Evidence for peri-ictal blood–brain barrier dysfunction in patients with epilepsy

Abstract

Epilepsy has been associated with a dysfunction of the blood-brain barrier. While there is ample evidence that a dysfunction of the blood-brain barrier contributes to epileptogenesis, blood-brain barrier dysfunction as a consequence of single epileptic seizures has not been systematically investigated. We hypothesized that blood-brain barrier dysfunction is temporally and anatomically associated with epileptic seizures in patients and used a newly-established quantitative MRI protocol to test our hypothesis. Twenty-three patients with epilepsy undergoing inpatient monitoring as part of their presurgical evaluation were included in this study (10 females, mean age ± standard deviation: 28.78 ± 8.45). For each patient, we acquired quantitative T1 relaxation time maps (qT1) after both ictal and interictal injection of gadolinium-based contrast agent. The postictal enhancement of contrast agent was quantified by subtracting postictal qT1 from interictal qT1 and the resulting ΔqT1 was used as a surrogate imaging marker of peri-ictal blood-brain barrier dysfunction. Additionally, the serum concentrations of MMP9 and S100, both considered biomarkers of blood-brain barrier dysfunction, were assessed in serum samples obtained prior to and after the index seizure. Fifteen patients exhibited secondarily generalized tonic-clonic seizures and eight patients exhibited focal seizures at ictal injection of contrast agent. By comparing ΔqT1 of the generalized tonic-clonic seizures and focal seizures groups, the anatomical association between ictal epileptic activity and postictal enhancement of contrast agent could be probed. The generalized tonic-clonic seizures group showed significantly higher ΔqT1 in the whole brain as compared to the focal seizures group. Specific analysis of scans acquired later than 3 h after the onset of the seizure revealed higher ΔqT1 in the generalized tonic-clonic seizures group as compared to the focal seizures group, which was strictly lateralized to the hemisphere of seizure onset. Both MMP9 and S100 showed a significantly increased postictal concentration. The current study provides evidence for the occurrence of a blood-brain barrier dysfunction, which is temporally and anatomically associated with epileptic seizures. qT1 after ictal contrast agent injection is rendered as valuable imaging marker of seizure-associated blood-brain barrier dysfunction and may be measured hours after the seizure. The observation of the strong anatomical association of peri-ictal blood-brain barrier dysfunction may spark the development of new functional imaging modalities for the post hoc visualization of brain areas affected by the seizure.

The blood–brain barrier in health and disease: Important unanswered questions

“…There is a clear association between epilepsy and BBB dysfunction. BBB leakage in epilepsy patients is visible with contrast-enhanced MRI (Horowitz et al, 1992; Alvarez et al, 2010; Rüber et al, 2018; Fig. 2 I), and analysis of brain tissue from epileptic patients shows increased parenchymal albumin (Cornford et al, 1998a; Mihály and Bozóky, 1984), implicating blood-to-brain extravasation of large molecules.…”

Structural, Molecular, and Functional Alterations of the Blood-Brain Barrier during Epileptogenesis and Epilepsy: A Cause, Consequence, or Both?

“…The mechanisms underlying seizure-induced BBB alterations are not fully understood. The relatively rapid increase in permeability during seizures (within~30 min), together with a more lasting effect (for hours) [35] suggest multiple mechanisms act in concert to alter BBB properties. For example, seizure-induced increases in brain glutamate levels may lead to barrier dysfunction [21,36].…”

Potent and lasting seizure suppression by systemic delivery of antagomirs targeting miR-134 timed with blood-brain barrier disruption

“…Human MRI studies using contrast agents have shown that epilepsy-causing brain injuries are associated with temporal and anatomical BBB dysfunction ( 21 ), and BBB disruption can occur after seizures ( 29 ). To provide a clinical context to our animal model findings, we analysed contrast-enhanced MRI brain imaging studies of a set of three patients who recently experienced seizures (Fig.…”

“…While prolonged or repeated seizures are known to cause disruption of the BBB, the focus until now has been on understanding how this contributes to epilepsy ( 20, 29 ). Here we asked whether BBB disruption after status epilepticus could be appropriated to deliver a systemically-administered antagomir to treat epilepsy.…”

“…Three epilepsy patients undergoing inpatient monitoring as part of their presurgical evaluation (#1: male, 24 years old | #2: male, 34 years old | #3: female, 34 years old) at the Department of Epileptology at the University of Bonn Medical Center were postictally and interictally scanned in a 3T MAGNETOM Trio (Siemens Healthineers®) applying quantitative MRI. As described ( 29 ), we acquired quantitative T1 relaxation time maps (qT1) after both ictal and interictal injection of gadolinium-based contrast agent and an additional pre-contrast qT1 scan. The injection-to-MRI time intervals were ensured to be equal for both postictal and interictal scans.…”