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Mechanisms of Altered Cortical Excitability in Photosensitive Epilepsy Mechanisms of altered cortical excitability in photosensitive epilepsy Daniela Brazzo Doctor of Philosophy ASTON UNIVERSITY December 2010 This copy of the thesis has been supplied on condition that anyone who consults it is understood to recognise that its copyright rests with its author and that no quotation from the thesis and no information derived from it may be published without proper acknowledgement. 1 ASTON UNIVERSITY Mechanisms of altered cortical excitability in photosensitive epilepsy Daniela Brazzo Doctor of Philosophy 2010 Despite the multiplicity of approaches and techniques so far applied for identifying the pathophysiological mechanisms of photosensitive epilepsy, a generally agreed explanation of the phenomenon is still lacking. The present thesis reports on three interlinked original experimental studies conducted to explore the neurophysiological correlates and the phatophysiological mechanism of photosensitive epilepsy. In the first study I assessed the role of the habituation of the Visual Evoked Response test as a possible biomarker of epileptic visual sensitivity. The two subsequent studies were designed to address specific research questions emerging from the results of the first study. The findings of the three intertwined studies performed provide experimental evidence that photosensitivity is associated with changes in a number of electrophysiological measures suggestive of altered balance between excitatory and inhibitory cortical processes. Although a strong clinical association does exist between specific epileptic syndromes and visual sensitivity, results from this research indicate that photosensitivity trait seems to be the expression of specific pathophysiological mechanisms quite distinct from the “epileptic” phenotype. The habituation of Pattern Reversal Visual Evoked Potential (PR-VEP) appears as a reliable candidate endo-phenotype of visual sensitivity. Interpreting the findings of this study in the context of the broader literature on visual habituation we can hypothesise the existence of a shared neurophysiological background between photosensitive epilepsy and migraine. Future studies to elucidate the relationship between the proposed indices of cortical excitability and specific polymorphisms of excitatroy and inhibitory neurotransmission will need to be conducted to assess their potential role as biomarkers of photosensitivity. Key words: photosensitivity, cortical excitability, evoked potentials, thalamocortical dysrhythmia, gamma oscillations. 2 Acknowledgments I would like to thank all the people who supported, helped and guided me during my years as Doctoral student at Aston University. The first and biggest thank goes to Professor Stefano Seri, who has been an invaluable supervisor, an attent coach and a constantly supportive mentor throughout these years. Without his professional and personal guidance during my experience of “expatriate researcher”, this thesis and the path leading to it would not have been possible. I would also like to thank Professor Paul Furlong for his role of second supervisor. I am sincerely grateful to all the colleagues from Wellcome Laboratory for MEG Studies of Aston University, in particular Dr Jade N. Thai and Ms Andrea Scott for their help in recording and analysing patients’ data. I am also indebted with all the staff from the Department of Clinical Neurophysiology, The Birmingham Children’s Hospital, and from “Istituto Casimiro Mondino” of Pavia, for the opportunity to access numerous interesting clinical cases and to collect the EEG recordings for my experimental studies. I also owe a lot to the numerous researchers, co-authors and collaborators with whom I exchanged ideas and from whom I got inspiration for my work. A special thank to Dr Giorgio Di Lorenzo for his contribution and advice. I also thank the many women and men, patients and volunteers who kindly collaborated with their time to my research work. 3 List of contents Page Chapter 1. Introduction 10 1.1 Overview and terminology 11 1.1.1 History 15 1.2 Epidemiology 16 1.2.1 Photosensitivity in other epilepsy syndromes 16 1.2.2 Pure photosensitive epilepsy 17 1.2.3 Pattern-sensitive epilepsy 18 1.2.4 Video games epilepsy 19 1.3 Triggering factors 19 1.4 Pathophysiology 21 1.4.1 Animal models: the Papio papio baboon 21 1.4.1.1 Electrophysiological studies 22 1.4.1.2 Biochemical and pharmacological studies 23 1.4.1.3 Neuroimaging studies 24 1.4.2 Human data 27 1.4.2.1 Neurophysiological studies 27 1.4.2.2 Neuroimaging studies 37 1.5 Genetics 42 1.6 Conclusions 45 Chapter 2. Abnormal Visual