A Molecular Approach to Understanding

and Treating Long-term Morbidity

Robert DeLorenzo, MD
 A Molecular Approach to
Understanding and Treating Long
Term Morbidity Following
Status Epilepticus

Robert DeLorenzo,, MD,, PhD,, MPH

George Bliley Professor of Neurology
Professor of Pharmacology and Toxicology
Professor of Molecular Biophysics and
Biochemistry
Virginia Commonwealth University

Status Epilepticus

• Major Neurological Emergency

• Common in ER Setting
• Common in Hospital Setting
• New Advances in Treatment
• Less Known About Morbidity

What is SE and How Do We Identify It:

A Time Definition of GTC SE
• 30 minutes: (1993)
• 20 minutes: Benbadis et al. (2001)
• 10 minutes: VA cooperative trial, Treiman et al
(1998).
• 5 minutes: Wasterlain (1997 Santa Monica
meeting), Lowenstein (1998), Lowenstein, Bleck
and Macdonald (1999), and Meldrum (1999)

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 A Hypothetical Curve of the Transition to SE
Chen

minutes
Time constant=30 minutes

Types of status
Epilepsia partialis continua – 2 types
SMA status
Aura continua
Complex partial status - Mesial temporal
Neocortical
Tonic-clonic status
Absence status - Typical absence
Atypical absence
Myoclonic absence
Myoclonic status
Tonic status
Subtle status Engel

Morbidity of SE:
Main Morbidities
Let’s Look at Each of These
q
• Acquired Epilepsy
p p y
• Cognitive Impairment
• Affective Disorders:
Depression

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 Acquired Epilepsy

• Acquired Epilepsy (AE) occurs following

SE
• Various studies indicate that approximately
20% of SE cases develop AE
• AE is the most studied Morbidity of SE
• Many animal models
• Use convulsants to produce SE

Acquired Epilepsy (AE)

•Epileptogenesis
–Transformation of healthy CNS tissue with a
functional balance between excitation and inhibition to
brain with hyper excitable neuronal populations
manifesting spontaneous recurrent seizures

Common Brain Injuries

Causing Acquired
Epilepsy
• Stroke
• Status Epilepticus
• Traumatic Injury
• Infection

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Animal Models of SE to Evaluate
Mechanism for Epileptogenesis
•SE HNC Model 1. Elevated [Ca2+]i Levels
In Vitro 2. Altered Ca2+ Homeostatic
Mechanisms
•GET HNC Model 1. Elevated [Ca2+]i Levels
In Vitro 2. Altered Ca2+ Homeostatic
Mechanisms
•Pilocarpine Model 1. Elevated [Ca2+]i Levels
In Vivo 2. Altered Ca2+ Homeostatic
Mechanisms
Organophosphate Models
Kianic Acid Model

Pilocarpine Model: In Vivo

• Rat model of temporal lobe epilepsy
• Pilocarpine induced status epilepticus
• Latency period of 2-
2-3 weeks
• Mirrors human epileptogenesis
– Hippocampal cell loss
– Mossy fiber sprouting
– Loss of inhibitory tone
• Spontaneous recurrent seizures for the
lifetime of the animal

Methods-- Pilocarpine Model

Methods

Scopolamine Pilocarpine Diazepam

1 mg/kg i.p. 375 mg/kg i.p. 5 mg/kg i.p.
1 hr after
30 min SE

2 hrs

2-3 REPEAT
Monitor for weeks STEP 3
seizure
(twice if
activity
necessary)

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 DEAD CELLS
DON’T SEIZE
• Injury through elevated intra
neuronal calcium produces 2
general effects:
– Dead Neurons
Neurons--very elevated Ca2+
– Injured Neurons
Neurons--moderate Ca2+
increase
Only surviving
surviving--injured neurons
can create seizures

Focus on Surviving
Neurons After SE
• Breakthrough in our understanding of the
cause and prevention of Acquired Epilepsy
• Surviving neurons develop neuronal
plasticity and calcium elevations
• These plasticity changes alter the surviving
neurons and lead to seizures
• Surviving neurons have altered calcium
homeostasis

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 Novel Approach

Calcium is the Major Cause of

Injury Induced Neuronal Cell
Death and Neuronal Injury

Thus Calcium Changes After

Injury Represent an Excellent
Target to Study the Molecular
Basis of AE

Neuronal Plasticity
• Acquired Epilepsy is one of the best
examples of neuronal plasticity
• Injury causes a permanent change in
the brain that leads to seizures
• Calcium is a major molecular cause of
these permanent plasticity changes

Calcium Hypothesis
Of Epileptogenesis

•Ca2+ is a major second messenger that induces

the injury associated plasticity changes in
surviving neurons resulting in AE
•Permanent changes in Ca2+ levels and Ca2+
homeostatic mechanism maintain the epileptic
phenotype
•Blocking the Ca2+ induction or reversing the long
term alterations in Ca2+ dynamics can prevent
epileptogenesis

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 Models to Study AE
Demonstrating the Role of Calcium

•Status Epilepticus (SE) HNC Model of AE:

In Vitro
t o Model
ode oof S
SE-induced
SE- duced AE
•Glutamate Excitotoxicity HNC Model of
AE: In Vitro Model of Stroke-
Stroke-induced AE
•Pilocarpine SE Model of AE: In Vivo Model
of SE
SE--induced AE

The Calcium Plateau

After SE

NEW Discovery from our lab:

