Interindividual variability of CYP2C19-catalyzed drug metabolism due to differences in gene diplotypes and cytochrome P450 oxidoreductase content.

Large interindividual variability has been observed in the metabolism of CYP2C19 substrates in vivo. The study aimed to evaluate sources of this variability in CYP2C19 activity, focusing on CYP2C19 diplotypes and the cytochrome P450 oxidoreductase (POR). CYP2C19 gene analysis was carried out on 347 human liver samples. CYP2C19 activity assayed using human liver microsomes confirmed a significant a priori predicted rank order for (S)-mephenytoin hydroxylase activity of CYP2C19*17/*17 > *1B/*17 > *1B/*1B > *2A/*17 > *1B/*2A > *2A/*2A diplotypes. In a multivariate analysis, the CYP2C19*2A allele and POR protein content were associated with CYP2C19 activity. Further analysis indicated a strong effect of the CYP2C19*2A, but not the *17, allele on both metabolic steps in the conversion of clopidogrel to its active metabolite. The present study demonstrates that interindividual variability in CYP2C19 activity is due to differences in both CYP2C19 protein content associated with gene diplotypes and the POR concentration.The Pharmacogenomics Journal advance online publication, 1 September 2015; doi:10.1038/tpj.2015.58.

Effect of localization of missense mutations in SCN1A on epilepsy phenotype severity.

BACKGROUND AND METHODS: Many missense mutations in the voltage-gated sodium channel subunit gene SCN1A were identified in patients with generalized epilepsy with febrile seizures plus (GEFS+) and severe myoclonic epilepsy of infancy (SMEI), although GEFS+ is distinct from SMEI in terms of clinical symptoms, severity, prognosis, and responses to antiepileptic drugs. The authors analyzed the localization of missense mutations in SCN1A identified in patients with GEFS+ and SMEI to clarify the phenotype-genotype relationships. RESULTS: Mutations in SMEI occurred more frequently in the "pore" regions of SCN1A than did those in GEFS+. These SMEI mutations in the "pore" regions were more strongly associated than mutations in other regions with the presence of ataxia and tendency to early onset of disease. The possibility of participation of ion selectivity dysfunction of the channel in the pathogenesis of SMEI was suggested by a mutation in the pore region (R946C) identified in a SMEI patient. CONCLUSIONS: There was a significant phenotype-genotype relationship in generalized epilepsy with febrile seizures plus and severe myoclonic epilepsy of infancy with SCN1A missense mutations. More severe sodium channel dysfunctions including abnormal ion selectivity that are caused by mutations in the pore regions may be involved in the pathogenesis of SMEI.

Acute pancreatic damage associated with convulsive status epilepticus: a report of three cases.

Three cases involving a previously unreported association of acute pancreatic damage following convulsive status epilepticus (SE) are presented. A review of literature failed to reveal a similar association between SE and acute pancreatic damage. As possible pathophysiological mechanisms of this so far unknown sequel of SE, increased intraduodenal pressure during SE leading to the reflux of the duodenal contents into the pancreatic duct, along with altered metabolism of oxygen-derived free radicals during a prolonged seizure with hypoxia and ischemia resulting in acinar cell injury are suggested. We believe that SE should be considered as an additional risk factor of acute pancreatitis and that pancreatic enzymes should be monitored in patients who have prolonged seizures.

Long-term follow-up study of Lennox-Gastaut syndrome in patients with severe motor and intellectual disabilities: with special reference to the problem of dysphagia.

A long-term follow-up study of Lennox-Gastaut syndrome (LGS) ( > 10 years) was conducted with 38 patients with severe motor and intellectual disabilities (SMID) to clarify the relationship between the rapid development of dysphagia and epileptic seizures, and to elucidate the long-term evolution of LGS in patients with SMID. Those who showed a relatively favourable seizure outcome were compared to those with a poor seizure outcome. Poor seizure outcome correlated strongly with: (a) an early appearance of dysphagia and additional deterioration of the already retarded mental function; (b) a predominance of atypical absence seizures; and (c) persistent frequent epileptiform discharges during electroencephalographic evaluations. Neither age at seizure onset nor intelligence level at the time of the last examination was correlated with seizure prognosis. Further, seizure prognosis was not related to the aetiology of LGS. Repeated seizures apparently caused development of progressive epileptic encephalopathy, in addition to the underlying severe brain damage. Since development of dysphagia burdens an already severely handicapped patient with intensive medical care, efforts to reduce the seizures and design a long-term care plan are of great importance.

