitory synapses can occur under conditions when glial uptake incompletely clears synaptically released glutamate. Our anatomical studies also suggest that perisomatic inhibitory synapses, unlike synapses within dendritic layers of hippocampus, are not capable of glutamate uptake and therefore transporter-mediated dynamic regulation of inhibition is a unique feature of axodendritic synapses that may play a role in maintaining a homeostatic balance of inhibition and excitation.

In vivo metabotropic glutamate receptor 5 (mGluR5) antagonism prevents cocaine-induced disruption of postsynaptically maintained mGluR5-dependent long-term depression.

Metabotropic glutamate receptor 5 (mGluR5) plays a critical role in psychostimulant-induced behavior, yet it is unclear whether mGluR5 is activated by psychostimulant administration, or whether its role is constitutive. We previously reported that activation of mGluR5 with the group I mGluR agonist (RS)-3,5-dihydroxyphenylglycine (DHPG) can induce a long-term depression (DHPG-LTD) of glutamatergic transmission in the bed nucleus of the stria terminalis (BNST), and that ex vivo induction of this LTD is disrupted by repeated in vivo administration of cocaine. Here we demonstrate that DHPG-LTD is not maintained by alterations in glutamate release, and that postsynaptic endocytosis is necessary. Furthermore, we find that a single administration of cocaine produces a transient disruption of DHPG-LTD, and the duration of this disruption was increased by repeated days of cocaine administration. The disruption produced by cocaine was not permanent, because DHPG-LTD could be induced 10 d after cocaine administration. To test the role of mGluR5 in vivo in the cocaine-induced disruption of DHPG-LTD, we injected mice with the mGluR5 antagonist 2-methyl-6-(phenylethynyl)-pyridine before cocaine. mGluR5 antagonism during in vivo cocaine administration rescued subsequent ex vivo induction of DHPG-LTD. The effects of in vivo cocaine could be mimicked by application of cocaine to BNST-containing slices, suggesting that the actions of cocaine are local. Thus, using a novel strategy of in vivo antagonist-induced rescue of ex vivo agonist effects for the same receptor, we provide evidence suggesting that mGluR5 activation is actively recruited by in vivo cocaine.

Generalized-onset seizures with secondary focal evolution.

The international seizure classification recognizes that partial-onset seizures can become secondarily generalized, but generalized-onset seizures are expected to remain generalized. We report six patients who had recorded seizures with generalized onset, but subsequent evolution into a focal discharge. The clinical seizure onset was generalized absence or myoclonic, and the most common subsequent clinical pattern was prolonged behavioral arrest with mild automatisms, and then postictal confusion. The ictal discharge started with generalized spike-and-wave activity and then acquired a focal predominance. Interictal epileptiform activity was generalized. There were no focal magnetic resonance imaging abnormalities. Four patients were misdiagnosed with complex partial seizures. All patients were initially refractory, but three became seizure-free and three improved after treatment with antiepileptic medications appropriate for absence or myoclonic seizures. Generalized-onset seizures that acquire focal features are easily misdiagnosed as complex partial. These seizures have a more favorable response to medications effective against generalized absence and myoclonic seizures.

NKCC1 and KCC2 prevent hyperexcitability in the mouse hippocampus.

During postnatal development of the central nervous system (CNS), the response of GABA(A) receptors to its agonist undergoes maturation from depolarizing to hyperpolarizing. This switch in polarity is due to the developmental decrease of the intracellular Cl concentration in neurons. Here we show that absence of NKCC1 in P9-P13 CA3 pyramidal neurons, through genetic manipulation or through bumetanide inhibition, results in a significant increase in cell excitability. Furthermore, the pro-convulsant agent 4-aminopyridine induces seizure-like events in NKCC1-null mice but not in wild-type mice. Measurements of muscimol responses in the presence and absence of NKCC1 shows that the Na-K-2Cl cotransporter only marginally affects intracellular Cl(-) in P9-P13 CA3 principal neurons. However, large increases in intracellular Cl(-) are observed in CA3 pyramidal neurons following increased hyperexcitability, indicating that P9-P13 CA3 pyramidal neurons lack robust mechanisms to regulate intracellular Cl(-) during high synaptic activity. This increase in the Cl(-) concentration is network-driven and activity-dependent, as it is blocked by the non-NMDA glutamate receptor antagonist DNQX. We also show that expression of the outward K-Cl cotransporter, KCC2, prevents the development of hyperexcitability, as a reduction of KCC2 expression by half results in increased susceptibility to seizure under control and 4-AP conditions.

