Treatment approach to a patient with catamenial epilepsy. case report

ABSTRACT Introduction: Catamenial epilepsy refers to the worsening or exacerbation of seizures due to hormonal changes during the menstrual cycle. It is thought to be secondary to the neuroactive properties of endogenous steroid hormones and the natural cyclic variation in their serum levels throughout the menstrual cycle. Case presentation: A 31-year-old female patient from Bogotá (Colombia) was admitted to the emergency department due to an episode of tonic-clonic seizure associated with the menstrual period. Since the onset of the seizures was related to menstruation (every 28 days), it was established that the patient had structural focal epilepsy with catamenial features. Advantages of medical vs. surgical treatment were discussed during a multidisciplinary medical board and it was decided to start pharmacological treatment with progestogens, which resulted in complete remission of the seizures as established during a follow-up visit. Conclusions: Catamenial epilepsy should be considered as a cause of epilepsy refractory to antiepileptic medications. Furthermore, it should be approached from a multidisciplinary perspective and its management should be focused on improving the patients' quality of life.

RESUMEN Introducción. La epilepsia catamenial se define como un empeoramiento o la exacerbación de las crisis epilépticas en relación con el cambio hormonal durante el ciclo menstrual femenino. Se cree que esta se produce por las propiedades neuroactivas de las hormonas esteroides endógenas y la variación cíclica natural en sus niveles séricos a lo largo de dicho ciclo. Presentación del caso. Mujer de 31 años de Bogotá (Colombia), quien fue llevada al servicio de urgencias por un episodio de crisis epiléptica con convulsiones tonicoclónicas asociado al período menstrual. Debido a que la aparición de las crisis epilépticas se asociaba con la menstruación (cada 28 días), se estableció que la paciente presentaba epilepsia focal estructural de características catameniales. En junta médica multidisciplinar se discutieron las ventajas del manejo médico y el manejo quirúrgico, y se decidió instaurar tratamiento farmacológico con progestágenos, el cual, tras seguimiento, evidenció supresión total de las crisis. Conclusiones. La epilepsia catamenial debe considerarse como una causa de epilepsia refractaria al tratamiento antiepiléptico. Además, su abordaje debe ser multidisciplinario y su tratamiento debe ir enfocado a mejorar la calidad de vida de los pacientes.

Neurosteroids: current perspective in therapy of neuropsychiatric disorders

Neurosteroids are natural or synthetic steroid derivatives which act locally in brain by modulating neuronal excitability. The objective of this study is to analyze available literature on classification, biosynthesis and mechanism of action, and therapeutic potential of neurosteroids. A review of literature pertaining to neurosteroids published from inception to 2018 was carried on data bases like PUBMED, Google Scholar and Science Direct. The search terms used were neurosteroids, neuro-active steroids, ganaxolone and GABA-A receptor modulators. Review of literature suggests neurosteroids are powerful neuro-modulators, involving rapid non-genomic and non-hormone receptor mechanisms. They are classified based on structure as pregnane, androstane and sulphated neurosteroids, and based on function as excitatory or inhibitory neurosteroids. They act via GABAA receptor (primarily), rho- GABA (?GABA), NMDA-glutamate and sigma receptor modulation. The inhibitory neurosteroids demonstrate sedative, anxiolytic and anticonvulsant actions, whereas the excitatory agents produce memory enhancing and anxiogenic effects. They show efficacy in various CNS and psychiatric conditions like epilepsy, anxiety, depression, learning and memory disorders and substance abuse. Endogenous neurosteroids have limited clinical use due to low bioavailability, lack of specificity and unwanted effects. Hence, synthetic agents like alphaxalone, ganaxolone, sepranolone and brexanolone which have better bioavailability and specificity, are being investigated in various phases of clinical trials. Neurosteroids are novel endogenous compounds with neuro-modulatory function and show promising effects in therapy of various neurological and psychiatric conditions. Further studies that prove their long term efficacy and safety may revolutionize the clinical approach to therapy of these conditions.

Relationship between neurosteroids and neuropsychiatric disorders such as anxiety and depression: Research advances / 国际药学研究杂志

Neurosteroids are synthesized from cholesterol within the microglia of the central nervous system. They are classified as dehydroepiandrosterone,progesterone, pregnenolone,allopregnanolone and other peripheral steroids. Neurosteroids such as allopregnanolone are positive allosteric modulators of GABAA receptors and exert anxiolytic and antidepressant-like behavior. Neuroactive steroids play a significant role in neurodevelopment in terms of internal environment homeostasis. This paper reviews the biosynthesis, metabolism regulatory effect on the response to stress and therapeutic potentials of neurosteroids.