Self-sustaining status epilepticus: a condition maintained by potentiation of glutamate receptors and by plastic changes in substance P and other peptide neuromodulators.

We describe a model of self-sustaining status epilepticus (SSSE) induced by stimulation of the perforant path in free-running rats. In this model, seizures can be transiently suppressed by intrahippocampal injection of a blocker of alpha-amino-3-hydroxy-5-methylisoxazole-4-propionic acid/ kainate synapses but return in the absence of further stimulation when the drug ceases to act. However, seizures are irreversibly abolished by blockers of N-methyl-D-aspartate receptors given locally or systemically. SSSE is enhanced by substance P and its agonists and blocked by its antagonists. SSSE induces novel expression of substance P-like immunoreactivity in hippocampal principal cells. These changes and those in other limbic peptides may contribute to the maintenance of SSSE and to the modulation of hippocampal excitability during epileptic seizures. NMDA

A case of epileptic negative myoclonus: therapeutic considerations.

This study presents a patient with epileptic negative myoclonus who showed interictal focal epileptic discharges in the centrotemporal region. The patient's seizures were exacerbated by carbamazepine, zonisamide, and valproate, but completely controlled by ethosuximide, and were suggested to have some relation with thalamocortical oscillation mechanisms. Ethosuximide is supposed to be a drug of worth to try to use in epileptic negative myoclonus patients with centrotemporal spike foci.

Chronic epilepsy with damage restricted to the hippocampus: possible mechanisms.

We studied the time course and possible mechanisms of the development of chronic epilepsy following unilateral stimulation of the perforant path. After 24 h of perforant path stimulation by a modified Sloviter method, lesions were restricted to the hippocampus, except for 2 of 24 rats with minimal entorhinal neuronal injury in layer 3. Lesions were exclusively ipsilateral in the polymorph layer of the hilus and in CA4-CA3C, predominantly ipsilateral in CA3, in CA1 and in the granule cell layer. Feedforward and feedback inhibition were studied by paired pulse stimulation. In the week following inhibition, there was complete loss of GABAA-mediated, short interstimulus interval (ISI)-dependent inhibition and frequency-dependent inhibition, and also of GABAB-mediated long ISI-dependent inhibition. Yet no spontaneous seizures were observed at that time. In the next four weeks, we saw no evidence of increasing excitatory drive such as would be expected from recurrent mossy fiber sprouting. On the contrary, there was progressive return of inhibition. By four weeks post-lesion, the majority of animals had developed spontaneous recurrent seizures, and/or seizures on 2 Hz stimulation (never seen in controls), in spite of complete or near-complete recovery of short ISI-dependent, GABAA-mediated inhibition. A small but significant loss of frequency-dependent inhibition persisted, but individual animals with complete recovery of frequency-dependent inhibition showed spontaneous seizures, suggesting that loss of GABAA-mediated inhibition was not the direct cause of chronic epilepsy. GABAB-mediated, long ISI-dependent inhibition continued to show a significant loss. The ratio of the population spike amplitude at 250 microA to the maximal population spike amplitude, a measure of granule cell excitability, was unchanged immediately after stimulation, but increased in the next few weeks in a manner identical to that seen in kindling, suggesting the possibility that during the transient loss of inhibition, spontaneous kindling had occurred. Intracellular recordings from granule cells in hippocampal slices prepared from these animals showed a significant loss of GABAB-mediated slow inhibitory postsynaptic potentials (IPSPs). These data show that the sequellae of unilateral status epilepticus with damage restricted to the hippocampus are sufficient to cause chronic recurrent seizures. There is a possibility that chronic epilepsy is not the direct result of the loss of inhibitory drive or of a sprouting-induced increase in excitatory drive, but represents plastic changes akin to spontaneous kindling, possibly facilitated by loss of GABAB-mediated inhibition.

The effect of urethane anesthesia on evoked potentials in dentate gyrus.