Neuronal glutamate uptake Contributes to GABA synthesis and inhibitory synaptic strength.

Neurons must maintain a supply of neurotransmitter in their presynaptic terminals to fill synaptic vesicles. GABA is taken up into inhibitory terminals by transporters or is synthesized from glutamate by glutamic acid decarboxylase. Here we report that glutamate transporters supply GABAergic terminals in the hippocampus with glutamate, which is then used to synthesize GABA for filling synaptic vesicles. Glutamate transporter antagonists reduced IPSC and miniature IPSC (mIPSC) amplitudes, consistent with a reduction in the amount of GABA packaged into each synaptic vesicle. This reduction occurred rapidly and independently of synaptic activity, suggesting that modulation of vesicular GABA content does not require vesicle release and refilling. Raising extracellular glutamate levels increased mIPSC amplitudes by enhancing glutamate uptake and, consequently, GABA synthesis. These results indicate that neuronal glutamate transporters strengthen inhibitory synapses in response to extracellular glutamate. This modulation appears to occur under normal conditions and may constitute a negative feedback mechanism to combat hyperexcitability.

Poststroke seizures.

Stroke is the most common cause of seizures in the elderly, and seizures are among the most common neurologic sequelae of stroke. About 10% of all stroke patients experience seizures, from stroke onset until several years later. This review discusses current understanding of the epidemiology, pathogenesis, classification, clinical manifestations, diagnostic studies, differential diagnosis, and management issues of seizures associated with various cerebrovascular lesions, with a focus on anticonvulsant use in the elderly.

Dietary treatment in adults with refractory epilepsy: a review.

We review adjunctive ketogenic diet (KD) and modified Atkins diet (MAD) treatment of refractory epilepsy in adults. Only a few studies have been published, all open-label. Because of the disparate, uncontrolled nature of the studies, we analyzed all studies individually, without a meta-analysis. Across all studies, 32% of KD-treated and 29% of MAD-treated patients achieved ≥ 50% seizure reduction, including 9% and 5%, respectively, of patients with >90% seizure frequency reduction. The effect persists long term, but, unlike in children, may not outlast treatment. The 3:1 and 4:1 [fat]:[carbohydrate + protein] ratio KD variants and MAD are similarly effective. The anticonvulsant effect occurs quickly with both diets, within days to weeks. Side effects of both diets are benign and similar. The most serious, hyperlipidemia, reverses with treatment discontinuation. The most common, weight loss, may be advantageous in patients with obesity. Potential barriers to large-scale use of both diets in adults include low rate of diet acceptance and high rates of diet discontinuation. The eligible screened/enrolled subject ratios ranged from 2.9 to 7.2. Fifty-one percent of KD-treated and 42% of MAD-treated patients stopped the diet before study completion. Refusal to participate was due to diet restrictiveness and complexity, which may be greater for KD than MAD. However, long-term adherence is low for both diets. Most patients eventually stop the diet because of culinary and social restrictions. For treatment of refractory status epilepticus, only 14 adult cases of KD treatment have been published, providing insufficient data to allow evaluation. In summary, KD and MAD treatment show modest efficacy, although in some patients the effect is remarkable. The diets are well-tolerated, but often discontinued because of their restrictiveness. In patients willing to try dietary treatment, the effect is seen quickly, giving patients the option whether to continue the treatment.

Hypermotor seizures in patients with temporal pole lesions.

Hypermotor seizures are considered to be characteristic of frontal lobe epilepsy, with only rare occurrence in temporal lobe epilepsy. After noting hypermotor seizures in several patients with lesions involving the pole of the temporal lobe, we investigated whether temporal pole lesions were associated with hypermotor seizures. We systematically reviewed medical records, MRI images and pathological findings in consecutive patients who underwent epilepsy surgery over the preceding 10 years in our institution and identified eight patients with temporal pole lesions and intractable complex partial seizures. We analyzed all recorded seizures for semiology, classifying seizures as hypermotor or typical "psychomotor." Four patients exhibited hypermotor seizure semiology and four patients manifested typical psychomotor seizure characteristics. In patients with hypermotor seizures, scalp EEG tended to demonstrate lateral anterior temporal ictal onset, with lesser involvement of the sphenoidal electrode, while the patients with psychomotor seizures had initial inferomesial temporal rhythmic theta activity. Two patients with hypermotor seizures had implanted frontal and temporal subdural grids demonstrating orbitofrontal spread before hypermotor behavior. Patients underwent either anterior temporal lobectomy or lesionectomy. All improved considerably, with six patients seizure-free since surgery. We conclude that hypermotor seizures occur frequently in patients with temporal pole lesions. A search for temporal pole pathology is recommended for patients with hypermotor seizures and temporal epileptiform discharges. Modification of the surgical approach to include this region should be considered in patients who exhibit hypermotor seizures.

