Add-on treatment with cenobamate is already effective at low doses in refractory focal epilepsy: A prospective observational study.

OBJECTIVE: Cenobamate, a novel antiseizure medication with a dual mechanism of action, has been shown in pivotal trials to significantly improve seizure control in treatment-resistant focal epilepsy. We aimed to evaluate whether these promising results could be confirmed in a real-world setting with a follow-up period of up to 12 months. METHODS: Patients from a tertiary epilepsy center who received cenobamate add-on between June 2021 and October 2023 were followed up prospectively at 3, 6, and 12 months after treatment initiation for assessment of seizure outcomes and treatment-related adverse events. RESULTS: The clinical cohort included 112 adult patients with 30% nonlesional cases and a wide spectrum of epileptogenic lesions underlying refractory focal epilepsy. We observed a significant reduction in monthly seizure frequency of all seizure types already after 3 months of treatment at a median cenobamate dose of 100 mg/day. Forty-six percent of patients were responders with a ≥50% seizure reduction, 26% had a ≥75% seizure reduction, and 9% became seizure-free. Among the 74 patients with available follow-up of 12 months, the responder rates reached 55%, 35%, and 19% for ≥50%, ≥75%, and 100% seizure reduction, respectively. After 3 months of treatment, 38% of patients reported adverse effects, mainly (84%) mild to moderate in intensity. Adjustment of comedication allowed successful management of adverse effects in 32% of patients. At a group level, there was no correlation between the cenobamate daily dose and the incidence of adverse events. SIGNIFICANCE: We found a clinically relevant response to cenobamate already at a low daily dose of 100 mg also in a patient cohort with a higher degree of drug resistance than in pivotal trials. Our prospectively collected data provide real-world evidence for high efficacy and good tolerability of the drug, although no standardized treatment protocol or comparison with a control group was applied.

Physiological and pathological neuronal connectivity in the living human brain based on intracranial EEG signals: the current state of research.

Over the past decades, studies of human brain networks have received growing attention as the assessment and modelling of connectivity in the brain is a topic of high impact with potential application in the understanding of human brain organization under both physiological as well as various pathological conditions. Under specific diagnostic settings, human neuronal signal can be obtained from intracranial EEG (iEEG) recording in epilepsy patients that allows gaining insight into the functional organisation of living human brain. There are two approaches to assess brain connectivity in the iEEG-based signal: evaluation of spontaneous neuronal oscillations during ongoing physiological and pathological brain activity, and analysis of the electrophysiological cortico-cortical neuronal responses, evoked by single pulse electrical stimulation (SPES). Both methods have their own advantages and limitations. The paper outlines available methodological approaches and provides an overview of current findings in studies of physiological and pathological human brain networks, based on intracranial EEG recordings.

Value of ultralong-term subcutaneous EEG monitoring for treatment decisions in temporal lobe epilepsy: A case report.

Treatment decisions in epilepsy critically depend on information on the course of the disease, its severity and options for specific local interventions. We here report a patient with pharmaco-resistant non-lesional temporal lobe epilepsy with evidence for predominant right temporal epileptogenesis. While seizure frequency had been grossly underestimated for many years, ultralong-term monitoring with a subcutaneous EEG device revealed actual seizure frequency (66 over 11 months vs four patient-documented seizures), providing objective data on treatment efficacy and additional supportive lateralizing information that played a decisive role for the choice of surgical treatment, which had been rejected by the patient prior to this information.

In vivo-assessment of the human temporal network: Evidence for asymmetrical effective connectivity.

The human temporal lobe is a multimodal association area which plays a key role in various aspects of cognition, particularly in memory formation and spatial navigation. Functional and anatomical connectivity of temporal structures is thus a subject of intense research, yet by far underexplored in humans due to ethical and technical limitations. We assessed intratemporal cortico-cortical interactions in the living human brain by means of single pulse electrical stimulation, an invasive method allowing mapping effective intracortical connectivity with a high spatiotemporal resolution. Eighteen subjects with normal anterior-mesial temporal MR imaging undergoing intracranial presurgical epilepsy diagnostics with multiple depth electrodes were included. The investigated structures were temporal pole, hippocampus, amygdala and parahippocampal gyrus. Intratemporal cortical connectivity was assessed as a function of amplitude of the early component of the cortico-cortical evoked potentials (CCEP). While the analysis revealed robust interconnectivity between all explored structures, a clear asymmetry in bidirectional connectivity was detected for the hippocampal network and for the connections between the temporal pole and parahippocampal gyrus. The amygdala showed bidirectional asymmetry only to the hippocampus. The provided evidence of asymmetrically weighed intratemporal effective connectivity in humans in vivo is important for understanding of functional interactions within the temporal lobe since asymmetries in the brain connectivity define hierarchies in information processing. The findings are in exact accord with the anatomical tracing studies in non-human primates and open a translational route for interventions employing modulation of temporal lobe function.

Recurrent episodes of falls and amnestic confusional states as diagnostic challenge in the elderly.