We examined the effect of urethane (1000 mg/kg, followed by 50 mg/kg per h, i.v.), an anesthetic commonly used by physiologists, on evoked potentials recorded in dentate gyrus in adult Wistar rats by stimulating the ipsilateral perforant path, via chronically implanted electrodes. Urethane decreased paired-pulse inhibition. Under urethane, with paired-pulse stimulation, the ratio of the second population spike amplitude to the first increased by 11.1-20.7% at 25-60 ms interstimulus interval (n = 18, P < 0.05). At 25 ms, the proportion was 3.6 +/- 1.6 while awake, and 14.7 +/- 3.5 under urethane. Urethane depressed granule cell excitability and strength of synaptic responses. Under urethane, the ratio of the population spike amplitude obtained at 250 microA stimulation to the maximal response in the same input/output response examination decreased by 20%, and the ratio of the excitatory postsynaptic response slopes fell by 10%. These results indicate that urethane affects neurotransmission in the hippocampus, and suggest that its effect may be exerted in part on excitatory neurotransmission.

123I-IMP SPECT findings in mitochondrial encephalomyopathies.

We performed N-isopropyl-[123I]p-iodoamphetamine (IMP) single photon emission computed tomography (SPECT) in three patients with Leigh syndrome, two patients with mitochondrial encephalomyopathy, lactic acidosis and stroke-like episodes (MELAS), and two siblings with progressive external ophthalmoplegia (PEO). The SPECT images were compared with the findings on magnetic resonance imaging (MRI) and computed tomography (CT). All Leigh syndrome patients showed low accumulation areas (LAA) bilaterally in the frontal lobes and the basal ganglia. The frontal lobe LAA was seen even in an area without abnormalities on CT/MRI. Each MELAS patient showed a focal LAA. SPECT could also detect an old stroke-like lesion that was no longer shown by CT/MRI. However, SPECT did not show LAA in the basal ganglia, which showed calcification on CT or abnormal signal intensity on MRI. MRI in the 2 PEO patients showed lesions bilaterally in the basal ganglia in one, and in the internal capsules in the other. SPECT showed LAA not only in corresponding areas, but also in the occipital lobes, where no lesions were revealed by MRI. Thus, 123I-IMP SPECT was more sensitive than CT/MRI for detecting stroke-like lesions in MELAS patients, although it did not detect small lesions in the basal ganglia. LAA in the frontal lobes and occipital lobes may be SPECT findings characteristic of Leigh syndrome and PEO, respectively.

Chronic epileptogenicity following focal status epilepticus.

We examined chronic epileptogenicity in the perforant path stimulation model of focal status epilepticus. After 24 h of perforant path stimulation, every stimulation elicited multiple population spike discharges, and this phenomenon persisted more than 2-3 months after stimulation. Short (10-100 ms) interstimulus interval-dependent paired-pulse inhibition was almost completely lost right after stimulation, but recovered progressively over the following month. Long (200-1000 ms) interstimulus interval-dependent paired-pulse inhibition decreased, and in spite of a partial recovery, remained significantly reduced 4 weeks after stimulation. Frequency-dependent paired-pulse inhibition was lost immediately after stimulation. One month later, inhibition at 2 Hz remained significantly reduced, although in individual rats recovery ranged from poor to complete. Input/output response curves showed increased population spike amplitude but no change of the slope of excitatory postsynaptic potentials. 3-4 weeks after stimulation, spontaneous generalized motor convulsions were observed in half of the stimulated rats. In all of the stimulated rats, the kindling phenomenon was significantly accelerated compared with non-stimulated controls, and class 5 convulsions were elicited in 3.3 +/- 1.0 trials in stimulated rats, against 11.0 +/- 2.5 trials in controls.

Seizures, brain damage and brain development.

Recent evidence suggests that hippocampal damage can be both the result of seizure activity and the cause of further chronic epilepsy. A review of current models of status epilepticus-induced brain damage reveals that excitotoxic mechanisms probably mediate the lesions in most brain regions. NMDA receptors appear to play a dominant role, although non-NMDA glutamate receptors are important in several specific neuronal populations. In the immature brain, a number of unique metabolic features determine a different set of vulnerabilities, resulting in a brain which is more resistant than the adult's to certain mechanisms of brain damage, but quite vulnerable to others. The inhibition of growth by severe seizure activity has implications for the developing brain that have not yet been fully explored. The mechanisms by which seizure-induced hippocampal lesions cause chronic epilepsy have been explored in several recent animal models. A rearrangement of hippocampal circuits may result from death of selected populations of inhibitory neurons, or from misdirected regeneration by excitatory neurons. It could lead to chronic epilepsy through loss of normal inhibition, through sprouting of new excitatory connections, through conservation of excitatory connections which in a healthy brain would be pruned during development, or through facilitation of kindling by one of these mechanisms. These recent results are beginning to reconcile the pathology seen in human hippocampi ablated for intractable epilepsy with that observed in experimental animals, and offer the promise of even greater advances in the future. They suggest a mechanism for Gower's dictum that "seizures beget seizures" and highlight the importance of the interneurons of the dentate gyrus in epileptogenesis.