Relationship between neurosteroids and neuropsychiatric disorders such as anxiety and depression:research advances / 国际药学研究杂志

Neurosteroids are synthesized from cholesterol within the microglia of the central nervous system. They are classi?fied as dehydroepiandrosterone,progesterone,pregnenolone,allopregnanolone and other peripheral steroids. Neurosteroids such as al?lopregnanolone are positive allosteric modulators of GABAA receptors and exert anxiolytic and antidepressant-like behavior. Neuroac?tive steroids play a significant role in neurodevelopment in terms of internal environment homeostasis. This paper reviews the biosynthe?sis,metabolism regulatory effect on the response to stress and therapeutic potentials of neurosteroids.

Trastornos hormonales en pacientes con epilepsia / Hormonal Disorders in Patients with Epilepsy

La epilepsia es una de las enfermedades neurológicas crónicas más comunes cuya etiología es multifactorial (congénita, traumatismos, infecciones en el sistema nervioso central, etc.). Existen varias interacciones multidireccionales entre ejes hormonales, crisis epilépticas y la utilización de medicación destinada para su control. Las alteraciones en los niveles endógenos o exógenos de hormonas pueden afectar la excitabilidad neuronal y la susceptibilidad a crisis o indirectamente a través de alteraciones en las concentraciones de drogas antiepilépticas e inversamente anormalidades estructurales y fisiológicas del cerebro afectado por la epilepsia o su medicación pueden afectar los diferentes ejes hipotálamo-hipofisarios.

Epilepsy is one of the most common chronic neurological diseases with multifactorial etiology (congenital, trauma, central nervous system infection, etc.). There are several multidirectional interactions between hormonal axes, seizures and the use of medication to control this disease. For example, alterations in endogenous or exogenous hormonal levels can directly affect neuronal excitability as well as susceptibility to crises or indirectly through changes in the concentrations of antiepileptic drugs and, conversely, structural and physiological abnormalities of the brain affected by epilepsy or medication can affect the different hypothalamic-pituitary axes.

Etifoxine for Pain Patients with Anxiety

Etifoxine (etafenoxine, Stresam(R)) is a non-benzodiazepine anxiolytic with an anticonvulsant effect. It was developed in the 1960s for anxiety disorders and is currently being studied for its ability to promote peripheral nerve healing and to treat chemotherapy-induced pain. In addition to being mediated by GABA(A)alpha2 receptors like benzodiazepines, etifoxine appears to produce anxiolytic effects directly by binding to beta2 or beta3 subunits of the GABA(A) receptor complex. It also modulates GABA(A) receptors indirectly via stimulation of neurosteroid production after etifoxine binds to the 18 kDa translocator protein (TSPO) of the outer mitochondrial membrane in the central and peripheral nervous systems, previously known as the peripheral benzodiazepine receptor (PBR). Therefore, the effects of etifoxine are not completely reversed by the benzodiazepine antagonist flumazenil. Etifoxine is used for various emotional and bodily reactions followed by anxiety. It is contraindicated in situations such as shock, severely impaired liver or kidney function, and severe respiratory failure. The average dosage is 150 mg per day for no more than 12 weeks. The most common adverse effect is drowsiness at the initial stage. It does not usually cause any withdrawal syndromes. In conclusion, etifoxine shows less adverse effects of anterograde amnesia, sedation, impaired psychomotor performance, and withdrawal syndromes than those of benzodiazepines. It potentiates GABA(A) receptor-function by a direct allosteric effect and by an indirect mechanism involving the activation of TSPO. It seems promising that non-benzodiazepine anxiolytics including etifoxine will replenish shortcomings of benzodiazepines and selective serotonin reuptake inhibitors according to animated studies related to TSPO.

To study the oxidative stress induced by lindane in epileptic rats brains and their modulation by neurosteroids.

