Reviewer #2 (Public review):
Summary:
The authors have attempted to modify and adapt the IH-KA model in mice to provide an improved approach to screening for new ASDs by partially mitigating the problem of randomly occurring seizures and relatively low seizure frequency in the IH-KA model. The authors used KA micro-injections to selectively kill the hippocampal CA3 area as a way to induce temporal lobe "epileptogenesis" (TLE), and then used optogenetics to activate CA1 pyramidal cells specifically. This approach allowed the authors to trigger generalized seizures where the tonic-clonic pattern of electrical activity was reminiscent of actual tonic-clonic behavioral convulsions. Administration of levitracetam (LEV) and diazepam (DZP), two widely used ASDs with different mechanisms, reduced the probability of optogenetically activated epileptic seizures in IH-KA mice, thus seeming to provide evidence for a new approach to screen ASDs. A variety of problems and issues with the approach and the results lead to confounds that raise serious concerns about the conclusions.
Major strengths and weaknesses of the Methods and Results:
Strengths:
The authors have designed a method for triggering seizures, and the figures show bona fide electrographic seizures with concomitant convulsive behavioral components. The optogenetically evoked seizures in IH-KA mice had the electrical properties of actual seizures and the tonic-clonic components were readily apparent. These seizures appeared different from seizures evoked in naïve mice, and the authors attribute this difference to the epileptogenic process, but this may not be correct.
The ASDs (i.e., LEV and DZP) reduced the success rate of the optogenetically evoked seizures in IH-KA mice, thus suggesting the potential usefulness of the model for testing ASDs. The paper discusses whether the Epilepsy Therapy Screening Program (ETSP) will be able to use this modification of the IH-KA model in place of (1) ASD screening with acute seizures in naïve animals, where the brain has not undergone "epileptogenesis", (2) testing ASDs on hippocampal paroxysmal discharges (HPDs) in the IH-KA model, which has undergone epileptogenesis, or (3) spontaneous epileptic seizures in animal models of TLE based on systemic treatments that lead to acute convulsive status epilepticus that have later undergone epileptogenesis. This proposed version of the IH-KA model aims to address the former problem (#1, above) by using a mouse model of TLE, and to address the latter problems (#2 and #3, above) of the seemingly random occurrence of epileptic seizures and the low seizure frequency by using optogenetically "triggered" seizures.
Weaknesses
Although the figures provide excellent examples of individual electrographic seizures and compare induced seizures in epileptic and naïve animals, it is unclear which criteria were used to identify an actual seizure induced by the optogenetic stimulus, versus a hippocampal paroxysmal discharge (HPD), an "afterdischarge", an "electrophysiological epileptiform event" (EEE, Ref #36, D'Ambrosio et al., 2010 Epilepsy Currents), or a so-called "spike-wave-discharge" (SWD). Were HPDs or these other non-seizure events ever induced using stimulation in animals with IH-KA? A critical issue is that these other electrical events are not actual seizures, and it is unclear whether they were included in the column showing data on "electrographic afterdischarges" in Figure 5 for the studies on ASDs. This seems to be a problem in other areas of the paper, also.
The differences between the optogenetically evoked seizures in IH-KA vs naïve mice are interpreted to be due to the "epileptogenesis" that had occurred, but the lesion from the KA-induced injury would be expected to cause differences in the electrically and behaviorally recorded seizures - even if epileptogenesis had not occurred. This is not adequately addressed.
The authors did not test whether an apparent "kindling" effect, apparently seen in naïve controls, also occurred in animals micro-injected with kainic acid (KA). This effect could cause model instability that might result in variability in response to ASDs. It is not clear whether the number of optogenetically induced seizures in epileptic animals would affect the response to drugs. It is also unclear how much of an improvement the animal model in the present work is over other similar models of TLE, where electrically triggered seizures could simply be applied to one of them.