New-onset paroxysmal events in patients over 60 years of age are often diagnostically challenging owing to atypical presentation. Recurrent falls and transient states of confusion are especially common in the elderly population, yet their causes often remain undiagnosed due to concomitant cognitive deficits and motor impairments. We present an elderly patient with newly occurring 'blackouts' without obvious triggers and transient states of confusion for which he was amnestic. All neurological exams including brain MRI scan and routine electroencephalography (EEG) were normal. Long-term ECG monitoring using an event recorder captured an asystole during a habitual episode, leading to the diagnosis of syncope and pacemaker implantation. A subsequent video EEG monitoring performed due to ongoing unexplained confusional states revealed both bradycardia and long-lasting confusional states to be caused by unrecognised temporal lobe seizures. Ictal video EEG monitoring may play a crucial role in establishing a diagnosis of atypical temporal lobe seizures in the elderly.

Rapid antiepileptic drug withdrawal may obscure localizing information obtained during presurgical EEG recordings.

Withdrawal of antiepileptic drugs (AEDs) is a standard procedure during presurgical epilepsy assessment. Rapid and, at times, even pre-hospital withdrawal of medication is performed in some centres to enhance the yield of recorded seizures during video-EEG monitoring. AED withdrawal, however, affects the propensity and speed of propagation of epileptic activity, may evoke more severe seizures, and may cause pitfalls in EEG interpretation. We report a case which had been recommended to undergo intracranial EEG recordings in order to clarify apparently discordant MRI findings and ictal EEG patterns when monitoring was performed following complete AED withdrawal. Re-evaluation to assess scalp EEG patterns at several drug levels during slow AED tapering showed a loss of localizing information with AED withdrawal due to contralateral and bitemporal spread of frontal epileptic activity. Our report demonstrates that in individual cases, rapid AED withdrawal during presurgical video-EEG monitoring can impair the validity of EEG recordings and lead to unnecessary risks and investigations during workup.

Ripple-triggered stimulation of the locus coeruleus during post-learning sleep disrupts ripple/spindle coupling and impairs memory consolidation.

Experience-induced replay of neuronal ensembles occurs during hippocampal high-frequency oscillations, or ripples. Post-learning increase in ripple rate is predictive of memory recall, while ripple disruption impairs learning. Ripples may thus present a fundamental component of a neurophysiological mechanism of memory consolidation. In addition to system-level local and cross-regional interactions, a consolidation mechanism involves stabilization of memory representations at the synaptic level. Synaptic plasticity within experience-activated neuronal networks is facilitated by noradrenaline release from the axon terminals of the locus coeruleus (LC). Here, to better understand interactions between the system and synaptic mechanisms underlying "off-line" consolidation, we examined the effects of ripple-associated LC activation on hippocampal and cortical activity and on spatial memory. Rats were trained on a radial maze; after each daily learning session neural activity was monitored for 1 h via implanted electrode arrays. Immediately following "on-line" detection of ripple, a brief train of electrical pulses (0.05 mA) was applied to LC. Low-frequency (20 Hz) stimulation had no effect on spatial learning, while higher-frequency (100 Hz) trains transiently blocked generation of ripple-associated cortical spindles and caused a reference memory deficit. Suppression of synchronous ripple/spindle events appears to interfere with hippocampal-cortical communication, thereby reducing the efficiency of "off-line" memory consolidation.

Effects of mGlu1 receptor blockade on working memory, time estimation, and impulsivity in rats.

RATIONALE: Metabotropic glutamate 1 (mGlu1) receptor antagonists were reported to induce cognitive deficits in several animal models using aversive learning procedures. OBJECTIVE: The present study aimed to further characterize behavioral effects of mGlu1 receptor antagonists using appetitively motivated tasks that evaluate working memory, timing, and impulsivity functions. MATERIALS AND METHODS: Separate groups of adult male Wistar rats were trained to perform four food-reinforced operant tasks: delayed non-matching to position (DNMTP), differential reinforcement of low rates of responding 18 s (DRL 18-s), signal duration discrimination (2-s vs 8-s bisection), and tolerance to delay of reward. Before the tests, rats were pretreated with (3-ethyl-2-methyl-quinolin-6-yl)-(4-methoxy-cyclohexyl)-methanone methanesulfonate (EMQMCM; 2.5-10 mg/kg, i.p.; JNJ16567083). RESULTS: In DNMTP task, EMQMCM produced delay-dependent increases in performance accuracy so that, at 10 mg/kg dose level, percentage of correct lever choices was enhanced at 8- and 16-s delays. In DRL task, at all three tested doses, response rates were higher, and reinforcement rates were lower than under control conditions. In signal duration discrimination tasks, EMQMCM did not have any specific effects on temporal control. In tolerance to delay of reward, EMQMCM (5 and 10 mg/kg) facilitated choice of the lever associated with large reward at longer delay levels. CONCLUSIONS: Blockade of mGlu1 receptors improves working memory and reduces impulsive choice at the doses that have no effects on time perception but appear to facilitate impulsive action.