Prognostication of responsive neurostimulation system responsiveness using presurgical magnetoencephalography.

This scientific commentary refers to 'Network connectivity predicts effectiveness of responsive neurostimulation in focal epilepsy', by Fan et al. (https://doi.org/10.1093/braincomms/fcac104).

Perspectives on Understanding Aberrant Brain Networks in Epilepsy.

Epilepsy is a neurological disorder affecting approximately 70 million people worldwide. It is characterized by seizures that are complex aberrant dynamical events typically treated with drugs and surgery. Unfortunately, not all patients become seizure-free, and there is an opportunity for novel approaches to treat epilepsy using a network view of the brain. The traditional seizure focus theory presumed that seizures originated within a discrete cortical area with subsequent recruitment of adjacent cortices with seizure progression. However, a more recent view challenges this concept, suggesting that epilepsy is a network disease, and both focal and generalized seizures arise from aberrant activity in a distributed network. Changes in the anatomical configuration or widespread neural activities spanning lobes and hemispheres could make the brain more susceptible to seizures. In this perspective paper, we summarize the current state of knowledge, address several important challenges that could further improve our understanding of the human brain in epilepsy, and invite novel studies addressing these challenges.

Controversies on the network theory of epilepsy: Debates held during the ICTALS 2019 conference.

Debates on six controversial topics on the network theory of epilepsy were held during two debate sessions, as part of the International Conference for Technology and Analysis of Seizures, 2019 (ICTALS 2019) convened at the University of Exeter, UK, September 2-5 2019. The debate topics were (1) From pathologic to physiologic: is the epileptic network part of an existing large-scale brain network? (2) Are micro scale recordings pertinent for defining the epileptic network? (3) From seconds to years: do we need all temporal scales to define an epileptic network? (4) Is it necessary to fully define the epileptic network to control it? (5) Is controlling seizures sufficient to control the epileptic network? (6) Does the epileptic network want to be controlled? This article, written by the organizing committee for the debate sessions and the debaters, summarizes the arguments presented during the debates on these six topics.

Seizure susceptibility and infraslow modulatory activity in the intracranial electroencephalogram.

OBJECTIVE: Studies of infraslow amplitude modulations (<0.15 Hz) of band power time series suggest that these envelope correlations may form a basis for distant spatial coupling in the brain. In this study, we sought to determine how infraslow relationships are affected by antiepileptic drug (AED) taper, time of day, and seizure. METHODS: We studied intracranial electroencephalographic (icEEG) data collected from 13 medically refractory adult epilepsy patients who underwent monitoring at Yale-New Haven Hospital. We estimated the magnitude-squared coherence (MSC) at <0.15 Hz of traditional EEG frequency band power time series for all electrode contact pairs to quantify infraslow envelope correlations between them. We studied, first, hour-long background icEEG epochs before and after AED taper to understand the effect of taper. Second, we analyzed the entire record for each patient to study the effect of time of day. Finally, for each patient, we reviewed the clinical record to find all seizures that were at least 6 hours removed from other seizures and analyzed infraslow envelope MSC before and after them. RESULTS: Infraslow envelope MSC increased slightly, but significantly, after AED taper, and increased on average during the night and decreased during the day. It was also increased significantly in all frequency bands up to 3 hours preseizure and 1 hour postseizure as compared to background icEEG (61 seizures studied). These changes occurred for both daytime and nighttime seizures (28 daytime, 33 nighttime). Interestingly, there was significant spatial variability to these changes, with the seizure onset area peaking at 3 hours preseizure, then showing progressive desynchronization from 3 hours preseizure to 1 hour postseizure. SIGNIFICANCE: Infraslow envelope analysis may be used to understand long-term changes over the course of icEEG monitoring, provide unique insight into interictal electrophysiological changes related to ictogenesis, and contribute to the development of novel seizure forecasting algorithms.

Regional and network relationship in the intracranial EEG second spectrum.

OBJECTIVE: We examined low-frequency amplitude modulations of band power time-series, i.e. the second spectrum, of the intracranial EEG (icEEG) for evidence of support for spatial relationships between different parts of the brain and within the default mode network (DMN). METHODS: We estimated magnitude-squared coherence (MSC) of the running power in the delta, theta, alpha, beta, and gamma frequency bands for one-hour background icEEG epochs recorded from 9 patients. We isolated two test areas within the DMN and one control area outside it. We tested if the relationship between DMN areas was stronger than the relationship between each of these areas and the control location, and between all intrahemispheric contact pairs with similar intercontact distance. RESULTS: We observed very low values of second spectrum relationship between different parts of the brain, except at very short distances. These relationships are strongest in the delta band and decrease with increasing frequency, with gamma band relationships being the weakest. Our DMN-specific analysis showed no enhanced connectivity in the second spectrum in DMN locations in any frequency band. CONCLUSIONS: Though we observed significantly nonzero relationships in lower frequency bands, second spectrum relationships are consistently very low across the entire brain in every frequency band. SIGNIFICANCE: This study suggests a lack of support for the DMN in the icEEG second spectrum.

