Epilepsia, 42(Suppl. 3):24, 2001 Blackwell Science, Inc.

International League Against Epilepsy

Do Interictal Discharges Promote or Control Seizures? Experimental Evidence from an In Vitro Model of Epileptiform Discharge
Massimo Avoli
Montreal Neurological Institute and Departments of Neurology and Neurosurgery and Physiology, McGill University, Montre al, Que bec, Canada

Summary: Interictal and ictal discharges are recorded from limbic structures in temporal lobe epilepsy patients. In clinical practice, interictal spikes are used to localize the epileptogenic area, but they also are assumed to promote ictal events. Here I review data obtained from combined slices of mouse hippocampusentorhinal cortex that indicate an inverse relation between interictal and ictal events. In this preparation, application of 4-aminopyridine or Mg2+-free medium induce (a) interictal discharges that originated from CA3 and propagate (via the Schaffer collaterals) to CA1 and entorhinal cortex, to return to the hippocampus through the dentate area; and (b) ictal discharges that initiate in the entorhinal cortex and propagate to the hippocampus via the dentate gyrus. Interictal activity occurs throughout the experiment (up to 6 h), whereas ictal discharges disappear after 12 h. Schaffer collateral cut abolishes interictal

discharges in CA1, entorhinal cortex, and dentate and reestablishes entorhinal ictal discharges. Moreover, ictal discharge generation in the entorhinal cortex after Schaffer collateral cut is prevented by mimicking CA3 activity with rhythmic electrical stimulation of CA1 outputs. Thus hippocampal interictal activity controls the ability of the entorhinal cortex to generate seizures. It also may be proposed that Schaffer collateral cut may model the epileptic condition in which CA3 damage results in loss of hippocampal control over the entorhinal cortex. In conclusion, these experiments demonstrate that interictal activity controls rather than promotes ictal events, and functional integrity of CA3 constitutes a critical control mechanism in temporal lobe epilepsy. Key Words: 4-Aminopyridine Entorhinal cortexEpileptiform dischargesHippocampus Limbic seizuresMg2+-free epileptogenesis.

BACKGROUND Interictal activity is characterized by brief, epileptic spikes that are recorded in the electroencephalogram (EEG) and by definition, are not associated with any clinical symptom. Interictal discharges are commonly used to localize the epileptogenic focus. However, some studies also have suggested that interictal and ictal (i.e., seizure) discharges may have a parallel time course. Moreover, it has been reported that in some experimental models of epilepsy, interictal discharges may lead to the onset of ictal activity, a phenomenon that has been termed interictal to ictal transition. This evidence, although largely anecdotal, has led to several assumptions that often guide the clinicians in treating epileptic patients (1). For instance, the occur-

rence of interictal spikes is taken into account for discontinuing antiepileptic drugs (AEDs) in seizure-free patients. It also is granted that interictal discharges can be activated by reducing AEDs. However, the precise relation between interictal and ictal discharges remains unclear. Clinical evidence indicates that no systematic change in rate of interictal spikes occurs before the onset of temporal lobe seizures (13), although it is not uncommon to see a reduction in this rate just before the onset of an ictal discharge (3). LIMBIC SEIZURES IN VITRO During the last decade, several studies have analyzed the physiologic and pharmacologic characteristics of interictal and ictal discharges in the in vitro slice preparation (48). Most of these experiments were performed in combined slices of the rat hippocampusentorhinal cortex treated with chemical convulsants. In this type of preparation, prolonged ictal discharges initiate in the deep layers of the entorhinal cortex and propagate to the 2

Address correspondence and reprint requests to Dr. M. Avoli at Departments of Neurology & Neurosurgery, and of Physiology, McGill University and Montreal Neurological Institute, 3801 University, Room 794, Montreal, QC, H3A 2B4, Canada. E-mail: cyav@musica. mcgill.ca