Habituation in Paediatric Photosensitive Epilepsy 47 2.1 Abstract 48 2.2 Objectives 49 2.3 Background 49 2.3.1 Habituation 49 2.3.1.1 Definition 49 2.3.1.2 Characteristics of habituation 51 2.3.1.3 Theories of habituation 53 2.3.1.4 Visual habituation 55 2.4 Materials and methods 56 2.4.1 Subjects 56 2.4.2 Data acquisition 62 2.4.3 Visual habituation paradigm 62 2.4.4 Power calculation and statistical analysis 66 2.5 Results 69 2.5.1 Basic statistics 69 4 Page 2.5.2 Repeated measure ANOVA 70 2.5.3 Slope 73 2.6 Discussion 74 2.7 Conclusions 79 Chapter 3. Pre-stimulus alpha power, VEP amplitude and cortical excitability 80 3.1 Abstract 81 3.2 Objectives 82 3.3 Background 83 3.3.1 Posterior alpha oscillations 83 3.4 Material and methods 85 3.4.1 Subjects 85 3.4.2 Data acquisition 86 3.4.3 Data processing for pre-stimulus analysis 87 3.4.4 Statistical analysis 88 3.5 Results 89 3.6 Discussion 95 3.7 Conclusions 97 Chapter 4. Thalamocortical dysrhythmia in photosensitive epilepsy 98 4.1 Abstract 99 4.2 Objectives 101 4.3 Background 102 4.3.1 Theta oscillations 102 4.3.2 Gamma oscillations 103 4.3.3 Thalamocortical dysrhythmia 106 4.3.3.1 Thalamic neurons 109 4.4 Materials and methods 111 4.4.1 Subjects 111 4.4.2 Data acquisition 113 4.4.2.1 Dense array EEG 113 4.4.3 Visual paradigm 114 4.4.4 Data analysis 115 4.4.4.1 ICA analysis 115 4.5 Results 125 4.6 Discussion 129 4.7 Conclusions 134 Chapter 5. Thesis conclusions 135 5.1 Conclusions 136 5.2 Limitations 139 5 Page 5.3 Future research 140 References 141 Appendix 1. Abdominal migralepsy or simple comorbidity between abdominal migraine and photosensitivity? A case report of shared neurophysiological background 164 A.1 Introduction 165 A.1.1 Abdominal migraine 165 A.1.2 Migralepsy 167 A.2 Case report 169 A.3 Discussion 175 A.4 Conclusions 179 Appendix 2. List of abbreviations 180 6 List of Tables Page Chapter 1 Table 1.1. Definitions of photic-induced responses and epilepsy types 14 Table 1.2. Summary of principal studies on Papio papio 26 Table 1.3. Principal neurophysiological studies on physical characteristics of visual stimuli 31 Table 1.4. Summary of principal studies on excitability of occipital cortex 34 Table 1.5. Principal spectral analysis studies 36 Table 1.6. Summary of principal neuroimaging studies 41 Table 1.7. Principal genetic studies 44 Chapter 2 Table 2.1. Clinical data of PS and IGE patients 58 Table 2.2. Raw latencies in ms for the three groups 64 Table 2.3. Raw amplitudes in µV for the three groups 65 Table 2.4. Results of repeated measure ANOVA models 72 Chapter 3 Table 3.1. Matrix of correlations involving absolute band powers 92 Table 3.2. Matrix of correlations involving relative band powers 93 Table 3.3. Results of regression analysis with absolute and relative band powers 94 Chapter 4 Table 4.1. Subjects characteristics 112 Appendix 1 Table A.1.1. Diagnostic criteria of abdominal migraine 167 Table A.1.2. Diagnostic criteria for hemicrania epileptica 169 Table A.1.3. Diagnostic criteria for migralepsy 169 Appendix 2 Table A.2.1. List of abbreviations used in the thesis 181 7 List of Figures Page Chapter 2 Figure 2.1. Example of PPR type 1-2 58 Figure 2.2. Example of PPR type 1-2 59 Figure 2.3. Example of PPR type 2 59 Figure 2.4. Example of PPR type 3 60 Figure 2.5. Example of PPR type 3-4 60 Figure 2.6. Example of PPR type 4 61 Figure 2.7. Example of PPR type 4 61 Figure 2.8. PR-VEP from a ND subject 68 Figure 2.9. PR-VEP from a PS subject 68 Figure 2.10.Trend, means and standard deviations (in microvolts) of the N75-P100 amplitude of the pattern reversal VEP across the six blocks 71 Figure 2.11.Slope of the interpeak amplitude N75-P100 for the three groups 73 Chapter 4 Figure 4.1. Dense Array EEG recording 114 Figure 4.2. EEGLAB spectopo plot for subject 9 (control group) 118 Figure 4.3. EEGLAB spectopo plot for subject 1 (PS group) 118 Figure 4.4. ERPS and ITC of component 17 in subject 8 (CONTROL group) 120 Figure 4.5. ERSP and ITC of component 31 in subject 8 (CONTROL group) 121 Figure 4.6. ERSP and ITC of component 41 in subject 2 (PS group) 122 Figure 4.7. ERSP and ITC of component 50 in subject 2 (PS group) 123 Figure 4.8. ERSP and ITC of component 28 in subject 2 (PS group) 124 Figure 4.9. Clusters of independent components of the post- stimulus single-trial EEG data 126 Figure 4.10. Cluster 1 mean scalp map, average ERP and spectrum and average ERSP and ITC 127 Figure 4.11. Cluster 2 mean scalp map, average ERP and spectrum for both groups and average ERSP and ITC for PS and CONTROL groups 128 Figure 4.12. Cluster 3 mean scalp map, average ERP and spectrum and average ERSP and ITC 129 Appendix 1 Figure A.1.1.
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