Progressive change in sleep over multiple nights of intracranial EEG monitoring.

OBJECTIVE: We evaluated changes to sleep structure during continuous intracranial EEG (icEEG) monitoring of epilepsy patients undergoing localization of the seizure onset area. METHODS: We studied 28 adult epilepsy patients who underwent icEEG monitoring for a median of 12 nights. We used a metric calculated from relative delta power (RDP) to evaluate the emergence of sleep cycles for every night of monitoring. We further evaluated the effect of seizures and AEDs on trends in the RDP metric. RESULTS: We observed oscillations corresponding to sleep cycles in the RDP time-series. There was a significant increasing trend in our RDP sleep metric over the course of monitoring. Seizures and AEDs did not significantly affect this trend. CONCLUSIONS: The RDP metric increased during icEEG monitoring, independent of seizures and AEDs. This increase may be due to a number of factors and these factors appear to outweigh the effects of seizures and AEDs. SIGNIFICANCE: Our results indicate that sleep is not uniform during icEEG monitoring, rather there is a considerable increasing, multi-night change in sleep structure.

A Peptide Uncoupling BDNF Receptor TrkB from Phospholipase Cγ1 Prevents Epilepsy Induced by Status Epilepticus.

The BDNF receptor tyrosine kinase, TrkB, underlies nervous system function in both health and disease. Excessive activation of TrkB caused by status epilepticus promotes development of temporal lobe epilepsy (TLE), revealing TrkB as a therapeutic target for prevention of TLE. To circumvent undesirable consequences of global inhibition of TrkB signaling, we implemented a novel strategy aimed at selective inhibition of the TrkB-activated signaling pathway responsible for TLE. Our studies of a mouse model reveal that phospholipase Cγ1 (PLCγ1) is the dominant signaling effector by which excessive activation of TrkB promotes epilepsy. We designed a novel peptide (pY816) that uncouples TrkB from PLCγ1. Treatment with pY816 following status epilepticus inhibited TLE and prevented anxiety-like disorder yet preserved neuroprotective effects of endogenous TrkB signaling. We provide proof-of-concept evidence for a novel strategy targeting receptor tyrosine signaling and identify a therapeutic with promise for prevention of TLE caused by status epilepticus in humans.

Deficiency of asparagine synthetase causes congenital microcephaly and a progressive form of encephalopathy.

We analyzed four families that presented with a similar condition characterized by congenital microcephaly, intellectual disability, progressive cerebral atrophy, and intractable seizures. We show that recessive mutations in the ASNS gene are responsible for this syndrome. Two of the identified missense mutations dramatically reduce ASNS protein abundance, suggesting that the mutations cause loss of function. Hypomorphic Asns mutant mice have structural brain abnormalities, including enlarged ventricles and reduced cortical thickness, and show deficits in learning and memory mimicking aspects of the patient phenotype. ASNS encodes asparagine synthetase, which catalyzes the synthesis of asparagine from glutamine and aspartate. The neurological impairment resulting from ASNS deficiency may be explained by asparagine depletion in the brain or by accumulation of aspartate/glutamate leading to enhanced excitability and neuronal damage. Our study thus indicates that asparagine synthesis is essential for the development and function of the brain but not for that of other organs.

Transient inhibition of TrkB kinase after status epilepticus prevents development of temporal lobe epilepsy.

Temporal lobe epilepsy is the most common and often devastating form of human epilepsy. The molecular mechanism underlying the development of temporal lobe epilepsy remains largely unknown. Emerging evidence suggests that activation of the BDNF receptor TrkB promotes epileptogenesis caused by status epilepticus. We investigated a mouse model in which a brief episode of status epilepticus results in chronic recurrent seizures, anxiety-like behavior, and destruction of hippocampal neurons. We used a chemical-genetic approach to selectively inhibit activation of TrkB. We demonstrate that inhibition of TrkB commencing after status epilepticus and continued for 2 weeks prevents recurrent seizures, ameliorates anxiety-like behavior, and limits loss of hippocampal neurons when tested weeks to months later. That transient inhibition commencing after status epilepticus can prevent these long-lasting devastating consequences establishes TrkB signaling as an attractive target for developing preventive treatments of epilepsy in humans.