After SE or Injury the

Neuronal Intracellular
Calcium Levels Remain
Markedly Elevated for Days

Acutely Isolated Neurons

SE Control

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 Chronic Epileptic Animals
Altered Calcium Homeostasis

A. Plateau

B. Block
Calcium

C. Block
Epilepsy

Impaired Ca2+ Handling

A B 0.55
Control
0.50
Ratio (340/380)

p<0.05 RM ANOVA
0.45

0.40

0.35

0.30

0.25

0.20
0 5 10 15 20 25 30

Time (min)

C 0.55
Epileptic
0.50
Ratio (340/380)

p<0.05 RM ANOVA
0.45

0.40

0.35

0.30

0.25

0.20
0 5 10 15 20 25 30

Time (min)

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 SE Causes Permanent
Alteration of
Calcium Homeostasis

1. Long Term effect of Epileptogenesis

2. Permanent change in calcium homeostasis
3. Maintenance of the Epileptic Phenotype

Calcium Plateau after SE

induced brain injury

A new discovery: Lasts for days

after the injury
j y

Window of opportunity to
initiate antiepileptogenic
treatments

Inhibition of the calcium

plateau prevents the
development of AE in the
pilocarpine model.

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 Development of Novel
Antiepileptogenic Agents

Experiments
From Our
F O L Lab
b

Other Potential Agents to

Prevention of Epileptogenesis

COMPARISION OF ANTIEPILEPTOGENIC
EFFECTS OF CARISBAMATE WITH AEDs

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Preventing the Development of
AE after SE is a Major Area for
Research and Current Research
is Possibly Leading to Novel
Therapeutic Approaches

Cognitive Impairment after SE

• Well established the SE can cause

cognitive impairment
• Severe refractory SE can cause severe
memory impairment
• Some patients often are so impaired they
need nursing home placement.
• We have all seen cases like this.

SE - Cognitive Impairment
• Intelligence in epilepsy: a prospective study in children.
Bourgeois BF et al., 1983, Ann Neurol.
• Verbal and visual memory impairment in children with
epilepsy. Jambaqué I et al., 1993, Neuropsychologia.
• The impact of childhood epilepsy on neurocognitive and
behavioral performance: a prospective longitudinal study.
B il t LL ett al.,
Bailet l 2000
2000, E
Epilepsia.
il i
• Severe memory impairment in a child with bi-bi-hippocampal
injury after status epilepticus. Jambaqué I et al., 2006, Dev
Med Child Neurol.
• Status epilepticus in immature rats leads to behavioural and
cognitive impairment and epileptogenesis. Pitkanen group,
2004, Eur. J. Neurosci.

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Understanding the Mechanisms
and Types of Cognitive
Impairment After SE is a Major
Area for Future Research
• This Research needs to be done on
patients-- need prospective long term follow
patients
up studies. These studies are expensive
and difficult to do in a controlled population
• This Research needs to be done in animal
models of SE. These studies are easier to
do to get an insight into mechanisms

Water Maze Test After

Pilocarpine SE Demonstrates
Cognitive Impairment

Novel Object Recognition Test

Shows Cognitive Impairment

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Depression is a Major Morbidity
Following SE

Depression in epilepsy
• Depression common co- co-morbidity in epilepsy (Lafrance et al.,
2008, Int. Rev. Neurobiol.)
• patients with epilepsy scored higher on depression and anxiety
scales than controls (Piazzni et al., 2001, Epilepsy Behav.)
• Depression in epilepsy does not depend on frequency of
seizures (Gilliam et al., 2007, Neurology)
• Mitigation of seizures does not lead to alleviation of depression
(Spencer et al., 2003, Neurology)
• Use of antidepressants for the treatment of depression in
epilepsy has been criticized as being based on “the largely
untested assumption that patients with depression and
epilepsy should respond to antidepressant drugs in the same
manner as depressed nonepileptic patients” (Kanner AM,
2003, Biol. Psych.)

Depression after SE: Adults

• Psychiatric disorders secondary to

nonconvulsive status epilepticus of frontal
origin. Chicharro-
Chicharro-Ciuffardi A et al, Actas
Esp Psiquiatr.,
Psiquiatr 2012
• Functional outcome after convulsive status
epilepticus. Stéphane Legriel, et al, Critical
Care Medicine, 2010

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 Depression After SE: Children

• Depression, anxiety and quality of life in

parents of children with epilepsy. Lv R et
al., Acta Neurol Scand., 2009
• Outcome of childhood status epilepticus
and lengthy febrile convulsions: findings of
national cohort study. Verity CM et al,
BMJ., 1993

Depression After SE Resistant

to Conventional
Antidepressants
• Recent studies have demonstrated that
(Prozac®)
antidepressants such as fluoxetine (Prozac®
are ineffective in treating depression in
epileptic rats suggesting that depression in
epileptic individuals may be mechanistically
different from depression in non-
non-epileptic
subjects (Mazarati et al., 2008, Brain,
Pineda et al., 2012, Neurotherapeutics).

Forced swim test

(Mazarati et al., 2008, Brain)

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 Forced Swim Test

Long Term Changes In

Gene Expression After SE
IS A Target for Future
Research

Elevated RyR-P 1 year Elevated PLCg 1 year after

•after OP exposure OP exposure

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 The Future For Research in
Understanding Basic
Mechanisms of the Major
Morbidities After SE IS Bright

This Research Will Hopefully

Lead to Novel Therapeutic
Interventions to Prevent the
Onset of AE
AE, Cognitive
Impairment and Depression
After SE

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