Background: Lindane is pesticide has been shown to affect the nervous system adversely. Previous work has shown that lindane is proconvulsant and neurosteroids (NS) has been shown to be neuroprotective against lindane-induced convulsions. As the mechanisms of lindane in epileptogenesis is not completely understood. The present study was designed to investigate the oxidative stress parameters of lindane toxicity in epileptogenesis and their modulation by NS like allopregnanolone (AP), and 4ʹ-chlorodiazepam (4ʹ-CD) in pentylenetetrazole (PTZ) kindling methods. Methods: Kindling was induced by injecting PTZ (30 mg/kg; s.c.) on alternate days i.e., 3 times in a week. Lindane was also administered (15 mg/kg p.o) on alternate days for 6 weeks. AP (2.5 mg/kg, intaperitoneal [i.p.]) and 4ʹ-CD (0.5 mg/kg, i.p.) single dose was given in kindled rats before lindane. Results: Following per oral administration of lindane for 6 weeks produced signifi cant oxidative stress in epileptic brain. There was an increase in brain malondialdehyde (MDA) level and decrease in reduced glutathione (GSH) levels. AP (2.5 mg/kg, i.p.) and 4ʹ-CD (0.5 mg/kg, i.p.) single dose administration were not able to reverse the effect of chronic exposure of lindane. Conclusion: The result of the present study provides evidence that oxidative stress produced in the brain after chronic exposure of lindane may be the mechanism of epileptogenesis. Though NS have been shown to be neuroprotective, but they failed to reverse chronic oxidative stress produced by lindane. Further studies are required to demonstrate interaction of NS with lindane in oxidative stress.

Effect of Neurosteroid Modulation on Global Ischaemia-Reperfusion-Induced Cerebral Injury in Mice

The present study was designed to investigate the putative effect of neurosteroid modulation on global ischaemia-reperfusion-induced cerebral injury in mice. Bilateral carotid artery occlusion followed by reperfusion, produced a significant rise in cerebral infarct size along with impairment of grip strength and motor coordination in Swiss albino mice. Administration of carbamazepine (16 mg/kg, i.p.) before global cerebral ischaemia significantly attenuated cerebral infarct size and improved the motor performance. However, administration of indomethacin (100 mg/kg, i.p.) attenuated the neuroprotective effect of carbamazepine. Mexiletine (50 mg/kg, i.p.) did not produce significant neuroprotective effect. It may be concluded that the neuroprotective effect of carbamazepine may be due to increase in synthesis of neurosteroids perhaps by activating enzyme (3alpha HSD) as indomethacin attenuated the neuroprotective effect of carbamazepine. The sodium channel blocking effect of carbamazepine may not be involved in neuroprotection as mexiletine, a sodium channel blocker, did not produce significant neuroprotective effect.

Neuroactive steroids and their role in epilepsy.

Neuroactive steroids are the certain steroids that alter neuronal excitability via the cell surface through interaction with certain neurotransmitter receptors. Neuroactive steroids regulate physiological functions of the central nervous system and have possible therapeutic potential in neurological diseases. They have been shown to affect neuronal excitability via their interaction with the ligand-gated ion channel family, such as the GABAA receptor by acting genomically as well as nongenomically. Positive modulators of GABAA receptor have anticonvulsant action as they enhance GABAergic transmission thereby increasing the seizure threshold. By virtue of these properties, neurosteroids appear to be relevant to pathophysiology and pharmacological treatment of many neurological diseases including catamenial epilepsy, stress induced epilepsy, temporal lobe epilepsy, alcohol withdrawal seizures, infantile spasm and status epilepticus. So far, only synthetic neurosteroid, ganaxolone has been tried in treatment of epilepsy and has shown good efficacy and tolerability. But, human data of trials are limited and hence, large double-blinded, placebo-controlled, randomized clinical trials are required before their use. The paper reviews the biosynthesis and GABAA receptor modulation of neurosteroids and their potential role in epilepsy.

Neuroprotección y traumatismo craneoencefálico / Neuroprotection and traumatic brain injury

Durante un proceso de lesión cerebral, por ejemplo en un traumatismo craneoencefálico, se activan respuestas que inducen daño cerebral o muerte celular; sin embargo, también se inducen respuestas de protección que intentan mantener la integridad y funcionalidad del cerebro; esto se conoce como neuroprotección. Efectivamente, posterior a un TCE, se desencadenan mecanismos que traen como consecuencia liberación de neurotransmisores excitadores tales como el glutamato, lo que provoca una entrada masiva de Ca²+ en las neuronas, activación de proteasas, lipasas, sintasa de óxido nítrico, endonucleasas, producción de radicales libres y potencialmente necrosis o apoptosis. Aunque hay reportes de sustancias neuro o cerebroprotectoras desde hace más de 50 años, es al final de la década de los ochenta del siglo pasado cuando comienza a aparecer un gran número de publicaciones tratando de entender los mecanismos neuroprotectores desencadenados por un insulto al cerebro. En este trabajo revisamos brevemente el concepto, la epidemiologia y los diversos agentes que se han utilizado para disminuir el daño causado por un traumatismo craneoencefálico.