Alterations of GABA A-receptor function and allosteric modulation during development of status epilepticus.

Partial limbic seizures in rodents induced by pilocarpine progress from stages I-II (mouth and facial movements; head nodding) to stage III (forelimb clonus) and then progress rapidly to stages IV-V (generalized limbic seizures; rearing, and rearing with falling) followed by status epilepticus (SE). Although limbic seizures in rodents are terminated by benzodiazepines, a group of gamma-aminobutyric acid type A (GABA(A))-receptor positive modulators, significant pharmacoresistance to benzodiazepines develops within minutes during SE. The alterations of GABA(A)-receptor function and allosteric modulation during development of SE are poorly understood. We induced seizures in juvenile rats by administration of lithium followed by pilocarpine, and whole cell recordings of miniature inhibitory postsynaptic currents (mIPSCs) were obtained from hippocampal dentate granule cells in brain slices. Compared with a sham-treated group, mIPSC amplitude was reduced and decay was accelerated at onset of the first occurrence of stage III (S3) seizures [S3(0)], resulting in a reduction in the total charge transfer at S3(0). Recovery of mIPSC amplitude and prolongation of mIPSC decay occurred 30 min after onset of S3 seizures [S3(30)]. The mIPSC frequency was not altered for S3(0) and S3(30) neurons compared with sham neurons. The net enhancement of total charge transfer by diazepam was smaller for S3(30) than that for sham and S3(0) neurons; however, the net reduction of total charge transfer by zinc was greater for S3(30) than that for sham and S3(0) neurons. These findings suggest that substantial plastic changes of GABA(A)-receptor function and allosteric modulation occur rapidly in neurons from juvenile animals during development of SE.

Glutamine uptake by System A transporters maintains neurotransmitter GABA synthesis and inhibitory synaptic transmission.

GABA synthesis is necessary to maintain synaptic vesicle filling, and key proteins in its biosynthetic pathways may play a role in regulating inhibitory synaptic stability and strength. GABAergic neurons require a source of precursor glutamate, possibly from glutamine, although it is controversial whether glutamine contributes to the synaptic pool of GABA. Here we report that inhibition of System A glutamine transporters with alpha-(methyl-amino) isobutyric acid rapidly reduced the amplitude of inhibitory post-synaptic currents and miniature inhibitory post-synaptic currents (mIPSCs) recorded in rat hippocampal area cornu ammonis 1 (CA1) pyramidal neurons, indicating that synaptic vesicle content of GABA was reduced. After inhibiting astrocytic glutamine synthesis by either blocking glutamate transporters or the glutamine synthetic enzyme, the effect of alpha-(methyl-amino) isobutyric acid on mIPSC amplitudes was abolished. Exogenous glutamine did not affect mIPSC amplitudes, suggesting that the neuronal transporters are normally saturated. Our findings demonstrate that a constitutive supply of glutamine is provided by astrocytes to inhibitory neurons to maintain vesicle filling. Therefore, glutamine transporters, like those for glutamate, are potential regulators of inhibitory synaptic strength. However, in contrast to glutamate, extracellular glutamine levels are normally high. Therefore, we propose a supportive role for glutamine, even under resting conditions, to maintain GABA vesicle filling.

Similarities in Mechanisms and Treatments for Epileptic and Nonepileptic Myoclonus.

Myoclonus is a disordered movement that may be an ictal phenomenon or may be due to various injuries in brain and spinal cord motor structures. Many epileptic and nonepileptic myoclonic conditions are associated with abnormalities in inhibitory neurotransmission. gamma-Aminobutyric acid type A (GABA(A))-receptor antagonists may trigger myoclonus. Several antiepilepsy drugs (AEDs) effective against myoclonic seizures [valproic acid (VPA), clonazepam (CZP), levetiracetam (LEV)] enhance GABAergic neurotransmission and improve myoclonic movement disorders. Together these associations suggest links between episodic disorders involving synchronous cortical discharges (seizures) and hyperkinetic movement disorders.