The authors offer little mention of other research using animal models of TLE to screen ASDs, of which there are many published studies - many of them with other strengths and/or weaknesses. For example, although Grabenstatter and Dudek (2019, Epilepsia) used a version of the systemic KA model to obtain dose-response data on the effects of carbamazepine on spontaneous seizures, that work required use of KA-treated rats selected to have very high rates of spontaneous seizures, which requires careful and tedious selection of animals. The ETSP has published studies with an intra-amygdala kainic acid (IA-KA) model (West et al., 2022, Exp Neurol), where the authors claim that they can use spontaneous seizures to identify ASDs for DRE; however, their lack of a drug effect of carbamazepine may have been a false negative secondary to low seizure rates. The approach described in this paper may help with confounds caused by low or variable seizure rates. These types of issues should be discussed, along with others.
While the paper may be relevant for the ETSP and contract research organizations (CROs), the paper was not written to attract the interest of biological scientists, even those in this specific area of epilepsy research. It may be of low interest to other neuroscientists.
The outcome measure for testing LEV and DZP on seizures was essentially the fraction of unsuccessful or successful activations of seizures, where high ASD efficacy is based on showing that the optogenetic stimulation causes fewer seizures when the drug is present. The final outcome measure is thus a percentage, which would still lead to a large number of tests to be assured of adequate statistical power. Thus, there is a concern about whether this proposed approach will have high enough resolution to be more useful than conventional screening methods so that one can obtain actual dose-response data on ASDs.
The key issue the authors aim to address is the 30-40% of patients with DRE, but the real problem with DRE patients is not that these people have seizures with no effect of the ASDs; rather, although ASD may reduce seizure burden, these patients continue to have some remaining seizures even after high doses of ASDs, which often leads to adverse effects from the particular ASDs.
In several sections of the paper, the authors argue that two different groups are similar on the basis that no statistical difference was found between the two groups (i.e., p > 0.05); however, the failure to find a statistically significant difference, particularly with relatively small sample sizes, is not rigorous evidence that the two groups are actually similar - they are just "not significantly different."
It remains unclear that the optogenetically induced seizures in this model are better than similarly induced seizures in a naïve animal, and there is no evidence that the model will be useful for finding new ASDs to treat DRE.
Do the results support the conclusions?
Although the Results show examples of clear tonic-clonic seizures, it is not at all clear whether this approach is a significant improvement over previous methods used on animal models of TLE. The presented data from this method shows it provides an ability to detect the effect of widely used ASDs, but not that it will have the resolution to find better ASDs. The outcome measure of successful vs failed seizure inductions does not necessarily translate to a pathway for finding new ASDs for DRE, which often is a function of the side effects of the proposed new ASD. Although the recorded seizures in IH-KA rats differ in waveform from the ones in naïve mice, this could be due to the pattern of damage resulting from the micro-injection of KA or the density of expressed Chr2, which could be affected by sclerosis.
Impact and utility of methods and data.
The authors state that this approach should be used to test for and discover new ASDs for DRE, and also used for various open/closed loop protocols with deep-brain stimulation; however, the paper does not actually discuss rigorously or critically the background literature on other published studies in these areas or how this approach will improve future research for a broader audience than the ETSP and CROs. Thus, it is not clear whether the utility will apply more widely and how extensive a readership will be attracted to this work.
Final Conclusions:
Although this is an Interesting if not elegant new model for testing ASDs, it could be seen as a version of kindling (plus brain damage) in a rodent model, where some of the pathology of TLE is induced through focal injection of KA in the CA3 area of the hippocampus. Unfortunately, no evidence was presented that it will be any better than other models, although it could be faster and maybe easier than models based on spontaneous seizures. Although it has some similarities to the pathology of human TLE, the ablating part of the hippocampus does not account for the more widespread pathology that usually occurs elsewhere in the brain, as studied with imaging and with anatomy in surgical specimens from patients with DRE.
Although this approach with seizure induction via an optogenetic approach adds specificity to the type of cell that is stimulated (i.e., CA1 pyramidal cells), it is not apparent why this provides a better or more effective tool than simple electrical induction of seizures in any TLE model. Most important, it remains unclear how this addresses any aspect of drug resistance. To improve the ASD discovery process, an important new model must make a significant reduction in seizure burden, and would ideally improve the percentage of patients that become seizure-free. It is not clear how this model will do that.
In the end, the authors have created a model with some of the pathology of TLE, where they can then induce actual seizures via specific optogenetic stimulation. So, although it is potentially elegant work, it remains unclear what new information this model will tell us about epilepsy, and most importantly DRE - or how it will improve treatment outcomes.