During a process of brain injury, e.g. head injury, responses to induce brain damage and / or cell death are activated, but also protective responses that attempt to maintain the integrity and functionality of the brain are induced. This is known as neuroprotection. Indeed a head injury triggers mechanisms that result in release of excitatory neurotransmitters such as glutamate, which causes an influx of Ca²+ into neurons, activation of proteases, lipases, nitric oxide synthase, endonucleases, free radicals production and potentially necrosis and / or apoptosis. Although the brain or neuroprotective substances research has more than 50 years, is at the end of the decade of 80's of last century when it began to appear a large number of publications trying to understand the neuroprotective mechanisms triggered by an insult to the brain. In this paper we briefly review the concept, epidemiology and strategies that have been used to minimize the damage caused by brain injury.

Role of Sigma Receptor and Neurosteroids in Pain Sensation / 한양의대학술지

The sigma-1 receptor has recently been implicated in a myriad of cellular functions and biological processes. Previous studies have demonstrated that the spinal sigma-1 receptor plays a pro-nociceptive role in acute pain and that the direct activation of sigma-1 receptor enhances the nociceptive response to peripheral stimuli, which is closely associated with calcium-dependent second messenger cascades including protein kinase C (PKC). In addition, the activation of sigma-1 receptor increases PKC- and protein kinase alpha (PKA)-dependent phosphorylation of the N-Methyl- D-aspartate (NMDA) receptor in the spinal cord, which results in the potentiation of intrathecal NMDA-evoked spontaneous pain behavior. Moreover, the blockade of spinal sigma-1 receptor suppresses the development of neuropathic pain and blocks the increase of phosphorylation of extracellular signal-regulated kinase (ERK) as well as pNR1 in the spinal cord. Recently, it was also reported that spinal neurosteroids such as pregnenolone and dehydroepiandrosterone sulfate, which are recognized as endogenous ligands for sigma-1 receptor, could produce mechanical hypersensitivity via sigma-1 receptor-mediated increase of pNR1. Collectively, these findings demonstrate that the activation of spinal sigma-1 receptor or the increase of neurosteroids is closely associated with the acute pain sensation or the development of chronic pain, and imply that sigma-1 receptor can be a new potential target for the development of analgesics.

Change in brain neurosteroid level of rats in morphine addiction and stress-induced addiction relapse condition / 中国药理学与毒理学杂志

AIM To investigate if morphine addiction and relapse to morphine-seeking is related to the change in neurosteroid levels in the brain of rats. METHODS Rats were injected ip morphine (5 mg·kg-1·d-1, 18:00-20:00) and trained in conditioned place preference (CPP) box, once daily for 10 d. CPP test was performed 24 h after the last training. After discontinuation of training for 7 d for CPP extinction, then intermittent and inescapable foot-shock (FS, 0.5 mA, 0.5 s on, 40 s off, 15 min) was applied to rats as the priming stimuli for relapse. CPP test was performed 2 h after FS. When CPP test finished, rats were decapitated and the levels of neurosteroids were analyzed using gas chromatography/mass spectrometry. RESULTS CPP was established when rats were injected morphine and trained for 10 d. At the same time, the levels of pregnenolone and allopregnanolone in the brain tissues of rats were significantly increased. When CPP was reinstated in morphine-treated rats by FS-stress after 7 d CPP extinction, the levels of dehydroepiandrosterone and dehydroepiandrosterone sulfate were significantly increased. CONCLUSIONThe development of morphine addiction and relapse may be related to endogenous neurosteroids in rat brain tissues.

Effects of morphine dependence and withdrawal on neurosteroids and amino acid transmitters of rat amygdala / 解放军医学杂志