Changes of NMDA receptor binding in spontaneously epileptic rat and parent strains.

We measured the binding of [3H]3-[(+/-)2-carboxypiperazin-4-yl] propyl-1-phosphonic acid ([3H]CPP), a competitive ligand for N-methyl-D-aspartate (NMDA) receptors, in double mutant spontaneously epileptic rats (SER: zi/zi, tm/tm) and their parent strains, zitter rats and tremor rats, and WTC rats (control rats from tremor rats derived from Kyoto:Wistar rats) before and after the onset of seizures in tremor rats and SER. Significantly lower [3H]CPP binding receptor density (Bmax) was found in the cortex of SER and zitter rats at 12-15 weeks of age than in that of WTC rats and tremor rats, and at 4 weeks of age the Bmax in zitter rats was lower than that in the other strains. The reduction of Bmax in SER at 12-15 weeks of age may reflect a down regulation of NMDA receptors due to repetitive tonic seizures in SER.

Depth EEG in mutant epileptic E1 mice: demonstration of secondary generalization of the seizure from the hippocampus.

Mutant epileptic E1 mice are thought to have focal epilepsy of hippocampal origin because glucose utilization is increased in the hippocampus (HPC) during seizures in these mice. However, direct electrographic evidence is still lacking for the notion. We recorded electroencephalograms (EEGs) using depth electrodes in E1 and non-epileptic ddY mice. All the mice were subjected to a conventional seizure-provoking maneuver during EEG recording; each mouse was placed on a mesh floor and observed for 3 min, and then tossed up in the air. When the E1 mice showed signs of abortive seizures or prodromal symptoms including squeaking, running and myoclonus, sporadic spikes or sharp waves were generated exclusively in the HPC. When generalized convulsions followed these prodromes, the sporadic discharges evolved into a burst of generalized spikes which again predominated in the HPC. We also observed the cerebral cortex, amygdaloid, caudate, centro-median thalamic and ventral postero-lateral thalamic nuclei, all of which were found to be only secondarily involved. These findings provide the first electrical evidence that E1 mice have a secondarily generalized seizure that has its initiating focus in the HPC.

Age- and seizure-related changes in noradrenaline and dopamine in several brain regions of epileptic El mice.

Noradrenaline (NA) and dopamine (DA) levels in six brain regions of stimulated and nonstimulated El (El[s] and El[ns]) mice and their maternal ddY mice were determined at various ages and various times after a convulsion. The NA levels in the striatum and hippocampus of 12-week-old El[s] and El[ns] mice were lower than in ddY mice, and remained lower in 23-week-old El[s] mice, but not in El[ns] mice. DA levels were lower in the striatum of El[s] mice than in El[ns] and ddY mice at 16 and 23 weeks of age. NA levels decreased during seizure in the striatum and hippocampus of El[s] mice, and returned to preconvulsive levels 1 hr after convulsion in the striatum and 30 min in the hippocampus. DA levels in the striatum of El[s] mice decreased during convulsion and increased from 1 to 10 min after convulsion. These changes suggest that the NAergic systems in the striatum and hippocampus and the DAergic system in the striatum have important roles in relation to seizure susceptibility in El mice.

Ring 14 chromosome with complex partial seizures: a case report.

A two-year-old girl was found to have a ring 14 chromosome: [46, XX, r(14) (P13 q32.3)]. Her development, including verbal ability, was retarded, her CT scan displayed a low density area anterior to the left temporal lobe, and she suffered from complex partial seizures. Focal central nervous system abnormalities may be present in patients with ring 14 chromosome, and their seizures are not exclusively of the primary generalized type. This is the first case with ring 14 chromosome and complex partial seizures.