IN VITRO LIMBIC SEIZURES hippocampus proper via the perforant path/dentate gyrus. These ictal discharges are mainly caused by N-methylD-aspartate (NMDA)-receptormediated conductances. In addition, brief interictal events originate in the hippocampal CA3 subfield and are insensitive to NMDA-receptor antagonists but abolished after blockade of non-NMDA receptors. It should be emphasized that temporal lobe epilepsy patients have seizure discharges in limbic structures such as the entorhinal cortex and the hippocampus proper. Moreover, the entorhinal cortex is highly susceptible to generate seizure activity in these patients (9,10). Findings similar to those obtained in the rat also have been obtained in combined mouse brain slices, where reciprocal connections between the hippocampus and entorhinal cortex can be better maintained after slicing (11). In this preparation as well, interictal and ictal discharges (induced by application of 4-aminopyridine or Mg2+-free medium) originate from the CA3 and the entorhinal cortex, respectively. However, in mouse hippocampusentorhinal cortex slice, ictal discharges disappear over time (12 h) whereas interictal activity does occur throughout the experiment. This CA3 interictal activity propagates via the CA1 area and the subiculum to the entorhinal cortex, from where they return to CA3 via the perforant path and the dentate gyrus. This reentry of interictal discharge is similar to the hippocampusentorhinal cortex loop described in the isolated guinea-pig brain preparation, where it may be involved in sustaining and amplifying limbic seizures (12). HIPPOCAMPAL OUTPUTS MAY CONTROL ENTORHINAL CORTEX EXCITABILITY The role played by the hippocampusentorhinal cortex loop in amplifying seizures could not be demonstrated in the mouse combined hippocampusentorhinal cortex slice. After lesion of the Schaffer collaterals (which allow CA3 outputs to activate CA1 pyramidal cells), interictal discharges stopped occurring in the CA1, the entorhinal cortex, and dentate gyrus. However, this cut allowed ictal discharges to be reestablished in those experiments in which it had disappeared, or caused a significant prolongation of the ictal activity whenever it had not disappeared. This evidence indicates that CA3-driven interictal discharges propagate through the hippocampalentorhinal loop and prevent the occurrence of prolonged ictal discharges (i.e., limbic seizures) originating in the entorhinal cortex. Temporal lobe epilepsy patients present a histopathologic pattern of neuronal damage, known as mesial temporal sclerosis, that is characterized by a rather selective loss of neurons in layer III of the entorhinal cortex, dentate hilus, and CA1 and CA3 areas (13,14). This pattern of brain damage also is found in animal models of chronic temporal lobe epilepsy (15).

Experimental evidence indicates that in mesial temporal sclerosis, both cell loss and the consequent synaptic reorganization contribute to epileptogenesis. The Schaffer collateral performed in the mouse combined slice may indeed mimic the hippocampal neuronal loss that occurs in temporal lobe epilepsy patients or animal models, where CA3 neurons are damaged, thus resulting in a decreased function of hippocampal outputs directed to the entorhinal cortex. Hence, these data may support the view that the functional integrity of CA3 neurons and thus hippocampal outputs represents a critical control point for seizure generation and recurrence, as seen in temporal lobe epilepsy patients. ACTIVATION OF HIPPOCAMPAL OUTPUTS ABOLISHES SEIZURES ORIGINATING IN THE ENTORHINAL CORTEX The studies performed in the combined mouse hippocampusentorhinal cortex slice indicate that the inhibitory control exerted by CA3-driven hippocampal interictal activity on the expression of ictal discharges in the entorhinal cortex can be mimicked by electrical stimuli of the hippocampal outputs. Accordingly, rhythmic stimulation (0.251.5 Hz) of the CA1 hippocampal output region after Schaffer collateral cut suppressed the occurrence of ictal discharges induced by 4-aminopyridine or low Mg2+-free medium in the entorhinal cortex (11). This evidence indicates that rhythmic, low-frequency stimulation of hippocampal outputs (which resembles CA3-driven interictal activity) may help restore the lost CA3 neuronal function in animal models of chronic limbic seizures as well as in patients with temporal lobe epilepsy. It also may be proposed that pharmacologic procedures able to increase selectively the function of CA3 neurons may be used for decreasing the propensity of entorhinal cortex neurons to generate seizures. CONCLUSIONS The evidence reviewed here indicates that CA3 neuron activity controls the excitability of the entorhinal cortex. In addition it suggests that interictal discharges interfere with the occurrence of ictal activity. These data are at odds with those obtained in some acute models of epileptiform discharge in which interictal events may lead to the occurrence of ictal activity. Moreover, in the kindling model of temporal lobe epilepsy, spiking becomes more frequent as the kindling process evolves, and it increases before the appearance of spontaneous seizures (16,17). However, these data have not been confirmed in experiments in which the EEG of kindled cats was continuously monitored (18). An inverse relation between ictal and interictal discharges also has been demonstrated by using agents that
Epilepsia, Vol. 42, Suppl. 3, 2001

M. AVOLI
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Epilepsia, Vol. 42, Suppl. 3, 2001