Objective To investigate the effects of morphine dependence and withdrawal on neurosteroids and amino acid transmitters of rat amygdala. Methods Morphine dependence was induced by pretreatment with increasing doses of morphine for 7 days. Withdrawal was precipitated by naloxone (2mg/kg). Withdrawal syndromes were observed and scored. After decapitation, amygdala was dissected out. Nomadic and conjugated neurosteroids were extracted using liquid-liquid extraction and solid phase extraction. Concentrations of neurosteroids including dehydroepiandrosterone (DHEA), pregnenolone (PREG), allopregnanolone (AP), dehydroepiandrosterone sulfate (DHEAS) and pregnenolone sulfate (PREGS) were detected with HPLC-MS. Concentrations of glycine (GLY), glutamate (GLU) and gamma-aminobutyric acid (GABA) were quantitated by HPLC-ECD with pre-column OPA derivatization. Results Compared with saline control, the DHEA level in rat amygdala of morphine dependent group decreased by 33% (P＜0.01). Compared with naloxone control, the PREG and AP levels in rat amygdala of morphine withdrawal group increased by 45% (P＜0.05) and 42% (P＜0.05) respectively; the GABA level decreased by 18% (P＜0.01). Compared with morphine dependent group, the PREG and PREGS levels in rat amygdala of morphine withdrawal group increased by 60% and 40% respectively (P＜0.05); the glycine level decreased by 14% (P＜0.05). Conclusion The DHEA in rat amygdala may play a role in the development of morphine dependence but not involved in the manifestation of withdrawal symptoms. Other neurosteroids (including PREG, AP and PREGS) in rat amygdala seem to be involved in withdrawal but not in dependence. The synthesis and release of inhibitory amino acids in amygdala were depressed when withdrawal was precipitated by naloxone. The results suggest that different changes of neurosteroids and amino acids exist in stages of morphine dependence and withdrawal.

The synthesis and metabolism of neurosteroids and the effects on the nervous system / 中国临床药理学与治疗学

Neurosteroids exist in central and peripheral nervous system, independence of peripheral glands, including pregnenolone, progesterone, allopregnanolone, and dehydroepiandrosterone, etc. They can be synthesized in the nervous system from sterol or sterol precursors catalyzed by certain enzymes. They play roles by interacting with GABAA, NMDA or?receptors, and have effects on memory, sleep, convulsion, cellular excitability, etc.

The Effect of Morphine Dependence and Withdrawal on the Levels of Neurosteroids in Hippocampus of Male Rat / 中国心理卫生杂志

Objective: To investigate the effect of morphine dependence and withdrawal on the levels of neurosteroids in hippocampus of male rat.Methods: Rats were given (ip) increasing doses of morphine to form morphine physical dependence, withdrawal syndromes were precipitated by naloxone. The conditioned place preference (CPP) was used to establish morphine psychological dependence. The concentrations of dehydroepiandrosterone (DHEA), dehydroepiandrosterone sulfate (DHEAS), pregnenolone (PREG), pregnenolone sulfate (PREGS), and allopregnanolone (AP) in rat hippocampus and plasma were quantified by liquid chromatography-mass spectrometry. Results:The rat model of morphine physical and psychological dependence were successfully established by ip increasing doses of morphine for 7 days and 5mg?kg~ -1 morphine for 10 days respectively. Compared with saline control group, morphine physical dependence increased DHEA and PREG contents in rat hippocampus (0.88?0.19/0.67?0.17,t=2.52,10.94?2.02/7.53?2.64,t=3.24,P

Effect of morphine dependence and relapse on the levels of neurosteroids in male rat brain regions / 中国药理学通报

Aim To investigate the effect of morphinedependence and relapse on the levels of neurosteroidsin male rat frontal cortex(Fc) and hippocampus(Hc).Methods Morphine-induced conditionedplace preference(CPP) paradigm in rat was used andfootshock stress was given to rats to reinstate morphineCPP.The contents of pregnenolone(PREG),preg-nenolone sulfate(PREGS),allopregnanolone(AP),dehydroepiandrosterone(DHEA),and dehydroepi-androsterone sulfate(DHEAS) in rat Fc homogenates,Hc homogenates and plasma were determined with liq-uid chromatography-mass spectrometry.Results 5 mg.kg-1morphine conditioning during 10 days resultedin acquisition of CPP and intermittent footshock reacti-vated morphine CPP following 7 days drug-free peri-ods.Compared with saline group,morphine-inducedCPP elevated DHEA and PREG contents in Fc(P

Effect of morphine dependence on the levels of neurosteroids and amino acid transmitters in rat nucleus accumbens / 中国药理学通报

Aim To detect the effect of morphine dependence and withdrawal on the levels of neurosteroids and amino acid neurotransmitters in nucleus accumbens in rat morphine dependent model. Methods Nucleus accumbens was dissected out from morphine dependent and naloxone precipitated withdrawal rats. The contents of neurosteroids including dehydroepiandrosterone, pregnenolone, allopregnanolone, dehydroepiandrosterone sulfate and pregnenolone sulfate were detected with liquid chromatography-negative atmospheric pressure with ionization mass spectrometry(LC-MS). The contents of glycine, glutamate and ?-aminobutyric acid were quantitated by HPLC-ECD with precolumn derivatization. Results Compared with saline group,in nucleus accumbens of morphine withdrawal rats, the level of dehydroepiandrosterone sulfate (P