Alterations of benzodiazepine receptor binding in tremor rats with absence-like seizures.

Tremor rats begin to exhibit clinical or electrical absence-like seizures after 6 weeks of age, and by 14 weeks of age, all have seizures. Central-type benzodiazepine receptor binding was investigated in tremor rats and control rats, aged 4 weeks and 16 weeks. Significantly lower benzodiazepine receptor density and no differences in affinity were found in the hippocampus of the tremor rats in comparison with that of control rats at both ages. This abnormality is considered to be due to a tremor gene and may be the cause of absence-like seizures in tremor rats. A significantly lower receptor density was found in the cerebellum at 4 weeks of age in the tremor rats than in the control rats. These changes may be related to tremorous movements in the tremor rats. Receptor density was significantly lower in the brainstems of tremor rats and control rats at 16 weeks of age than at 4 weeks of age, and the decrease was more marked in control rats. These facts may reflect a reduced decrease in the response to the dysfunction of gamma-aminobutyric acidergic neurons, or the function of the gamma-aminobutyric acid/benzodiazepine receptor system may be secondarily increased to suppress seizures in 16-week-old tremor rats.

Association of NMDA receptor sites and seizures of El mice.

To investigate the possible role of N-methyl-D-aspartate (NMDA) receptors in the seizures of El mice, a genetic animal model of epilepsy, we measured [3H]3-[(+)-2-(carboxypiperazin-4-yl)][1,2-3H]- propyl-1-phosphonic acid (CPP) binding in several brain regions of El and ddY mice. At 22-24 weeks of age, the maximum number of binding sites (Bmax) of [3H]CPP was lower only in the cerebral cortex of both stimulated and unstimulated El mice (El(+) and El(-), respectively) than in that of ddY mice. A reduction in Bmax values of cortical [3H]CPP binding of El mice was detected after the age of 12 weeks. Cortical [3H]CPP binding in El(+) mice decreased further transiently after evoked seizures. No significant change was observed in El(-) mice after postural stimulation. These results suggest that El(+) and El(-) mice share seizure propensity and that activation of NMDA receptors is involved in the seizures of El mice.

Benzodiazepine receptor binding in the spontaneously epileptic rat and its parent strains.

Central type benzodiazepine (BDZ) receptor binding in spontaneously epileptic rats (SER) and their parent strains, tremor rats and zitter rats, and Kyoto/Wistar rats were investigated. Significantly lower BDZ receptor densities (Bmax) and no differences in affinity (KD) were found in the hippocampus of the two epileptic strains, SER and tremor rats, in comparison with Kyoto/Wistar rats and zitter rats. This abnormality is considered to be due to a tremor gene and to be related to absence-like seizures in SER and tremor rats. A significant decrease of KD and an increase of Bmax in the brain stem were found in SER in comparison with Kyoto/Wistar rats. These changes may be due to a zitter gene, since zitter rats show the same tendency, and they may be related to tonic seizures in SER. Bmax was significantly increased in the cerebellum and hippocampus of the zitter rats, while KD was not changed, in comparison with Kyoto/Wistar rats and tremor rats. These changes may reflect the relatively selective loss of tissue lacking BDZ receptors or an upregulation in response to the loss of GABAergic neurons in zitter rats.

Ictal 99mTc-HMPAO SPECT in alternating hemiplegia.

99mTc-hexamethylpropylenamine oxime (99mTc-HMPAO) single-photon emission computed tomography (SPECT) was performed in a patient with alternating hemiplegia during 2 episodes of the disease. The regional cerebral blood flow patterns correlated with the clinical manifestations during both episodes. Hyperperfusion of the contralateral hemisphere was suggested by asymmetric 99mTc-HMPAO uptake, whereas symmetric 123I-N-isopropyl-p-iodoamphetamine uptake was detected during the interictal period. The results suggested that alternating hemiplegia in infants represents an atypical manifestation of epilepsy, despite the lack of paroxysmal electroencephalographic abnormalities during the episodes. 99mTc-HMPAO SPECT appears to be a useful method for detecting transient regional cerebral blood flow alterations during paroxysmal events because the tracer is rapidly available for emergencies and retains a fixed distribution for 5-8 hours, sufficient time to allow for SPECT acquisition.